In this section
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.
Features on examination:
Features on investigations:
Suggestive features on history
Suggestive features on examination
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
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.
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.
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.
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.
For advice and inter-hospital (including ICU level) transfers ring the Sick Child Hotline: (03) 9345 7007
Information Specific to RCH - Including who to consult for inpatients.
Textbook of Pediatric Emergency Medicine, 6th Edition, Editor: Fleisher, Gary R.; Ludwig, Stephen
Last updated January 2013