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Acute Scrotum

The acute scrotum presents as testicular pain or swelling. Testicular torsion represents a surgical emergency because the likelihood of testicular salvage diminishes with the duration of torsion. Testicular torsion must be quickly excluded in any patient who presents with an acute scrotum.

The history and physical examination can significantly narrow the differential diagnosis of an acute scrotum, if not establish the exact cause. None of the conditions responsible for acute scrotal pain or swelling has a single pathognomonic finding, but the combined background information and physical findings frequently suggest the correct diagnosis of scrotal pain (Table 1).

The age of the patient is important. Testicular torsion is most common in neonates and postpubertal boys, although it can occur in males of any age. Schönlein-Henoch purpura and torsion of a testicular appendage typically occur in prepubertal boys, whereas epididymitis most often develops.

The onset and duration of pain must be carefully determined. Testicular torsion usually begins abruptly, as if a switch has been flipped. The pain is severe, and the patient often appears uncomfortable. Moderate pain developing gradually over a few days is more suggestive of epididymitis or appendiceal torsion. With either of these conditions, the patient may appear relatively comfortable

The physician needs to be aware that an embarrassed child may state that he has lower abdominal or inguinal pain.

Diagnosis of Selected Conditions Responsible for the Acute Scrotum
Condition
Onset of symptoms
Age
Tenderness
Urinalysis
Cremasteric reflex
Treatment
Testicular torsion Acute Early puberty Diffuse Negative Negative Surgical exploration
Appendiceal torsion Subacute Prepubertal Localized to upper pole Negative Positive Bed rest and scrotal elevation
Epididymitis Insidious Adolescence Epididymal Positive or negative Positive Antibiotics

A history of trauma does not exclude the diagnosis of testicular torsion. Scrotal trauma incurred during sports activities or rough, boisterous play often causes severe pain of short duration. Pain that persists for more than one hour after scrotal trauma.

Information should always be obtained about prior occurrence of pain. When asked, many patients with torsion describe previous incidents.

Physical Examination

The physician can often assess the severity of pain by observing the patient before beginning the physical examination.

Diagnostic Studies

Urinalysis should be performed to rule out urinary tract infection in any patient with an acute scrotum. Pyuria with or without bacteria suggests infection and is consistent with epididymitis. Based on our experience, a white blood cell count is not helpful.

Treatment

Spermatic Cord Torsion
The "bell clapper" deformity is one underlying cause of testicular torsion in older children. In this deformity, the testicle lacks a normal attachment to the tunica vaginalis and therefore hangs freely. As a result, the spermatic cord can twist.

Torsion of Testicular Appendages
The appendix testis, a müllerian duct remnant located at the superior pole of the testicle, is the most common appendage to undergo torsion. The epididymal appendix, located on the head of the epididymis, is a wolffian duct remnant and may also become twisted.

Epididymitis or Orchitis
Epididymitis in adolescents and young adults is often related to sexual activity and does not present with a urinary tract infection.

Scrotal Trauma
Severe testicular injury is uncommon and usually results from either a direct blow to the scrotum or a straddle injury. Damage occurs when the testis is forcefully compressed against the pubic bones. A spectrum of injuries may occur.

Other Causes
Acute idiopathic scrotal edema is another possible cause of an acute scrotum. This condition is characterized by the rapid onset of significant edema without tenderness. Erythema may be present. The patient is usually afebrile, and all diagnostic tests are negative.

Schönlein-Henoch purpura, a systemic vasculitic syndrome of uncertain etiology, is characterized by nonthrombocytopenic purpura, arthralgia, renal disease and abdominal pain.

A hydrocele occurs because of a patent processus vaginalis. The hydrocele can seal off, trapping peritoneal fluid around the testis, or it can persist and dilate, possibly causing bowel herniation. Most hydroceles resolve spontaneously.