Case Based Pediatrics For Medical Students and Residents
Department of Pediatrics, University of Hawaii John A. Burns School of Medicine
Chapter XIII.10. Acute Scrotum
Robert G. Carlile, MD
May 2002

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A 10 year old male presents with a chief complaint of acute onset of left scrotal pain 3 hours earlier, which awoke him from sleep. The pain is constant and does not change with position. There is no history of trauma. He has no dysuria, fever, chills, nausea or vomiting.

Exam: He is afebrile in moderate distress secondary to left scrotal pain. The left hemiscrotum is edematous and erythematous. The left testicle has a transverse lie, with marked tenderness to palpation. The cremasteric reflex is absent on the left. The right hemiscrotum and testicle are normal on exam. The circumcised penis is normal, with no urethral discharge present.

A CBC and urinalysis are normal (this results in an unnecessary delay of one hour). Color Doppler ultrasound scanning of the scrotum demonstrates the absence of blood flow to the left testicle and epididymis. Normal blood flow to the right testicle is present. No testicular masses are noted.

An emergent urological consultation is obtained. Scrotal exploration, under anesthesia, reveals a 720 degree torsion of the left spermatic cord, an ischemic testicle, and a "bell-clapper" deformity. With detorsion, the left testicle's normal color returns. The left testicle is then "fixed" to the scrotal wall to prevent retorsion. The right testicle is also fixed to the scrotal wall. Postoperatively, his pain was markedly relieved with the detorsion of the left testicle, and the remainder of his recovery is unremarkable.


The acute scrotum is a true urologic emergency. The window of opportunity to salvage a torsed, ischemic testicle is only 6 hours (1). Acute scrotal swelling should be considered testicular torsion until proven otherwise.

Puberty is the most common age at which testicular torsion occurs, with the newborn period being the second most common. The incidence is 1 in 4000 males younger than 25 years (2).

Testicular torsion can be classified into two types, relative to the tunica vaginalis' relationship to the area of the spermatic cord that twists: extravaginal and intravaginal. Extravaginal torsions occur perinatally, during testicular descent and prior to testicular fixation in the scrotum (2). This incomplete fixation of the gubernaculum (the fibrous cord extending from the fetal testis to the fetal scrotum which occupies the potential inguinal canal and guides the testis in its descent) to the scrotal wall allows the entire testes and tunica free rotation within the scrotum (3). The rotation of the cord is "extravaginal" because the rotation of the cord is proximal to the attachment of the tunica vaginalis that encloses the testes. These comprise 5% of all testicular torsions (4).

Intravaginal torsion occurs in the remaining 95% of all testicular torsions (4). A congenital high attachment of the tunica vaginalis on the spermatic cord allows the testes to rotate on the cord, within the tunica vaginalis. This is the "bell-clapper" deformity which is a horizontal lie of the testicle instead of the normal vertical lie. It is called a bell clapper deformity because the testicle resembles a horizontal oval hanging from a cord at its midpoint (like the clapper in a bell) as opposed to the normal testicle which resembles the letter "b" or "d" with the testicle positioned vertically attached to the cord on its side. This deformity is commonly bilateral, which places the contralateral testicle at risk for torsion also (3). As viewed from below, the testes rotate inward or medially during a torsion; the right clockwise and the left counter clockwise.

The acute onset of severe testicular pain with associated nausea and vomiting is very suggestive of testicular torsion, especially in the adolescent. Fever and dysuria are not common in testicular torsion. Intermittent testicular torsion is suspected when brief episodes of acute testicular pain occur recurrently. Torsion of a testicular or epididymal appendage (appendix testis or appendix epididymis) usually presents in mid childhood with mild discomfort of a few days duration (2).

Epididymitis and/or orchitis, on the other hand, may be associated with fever, dysuria, and a more gradual onset of scrotal pain, usually over several days. A history of urethral strictures, posterior urethral valves, myelodysplasia with neurogenic bladder, and severe hypospadias with utricular enlargement may predispose to urinary tract infection, with secondary reflux into the ejaculatory ducts causing epididymitis (2). A history of scrotal pain and swelling associated with fever and parotid gland swelling suggest mumps orchitis.

