Evaluation of the acute scrotum in adults Author Robert C Eyre, MD Section Editor Michael P O'Leary, MD, MPH Deputy

Editor Fenny H Lin, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Dec 2012. | This topic last updated: feb 11, 2012. INTRODUCTION The spectrum of conditions that affect the scrotum and its contents ranges from incidental findings that merely require patient reassurance to acute pathologic events that require immediate surgical intervention. This topic reviews the clinical evaluation and management of the acute scrotum. Nonacute scrotal pathology in adults and scrotal disorders in children are discussed in detail separately. (See "Evaluation of nonacute scrotal pathology in adult men" and "Evaluation of scrotal pain or swelling in children and adolescents".) NORMAL ANATOMY The testis, tunica vaginalis, epididymis, spermatic cord, and appendix testis are important anatomic structures that may be involved in acute scrotal pathology (figure 1): The testis or testicle is the male gonad responsible for production of sperm and androgens, primarily testosterone. The tunica vaginalis is a potential space that encompasses the anterior two-thirds of the testicle. Different types of fluid may accumulate within the tunica vaginalis (ie, water in hydrocele, blood in hematocele, and pus in pyocele). The epididymis is a tightly coiled tubular structure located on the posterior aspect of the testis running from its superior to inferior poles. Sperm travels from the tubules of the rete testis into the epididymis, which ultimately joins the vas deferens. The function of the epididymis is to aid in the storage and transport of sperm cells that are produced in the testes, as well as to facilitate sperm maturation. The spermatic cord, which consists of the testicular blood vessels and the vas deferens, is connected to the base of the epididymis and runs into the abdomen. The appendix testis is a small vestigial structure on the anterosuperior aspect of the testis (an embryologic remnant of the Mllerian duct system) (figure 2). It measures about 0.3 cm and its pedunculated shape predisposes it to torsion (twisting), particularly during childhood.

EVALUATION The most important objective in the evaluation of the acute scrotum is to identify any urologic emergency, which requires immediate surgical intervention. Delayed surgical intervention of a urologic emergency can lead to loss of the testis, infertility, and other severe complications. The most common urologic emergencies presenting in adults with acute scrotal pain include testicular torsion, severe infectious epididymitis, and Fourniers gangrene (necrotizing fasciitis of the perineum). (See 'Testicular torsion' below and 'Epididymitis' below and "Necrotizing soft tissue infections".)

The evaluation of acute scrotal pain includes a thorough history, physical examination, Doppler ultrasound, and urine studies. Certain signs and symptoms are particularly helpful in determining the etiology of acute scrotal pain (table 1). Patients should be asked about the onset of the pain (abrupt, insidious), location of pain, history of trauma or surgical intervention, urinary complaints (frequency, urgency, dysuria), and any systemic symptoms (fever, rigors). The clinician should perform a thorough physical examination of the abdomen, inguinal region, spermatic cord, scrotal skin, testes, tunica vaginalis (which may have fluid), and epididymis (figure 1). The cremasteric reflex should be assessed by stroking or gently pinching the skin of the upper thigh while observing the ipsilateral testis. A normal response is cremasteric contraction with elevation of the testis. An absent reflex helps distinguish testicular torsion from epididymitis and other causes of scrotal pain, in which the reflex is typically intact [1]. A urinalysis and urine culture should be performed, since pyuria and/or bacteriuria suggest bacterial epididymitis or other infection as the underlying cause. Color Doppler ultrasound should be performed to rule out testicular torsion in equivocal cases. Ultrasound can quickly detect blood flow and soft tissue abnormalities, helping to differentiate benign and pathologic causes of scrotal pain.

DIFFERENTIAL DIAGNOSIS The most common causes of acute scrotal pain in adults are testicular torsion and epididymitis. Other conditions that may result in acute scrotal pathology include Fourniers gangrene (necrotizing fasciitis of the perineum), torsion of the appendix testis, trauma/surgery, testicular cancer, inguinal hernia, Henoch-Schnlein purpura, mumps, and referred pain. Testicular torsion Testicular torsion is a urologic emergency that is more common in neonates and postpubertal boys, although it can occur at any age [2]. In one retrospective chart review, 17 of 44 cases (39 percent) of testicular torsion presenting to the hospital occurred in men ages 21 and older [3]. The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent [2,4-7]. Testicular torsion in children is discussed separately. (See "Causes of scrotal pain in children and adolescents", section on 'Testicular torsion'.) Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis. If fixation of the lower pole of the testis to the tunica vaginalis is insufficiently broad-based or absent, the testis may torse (twist) on the spermatic cord, potentially producing ischemia from reduced arterial inflow and venous outflow obstruction (figure 3). Testicular torsion may occur after an inciting event (eg, trauma) or spontaneously. It is generally felt that the testis suffers irreversible damage after 12 hours of ischemia due to testicular torsion [8,9]. Infertility may result, even with a normal contralateral testis, because the disruption of the immunologic "blood-testis" barrier may expose antigens from germ cells and sperm to the general circulation and lead to the development of anti-sperm antibodies [10]. Clinical features and diagnosis The diagnosis of testicular torsion is usually determined by acute onset of severe symptoms and characteristic physical findings, although ultrasound may be needed in equivocal cases. The onset of pain in testicular torsion is usually sudden and often occurs several hours after vigorous physical activity or minor trauma to the testicles [11]. There may be associated nausea

and vomiting. Another typical presentation, particularly in children, is awakening with scrotal pain in the middle of the night or in the morning, likely related to cremasteric contraction with nocturnal sexual stimulation during the rapid eye movement (REM) sleep cycle. The patient should be asked about prior similar episodes that might suggest intermittent testicular torsion. The classic finding on physical examination is an asymmetrically high-riding testis on the affected side with the long axis of the testis oriented transversely instead of longitudinally secondary to shortening of the spermatic cord from the torsion, also called the bell clapper deformity ( figure 4). Profound testicular swelling may occur early in the course of torsion, while a reactive hydrocele and overlying erythema of the scrotal wall may be a later sign (12 to 24 hours). In the early stages, an experienced examiner can often differentiate the swollen, exquisitely tender testis from a softer, less tender epididymis posteriorly. It is frequently possible to detorse a testis during examination by gentle rotation away from the midline. Relief of pain with detorsion indicates likely testicular torsion. (See 'Manual detorsion' below.) The cremasteric reflex should be assessed by stroking or gently pinching the skin of the upper thigh while observing the ipsilateral testis. A normal response is cremasteric contraction with elevation of the testis. The reflex is usually absent in patients with testicular torsion (table 1). This helps distinguish testicular torsion from epididymitis and other causes of scrotal pain, in which the reflex is typically intact [1]. If the etiology of an acute scrotal process is equivocal after history and physical examination, color Doppler ultrasonography is the diagnostic test of choice to differentiate testicular torsion from other causes, including epididymitis. In a study of 56 patients who underwent surgical exploration for acute scrotal pain and had Doppler ultrasound examinations performed preoperatively [4], none of the 22 patients who had testicular torsion at surgical exploration had a detectable Doppler signal over the affected side (sensitivity 100 percent). In contrast, normal testicular blood flow and cordcompression tests were demonstrated clearly in 33 of 34 patients who did not have testicular torsion (specificity 97 percent). In another report, color Doppler ultrasonography had a sensitivity and specificity of 82 and 100 percent, respectively, for the diagnosis of testicular torsion [12]. Subsequent studies confirm the high sensitivity and specificity of ultrasound in the diagnosis of testicular torsion, although results may vary based on individual ultrasound technique [13,14]. If there is no immediate access to ultrasound, or if ultrasound does not exclude testicular torsion, then surgical exploration is required [15]. In addition, lack of immediate access to scrotal ultrasound should not delay surgical exploration. Patients suspected of having testicular torsion should be sent immediately to a urologist or to an emergency room for surgical evaluation. Treatment Treatment for suspected testicular torsion is immediate surgical exploration with intraoperative detorsion and fixation of the testes. Delay in detorsion of a few hours may lead to progressively higher rates of nonviability of the testis. Manual detorsion is performed if surgical intervention is not immediately available. Surgery Detorsion and fixation of both the involved testis and the contralateral uninvolved testis should be done since inadequate gubernacular fixation is usually a bilateral defect. Longer periods of ischemia (>12 hours) may cause infarction of the testis with liquefaction requiring orchiectomy. The outcome of surgery may be better in children than in adults. In one retrospective study, the testicular salvage rates of patients age <21 years and age 21 years were 70 and 41 percent, respectively [3]. While the time to presentation was the most important factor affecting the salvage

rate, adult men also had a greater degree of cord twisting than the younger group, which may partly explain the difference in outcomes. Manual detorsion If surgery is not immediately available (within two hours), it is reasonable to attempt to manually detorse the testicle [16]. However, manual detorsion should not delay surgery. The classic teaching is that the testis usually rotates medially during torsion and can be detorsed by rotating it outward toward the thigh. However, in a retrospective analysis of 200 consecutive males age 18 months to 20 years who underwent surgical exploration for testicular torsion, lateral rotation was present in one-third of cases [17]. The degree of twisting of the testis may range from 180 to 720 degrees, requiring multiple rounds of detorsion. Successful detorsion is suggested by [18]: Relief of pain Resolution of the transverse lie of the testis to a longitudinal orientation Lower position of the testis in the scrotum Return of normal arterial pulsations detected with a color Doppler study

