Scrotal Pain

Do infants and toddlers get testicular torsion?

Neonates most frequently have extravaginal torsion (twisting above the tunica vaginalis), which usually occurs in utero and is more often but not invariably associated with a nonviable testicle despite early discovery. Intravaginal testicular torsion (twisting of the spermatic cord within the tunica vaginalis) is most common in the second decade of life and is rare before the age of 10 years. Nevertheless, boys of any age with acute scrotal pain and swelling require prompt attention, radiologic evaluation, and possible surgical evaluation.

Al-Salem AH: Intrauterine testicular torsion: A surgical emergency. J Pediatr Surg 2007;42(11):1887-1891.

Sorensen MD, Galansky SH, Striegl AM, et al: Perinatal extravaginal torsion of the testis in the first month of life is a salvageable event. Urology 2003;62(1):132-134.

What are some of the important factors in the patient’s history that suggest testicular torsion?

Boys with testicular torsion will frequently report relatively sudden onset of unilateral scrotal pain and often nausea and vomiting. They may report that they had this pain on prior occasions, but that information does not argue against acute testicular torsion. Fever and painful voiding are uncommon. A history of trauma does not preclude and can even predispose the patient to torsion. It is important to recognize that the child with scrotal disease often reports lower abdominal or groin pain. Always perform a genital examination on the male patient reporting abdominal pain. Conversely, it is important to examine the abdomen of all patients with scrotal pain to evaluate peritoneal inflammation, intestinal obstruction, and abdominal masses.

Beni-Israel T, Goldman M, Bar Chaim S, Kozer E: Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med 2010;28(7):786-789.

Boettcher M, Bergholz R, Krebs TF, et al: Clinical predictors of testicular torsion in children. Urology 2012;79(3):670-674.

Liang T, Metcalfe P, Sevcik W, Noga M: Retrospective review of diagnosis and treatment in children presenting to the pediatric department with acute scrotum. AJR Am J Roentgenol 2013;200(5):W444-W449.

Seng YJ, Moissinac K: Trauma induced testicular torsion: A reminder for the unwary. Emerg Med J 2000;17:381-382.

What is the “bell clapper deformity”?

Normally, the testicle is fixed to the posterior wall of the scrotum. Although it is almost impossible to detect this on physical examination, the majority of patients with testicular torsion have a congenital condition called the bell clapper deformity , whereby the tunica vaginalis completely envelops the testicle. This allows the testicle and spermatic cord to twist in relation to the tunica vaginalis, compressing the vessels and nerves within. Although the deformity is bilateral, symptoms usually occur unilaterally. The left testicle is more commonly affected because the left spermatic cord is usually longer than the right. With this deformity, some children present with intermittent symptoms, and in these cases, do not discount the diagnosis of testicular torsion.

Hayn MH, Herz DB, Bellinger MF, Schneck FX: Intermittent torsion of the spermatic cord portends an increased risk of acute testicular infarction. J Urol 2008;180(4 Suppl):1729-1732.

What is manual detorsion?

This is a temporizing procedure to manage testicular torsion. Manual detorsion in the emergency setting can allow the testicle to remain viable until emergency surgery can be performed. Although the testicle can twist in either direction, it more commonly twists medially, toward the contralateral thigh. In the manual detorsion procedure, one holds the affected testicle between the thumb and forefinger and untwists 360 degrees toward the ipsilateral thigh—like opening the pages of a book ( Fig. 23-1 ). If relief is noted, the testicle should be rotated another 360 degrees or more, because the usual twist is 720 degrees. The direction can be reversed if more pain or swelling occurs after the initial maneuver. The trick is not to be shy or reserved while performing this procedure; it will hurt while it is being done, but if done correctly it will greatly relieve symptoms almost immediately. Sedation and analgesia may be warranted to facilitate the detorsion procedure. When this procedure is successful, bedside ultrasound may reveal increased blood flow to the testicle, but surgical correction (bilateral orchiopexy) is still necessary after this maneuver. It is important to get urology involved promptly.

Bomann JS, Moore C: Bedside ultrasound of a painful testicle: Before and after manual detorsion by an emergency physician. Acad Emerg Med 2009;16(4):366.

Sessions AE, Rabinowitz R, Hulbert WC, et al: Testicular torsion: Direction, degree, duration and disinformation. J Urol 2003;169:663-665.

How long will a torsed testicle remain viable after the onset of pain?

Timing is crucial in the diagnosis and management of testicular torsion. In general, the prognosis is excellent if the testis is detorsed within 3 hours of symptom onset. Almost 100% of testes detorsed within 3 hours of onset of symptoms will be viable. About 75% of testes detorsed after 8 hours, 10% to 20% of testes detorsed after 12 hours, and 0% of testes detorsed after 24 hours will be viable.

What is the “blue dot sign”?

This refers to a blue discoloration on the upper outer pole of the scrotum, associated with torsion of the appendix testis. It signifies the appearance of a hemorrhagic appendix testis visible through the scrotal wall.

What is torsion of the appendix testis?

There are many appendages to the testis that are not functional but can certainly cause problems for younger children. The testicular appendix that is located on the superior pole of the testis is the most common appendage to twist on its pedicle and compromise vascular supply. This causes pain and swelling of the scrotum, albeit less so than with testicular torsion. This occurs most often in school-aged children and early adolescents, and rarely in those over the age of 20 years. Nausea and vomiting are rare, and on physical examination the cremasteric reflex should be brisk unless swelling is severe. The diagnosis is more easily made if tenderness is located on the anterior or lateral pole of the testicle or there is a “blue dot sign.” If the diagnosis can be secured, torsion of the appendix testis is treated with oral analgesics and bed rest. The appendix will likely autoamputate, with no known sequelae.

Kadish HA, Bolte RG: A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics 1998;102:73-76.