Inguinal hernia and/or hydroceles may present with similar symptoms to acute testicular torsion. A history of constipation or upper respiratory infection, both causing increases in intraabdominal pressure may be present.

Henoch-Schonlein purpura, an uncommon cause of acute scrotal swelling (usually bilateral), is associated with a history of vasculitis and associated onset of a cutaneous purpuric scrotal rash (2).

Trauma, even minor, may be a cause of testicular pain and should be sought in the history (straddle injury, wrestling, sports). A history of trauma may suggest a traumatic etiology of pain and swelling, but this does not necessarily rule out the presence of testicular torsion.

The physical exam should be begun in conjunction with the history taking. The level of distress is noted along with vital signs and examination of the abdomen. There should be a specific notation of the presence or absence of inguinal and scrotal swelling, urethral discharge, scrotal or perineal ecchymoses or rashes, and lastly the appearance of the testes and area of pain and/or tenderness. The absence of a cremasteric reflex, in conjunction with testicular tenderness, is commonly associated with testicular torsion (5). This reflex is usually present in epididymitis. It is elicited by gently stroking the skin of the inner thigh: the presence of the cremasteric muscle results in movement of the testicle in the ipsilateral hemiscrotum.

Acute testicular torsion should be considered the leading diagnosis until it is ruled out. The acute onset of severe unilateral unrelenting pain, tenderness, high riding testicle, with absent cremasteric reflex and no change in pain in response to testicular elevation (Prehn's sign), highly suggest testicular torsion. In testicular torsion, the affected testicle may be more cephalad than normal and it may lie transversely (horizontally). A change in position is not seen in epididymitis or orchitis.

If one is able to palpate the testicle separate from the epididymis, one can distinguish between testicular torsion, epididymitis, and testicular appendage torsion. The affected testicle is exquisitely tender in testicular torsion, and the epididymis may not be palpable, but is also tender if palpable. In epididymitis/orchitis, the testicle itself is not tender, but the epididymis is palpable and tender. Epididymitis has a more gradual onset, with tenderness being present. A cremasteric reflex is usually present, and the pain may be relieved with testicular elevation. Fever, pyuria, and dysuria may be present.

A torsion of a testicular appendage may present in a fashion similar to that of acute testicular torsion. The tenderness may be well localized to the upper part of the testes and a characteristic "blue dot" sign in the skin of the scrotum may be applicable. This blue dot is due to venous congestion of the appendix testis of the torsed appendage.

Color Doppler ultrasound scanning has great utility in differentiating between the above diagnoses and ruling out testicular torsion (6). Absence of blood flow to the affected testicle is noted in testicular torsion, whereas increased blood flow is noted in epididymitis/orchitis. Flow to the testicle will be present in appendage torsion. Of course, these findings should be combined with the signs and symptoms, and not taken in isolation. Testicular anatomy is also appreciated with ultrasound, helping to evaluate for testicular rupture, hematomas, and tumors.

Nuclear scintigraphy is not commonly used today in the evaluation of the acute scrotum. CBC and urinalysis are helpful in evaluating infectious etiologies, but waiting for these results should not delay a Doppler ultrasound study. A hernia or hydrocele or varicocele can be distinguished on exam.

Acute testicular torsion requires emergent scrotal exploration, detorsion of the affected testicle, with orchiectomy if testicular ischemia and necrosis persists, or testicular fixation if blood flow and testicular viability is restored with detorsion. In either case, the contralateral testicle should be explored and testicular fixation performed with permanent suture.

Epididymitis/orchitis can be treated with antibiotic and anti-inflammatory drugs. Occasionally "sepsis" may result from severe cases, requiring hospitalization with intravenous antibiotics. The majority can be treated with outpatient antibiotics. Activity should be limited.

Acute testicular appendage torsion may be observed, with analgesics/anti-inflammatories if the diagnosis is firm. No testicular fixation is necessary as these are not commonly associated with abnormalities of the attachments. If the diagnosis is in doubt, emergent scrotal exploration is indicated.