Surgical exploration is necessary even after clinically successful manual detorsion because orchiopexy (securing the testicle to the scrotal wall) must be performed to prevent recurrence, and residual torsion may be present that can be further relieved [17]. Epididymitis Epididymitis is the most common cause of scrotal pain in adults in the outpatient setting, accounting for 600,000 cases per year in the United States [19]. More advanced cases often present with testicular swelling and pain (epididymo-orchitis). As the evaluation and management of epididymo-orchitis is similar to that of epididymitis [20,21], we will refer to epididymitis in this section and discuss epididymo-orchitis only for specific differences. Epididymitis is most commonly infectious in etiology, but can also be due to noninfectious causes (eg, trauma, autoimmune disease) [22]. Infectious Infectious epididymitis can present as an acute (<6 weeks) or chronic (6 weeks) condition. Several different bacterial pathogens can lead to infectious epididymitis, particularly those that are sexually transmitted diseases. Acute bacterial epididymitis can cause serious illness in rare cases. This is characterized by severe swelling and exquisite pain of surrounding structures, often accompanied by high fever, rigors, and irritative voiding symptoms (frequency, urgency, dysuria) secondary to an associated urinary tract infection. Urinary symptoms are also commonly seen in conjunction with acute prostatitis (epididymo-prostatitis), particularly in older men who may have underlying prostatic obstruction or have undergone recent urologic instrumentation. A chronic presentation of infectious epididymitis is more typical, with an otherwise healthy male complaining of scrotal pain. Several factors may predispose post-pubertal boys and men to develop chronic epididymitis, including sexual activity, heavy physical exertion, and bicycle or motorcycle riding. Complaints of irritative voiding symptoms are usually lacking. Patients who present with recurrent epididymitis should be evaluated for a structural abnormality of the urinary tract [23,24]. Chlamydia trachomatis and Neisseria gonorrhoeae are the most common organisms responsible for bacterial epididymitis in men under the age of 35 [22,25,26]. Sexually transmitted organisms are less likely to be the cause of epididymitis in older men, Escherichia. coli, other coliforms, and

Pseudomonas species are more common. Men who engage in anal insertive intercourse are also at increased risk for epididymitis due to exposure to coliform bacteria in the rectum. Other less common organisms that can cause epididymitis include Ureaplasma species, Mycobacterium tuberculosis, and Brucella species; in patients with HIV infection, Cytomegalovirus and Cryptococcus can also cause epididymitis. (See "Genital Chlamydia trachomatis infections in men", section on 'Epididymitis' and "Epidemiology, pathogenesis, and clinical manifestations of Neisseria gonorrhoeae infection", section on 'Epididymitis'.) Clinical features and diagnosis Diagnosis of infectious epididymitis is generally made based on physical examination findings and may be confirmed with urine studies. In acute infectious epididymitis, palpation reveals induration and swelling of the involved epididymis with exquisite tenderness. More advanced cases often present with testicular swelling and pain (epididymo-orchitis) with scrotal wall erythema and a reactive hydrocele. In cases where severe testicular pain is present, testicular torsion and Fourniers gangrene must be considered in the differential diagnosis (see 'Testicular torsion' above and 'Fournier's gangrene' below). Rarely, patients may present with concomitant prostatic pain and tenderness (epididymo-prostatitis). (See "Acute and chronic bacterial prostatitis".) The physical examination of chronic epididymitis shows more subtle degrees of epididymal induration and tenderness, with or without swelling. Sometimes an inflammatory nodule is felt with an otherwise soft, nontender epididymis. A urinalysis and urine culture should be performed in all patients suspected of epididymitis, although urine studies are often negative in patients without urinary complaints [8]. A urethral swab should be obtained in patients with urethral discharge and sent for culture and nucleic acid amplification testing for chlamydia and gonorrhea. Ultrasound should be performed in patients with acute onset of testicular pain to assess for testicular torsion. Surgical exploration should be performed to rule out testicular torsion in equivocal cases. (See 'Testicular torsion' above.) Treatment Treatment varies according to the severity of the case at presentation and the likely organisms involved [19]. Patients with severe epididymitis and testicular pain should be evaluated by a urologist to determine the need for surgical exploration [21]. Acutely febrile patients with sepsis often require hospitalization for intravenous hydration and parenteral antibiotics. Ice, scrotal elevation, and nonsteroidal antiinflammatory drugs (NSAIDs) are helpful adjuncts. Less severe cases can be treated on an outpatient basis with oral antibiotics, ice, and scrotal elevation. (See "Sepsis and the systemic inflammatory response syndrome: Definitions, epidemiology, and prognosis".) Well-designed randomized trials and observational studies are not available to help direct choice of antibiotic therapy. While awaiting culture results, we recommend the following treatment regimen for infectious epididymitis, based on the US Centers for Disease Control and Prevention (CDC) guidelines [20,27]: All men should be empirically treated with regimens that cover C. trachomatis and N. gonorrhoeae. The first-line treatment regimen includes ceftriaxone (250 mg intramuscular injection in one dose) plus doxycycline (100 mg by mouth twice a day for ten days). Quinolones alone are no longer recommended for the treatment of epididymitis if N. gonorrhoeae is suspected (eg, in patients with acute urethritis or proctitis, high risk for sexually transmitted disease), due to increasing resistance of N. gonorrhoeae to these

agents. (See "Epidemiology, pathogenesis, and clinical manifestations of Neisseria gonorrhoeae infection", section on 'Clinical manifestations in men'.) Men age 35 years and men who practice insertive anal intercourse should be treated with ceftriaxone along with a fluoroquinolone that covers enteric organisms, such as ofloxacin (300 mg by mouth twice a day for ten days) or levofloxacin (500 mg by mouth once daily for ten days). Fluoroquinolones may be given alone if there is a negative urethral culture or nucleic acid amplification test for N. gonorrhoeae.

Patients with bacterial epididymitis treated with antibiotics should improve within two or three days. If no improvement is noted, other causes of scrotal pain and referral to a urologist should be considered. Patients who have epididymitis due to culture-proven C. trachomatis or N. gonorrhoeae should also be instructed to refer their sex partners for evaluation and treatment. Noninfectious Noninfectious epididymitis is generally a chronic condition. It can be precipitated by trauma, autoimmune disease, or vasculitis. However, no etiology is found in many cases. Idiopathic noninfectious epididymitis is thought to occur due to reflux of urine through the ejaculatory ducts and vas deferens into the epididymis, producing a "chemical" inflammation with resultant swelling, causing ductal obstruction. Idiopathic noninfectious epididymitis can occur, however, even in men who have had a previous vasectomy. Typical inciting factors include prolonged periods of sitting (eg, long plane or car travel, sedentary desk jobs) or vigorous exercise (eg, heavy lifting). Unlike patients with infectious epididymitis, patients with noninfectious epididymitis have less epididymal inflammation (pain, swelling). The diagnosis is usually made after the exclusion of other etiologies, particularly infectious epididymitis. No further evaluation is necessary for noninfectious epididymitis. Treatment of noninfectious epididymitis is conservative, including scrotal elevation, rest from athletic activity, warm baths, and NSAIDs. Orchitis With the exception of mumps orchitis, isolated orchitis without epididymitis is very uncommon in adults and so epididymo-orchitis should be the primary diagnosis to consider when an adult appears to have orchitis. (See 'Epididymitis' above.) However, in non-immune adults, viruses similar to those seen in children can rarely cause orchitis. (See "Causes of scrotal pain in children and adolescents", section on 'Orchitis'.) Fournier's gangrene Fourniers gangrene is a necrotizing fasciitis of the perineum caused by a mixed infection with aerobic/anaerobic bacteria, which often involves the scrotum. (See "Necrotizing soft tissue infections".) Clinical features and diagnosis Fourniers gangrene is characterized by severe pain that generally starts on the anterior abdominal wall, migrates into the gluteal muscles and onto the scrotum and penis (picture 1). A number of clinical features may indicate a necrotizing infection, such as tense edema outside the involved skin, blisters/bullae, crepitus, and subcutaneous gas, as well as systemic findings, such as fever, tachycardia, and hypotension. CT and MRI may be helpful in showing air along the fascial planes or deeper tissue involvement. However, imaging studies should not delay surgical therapy when there is evidence clinically of progressive soft tissue infection. (See "Necrotizing soft tissue infections", section on 'Clinical manifestations'.)

Treatment Treatment of necrotizing fasciitis consists of early and aggressive surgical exploration and debridement of necrotic tissue, antibiotic therapy, and hemodynamic support as needed. Antibiotic therapy alone is usually associated with a 100 percent mortality rate, highlighting the need for surgical debridement. Patients with Fourniers gangrene may require cystostomy, colostomy, or orchiectomy. (See "Necrotizing soft tissue infections", section on 'Treatment'.) Other causes Torsion of the appendix testis Most cases of torsion of the appendix testis occur between the ages of 7 and 14 years, with a mean age of 10.6 years [28]. It is the leading cause of acute scrotal pathology in childhood. Torsion of the appendix testis rarely occurs in adults [29]. (See "Causes of scrotal pain in children and adolescents", section on 'Torsion of the appendix testis or appendix epididymis'.) The onset of testicular pain from torsion of the appendix testis is usually more gradual than with testicular torsion. It is not uncommon for patients to have several days of scrotal discomfort before they present for evaluation. Pain ranges widely from mild to severe. On physical examination, a reactive hydrocele is usually present that may transilluminate, and tenderness can often be localized to the exact location of the appendix testis on the anterosuperior testis. Careful inspection of the scrotal wall at this location may detect the classic "blue dot" sign (picture 2), caused by infarction and necrosis of the appendix testis [30]. It is typically possible to discriminate the tender appendix testis from a normal, non-swollen testis and epididymis that are not appreciably tender. If the diagnosis is unclear after the physical examination, a testicular ultrasound can be performed that will show the torsed appendage as a lesion of low echogenicity with a central hypoechogenic area. Color Doppler reveals normal blood flow to the testis with an occasional increase on the affected side, possibly due to inflammation. Management of acute torsion of the appendix testis usually includes conservative treatment, which includes rest, ice, and NSAIDs. Recovery is generally slow with this approach, and pain may last for several weeks to months. Surgical excision of the appendix testis is reserved for patients who have persistent pain. Trauma It is common for men to suffer minor episodes of scrotal trauma. However, only rarely does trauma result in severe testicular injury, usually due to compression of the testis against the pubic bones from a direct blow or straddle injury. The spectrum of traumatic complications can range from a hematocele (blood within the tunica vaginalis) to infection with pyocele (pus within the tunica vaginalis) to testicular rupture. Color Doppler ultrasonography can accurately diagnose the extent of injury. Testicular rupture requires surgical repair. Lesser injuries are managed according to the clinical severity and often can be treated conservatively. Post-vasectomy Patients who have had a vasectomy may develop asymptomatic firmness in the entire epididymis secondary to ductal obstruction. Some men will develop a painful nodule at the site of division of the vas deferens on the testicular side. The nodule is a sperm granuloma that forms because of leakage of sperm from the lumen of the vas deferens, creating an immunologic response to the "foreign" protein, which was previously sequestered from immune surveillance by the blood-testis barrier. Treatment is initially conservative with NSAIDs and scrotal elevation. Rarely, patients who have intractable pain may require surgical excision of the granuloma. Testicular cancer While most testicular tumors present as painless nodules or masses, rapidly growing germ cell tumors may cause acute scrotal pain secondary to hemorrhage and infarction. A

