Acute scrotal pain or swelling

PIC Endorsed

Key Points

Testicular torsion is an emergency. It requires immediate referral to a surgeon
Surgical evaluation should be undertaken in all cases where testicular torsion cannot be confidently excluded
Ultrasound should only be considered in selected cases of testicular pain, after surgical assessment, to avoid delays in management
Scrotal trauma/bruising, especially in infants or where the causal mechanism is unclear, should prompt the clinician to consider child abuse

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

Assessment

Scrotal pain +/- swelling

	Testicular torsion	Irreducible hernia	Torsion of testicular appendage	Epididymo-orchitis	Trauma eg 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	Severe Usually sudden onset May radiate to iliac fossa or thigh May be painless in neonates	Irritable	Usually sudden onset Usually minimal at rest	Sudden or subacute onset May improve with elevation	May be delayed
Swelling	Yes	Yes May extend to scrotum	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
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	Bruising (consider causes, eg NAI)
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 collection)
- Bacterial infection more likely in child with structural urinary tract abnormalities, recent instrumentation of urinary tract, or STI
- A normal urine does not exclude epididymo-orchitis
Urine chlamydia and gonorrhoea PCR testing (if STI clinically suspected)
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

Treatment

Diagnosis	Management
Testicular torsion	If suspected, or cannot be confidently excluded: Urgent surgical review Fasting or clear fluids until surgical review Provide adequate analgesia
Irreducible hernia	Urgent surgical review Fasting or clear fluids until surgical review Consider a nasogastric tube on free drainage if bowel obstruction is suspected Provide adequate analgesia
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
Trauma	Surgical review for all testicular trauma, unless the testis is clearly felt to be normal and without significant tenderness In cases of suspected child abuse presenting with testicular or scrotal trauma, see Child abuse
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

In cases of suspected child abuse, see Child abuse

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

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)

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)

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)

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)

McBride, C et al 2017, Acutely painful scrotum: Tips, traps, tricks and truths, J Paediatr Child Health, 53:1054-1059.

The Royal Children's Hospital Melbourne

Clinical Practice Guidelines