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Acute scrotal pain or swelling

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  • See also

    Penis & foreskin
    Acute abdominal pain

    Key Points

    1. Testicular torsion is an emergency. It requires immediate referral to a surgeon
    2. Surgical evaluation should be undertaken in all cases where testicular torsion cannot be confidently excluded
    3. Ultrasound should only be considered in selected cases, after surgical assessment

    Background

    • The most common causes of acute scrotal pain and/or swelling are torsion of the testicular appendage (appendix testis), epididymitis and testicular torsion
    • Delays in surgical management of testicular torsion result in higher rates of testicular loss (>40%).  Common causes of delay include location of presentation, use of ultrasound, and transferring to a tertiary centre

    Assessment

    Red flags in red

    Pain and/or swelling

     

    Testicular torsion

    Irreducible hernia

    Torsion of testicular appendage

    Epididymo-orchitis

    Testicular or epididymal rupture

    Typical age group

    Pubertal (and rarely neonates)

    Infants

    Pre-pubertal
    (7-12 years)

    <2 years and post-pubertal
    (rarely pre-pubertal)

    -

    Pain

    Usually sudden
    Severe
    May radiate to iliac fossa or thigh

    Irritable

    Usually sudden
    Usually minimal at rest

    Sudden or subacute
    May improve with elevation

    May be delayed

    Swelling

    Yes  (may be painless in neonates)

    Yes - may extend to scrotum

    Yes

    Yes

    Yes - may be delayed

    Fever

    Unusual

    Unusual

    Unusual

    Common

    Unusual

    Nausea and vomiting

    Common (90%)

    Common

    Uncommon

    Uncommon

    Uncommon

    Dysuria or discharge

    No

    No

    No

    Common

    No

    Trauma

    Occasionally

    No

    No

    No

    Yes

    Gait

    Impaired

    -

    -

    -

    -

    Position of testis

    High riding or horizontal

    -

    Normal

    -

    -

    Palpation

    Tender
    Thickened spermatic cord

    Firm and tender
    Swelling not reducible

    Focal tenderness of upper pole of testis

    Tender postero-lateral testis

    Tender

    Oedema crosses midline

    No

    No

    No

    Possible

    Possible

    Discoloration

    Red/blue
    Dark in neonate

    -

    Blue dot sign

    Red

    Bruised

    Cremasteric reflex

    Usually absent

    Usually present

    Usually present

    Usually present

    Usually present

    Reactive hydrocele

    Possible

    No

    No

    Possible

    Possible


    Non-painful scrotal swelling  

     

    Hydrocele

    Varicocele

    Idiopathic scrotal oedema

    Tumour/ 
    leukaemia

    Typical age group

    Infants

    Peri-pubertal

    3-7 years

    1-8 years

    Fever

    Unusual

    Unusual

    Unusual

    Possible

    Palpation

    Soft
    Non-tender
    Fluctuant

    "Bag of Worms"
    Occasionally tender

    Non-tender
    May have low-grade discomfort

    Hard
    Non-tender
    May be painful if rapidly growing

    Swelling pattern

    Scrotal

    Predominantly left-sided

    Can extend across midline and into perineum, groin, penis

    Unilateral or bilateral

    Discoloration

    No

    No

    Bland, purplish

    No

    Transilluminable

    Brightly

    No

    No

    No

    Reactive hydrocele

    -

    No

    No

    Possible


    Management

    Investigations

    • Blood tests, ultrasound and Doppler ultrasound are not useful in the acute setting
    • Once testicular torsion and irreducible hernia have been confidently excluded, ultrasound may be considered if the diagnosis remains unclear
    • Colour doppler flow ultrasound may assess blood flow, anatomy, and may localise swelling and fluid collections
    • Consider urinalysis and urine MCS

    For suspected epididymo-orchitis

    • Urine MCS (ideally first pass)
    • Urine chlamydia and gonorrhoea PCR testing (if STI clinically suspected)
    • A normal urine does not exclude epididymo-orchitis
    • Viral causes include enterovirus, adenovirus and rarely mumps.  Mumps orchitis occurs 4-6 days after parotitis. If mumps is suspected: RT-PCR and/or IgM
    • Bacterial infection more likely in child with structural urinary tract abnormalities, recent instrumentation of urinary tract, or STI

    Management:

    Urgent surgical review is required for suspected testicular torsion (or if this cannot be confidently excluded), or irreducible hernia

    • Fasting or clear fluids until surgical review
    • Consider a nasogastric tube on free drainage if bowel obstruction is suspected
    • Provide adequate analgesia

    Diagnosis

    Management

    Torsion of testicular appendage

    May be difficult to distinguish from testicular torsion
    Requires surgical exploration if unable to confidently exclude testicular torsion
    Once diagnosis confirmed, treatment is supportive, with analgesia and rest
    Pain should resolve in 2-10 days

    Testicular or epididymal rupture

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

    Suspected epididymo-orchitis

    Antibiotics - IV if systemically unwell/young infant, oral if well
    Second episode - renal tract ultrasound and urological review
    Slow to resolve. May have weeks of gradually subsiding scrotal discomfort and swelling

    Hydrocele

    Spontaneous resolution in the first year; 90% by 2 years
    Consider outpatient surgical referral for repair if present after 2 years of age

    Varicocele

    Refer to surgical outpatients

    Idiopathic scrotal
    oedema

    Scrotal oedema can occur in setting of systemic disease eg nephrotic syndrome
    If idiopathic, resolves spontaneously over 1-5 days. No intervention required


    Consider consultation with local paediatric team when

    Surgical evaluation should be undertaken in all cases where testicular torsion cannot be confidently excluded

    Consider transfer when

    Surgical evaluation unavailable at local hospital

    For emergency advice and paediatric or neonatal ICU transfers, see  Retrieval Services .

    Consider discharge when

    • Surgical advice has been provided
    • Follow up plan in place and review scheduled (if required)

    Parent information

    Inguinal hernia
    Abdominal pain
    Testicle injuries and conditions

    Last Updated July 2020

  • Reference List

    1. Brenner, J et al. Causes of painless scrotal swelling in children and adolescents. Retrieved from https://www.uptodate.com/contents/causes-of-painless-scrotal-swelling-in-children-and-adolescents (viewed May 2020)
    2. Brenner, J et al. Causes of scrotal pain in children and adolescents. Retrieved from https://www.uptodate.com/contents/causes-of-scrotal-pain-in-children-and-adolescents(viewed May 2020)
    3. Brenner, J et al. Evaluation of nontraumatic scrotal pain or swelling in children and adolescents. Retrieved from https://www.uptodate.com/contents/evaluation-of-nontraumatic-scrotal-pain-or-swelling-in-children-and-adolescents(viewed May 2020)
    4. Children’s Health Queensland Hospital and Health Service, Acute scrotal pain – Emergency management in children. Retrieved from https://www.childrens.health.qld.gov.au/guideline-acute-scrotal-pain-emergency-management-in-children/ (viewed May 2020)
    5. McBride, C et al 2017, Acutely painful scrotum: Tips, traps, tricks and truths, J Paediatr Child Health, 53:1054-1059.