mass is generally palpable, and ultrasound is usually sufficient to make a diagnosis of testicular cancer. (See "Evaluation of nonacute scrotal pathology in adult men", section on 'Testicular cancer'.) Inguinal hernia Herniation of bowel or omentum through the spermatic cord into the scrotum can present with pain and a scrotal mass. A strangulated hernia may present with severe pain (picture 3). Pain with inguinal hernias is most likely to be localized in the groin or abdomen rather than the scrotum. On examination, bowel sounds may be audible in the scrotum with herniated bowel. Herniography, ultrasound, or MRI help to differentiate the precise nature of intrascrotal masses. Management of inguinal hernias involves watchful waiting versus surgical correction. (See "Classification, clinical features and diagnosis of inguinal and femoral hernias in adults" and "Overview of treatment for inguinal and femoral hernias".) Henoch-Schnlein purpura Henoch-Schnlein purpura is a systemic vasculitis characterized by nonthrombocytopenic purpura, arthralgia, renal disease, abdominal pain, gastrointestinal bleeding, and occasionally scrotal pain. Scrotal pain can be the presenting symptom, and onset may be acute or insidious. The diagnosis is usually made clinically, but ultrasound may need to be performed to distinguish Henoch-Schnlein purpura from testicular torsion. Treatment is supportive. (See "Clinical manifestations and diagnosis of Henoch-Schnlein purpura" and "Management of Henoch-Schnlein purpura".) Mumps Mumps is an acute, self-limited, viral syndrome characterized by malaise, headache, myalgias, anorexia, and parotid swelling. Epididymo-orchitis is the most common complication of mumps infection in the adult male, with most patients having fever and parotitis preceding the onset of orchitis. Patients often report severe testicular pain, and swelling and erythema of the scrotum (picture 4); bilateral involvement is noted in up to 30 percent of cases. Patients with epididymoorchitis are treated symptomatically with ice packs, scrotal elevation, and NSAIDs. (See "Epidemiology, clinical manifestations, diagnosis and management of mumps", section on 'Orchitis'.) Referred pain Men who have the acute onset of scrotal pain without local inflammatory signs or a scrotal mass on examination may be suffering from referred pain to the scrotum. The diseases that may cause referred scrotal pain are diverse, reflecting the anatomy of the three somatic nerves that travel to the scrotum: the genitofemoral, ilioinguinal, and posterior scrotal nerves [31]. Causes of referred pain include abdominal aortic aneurysm, urolithiasis, lower lumbar or sacral nerve root impingement, retrocecal appendicitis, retroperitoneal tumor, and postherniorrhaphy pain. Acute idiopathic scrotal edema Some men develop significant scrotal/penile edema of unknown etiology, usually without pain [32,33]. The condition has been more frequently reported in children, but also occurs in adults [33]. This condition should be differentiated from anasarca (generalized edema), in which excess extracellular fluid can collect in the loose scrotal sac. (See "Clinical manifestations and diagnosis of edema in adults".) In men with acute idiopathic scrotal edema, ultrasonography should be performed to assess for underlying testicular abnormalities. Ultrasound typically shows thickening of the subcutaneous scrotal tissue without other lesions or masses [32]. There is no treatment for idiopathic scrotal edema except scrotal elevation. Symptoms typically resolve spontaneously within 48 hours [32]. INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond the Basics. The Basics patient education pieces are written in plain language, th th at the 5 to 6 grade reading level, and they answer the four or five key questions a patient might

have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, th th more sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of interest.) Basics topics (see "Patient information: Epididymitis (The Basics)")

SUMMARY AND RECOMMENDATIONS The most common causes of acute scrotal pain in adults primarily include testicular torsion and epididymitis. Other causes include Fourniers gangrene (necrotizing fasciitis of the perineum), torsion of the appendix testis, trauma/surgery, testicular cancer, inguinal hernia, Henoch-Schnlein purpura, mumps, and referred pain. (See 'Differential diagnosis' above.) The most important objective in the evaluation of acute scrotal pain is to identify any urologic emergency, which requires immediate surgical intervention. The most common urologic emergencies presenting in adults with acute scrotal pain include testicular torsion, severe infectious epididymitis, and Fourniers gangrene. Evaluation of acute scrotal pain includes the history, physical examination, Doppler ultrasound, and urine studies. Certain signs and symptoms are particularly helpful in determining the etiology of acute scrotal pain (table 1). (See 'Evaluation' above.) Testicular torsion generally presents with the abrupt onset of severe testicular pain. The testis may lie transversely in the scrotum and be retracted (figure 3), and the cremasteric reflex is typically absent. Doppler ultrasound of the scrotum is a useful adjunct in equivocal cases but should not delay surgical exploration in cases of suspected testicular torsion. Immediate detorsion is required to maintain viability of the testis. In patients suspected with testicular torsion, we recommend immediate surgical exploration rather than manual detorsion (Grade 1B). If surgical treatment is not immediately available, manual detorsion should be performed. Surgical exploration is necessary even after clinically successful manual detorsion because orchiopexy (securing the testicle to the scrotal wall) must be performed to prevent recurrence, and residual torsion may be present that can be further relieved. (See 'Testicular torsion' above.) Infectious epididymitis can be characterized as acute (<6 weeks) or chronic (6 weeks). Acute bacterial epididymitis can rarely cause serious illness. This is characterized by severe epididymal swelling, pain, and tenderness, often with high fever, rigors, and irritative voiding symptoms. In cases where severe testicular pain is present, the patient should be referred to a urologist. (See 'Epididymitis' above.) Management of infectious epididymitis includes ice, scrotal elevation, and NSAIDs. In addition, oral antibiotics should be administered (see 'Infectious' above): In all patients with infectious epididymitis, we suggest ceftriaxone (250 mg intramuscular injection in one dose) plus doxycycline (100 mg by mouth twice a day for 10 days) (Grade 2C).

For men age 35 years and in men who practice insertive anal intercourse, we suggest ofloxacin (300 mg by mouth twice a day for 10 days) or levofloxacin (500 mg by mouth once daily for 10 days), in addition to ceftriaxone (Grade 2C). Fluoroquinolones may be given alone if there is a negative gonococcal culture or nucleic acid amplification test.

In patients with noninfectious epididymitis, treatment is conservative, including scrotal elevation, rest, and NSAIDs. (See 'Noninfectious' above.) Fourniers gangrene (necrotizing fasciitis of the perineum) is characterized by severe pain that generally starts on the anterior abdominal wall, migrating into the gluteal muscles and onto the scrotum and penis (picture 1). Pain is accompanied by edema outside the involved skin, blisters/bullae, crepitus, as well as systemic findings, such as fever, tachycardia, and hypotension. Treatment of necrotizing fasciitis consists of early and aggressive surgical debridement, antibiotic therapy, and hemodynamic support as needed. (See "Necrotizing soft tissue infections".) Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES

1. Rabinowitz R. The importance of the cremasteric reflex in acute scrotal swelling in children. J Urol 1984; 132:89. 2. Molokwu CN, Somani BK, Goodman CM. Outcomes of scrotal exploration for acute scrotal pain suspicious of testicular torsion: a consecutive case series of 173 patients. BJU Int 2011; 107:990. 3. Cummings JM, Boullier JA, Sekhon D, Bose K. Adult testicular torsion. J Urol 2002; 167:2109. 4. al Mufti RA, Ogedegbe AK, Lafferty K. The use of Doppler ultrasound in the clinical management of acute testicular pain. Br J Urol 1995; 76:625. 5. Watkin NA, Reiger NA, Moisey CU. Is the conservative management of the acute scrotum justified on clinical grounds? Br J Urol 1996; 78:623. 6. Tajchner L, Larkin JO, Bourke MG, et al. Management of the acute scrotum in a district general hospital: 10-year experience. ScientificWorldJournal 2009; 9:281. 7. Hegarty PK, Walsh E, Corcoran MO. Exploration of the acute scrotum: a retrospective analysis of 100 consecutive cases. Ir J Med Sci 2001; 170:181. 8. Wampler SM, Llanes M. Common scrotal and testicular problems. Prim Care 2010; 37:613. 9. Dunne PJ, O'Loughlin BS. Testicular torsion: time is the enemy. Aust N Z J Surg 2000; 70:441. 10. Jarow JP, Sanzone JJ. Risk factors for male partner antisperm antibodies. J Urol 1992; 148:1805. 11. Schmitz D, Safranek S. Clinical inquiries. How useful is a physical exam in diagnosing testicular torsion? J Fam Pract 2009; 58:433. 12. Wilbert DM, Schaerfe CW, Stern WD, et al. Evaluation of the acute scrotum by color-coded Doppler ultrasonography. J Urol 1993; 149:1475. 13. Kapasi Z, Halliday S. Best evidence topic report. Ultrasound in the diagnosis of testicular torsion. Emerg Med J 2005; 22:559. 14. Pepe P, Panella P, Pennisi M, Aragona F. Does color Doppler sonography improve the clinical assessment of patients with acute scrotum? Eur J Radiol 2006; 60:120. 15. Liguori G, Bucci S, Zordani A, et al. Role of US in acute scrotal pain. World J Urol 2011; 29:639. 16. Cornel EB, Karthaus HF. Manual derotation of the twisted spermatic cord. BJU Int 1999; 83:672. 17. Sessions AE, Rabinowitz R, Hulbert WC, et al. Testicular torsion: direction, degree, duration and disinformation. J Urol 2003; 169:663. 18. Perron CE. Pain--Scrotal. In: Textbook of Pediatric Emergency Medicine, 4th ed, Fleisher GR, Ludwig S (Eds), Lippincott, Williams & Wilkins, Philadelphia 2000. p.473. 19. Trojian TH, Lishnak TS, Heiman D. Epididymitis and orchitis: an overview. Am Fam Physician 2009; 79:583.

