Clinical Practice Guidelines

Acute scrotal pain or swelling

  • Background to condition:

    Any acute scrotal pain requires immediate surgical assessment for torsion of the testis or strangulated inguinal hernia, which are surgical emergencies. In practice it is often difficult to be certain of the diagnosis clinically i.e. sometimes the diagnosis may only be made by surgical exploration. 

    How to assess: 

    Acute Scrotal Pain or Swelling

    Features on history:

    • age of the child: neonatal, prepubertal, adolescent
    • onset and severity
    • trauma
    • fever
    • sexual activity
    • prior genitourinary surgeries / known urological abnormality 

    Features on examination:

    • observation of the patients gait and resting position
    • natural position of the testis in the scrotum while standing
    • presence or absence of cremasteric reflex (this is absent in torsion)
    • palpation of lower abdomen, inguinal canal and cord
    • palpation of scrotum and contents, compare with unaffected hemiscrotum
    • transillumination
    • Is the swelling reducible? 

    Features on investigations:

    • Check urinalysis, and send sample for M & C.
    • Blood tests are not useful in the acute setting.
    • Doppler ultrasound is not useful in the acute setting.
      • However, colour Doppler flow ultrasound can assess anatomy and blood flow. Swelling and fluid collections can be localised. Once a testicular torsion and incarcerated hernia has been excluded by surgical consultation ultrasound may be considered if the diagnosis remains unclear. 

    Acute management:

    Diagnosis

    Suggestive features on history

    Suggestive features on examination

    Acute management

    Testicular torsion

    Sudden onset testicular pain and swelling; occasionally nausea, vomiting. Note: pain may be in the iliac fossa, may be associated with sports activity

    Discolouration of scrotum; exquisitely tender and swollen testis, riding high. Cremasteric reflex is usually absent.

    Early surgical consultation is vital, as delay in scrotal exploration and detorsion of a torted testis will result in testicular infarction within 8-12 hours. Keep the child fasted.

    Torsion of the appendix testis (hydatid of Morgagni)

    More gradual onset of testicular pain

    Focal tenderness at upper pole of testis; "blue dot" sign - necrotic appendix seen through scrotal skin Note: Difficult to distinguish from testicular torsion

    Analgesia, rest. The pain usually resolves in 2 to 12 days, pain should have lessened within 48 hours. Suspected torsion of the appendix testis often requires surgical exploration

    Epididymoorchitis

    Onset may be insidious; fever, vomiting, urinary symptoms; rare in pre-pubertal boys, unless underlying genitourinary anomaly, when associated with UTI.

    Mumps orchitis occurs from 4 to 6 days after parotitis manifests.

    Red, tender, swollen hemiscrotum; tenderness most marked posteriolateral to testis. Pyuria may be present.

    Should be managed with antibiotics once a suitable urine sample has been sent. Young infants or systemically unwell children should be admitted for i.v. antibiotics (eg. amoxycillin and gentamicin). Most patients can be successfully managed as out-patients, with co-trimoxazole. Adolescents with epididymoorchitis should have a first-pass urine sample (ideally first morning urine) for chlamydia and gonococcus PCR. The process is slow to resolve and the patient may have several weeks of gradually subsiding discomfort and scrotal swelling.

     

    Incarcerated inguinal hernia

    History of intermittent inguinoscrotal bulge, with associated irritability

    Firm, tender, irreducible, inguinoscrotal swelling

    Must be reduced or the contents of the hernia may become gangrenous.

    Idiopathic scrotal oedema

    Rapid onset of painless but notable oedema.

    Note: scrotal oedema can be secondary to diseases that cause generalised oedema.

    Bland violaceous oedema of scrotum, extending into perineum + penis; may be bilateral, testes not tender

    Usually resolves spontaneously over a couple of days. No intervention is required.

    Hydrocele

    Simple hydrocele: Swollen hemiscrotum in well, settled baby

    Note: can be seen with torsion, epididymitis, trauma or tumor.

    Soft, non-tender swelling adjacent to testis; testis can be felt to be normal in simple hydrocele; transilluminates brightly.

    Will often resorb and the tunica vaginalis close spontaneously in the first year. If still present at 2 years, surgical referral should be made for consideration of repair.

    Varicocele

    Collection of abnormally enlarged spermatic cord veins, found in teenage boys, mostly on the left.

    Mass of varicose veins ("bag of worms") above testicle, non-tender, more prominent when standing.

    Refer to gen surg outpatient clinic.

    Henoch Schonlein purpura

    Painful scrotal oedema, with purpuric rash over scrotum. May have associated vasculitic rash of buttocks and lower limbs, arthritis, abdominal pain with GI bleeding, and nephritis

    may be difficult to distinguish from testicular torsion in absence of other features

    See Henoch Schonlein Purpura CPG (link).

    Testicular or epididymis rupture

    Scrotal traumas e.g. straddle injury, bicycle handlebars, sports injury. Delayed onset of scrotal pain and swelling.

    Tender swollen testis. Bruising, oedema, haematoma, or haematocele may be present.

    Surgical evaluation should be undertaken in all testicular trauma, unless the testis clearly can be felt to be normal and without significant tenderness.

    Testis tumor

    Can be painful in rapid growing tumors associated with haemorrhage or infarction

    Painless, unilateral, firm to hard scrotal swelling. Leukaemic infiltration may present bilaterally.

    Refer to oncology.

    Antenatal torsion testis

    Newborn may present with painless, smooth, testicular enlargement.

    Does not transilluminate, dark in colour.

    Discuss with paediatric surgeon.

     

    Consider consultation with local paediatric or surgical team:

    • Surgical evaluation should be undertaken in ALL acute scrotal pain
    • Young infants or systemically unwell children with epididymoorchitis should be admitted for i.v. antibiotics 

    When to consider transfer to tertiary centre:  

    • Child requiring care beyond the comfort level of the hospital.  

    For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.
     

    Information specific to RCH - Including who to consult for inpatients. 

     

    Additional notes 

    Refs:

    Textbook of Pediatric Emergency Medicine, 6th Edition, Editor: Fleisher, Gary R.; Ludwig, Stephen

     

    Last updated January 2013