Trauma with rupture of the tunica albuginea of the testes requires exploration emergently, with debridement and repair. An isolated hematoma may be observed. Henoch-Schonlein purpuric scrotal swelling may be managed medically. Neonatal torsion may require exploration, if the diagnosis is made early enough, but unfortunately, the majority are diagnosed too late for testicle viability. Hernias and hydroceles should be repaired, emergently if incarcerated, electively if not.

The salvageability of a testicle within 6 hours of torsion is very good. Greater than 6 hours is more worrisome, but exploration should be performed to remove a necrotic testicle, even with a late presentation, as diminished fertility may result from leaving in an infarcted testicle (2). Epididymitis responds well to rest and antibiotic therapy. Any predisposing factors should be corrected.


Questions

1. What are the signs and symptoms that help to differentiate acute testicular torsion from epididymitis?

2. How is color Doppler ultrasound helpful in the differential diagnosis of acute scrotum?

3. What is the cremasteric Reflex? Prehn's sign? The blue dot sign? The bell clapper deformity?

4. What is the time frame most advantageous to restoring viability of a torsed testicle?

5. How is acute testicular torsion managed?

6. How is acute epididymitis managed?


References

1. Bloom DA, Wan J, Key D. Chapter 22 - Disorders of the Male External Genitalia and Inguinal Canal: Torsions. In: Kekalis P, King L, Belman AB (eds). Clinical Pediatric Urology. 1992, Philadelphia: WB Saunders, pp. 1032-1034.

2. Rabinowitz R, Hulbert WC. Acute Scrotal Swelling. Urol Clin North Am 1995:22(1):101-105.

3. Razdan S, Krane RJ. Chapter 4-Non traumatic Genitourinary Emergencies: Torsion of the Testes. In: Siroky MB, Edestein RA, Krane RJ (eds). Manual of Urology Diagnosis and Therapy, 2nd edition. 1999, Philadelphia: Lippincott, Williams and Wilkins, pp. 55-56.

4. Bartholomew TH, McIver G. Chapter 31 - Other Disorders of the Penis and Scrotum. In: Fonzales ET, Bauer SB (eds). Pediatric Urology Practice. 1999, Baltimore: Lippincott, Williams and Wilkins, pp. 538-546.

5. Kadish H, Bolte RG. A Retrospective Review of Pediatric Patients with Epididymitis, Testicular Torsion, and Torsion of Testicular Appendages. Pediatrics 1998:102(1):73-76.

6. Hulbert WC, Rabinowitz R. Diagnosing Testicular Torsion with Doppler US. Contemp Urol 1995:7(12):40-44.


Answers to questions
1.
Acute testicular torsion
Epididymitis
Onset
Acute
More gradual
Fever
Absent
May be present
Cremasteric reflex
Absent
Usually present
Scrotal life of testicle
Cephalad/transverse
Lower in scrotum
Prehn's sign
No change in pain
Decrease in pain
Pyuria
Absent
May be present
Dysuria
Absent
May be present

2. Blood flow to the testicles can be evaluated rapidly and the testicular anatomy can be assessed. Normal or increased blood flow is seen in epididymitis, while absent blood flow is indicative of torsion. Testicular rupture as in trauma, can also be identified.

3. Cremasteric reflex: Gently stroking the medial thigh elicits spermatic cord cremasteric muscle contraction and testicular movement. Prehn's sign: elevation of the affected testicle may improve the pain in epididymitis. Blue dot sign: a torsed ischemic testicular appendage may appear as a blue dot through the scrotal skin. Bell clapper deformity: incomplete investment of the tunica vaginalis onto the testicle and epididymis, with the testicle being predisposed to rotate, and torse, more easily than if the tunica vaginalis were present.

4. Detorsion within 6 hours of the onset of the torsion.

5. Acute scrotal exploration and testicular detorsion with bilateral testicular fixation (if the testicle was detorsed and salvageable).

6. Antibiotics for acute epididymitis.


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