20. Workowski KA, Berman S, Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010; 59:1. 21. Stewart A, Ubee SS, Davies H. Epididymo-orchitis. BMJ 2011; 342:d1543. 22. Tracy CR, Steers WD, Costabile R. Diagnosis and management of epididymitis. Urol Clin North Am 2008; 35:101. 23. Lewis AG, Bukowski TP, Jarvis PD, et al. Evaluation of acute scrotum in the emergency department. J Pediatr Surg 1995; 30:277. 24. Siegel A, Snyder H, Duckett JW. Epididymitis in infants and boys: underlying urogenital anomalies and efficacy of imaging modalities. J Urol 1987; 138:1100. 25. Doble A, Taylor-Robinson D, Thomas BJ, et al. Acute epididymitis: a microbiological and ultrasonographic study. Br J Urol 1989; 63:90. 26. Hawkins DA, Taylor-Robinson D, Thomas BJ, Harris JR. Microbiological survey of acute epididymitis. Genitourin Med 1986; 62:342. 27. Updated recommended treatment regimens for gonococcal infections and associated conditions -United States, April 2007. Available at: http://www.cdc.gov/std/treatment/2010/epididymitis.htm (Accessed on June 06, 2011). 28. Fisher R, Walker J. The acute paediatric scrotum. Br J Hosp Med 1994; 51:290. 29. Palestro CJ, Manor EP, Kim CK, Goldsmith SJ. Torsion of a testicular appendage in an adult male. Clin Nucl Med 1990; 15:515. 30. Ringdahl E, Teague L. Testicular torsion. Am Fam Physician 2006; 74:1739. 31. McGee SR. Referred scrotal pain: case reports and review. J Gen Intern Med 1993; 8:694. 32. Shah J, Qureshi I, Ellis BW. Acute idiopathic scrotal oedema in an adult: a case report. Int J Clin Pract 2004; 58:1168. 33. Ooi DG, Chua MT, Tan LG. A case of adult acute idiopathic scrotal edema. Nat Rev Urol 2009; 6:331. Topic 6873 Version 9.0

GRAPHICS

Normal testicular anatomy

The testicle is vertical and its anterior portion is surrounded by the tunica vaginalis.

Anatomy of the testicular appendages

Distinguishing conditions responsible for acute scrotal pain in adults

Pain location
Testis Epidiymis Diffuse Upper pole of testis

et

Cremasteric reflex
Negative Positive Positive Positive

Other clinical fin

High riding testis, bell-clapper deformity, profound testicular swelling Epididymal induration and tenderness, positive urinalysis or culture

Tense edema outside of involved skin, blisters/bullae, crepitus, fever, rigors, h Blue dot sign, tenderness over anterosuperior testis

Torsion of spermatic cord

Abnormality of testicular fixation permits torsion of spermatic vessels with subsequent infarction of the gonad

Causes of scrotal pain in children and adolescents Authors Joel S Brenner, MD, MPH Aderonke Ojo, MD Section Editors Amy B Middleman, MD, MPH, MS Ed Gary R Fleisher, MD Laurence S Baskin, MD, FAAP Deputy Editor James F Wiley, II, MD, MPH Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Dec 2012. | This topic last updated: jun 14, 2012. INTRODUCTION The spectrum of conditions that affect the scrotum and its contents ranges from incidental findings to pathologic events that require expeditious diagnosis and treatment (eg, testicular torsion, testicular cancer). The most common causes of acute scrotal pain in children and adolescents include testicular torsion, torsion of the appendix testis, and epididymitis. In one review of 238 consecutive boys, ages 0 to 19 years, who presented with acute scrotal pain to a children's hospital over a two-year period, 16 percent had testicular torsion, 46 percent had torsion of the appendix testis, and 35 percent had epididymitis [1]. The causes of scrotal pain will be reviewed here. The evaluation scrotal pain or swelling and causes of scrotal swelling are discussed separately. (See "Evaluation of scrotal pain or swelling in children and adolescents" and "Causes of painless scrotal swelling in children and adolescents".) TESTICULAR TORSION Testicular torsion is the most dramatic and potentially serious of the acute processes affecting the scrotal contents because it may result in the loss of the testicle. Normal testicular anatomy is depicted in the figure (figure 1). Intravaginal torsion results from inadequate fixation of the testis to the tunica vaginalis through the gubernaculum testis. The most common abnormality associated with testicular torsion is known as the "bell clapper" deformity: the testicle lacks the normal attachment to the tunica vaginalis (permitting increased mobility) and rests transverse within the scrotum (figure 2) [2]. The bell clapper deformity may be bilateral and predisposes to testicular torsion. If fixation of the lower pole of the testis to the tunica vaginalis is insufficiently broad-based or absent, the testis may torse (twist) on the spermatic cord (figure 3). The twisting of the spermatic cord within the tunica vaginalis causes venous compression and subsequent edema of the testicle and cord with ultimate ischemia of the testicle caused by arterial occlusion [2,3]. Neonatal testicular torsion, which is extravaginal, is discussed separately. (See "Neonatal testicular torsion".)

Testicular torsion has two peak incidences: a small one in the neonatal period and a large one during puberty, but it can occur at any age. The incidence is estimated to be 1 in 4000 in males younger than 25 years old [4]. Approximately 65 percent of cases occur in boys between the ages of 12 and 18 years [5,6]. The increased incidence during adolescence is thought to be secondary to the increasing weight of the testes during pubertal development [7]. Clinical presentation Patients classically present with an abrupt onset of severe testicular or scrotal pain, usually of less than 12 hours' duration [2,8,9]; however, inguinal or lower abdominal pain may be the presenting complaint [10]. Nearly 90 percent of patients may have associated nausea and vomiting [11,12]. The pain can be isolated to the scrotum or may radiate to the lower abdomen [5,7]. The pain is constant unless the testicle is torsing and detorsing. A typical presentation, particularly in children, is for the patient to awaken with scrotal pain in the middle of the night or in the morning. Many boys report a previous episode of pain [2,5,7,13]. However, one study reported only 8 percent of the patients with torsion had a history of pain in the past [8]. On physical examination, the scrotum may be edematous, indurated and erythematous and the affected testis usually is tender, swollen, and slightly elevated because of shortening of the cord from twisting. The testis may be lying horizontally, displacing the epididymis from its normal posterolateral position. A reactive hydrocele may also be present. The cremasteric reflex (elevation of the testis in response to stroking of the upper inner thigh) is absent in nearly all cases of torsion, but it also may be absent in boys without torsion, particularly if they are younger than six months [8,9,14-17]. Prehn reported that elevation of the scrotal contents relieves the pain in patients with epididymitis and aggravates or has no effect on the pain in patients with testicular torsion [5]. However, Prehn sign is not a reliable distinguishing feature between torsion and other diagnoses [5,13,18]. Intermittent torsion Intermittent testicular torsion, characterized by acute and intermittent sharp testicular pain and scrotal swelling, with rapid resolution (within seconds to a few minutes) and long intervals without symptoms, should be considered in all boys with a history of such scrotal pain and swelling without other identifiable causes [19,20]. In one review of 50 patients with intermittent testicular torsion, 26 percent reported nausea or vomiting, and 21 percent reported that the pain awakened them from sleep [20]. Physical findings of intermittent testicular torsion may include horizontal or very mobile testes, anterior epididymis, or bulkiness of the spermatic cord from partial twisting [19,20]. These findings are usually present to varying degrees on physical examination. However, the clinical and radiographic evaluations of some boys with intermittent torsion may be normal, highlighting the importance of immediate followup for recurrent or worsening pain. Boys with intermittent complaints and normal evaluation at the time of presentation should have a follow-up evaluation within seven days unless pain recurs sooner. Unfortunately, intermittent testicular torsion most often leaves no clinical trace, but on those occasions when intermittent testicular torsion is suspected, consultation with or referral to urology is recommended. Diagnosis The diagnosis of testicular torsion can be made clinically, as described above. One study found that the absence of ipsilateral cremasteric reflex, skin changes and the presence of nausea and or vomiting are most consistently predictive of torsion [21]. Radiologic evaluation (a color Doppler ultrasound or nuclear scan of the scrotum) should be undertaken if the certainty of the diagnosis is in question and the performance of imaging studies will not significantly delay

treatment. Demonstration of decreased testicular perfusion with either of these scans is consistent with testicular torsion. Decreased testicular perfusion also can be seen in some patients with a large hydrocele, abscess, hematoma, or scrotal hernia [12]. Negative scans (ie, normal or increased testicular flow) may occur rarely [9,19], usually with spontaneous detorsion and partial or intermittent torsion [19]. The Doppler ultrasound can discern testicular and epididymal size, scrotal fluid, scrotal wall thickening, enlarged appendix testis, and arterial flow in the testis and epididymis. The reported sensitivity and specificity of Doppler ultrasound in the detection of testicular torsion range from 69 to 100 percent and 77 to 100 percent, respectively [8,22-27]. The usefulness of Doppler ultrasound is limited in small prepubertal testes with lower blood flow. The nuclear scan measures testicular perfusion. The reported sensitivity and specificity of scintigraphy are 100 percent and 97 percent, respectively [23,27]. Management The diagnosis of testicular torsion, whether clinically or radiographically made, requires immediate consultation with an urologist (table 1). The treatment for a torsed testicle that remains viable involves surgical detorsion and fixation (orchiopexy) of both testes. Orchiectomy is performed if the testicle is nonviable. The viability of a torsed testicle is dependent upon the duration and completeness of torsion. Typical rates of viability according to duration of torsion have been described as follows [5,7,13]: Detorsion within 4 to 6 hours 100 percent viability Detorsion after 12 hours 20 percent viability Detorsion after 24 hours 0 percent viability

Surgery never should be delayed on the assumption of nonviability based on a clinical estimate of duration of torsion. Some patients with a prolonged period of symptoms may have had intermittent torsion or a partial torsion and testicles that are salvageable. The contralateral hemiscrotum typically is explored during surgery because the bell clapper deformity usually is bilateral. Exploration permits fixation of the contralateral testis to prevent future torsion [2,5,13,28]. Some authors report decreased fertility after unilateral testicular torsion when the testis is left in situ [29-32], possibly because of immune-mediated damage to the contralateral testis [31,33,34]. However, no evidence of decreased fertility or anti-sperm antibodies was found in one study of prepubertal boys with testicular torsion [35], and the fertility issue remains controversial. Manual detorsion Manual detorsion of the torsed testicle may be considered if the child presents before scrotal swelling develops [12,36,37]. Unless there are extenuating circumstances (ie, definitive care is hours away), the procedure should typically be performed by clinicians experienced in the technique, and only after appropriate sedation and analgesia have been administered [12]. (See "Procedural sedation in children outside of the operating room".) The classic teaching is that the testis usually rotates medially and is detorsed by rotating it outward toward the thigh. However, in a retrospective analysis of 200 consecutive boys aged 18 months to 20 years who underwent surgical exploration for testicular torsion, lateral rotation was present in one-third of cases [38].

