Scrotal Pain

Scrotal Pain: Excerpt from In A Page: Pediatric Signs and Symptoms

Acute scrotal pain demands immediate attention. Although not every cause constitutes an emergency, testicular torsion must be discovered immediately to save the testicle. Testicular pain should be triaged to an emergency center with access to Doppler evaluation and a surgery consult.

Differential Diagnosis

• Testicular torsion
  –Twisting of the spermatic cord and vessels, resulting in testicular ischemia
  –Patients present with an excruciatingly painful swollen testicle with or without a history of previous milder episodes (intermittent torsion)
  –May occur at any age (including in utero)

• Torsion of the appendix testis
  –May be difficult to distinguish clinically from testicular torsion
  –Typically, pain is less severe and the onset less acute (over several days as opposed to several hours)
  –Most common ages 7–12 years

• Testicular trauma
  –Blunt trauma occurs as saddle injuries, in sports such as soccer and baseball, and during altercations

• Epididymitis
  –Inflammation of the epididymis usually secondary to bacteria
  –Rare before puberty and often seen in sexually active young men with acutely swollen and painful testis
  –Pain is usually less acute in onset than torsion

• Inguinal hernia
  –Incarcerated inguinal hernia may present as a painful, edematous scrotum
• Orchitis
  –Inflammation of the testes due to viral infection; classically mumps
  –Patient presents with an acutely swollen, red testicle(s)
  –Uncommon since widespread vaccination
• Henoch-Schönlein purpura
  –Vasculitis characterized by palpable purpura usually in the lower half of the body
  –Painful testicular swelling can be a sign of this disorder
  • Varicocele
    –A collection of dilated veins in the scrotum
    –Usually painless, but occasionally patients may complain of chronic nagging pain and discomfort (especially during physical activity)
    –Presents after puberty

  Workup and Diagnosis

  • History
    –History of trauma, viral symptoms, rash
    –Sexual history and history of STDs
    –Past medical history of similar episodes
  • Physical exam
    –With testicular torsion, the absence of the cremasteric reflex is one of the most characteristic features; the affected testis is also often higher and more horizontal than the contralateral testis
    –In epididymitis and orchitis, elevation of the testis improves the pain, and the cremasteric reflex is usually preserved
    –In torsion of the appendix testis, a bluish dot may be seen in the superior portion of the affected testis
    –A hernia often can be felt extending from the inguinal area into the scrotum
    –A varicocele is described as feeling like a “bag of worms,” and is best examined with the patient standing
  • Urinalysis
    –Normal in patients with torsion
    –Pyuria is a feature of epididymitis
  • Doppler ultrasound is indicated for patients in whom the physical exam is not diagnostic; it may be bypassed by the surgeon in the interest of time when the exam is very specific for testicular torsion

  Treatment

  • Torsion
    –To salvage the testis, detorsion must take place within 6 hours of the onset of symptoms
    –Surgical exploration and detorsion is the approach of choice for children with suspected testicular torsion
    –With torsion of one testicle, the surgeon may elect to surgically fix the contralateral testicle to prevent future torsion
  • Torsion of the appendix testis is treated conservatively
  • Antibiotics, typically doxycycline, are used to treat epididymitis
  • Inguinal hernias are reduced surgically; surgical exploration of the contralateral side is often performed
  • Orchitis is treated supportively
  • HSP is treated supportively and sometimes with systemic corticosteroids
  • Varicoceles may not require treatment, but may interfere with fertility

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: Otalgia (Ear Pain) (In A Page: Pediatric Signs and Symptoms)

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