Clinical Practice Guidelines

Acute scrotal pain or swelling


  • Statewide logo

    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • Key points:

    • Testicular Torsion is an Emergency -> immediate referral to a Paediatric Surgeon is required
    • An ultrasound is not recommended prior to referral
    • Use a chaperone when performing a scrotal examination

    Testicular Torsion

    Incarcerated Hernia

    Torsion of Testicular appendage

    Epididymo-orchitis

    Testicular or Epididymal rupture

    Hydrocele

    Varicoceole

    Idiopathic scrotal oedema

    Tumour/
    Leukaemia

    Features on History

    Pain

    +++
    Sudden onset

    +++
    Irritable

    ++
    Gradual onset

    +

    ++

    -

    -

    -

    +/-

    Swelling

    ++

    +++

    ++

    ++

    ++

    ++

    ++

    ++

    Possibly

    Fever

    -

    -

    -

    +

    -

    -

    -

    -

    +/-

    Nausea and Vomiting

    ++

    ++

    -

    -

    -

    -

    -

    -

    -

    Sexual History

    -

    -

    -

    +

    -

    -

    -

    -

    -

    History of Urological abnormalities

    -

    -

    -

    +

    -

    -

    -

    -

    -

    History of Trauma

    -

    -

    -

    -

    ++

    -

    -

    -

    -

    Features on Examination

    Gait

    Impaired

    -

    -

    -

    -

    -

    -

    -

    -

    Position of Testis

    High riding/
    Horizontal

    -

    -

    -

    -

    -

    -

    -

    -

    Palpation

    Tender

    Firm and Tender

    Tender upper pole of testis

    Tender –posterior-lateral testis

    Tender

    Soft,
    Non tender

    "Bag of Worms"
    Non tender

    Non tender

    Hard,
    Non Tender

    Oedema crosses midline

    No

    No

    No

    Yes

    Yes

    Yes

    Yes

    Yes

    Possibly

    Swelling Reducible

    -

    No

    -

    -

    -

    -

    -

    -

    -

    Discoloration

    Red/Blue
    Dark in Neonate

    -

    Blue dot sign

    Red

    Bruised

    -

    -

    Bland, purplish

    -

    Trans illumination

    No

    No

    No

    No

    No

    Brightly

    No

    No

    No

    Cremasteric reflex

    Absent

    -

    -

    -

    -

    -

    -

    -

    -

    Features on investigation: 

    • Check urinalysis, and send sample for M, C &S.
    • 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 Features on history Features on exam Management

    Surgical Causes

     

     

     

    Testicular torsion

    Peak neonates and adolescents
    13-16years

    Sudden onset unilateral testicular pain and swelling
    Pain usually constant
    May be pain in iliac fossa
    May follow minor trauma/sport
    Associated Nausea/vomiting

    Neonate – painless, smooth testicular enlargement

    Discoloration of Hemiscrotum
    Very tender and swollen
    High riding/ horizontal testis
    Cremasteric reflex absent
    Reactive hydrocele
    Impaired gait

    Neonate – does not transilluminate. Dark colour

    Early surgical consult is vital – delay in exploration and detorsion will result in testicular infarction in 8-12 hours.
    Clear fluids until Surgical Review.

     

    Neonates – in utero, usually not viable. Discuss with Paediatric surgeon

    Incarcerated hernia

    Intermittent inguinoscrotal swelling, associated irritability
    +++Pain
    Worse with crying
    Nausea and Vomiting – if bowel entrapment

    Firm, tender, irreducible inguinoscrotal swelling

    Requires reduction as bowel may become necrotic – surgical referral

    Torsion hydatid (torsion of testicular appendage)

    Peak 11years (prepubertal boys)

    **difficult to distinguish from testicular torsion**

    More gradual onset testicular pain (1-2days)
    Focal tenderness
    At time of rapid testicular growth
    No nausea or vomiting

    Focally tender upper pole of testis
    Testis non tender
    “Blue dot” sign – necrotic appendage seen through skin
    Reactive hydrocele

    Analgesia, rest.
    Pain resolves 2-12days, should have lessened by 48 hours.
    Usually requires surgical exploration, during which can excise torted areas.

    Epididymoorchitis

    RARE pre-pubertal (unless underlying genitourinary abnormality associated with UTI)

    Adolescents with STI

    Insidious onset
    Fever
    Urinary symptoms – dysuria, frequency
    Urethral discharge
    May have history of recent instrumentation – catheter or cystoscopy

    **Mumps orchitis occurs 4-6days after parotitis**

    Red, swollen hemiscrotum
    Tenderness most marked posterior-lateral testis
    Pyuria may be present
    Tenderness improved with testicular elevation

    Urine (ideally first pass) MCS +/- chlamydia and gonorrhoea (adolescent) for PCR testing
    Antibiotics
    -IV BenzylPenecillin and gentamicin if systemically unwell/young infant
    - PO Co-trimoxazole if well
    (http://www.rch.org.au/clinicalguide/guideline_index/Antibiotics/#uti)

    Slow to resolve may have weeks of gradually subsiding scrotal discomfort and swelling.
    Second episode – Ix renal tract US / MCU

    Testicular or Epipdymal rupture

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

    Tender, swollen testis
    Bruising
    Oedema
    Haematoma or haematocele

    Surgical review in all testicular trauma, unless the testis is clearly felt to be normal and without significant tenderness

    Hydrocele – collection fluid in scrotum due to patent processus vaginalis

     

    1-2% boys born with
    Swollen hemiscrotum – cystic fluid around testis
    May fluctuate or be reducible if communicating
    Systemically well baby

    **Can be seen with torsion, trauma, tumour, epididymitis

    Soft, non-tender swelling adjacent to testis
    Testis normal within hydrocele, non-tender
    Transilluminates brightly

    Resorb and tunica vaginalis closes spontaneously in the first year- 90% by 2 years
    Consider surgical referral for repair if present after 2 years of age

    Varicocele

    Peri pubertal males
    Collection of abnormally enlarged spermatic cord veins
    Predominantly left sided

    Mass of varicose veins (“bag of worms”) above testicle
    Non tender
    More prominent with standing

    Refer to Paediatric Surgery OPC – consider OT if symptomatic, impaired testicular growth

    Medical Causes

     

     

     

    Idiopathic scrotal oedema

    Peak 3-7years

    Rapid onset of painless but notable oedema

    **Can be in setting of systemic disease E.g. nephrotic syndrome**

    Bland, purplish swelling over both hemiscortum, perineum + penis
    Testes non tender
    Palpable scrotal oedema

    Resolves spontaneously over 1-2days. No intervention required.

    Tumour / Leukaemia

    Can be painful if rapidly growing
    Associated with haemorrhage or infarction

    Painless
    Unilateral
    Firm to hard scrotal swelling
    Leukaemia infiltration may be bilateral

    Refer to oncology

    When to admit/consult local paediatric team, or who/when to phone consult at RCH:

    • Surgical evaluation should be undertaken in ALL acute scrotal pain
    • Young infants or systemically unwell children with epididymo-orchitis should be admitted for intravenous antibiotics 
    When to consider transfer:

    NETS/PETS phone number

    Last revised February, 2017