Successful detorsion is suggested by relief of pain, lower position of the testis in the scrotum, and return of normal arterial pulsations detected with a Doppler stethoscope [12]. Surgical exploration is necessary even after clinically successful manual detorsion because orchiopexy must be performed to prevent an additional episode [38]. Neonatal testicular torsion Neonatal testicular torsion is discussed separately. (See "Neonatal testicular torsion".) TORSION OF THE APPENDIX TESTIS OR APPENDIX EPIDIDYMIS The appendix testis is a small vestigial structure on the anterosuperior aspect of the testis (an embryologic remnant of the Mllerian duct system) (figure 4). It measures about 0.3 cm. The appendix epididymis is a vestigial remnant of the Wolffian duct that is located at the head of the epididymis. The pedunculated shape of these appendages predisposes them to torsion, which can produce scrotal pain that ranges from mild to severe. Torsion of the appendix testis or appendix epididymis (figure 4) occurs most commonly in boys between 7 and 12 years of age [39]. Clinical presentation The pain of torsion of the appendix testis or appendix epididymis is of sudden onset, like the pain of testicular torsion. Physical examination of boys with torsion of the appendix testis or epididymis typically demonstrates a nontender testicle and a tender localized mass that is palpable, usually at the superior or inferior pole. The appendix may be gangrenous or black and appears through the scrotum as the "blue dot sign" (picture 1). A normal cremasteric reflex may be present, and a reactive hydrocele may be palpated. Blood flow to the affected testis is normal or increased and can be demonstrated on Doppler ultrasound or nuclear scan [2]. Diagnosis The diagnosis of torsion of the appendix testis or appendix epididymis can be made clinically, as described above. Doppler ultrasound or nuclear scan may be helpful in cases where testicular torsion cannot otherwise be excluded. Testicular ultrasound will show the torsed appendage as a lesion of low echogenicity with a central hypoechogenic area [40]. Color Doppler reveals normal blood flow to the testis with an occasional increase on the affected side, possibly due to inflammation. Doppler may be less accurate in a prepubertal patient because of lower baseline testicular perfusion. Radionuclide imaging denotes a "hot dot" sign at the torsed appendage. However, this finding is unreliable if the symptoms are less than five hours old and will be seen in only 45 percent of patients whose symptoms have lasted 5 to 24 hours [41]. Management The management of a torsed appendix testis or appendix epididymis is supportive, with analgesics, bed rest, and scrotal support to help alleviate swelling (table 1). The pain should resolve in 5 to 10 days. Surgery (removal of the testicular appendix) is reserved for patients who have persistent pain; the contralateral hemiscrotum need not be explored [5,13,42]. EPIDIDYMITIS Inflammation of the epididymis is known as epididymitis (figure 5). Epididymitis occurs more frequently among late adolescents, but also occurs in younger boys who deny sexual activity [7,8,13]. Several factors may predispose postpubertal boys to develop subacute epididymitis, including sexual activity, heavy physical exertion, and direct trauma (eg, bicycle or motorcycle riding). Bacterial epididymitis in prepubertal boys is associated with structural anomalies of the urinary tract [43-45].

Among sexually active males, chlamydia is the most common microbial agent, followed by N. gonorrhea, E. coli, and viruses. Organisms that less commonly cause epididymitis include Ureaplasma, Mycobacterium, and cytomegalovirus, or cryptococcus in patients with HIV infection. Infectious epididymitis in prepubertal boys and adolescents who are not sexually active may be caused by Mycoplasma pneumoniae, enteroviruses, or adenoviruses [46]. Bacterial infection appears to be uncommon in such patients. As an example, an observational study of 97 cases of epididymitis who had urine cultures found that only 4 percent had a bacterial infection and, in patients with positive urine cultures, the organisms isolated frequently were not sensitive to commonly prescribed empiric antibiotics [47]. Clinical presentation Patients with epididymitis may present with acute or subacute onset of pain and swelling isolated to the epididymis [45]. A history of frequency, dysuria, urethral discharge, and/or fever may be present [2,8,12]. On physical examination, the affected testis has a normal vertical lie; the scrotum may be red and parchment-like (although this is an uncommon finding); scrotal edema is present in at least 50 percent of cases [8,10,11]. Sometimes an inflammatory nodule is felt with an otherwise soft, nontender epididymis. In contrast to patients with testicular torsion, patients with epididymitis usually have a normal cremasteric reflex (if they have a one under normal conditions) [2,8]. Patients with epididymitis may experience pain relief with elevation of the testis (Prehn sign), but this is not a reliable marker for epididymitis [5,13,18]. Patients with epididymitis may have leukocytosis and pyuria; however, urinalysis may be normal. Urine culture often is negative. In one retrospective study of patients with acute scrotal pathology, only 15 percent of those with epididymitis had a positive urinalysis (>10 white blood cells per highpower field) [8]. Earlier studies reported positive urinalysis in 24 to 59 percent of patients with epididymitis [44,48]. Diagnosis The diagnosis of epididymitis can be made clinically as described above. However, if the diagnosis is uncertain, Doppler ultrasonography or nuclear scan may be helpful, revealing increased blood flow to the affected epididymis [40,49]. A urinalysis and urine culture should be obtained in all patients with epididymitis. In addition, the Centers for Disease Control (CDC) recommend that providers obtain the following studies in patients who have findings consistent with sexually transmitted epididymitis [50]: Gram-stained smear and culture of urethral exudates or intraurethral swab specimen, or Nucleic acid amplification tests for N. gonorrhea and C. trachomatis, and Urine culture and first void urine for leukocytes Syphilis and HIV testing

Management Treatment varies according to the severity of the case at presentation and suspected etiology (table 1). Treatment for sexually transmitted epididymitis includes antibiotics [50], analgesics, scrotal support, elevation, and bed rest in the acute phase [50]. It is equally important to assure that the sexual partner gets treatment if a sexually transmitted disease is suspected as the etiology. The diagnosis and treatment regimen should be reevaluated if there is no improvement after three days of therapy [50].

The first-line treatment regimen recommended by the CDC when the most likely cause is chlamydia or gonorrhea includes ceftriaxone (250 mg IM in one dose) plus doxycycline (100 mg PO twice a day for 10 days) [50,51]. Quinolones are no longer recommended for the treatment of epididymitis if N. gonorrhoeae is suspected because of increasing resistance of N. gonorrhoeae to these agents. For acute epididymitis most likely caused by enteric organisms or with negative gonococcal culture or nucleic acid amplification test, ofloxacin (300 mg PO twice a day for 10 days) or levofloxacin (500 mg PO once daily for 10 days) may be used [51].

It should be noted that doxycycline is not approved for use in children younger than the age of eight years and that fluoroquinolones are not approved for use in patients younger than 18 years of age when other effective alternatives are available [52]. The treatment of epididymitis in prepubertal boys depends upon whether they have an associated urinary tract infection. Those who have pyuria, positive urine cultures, or underlying risk factors for urinary tract infection should be treated empirically with antibiotics that cover coliforms and achieve adequate levels in epididymal tissues (eg, trimethoprim-sulfamethoxazole, cephalexin) [12]. Additional evaluation of boys with urinary tract infection is discussed separately. (See "Acute management, imaging, and prognosis of urinary tract infections in infants and children older than one month", section on 'Imaging'.) The treatment of nonbacterial epididymitis is supportive and includes scrotal support, rest, NSAIDs, and possibly antibiotics [53]. OTHER CAUSES Trauma It is not uncommon for boys and men to suffer minor episodes of scrotal trauma; only rarely does a severe testicular injury result, usually because of compression of the testis against the pubic bones from a direct blow or straddle injury. The spectrum of injuries can range from a hematocele (hematoma in the tunica vaginalis) to an intratesticular hematoma to disruption of the tunica albuginea causing testicular rupture. Color Doppler ultrasonography can accurately diagnose the extent of injury. Testicular rupture requires surgical repair. Lesser injuries are managed according to the clinical severity and often can be treated nonoperatively. Incarcerated inguinal hernia Herniation of bowel or omentum into the scrotum can present with pain and a scrotal mass (picture 2). Bowel sounds may be audible in the scrotum. (See "Overview of inguinal hernia in children".) Henoch-Schnlein purpura Henoch-Schnlein purpura (HSP) is a systemic vasculitis syndrome characterized by nonthrombocytopenic purpura, arthralgia, renal disease, abdominal pain, gastrointestinal bleeding, and occasionally scrotal pain. In one review of 93 boys with HSP, 22 had scrotal involvement [54]. The onset of scrotal pain may be acute or insidious. In boys who lack other characteristic findings of HSP, sonography can usually distinguish HSP from testicular torsion. Treatment of HSP is supportive. (See "Management of Henoch-Schnlein purpura".) Orchitis Viral (mumps, rubella, coxsackie, echovirus, lymphocytic choriomeningitis virus, parvovirus) and bacterial (brucellosis) infections can cause orchitis in children and adolescents [55]. Clinical manifestations may include scrotal swelling, pain, and tenderness with erythema and shininess of the overlying skin, although the presentation may be more severe. (See appropriate topic reviews).

Patients with orchitis are treated symptomatically with bed rest, nonsteroidal antiinflammatory agents, support of the inflamed testis, and ice packs. (See "Epidemiology, clinical manifestations, diagnosis and management of mumps", section on 'Treatment'.) Referred pain Boys who have the acute onset of scrotal pain without local inflammatory signs or a mass on examination may be suffering from referred pain to the scrotum. The precise incidence of referred pain is unclear. The conditions that may cause referred scrotal pain are diverse, reflecting the anatomy of the three somatic nerves that travel to the scrotum: the genitofemoral, ilioinguinal, and posterior scrotal nerves [56]. Retrocecal appendicitis is an important (albeit uncommon) cause of referred scrotal pain in children and adolescents [57]. Reported causes of referred pain in adults include abdominal aortic aneurysm, urolithiasis, lower lumbar or sacral nerve root impingement, retrocecal appendicitis, retroperitoneal tumor, and postherniorrhaphy pain [56]. (See "Acute appendicitis in children: Clinical manifestations and diagnosis".) Nonspecific scrotal pain Sometimes older boys and young teenagers present with complaints of mild scrotal pain and a completely normal physical examination. These characteristics make testicular torsion and other pathologic conditions highly unlikely. Imaging of such patients is not usually necessary. They should be instructed to return for immediate evaluation if the pain increases in severity or is associated with testicular swelling. INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond the Basics. The Basics patient education pieces are written in plain language, th th at the 5 to 6 grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, th th more sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of interest.) Basics topic (see "Patient information: Epididymitis (The Basics)")

SUMMARY The clinical presentations, diagnosis, and management of the most common causes of testicular or scrotal pain in children and adolescents are described above (table 2 and table 1). The differential diagnosis of acute scrotal pain primarily includes testicular torsion, torsion of the appendix testis, and epididymitis. Testicular torsion generally presents with the abrupt onset of severe pain. The testicle may lie transversely in the scrotum and be retracted; the cremasteric reflex is typically absent. Testicular torsion is an emergency; timely diagnosis and treatment are vital for survival of the testis. At the time of diagnosis it is reasonable to attempt manual detorsion. (See 'Manual detorsion' above.) Torsion of the appendix testis also presents with the abrupt onset of pain, but the pain typically is less severe than in testicular torsion. Pain is localized to the region of the appendix testis (anterosuperior), and a "blue dot" sign may be apparent at the same

location (picture 1). Treatment may be symptomatic, or the appendix testis may be surgically excised. (See 'Torsion of the appendix testis or appendix epididymis' above.) Patients with epididymitis may present with acute or subacute onset of pain and swelling isolated to the epididymis. A history of frequency, dysuria, urethral discharge, and/or fever may be present. The affected testis has a normal vertical lie; scrotal edema often is present. Treatment depends on the severity of illness and the suspected etiology. (See 'Epididymitis' above.) In rare cases, retrocecal appendicitis may cause referred scrotal pain in children and adolescents. In these patients, primary scrotal or testicular pathology will be absent. Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES

1. Lewis AG, Bukowski TP, Jarvis PD, et al. Evaluation of acute scrotum in the emergency department. J Pediatr Surg 1995; 30:277. 2. Kass EJ, Lundak B. The acute scrotum. Pediatr Clin North Am 1997; 44:1251. 3. Tumeh SS, Benson CB, Richie JP. Acute diseases of the scrotum. Semin Ultrasound CT MR 1991; 12:115. 4. Williamson RC. Torsion of the testis and allied conditions. Br J Surg 1976; 63:465. 5. Edelsberg JS, Surh YS. The acute scrotum. Emerg Med Clin North Am 1988; 6:521. 6. Rohn RD. Male genitalia: Examination and findings. In: Comprehensive Adolescent Health Care,, Friedman SB, Fisher M, Schonberg SK, et al. (Eds), Mosby-Year Book, St. Louis 1998. p.1078. 7. Anderson MM, Neinstein LS. Scrotal disorders. In: Adolescent Health Care: A Practical Guide, Neinstein LS. (Ed), Williams & Wilkins, Baltimore 1996. p.464. 8. Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics 1998; 102:73. 9. Karmazyn B, Steinberg R, Kornreich L, et al. Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys. Pediatr Radiol 2005; 35:302. 10. Petrack EM, Hafeez W. Testicular torsion versus epididymitis: a diagnostic challenge. Pediatr Emerg Care 1992; 8:347. 11. Tunnessen WW Jr. Scrotal swelling. In: Signs and Symptoms in Pediatrics, 3rd, Lippincott, Williams & Wilkins, Philadelphia 1999. p.606. 12. Perron CE. Pain: Scrotal. In: Textbook of Pediatric Emergency Medicine, 5th, Fleisher GR, Ludwig S, Henretig FM. (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.525. 13. Pillai SB, Besner GE. Pediatric testicular problems. Pediatr Clin North Am 1998; 45:813. 14. Caldamone AA, Valvo JR, Altebarmakian VK, Rabinowitz R. Acute scrotal swelling in children. J Pediatr Surg 1984; 19:581. 15. Rabinowitz R. The importance of the cremasteric reflex in acute scrotal swelling in children. J Urol 1984; 132:89. 16. Nelson CP, Williams JF, Bloom DA. The cremasteric reflex: a useful but imperfect sign in testicular torsion. J Pediatr Surg 2003; 38:1248. 17. Caesar RE, Kaplan GW. The incidence of the cremasteric reflex in normal boys. J Urol 1994; 152:779. 18. Haynes BE, Bessen HA, Haynes VE. The diagnosis of testicular torsion. JAMA 1983; 249:2522. 19. Stillwell TJ, Kramer SA. Intermittent testicular torsion. Pediatrics 1986; 77:908. 20. Eaton SH, Cendron MA, Estrada CR, et al. Intermittent testicular torsion: diagnostic features and management outcomes. J Urol 2005; 174:1532. 21. Srinivasan A, Cinman N, Feber KM, et al. History and physical examination findings predictive of testicular torsion: an attempt to promote clinical diagnosis by house staff. J Pediatr Urol 2011; 7:470. 22. Lam WW, Yap TL, Jacobsen AS, Teo HJ. Colour Doppler ultrasonography replacing surgical exploration for acute scrotum: myth or reality? Pediatr Radiol 2005; 35:597.

23. Paltiel HJ, Connolly LP, Atala A, et al. Acute scrotal symptoms in boys with an indeterminate clinical presentation: comparison of color Doppler sonography and scintigraphy. Radiology 1998; 207:223. 24. Baker LA, Sigman D, Mathews RI, et al. An analysis of clinical outcomes using color doppler testicular ultrasound for testicular torsion. Pediatrics 2000; 105:604. 25. Yazbeck S, Patriquin HB. Accuracy of Doppler sonography in the evaluation of acute conditions of the scrotum in children. J Pediatr Surg 1994; 29:1270. 26. Kass EJ, Stone KT, Cacciarelli AA, Mitchell B. Do all children with an acute scrotum require exploration? J Urol 1993; 150:667. 27. Nussbaum Blask AR, Bulas D, Shalaby-Rana E, et al. Color Doppler sonography and scintigraphy of the testis: a prospective, comparative analysis in children with acute scrotal pain. Pediatr Emerg Care 2002; 18:67. 28. Sheldon CA. Undescended testis and testicular torsion. Surg Clin North Am 1985; 65:1303. 29. Bartsch G, Frank S, Marberger H, Mikuz G. Testicular torsion: late results with special regard to fertility and endocrine function. J Urol 1980; 124:375. 30. Krarup T. The testes after torsion. Br J Urol 1978; 50:43. 31. Mastrogiacomo I, Zanchetta R, Graziotti P, et al. Immunological and clinical study of patients after spermatic cord torsion. Andrologia 1982; 14:25. 32. Williamson RC, Thomas WE. Sympathetic orchidopathia. Ann R Coll Surg Engl 1984; 66:264. 33. Harrison RG, Lewis-Jones DI, Moreno de Marval MJ, Connolly RC. Mechanism of damage to the contralateral testis in rats with an ischaemic testis. Lancet 1981; 2:723. 34. Zanchetta R, Mastrogiacomo I, Graziotti P, et al. Autoantibodies against Leydig cells in patients after spermatic cord torsion. Clin Exp Immunol 1984; 55:49. 35. Puri P, Barton D, O'Donnell B. Prepubertal testicular torsion: subsequent fertility. J Pediatr Surg 1985; 20:598. 36. Garel L, Dubois J, Azzie G, et al. Preoperative manual detorsion of the spermatic cord with Doppler ultrasound monitoring in patients with intravaginal acute testicular torsion. Pediatr Radiol 2000; 30:41. 37. Cornel EB, Karthaus HF. Manual derotation of the twisted spermatic cord. BJU Int 1999; 83:672. 38. Sessions AE, Rabinowitz R, Hulbert WC, et al. Testicular torsion: direction, degree, duration and disinformation. J Urol 2003; 169:663. 39. Fisher R, Walker J. The acute paediatric scrotum. Br J Hosp Med 1994; 51:290. 40. Baldisserotto M. Scrotal emergencies. Pediatr Radiol 2009; 39:516. 41. Melloul M, Paz A, Lask D, et al. The pattern of radionuclide scrotal scan in torsion of testicular appendages. Eur J Nucl Med 1996; 23:967. 42. Flanigan RC, DeKernion JB, Persky L. Acute scrotal pain and swelling in children: a surgical emergency. Urology 1981; 17:51. 43. Merlini E, Rotundi F, Seymandi PL, Canning DA. Acute epididymitis and urinary tract anomalies in children. Scand J Urol Nephrol 1998; 32:273. 44. Siegel A, Snyder H, Duckett JW. Epididymitis in infants and boys: underlying urogenital anomalies and efficacy of imaging modalities. J Urol 1987; 138:1100. 45. Likitnukul S, McCracken GH Jr, Nelson JD, Votteler TP. Epididymitis in children and adolescents. A 20-year retrospective study. Am J Dis Child 1987; 141:41. 46. Somekh E, Gorenstein A, Serour F. Acute epididymitis in boys: evidence of a post-infectious etiology. J Urol 2004; 171:391. 47. Santillanes G, Gausche-Hill M, Lewis RJ. Are antibiotics necessary for pediatric epididymitis? Pediatr Emerg Care 2011; 27:174. 48. Gislason T, Noronha RF, Gregory JG. Acute epididymitis in boys: a 5-year retrospective study. J Urol 1980; 124:533. 49. Schalamon J, Ainoedhofer H, Schleef J, et al. Management of acute scrotum in children--the impact of Doppler ultrasound. J Pediatr Surg 2006; 41:1377. 50. Centers for Disease Control and Prevention, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1. 51. Updated recommended treatment regimens for gonococcal infections and associated conditions -United States, April 2007. www.cdc.gov/std/treatment/2006/GonUpdateApril2007.pdf (Accessed on April 18, 2007).

52. Committee on Infectious Diseases. The use of systemic fluoroquinolones. Pediatrics 2006; 118:1287. 53. Lau P, Anderson PA, Giacomantonio JM, Schwarz RD. Acute epididymitis in boys: are antibiotics indicated? Br J Urol 1997; 79:797. 54. Ioannides AS, Turnock R. An audit of the management of the acute scrotum in children with Henoch-Schonlein Purpura. J R Coll Surg Edinb 2001; 46:98. 55. Green MG. The genitalia. In: Pediatric Diagnosis: Interpretatino of Symptoms and Signs in Children and Adolescents, 6th, WB Saunders, Philadelphia 1998. p.101. 56. McGee SR. Referred scrotal pain: case reports and review. J Gen Intern Med 1993; 8:694. 57. Mndez R, Tellado M, Montero M, et al. Acute scrotum: an exceptional presentation of acute nonperforated appendicitis in childhood. J Pediatr Surg 1998; 33:1435. Topic 6446 Version 5.0

GRAPHICS

Normal testicular anatomy

The testicle is vertical and its anterior portion is surrounded by the tunica vaginalis.

Bell clapper deformity

In the "bell clapper" deformity, the testis lies horizontally and the tunica vaginalis extends up over the spermatic cord so that the testis is suspended within the tunica vaginalis by the spermatic cord.

Torsion of spermatic cord

Abnormality of testicular fixation permits torsion of spermatic vessels with subsequent infarction of the gonad.

The acute scrotum: suggested disposition and treatment

Torsion of appendage
Admission criteria: Testicular torsion excluded Severe pain Pain refractory to trial of analgesics and conservative management Treatment: Analgesics Rest

Acute epididymitis
Admission criteria:

Testicular torsion exclude Severe pain Immunocompromised

Not tolerating oral medica Treatment:

Children:

If pyuria >3 WBC/hpf Antibiotic course agai

If no pyuria and negat Antibiotics not require Extensive evaluation n

Sexually active adolesce

Heterosexual: empiric Homosexual: empiric

* Antibiotic choices include: Trimethoprim (TMP)-sulfamethoxazole (6-12 mg TMP component/kg per day divided every 12 hours) or cephalexin (25-50 mg/kg per day divided every 6-8 hours).

 Ceftriaxone (250 mg IM in one dose) plus doxycycline (100 mg PO twice a day for 10 days). Ofloxacin (300 mg PO twice a day for 10 days) or levofloxacin (500 mg PO once daily for 10 days) is recommended for adolescents in whom enteric organisms (coliforms) are most likely or in whom gonococcal culture or nucleic acid amplification test is negative.

Significant overlap in clinical fndings and diagnostic studies may occur for testicular torsion, torsed appendage, or acute epididymitis. Exploratory surgery may ultimately be necessary to determine the etiology of scrotal pain.

Adapted with permission from:

Burgher, SW. Acute scrotal pain. Emerg Med Clin North Am 1998; 16:781.

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2006. MMWR Recomm Rep 2006; 55:1.

Updated recommended treatment guidelines for gonococcal infections and associated treatment conditions - United States, April 2007. Available at: www.cdc.gov/std/treatment/2006/GonUpdateApril2007.pdf.

Anatomy of the testicular appendages

Evaluation of scrotal pain or swelling in children and adolescents Authors Joel S Brenner, MD, MPH Aderonke Ojo, MD Section Editors Amy B Middleman, MD, MPH, MS Ed Gary R Fleisher, MD Laurence S Baskin, MD, FAAP Deputy Editor James F Wiley, II, MD, MPH Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Dec 2012. | This topic last updated: feb 6, 2012. INTRODUCTION The spectrum of conditions that affect the scrotum and its contents ranges from incidental findings to pathologic events that require expeditious diagnosis and treatment (eg, testicular torsion, testicular cancer). The evaluation of scrotal pain or swelling in children and

adolescents will be discussed here. The causes of scrotal pain and swelling are discussed separately, as is the evaluation of the acute scrotum in adults. (See "Causes of scrotal pain in children and adolescents" and "Causes of painless scrotal swelling in children and adolescents" and "Evaluation of the acute scrotum in adults".) NORMAL ANATOMY The tunica vaginalis and the epididymis are two important landmarks for the testicular examination (figure 1). The tunica vaginalis is a structure containing a potential space that encompasses the anterior two-thirds of the testicle in which fluid from a variety of sources may accumulate. The epididymis usually is positioned posterolaterally to the testicle and must be differentiated from an abnormal mass. The spermatic cord, which consists of the testicular vessels and the vas deferens, is connected to the base of the epididymis. HISTORY A focused history in a boy with scrotal pain or swelling can help to narrow the differential diagnosis and lead to a more productive examination. The essential points include: Is there history of pain? If so, determine the onset and severity (remember that some adolescents may not report scrotal pain because of modesty or embarrassment) [1]. The major causes of acute scrotal pain in children and adolescents are testicular torsion, torsion of testicular or epididymal appendages, and epididymitis [2]. These and other causes of testicular and scrotal pain are discussed separately. (See "Causes of scrotal pain in children and adolescents".) Is there a history of trauma? Is there a history of change in testicular or scrotal size? If so, what is the onset of this change? Does scrotal size vary with time of day, position, or valsalva maneuver? Such changes are suggestive of communicating hydrocele (with or without an inguinal hernia) or varicocele. These conditions, and other causes of scrotal swelling are discussed separately. (See "Causes of painless scrotal swelling in children and adolescents".) Is the patient sexually active? Sexual activity may be associated with epididymitis, although epididymitis also occurs in prepubertal and nonsexually active males. (See "Causes of scrotal pain in children and adolescents", section on 'Epididymitis'.) Is the patient having difficulty voiding? Difficulty voiding suggests an intraabdominal, pelvic or rectal mass, urinary tract infection, or neurologic problem, including a lesion of the spinal cord. Is there flank pain or hematuria? These findings suggest a renal stone, which may cause referred pain in the scrotum. Is there abdominal pain associated with decreased appetite, nausea, and vomiting? These findings may be referred pain associated with testicular torsion.

EXAMINATION The patient and/or parents should receive a brief overview of the genital examination before the examination is begun. A parent and/or chaperone should be present for the examination if the patient and/or examiner prefers. Uninterrupted privacy must be guaranteed during the examination. The patient's undergarments should be removed, and a gown or towel (held by the patient) should be offered to alleviate any embarrassment. For most aspects of the examination the patient should be standing. The examiner can sit or stand. The evaluation of patients with scrotal pain or swelling should include a detailed examination of the abdomen, inguinal region, and genitalia, including the testes, epididymis, spermatic cord, scrotal skin, penis, and cremasteric reflex.

Genital examination Inspection The first step is to inspect the penis, pubic hair, and inguinal area while the patient is standing. The examiner should notice the presence or absence of any ulcers, papules, urethral discharge, piercings, tattoos, pubic hair infestation, or lymphadenopathy. Ulcers, papules, discharge, and lymphadenopathy may suggest a sexually transmitted infection. Piercings and tattoos may provide a portal of entry for skin and soft tissue infection. (See "Body piercing in adolescents and young adults" and "Sexually transmitted diseases: Overview of issues specific to adolescents", section on 'STD clinical patterns'.) The position of the testicles (eg, high versus low and horizontal versus vertical) should be evaluated. The left testicle usually lies slightly lower than the right testicle. Patients with varicoceles also should be examined in the supine position. (See "Causes of painless scrotal swelling in children and adolescents", section on 'Varicocele'.) Palpation The examiner should palpate the entire testicular surface by gently rolling it between his or her thumb and forefingers. The testicle should have the consistency of a hard-boiled egg. The epididymis should be palpated in the posterolateral position and followed to the spermatic cord (figure 1). The examiner should note any swelling or tenderness along any of these structures; if swelling is noted, transillumination may help to determine if it is cystic or solid in nature. (See "Causes of painless scrotal swelling in children and adolescents".) Cremasteric reflex The cremasteric reflex should be assessed by stroking the upper thigh while observing the ipsilateral testis. A normal response is cremasteric contraction with elevation of the testis. The reflex is present in the majority of healthy boys between the ages of 30 months and 12 years; it is less consistently present in infants and teenagers [3]. The reflex is almost always absent in patients with testicular torsion, which may help to distinguish this condition from other causes of scrotal pain (table 1) [4]. (See 'Differential diagnosis' below.) Prehn sign Prehn reported that elevation of the scrotal contents relieves the pain in patients with epididymitis and aggravates or has no effect on the pain in patients with testicular torsion [5]. However, Prehn sign is not a reliable distinguishing feature between testicular torsion, epididymitis, and other diagnoses [5-7]. ADDITIONAL EVALUATION Abdominal and rectal examinations are indicated if clinical suspicion exists for an abdominal or rectal mass, metastatic visceral disease, or prostatitis. Laboratory and radiologic studies that may be considered include: Complete blood count (leukocytosis may be present in testicular torsion or epididymitis). Urinalysis and urine culture (pyuria is common in epididymitis but unusual in testicular torsion or torsion of the appendix testis or appendix epididymis). Evaluation for sexually transmitted infections in patients who have findings consistent with sexually transmitted epididymitis. This may include Gram stain, culture, rapid molecular testing, or nucleic acid amplification testing of urethral discharge and/or nucleic acid amplification testing of urine. (See "Causes of scrotal pain in children and adolescents", section on 'Epididymitis'.) Color Doppler ultrasonography or scintigraphy to assess perfusion and exclude testicular torsion if it cannot be excluded clinically. Ultrasonography is usually preferred to scintigraphy, because it is more readily available and provides more specific visualization of both normal and pathological anatomy.

Scrotal exploration is necessary for diagnosis in cases when the clinical examination and imaging cannot exclude testicular torsion.

DIFFERENTIAL DIAGNOSIS The major considerations in the differential diagnosis of scrotal pain or swelling can be divided according to the predominant symptom: pain or swelling. An experienced clinician often can render an accurate diagnosis based upon the history and physical examination alone (table 1 and table 2). However, advances in color Doppler imaging of the scrotum have made this modality a useful adjunct to the history and physical examination in many cases. Pain predominant The most common causes of acute scrotal pain in children and adolescents are testicular torsion, torsion of the appendix testis, and epididymitis. Other causes include torsion of the appendix epididymis, trauma, Henoch-Schnlein purpura, orchitis, infection (eg, Fournier's gangrene), and referred pain (eg, from a renal stone). Distinguishing clinical features of these conditions are summarized below. Diagnosis and management are discussed in greater detail separately. (See "Causes of scrotal pain in children and adolescents".) Testicular torsion generally presents with the abrupt onset of severe pain [8-10]. The testicle may lie transversely in the scrotum and be retracted and/or swollen; the cremasteric reflex typically is absent. Testicular perfusion is decreased and can be assessed on Doppler ultrasound or nuclear scan of the scrotum). Although the clinical and radiographic evaluations may be normal at the time of presentation in a boy with an intermittent torsion that has been reduced, findings may be present to varying degrees on physical examination and imaging. (See "Causes of scrotal pain in children and adolescents", section on 'Testicular torsion' and "Neonatal testicular torsion".) Torsion of the appendix testis also presents with the abrupt onset of pain, but the pain is generally less severe than in testicular torsion [1,7,8]. The pain is initially localized to the region of the appendix testis (anterosuperior, (figure 2), although with progression and the development of a reactive hydrocele, diffuse swelling and tenderness may occur. A pathognomic "blue dot" sign may be apparent (picture 1). Testicular perfusion is normal on imaging studies. (See "Causes of scrotal pain in children and adolescents", section on 'Torsion of the appendix testis or appendix epididymis'.) Epididymitis often presents with a subacute onset of pain and swelling isolated to the epididymis (figure 1), except in cases of epididymo-orchitis [8,9]. The patient may have a history of frequency, dysuria, urethral discharge, and/or fever. Testicular perfusion is normal or increased on imaging studies. (See "Causes of scrotal pain in children and adolescents", section on 'Epididymitis'.) Incarcerated inguinal hernia usually presents with severe pain and a scrotal or inguinal mass (picture 2). (See "Overview of inguinal hernia in children".) Scrotal trauma usually is evident from the history. (See "Causes of scrotal pain in children and adolescents", section on 'Trauma'.) Henoch-Schnlein purpura (HSP) typically is characterized by nonthrombocytopenic purpura, arthralgia, and abdominal pain; however, occasionally scrotal pain may be the only manifestation. (See "Clinical manifestations and diagnosis of Henoch-Schnlein purpura".) Orchitis may be accompanied by systemic manifestations of the underlying infection (eg, brucellosis, mumps, coxsackie, etc). Boys who have the acute onset of scrotal pain without local inflammatory signs or a mass on examination may be suffering from referred pain to the scrotum. The precise incidence

of referred pain is unclear. The conditions that may cause referred scrotal pain are diverse and are discussed separately. (See "Causes of scrotal pain in children and adolescents", section on 'Referred pain'.) Fournier's gangrene (necrotizing fasciitis of the perineum) is characterized by fulminant destruction of tissue and systemic signs of toxicity. (See "Necrotizing soft tissue infections".)

Swelling predominant The most common causes of isolated scrotal swelling (as opposed to the generalized edema seen in conditions such as nephrosis) in children and adolescents are hydrocele, varicocele, spermatocele (epididymal cyst), and testicular cancer. Nephrotic syndrome and a number of other conditions producing generalized edema due to hypoproteinemia or increased hydrostatic pressure (eg, protein losing enteropathy, hepatic cirrhosis) also can present with bilateral scrotal swelling. Distinguishing clinical features of hydrocele, varicocele, spermatocele, and testicular cancer are summarized below. Diagnosis and management are discussed in greater detail separately. (See "Causes of painless scrotal swelling in children and adolescents" and "Etiology, clinical manifestations, and diagnosis of nephrotic syndrome in children".) A hydrocele is a cystic scrotal fluid collection that transilluminates. A hydrocele that communicates with the peritoneal cavity may increase in size during the day or with the valsalva maneuver. A noncommunicating hydrocele does not change in size or shape with crying or straining. (See "Causes of painless scrotal swelling in children and adolescents", section on 'Hydrocele'.) In patients with varicoceles, the spermatic cord has a "bag of worms" texture (figure 3). The varicocele may only be palpable during valsalva maneuver or with standing; varicoceles do not transilluminate. (See "Causes of painless scrotal swelling in children and adolescents", section on 'Varicocele'.) A spermatocele (epididymal cyst) is a painless, fluid-filled cyst of the head (caput) of the epididymis that may contain nonviable sperm. It transilluminates superior to the testis and can be palpated as distinct from the testis (figure 4). (See "Causes of painless scrotal swelling in children and adolescents", section on 'Spermatocele (epididymal cyst)'.) Testicular cancer usually presents as a painless mass that is firm and does not transilluminate (unless accompanied by a reactive hydrocele). (See "Clinical manifestations, diagnosis, and staging of testicular germ cell tumors", section on 'Clinical manifestations'.)

INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond the Basics. The Basics patient education pieces are written in plain language, th th at the 5 to 6 grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, th th more sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of interest.)

Basics topics (see "Patient information: Hydrocele (The Basics)" and "Patient information: Varicocele (The Basics)")

SUMMARY The causes of scrotal pain and swelling in children and adolescents range from incidental findings to pathologic events that require expeditious diagnosis and treatment (eg, testicular torsion). (See 'Introduction' above.) The evaluation should include a focused history, a complete examination with particular attention on the abdomen, inguinal region, and genitalia, including the testes, epididymis, spermatic cord, scrotal skin, penis, and cremasteric reflex. (See 'History' above and 'Examination' above.) Additional evaluation may include a complete blood count, urinalysis and urine culture; Gram stain, culture, rapid molecular testing, and nucleic acid testing of urethral discharge; nucleic acid amplification testing of urine; and Doppler ultrasonography or scintigraphy to assess testicular perfusion. Scrotal exploration is necessary for diagnosis in cases when the clinical examination and imaging cannot exclude testicular torsion. (See 'Additional evaluation' above.) The major considerations in the differential diagnosis of scrotal pain or swelling can be divided according to the predominant symptom. Major causes of scrotal pain in children and adolescents include testicular torsion, testicular appendiceal torsion, and epididymitis (table 1). These conditions are discussed in detail separately. (See "Causes of scrotal pain in children and adolescents".) Major causes of scrotal swelling in children and adolescents include hydrocele, varicocele, spermatocele, and testicular cancer (table 2). These conditions are discussed in detail separately. (See "Causes of painless scrotal swelling in children and adolescents".) Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Petrack EM, Hafeez W. Testicular torsion versus epididymitis: a diagnostic challenge. Pediatr Emerg Care 1992; 8:347. 2. Lewis AG, Bukowski TP, Jarvis PD, et al. Evaluation of acute scrotum in the emergency department. J Pediatr Surg 1995; 30:277. 3. Caesar RE, Kaplan GW. The incidence of the cremasteric reflex in normal boys. J Urol 1994; 152:779. 4. Rabinowitz R. The importance of the cremasteric reflex in acute scrotal swelling in children. J Urol 1984; 132:89. 5. Edelsberg JS, Surh YS. The acute scrotum. Emerg Med Clin North Am 1988; 6:521. 6. Haynes BE, Bessen HA, Haynes VE. The diagnosis of testicular torsion. JAMA 1983; 249:2522. 7. Pillai SB, Besner GE. Pediatric testicular problems. Pediatr Clin North Am 1998; 45:813. 8. Kass EJ, Lundak B. The acute scrotum. Pediatr Clin North Am 1997; 44:1251. 9. Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics 1998; 102:73. 10. Karmazyn B, Steinberg R, Kornreich L, et al. Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys. Pediatr Radiol 2005; 35:302. Topic 6449 Version 6.0

GRAPHICS

Normal testicular anatomy

The testicle is vertical and its anterior portion is surrounded by the tunica vaginalis.

Distinguishing features of conditions associated with scrotal pain in children and adolescents*
Testicular torsion Torsion of appendage

Perinatal and puberty Usually sudden Usually < 12 hours Typical Common Unusual Occasional Rare

Prepubertal Usually sudden Usually >12 hours Unusual Uncommon Unusual Unusual Rare

<2 yea

Usual

Usual

If prev

Uncom

Comm

Unusu

Comm

Bell-clapper Usually absent Testicular initially, then diffuse Common >12 hours

Palpable nodule "Blue dot" Usually present Appendage initially, then testis Common >12 hours

None

Usual

Epidid

Comm

Unusual No Common

Unusual No Uncommon

Comm Often

Comm

Decreased blood flow, spermatic cord knot Decreased blood flow

Normal or increased Normal or increased

Norma

Norma

*In some boys with scrotal pain, significant overlap in history, physical examination, and diagnostic studies exist. When testicular torsion cannot be excluded, surgical consultation is advised.

Color Doppler ultrasound is the preferred perfusion study.

Adapted from Burgher, SW. Emerg Med Clin North Am 1998; 16:781 and Haynes, BE, Bessen, HA, Haynes, VE. JAMA 1983; 249:2522.

Differential diagnosis of painless scrotal mass in children

Palpation
Firm "Bag of worms" Fluid-filled Small, soft, and localized cyst No No Yes Yes

Transilluminates?
No Yes No No

Increas

Adapted from From Kapphahn, C, Schlossberger, N. Diagnostic approach to scrotal masses. Adolescent Health Update 1992; 5:1.