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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 leisher, MD !aurence S Baskin, MD, AAP De"uty Editor James #iley, $$, MD, MPH Disclosures

All to"ics are u"dated as ne% e&idence 'ecomes a&aila'le and our "eer re&ie% "rocess is com"lete( !iterature re&ie% current throu)h* Se" +,-.( / 0his to"ic last u"dated* se" -1, +,-. on 2"toDate $30ROD240$O3 5 0he s"ectrum o6 conditions that a66ect the scrotum and its contents ran)es 6rom incidental 6indin)s to "atholo)ic e&ents that re7uire e8"editious dia)nosis and treatment 9e), testicular torsion, testicular cancer:( 0he most common causes o6 acute scrotal "ain in children and adolescents include testicular torsion, torsion o6 the a""endi8 testis, and e"ididymitis( $n one re&ie% o6 +.; consecuti&e 'oys, a)es , to -< years, %ho "resented %ith acute scrotal "ain to a children=s hos"ital o&er a t%o>year "eriod, -? "ercent had testicular torsion, @? "ercent had torsion o6 the a""endi8 testis, and .A "ercent had e"ididymitis B-C( 0he causes o6 scrotal "ain %ill 'e re&ie%ed here( 0he e&aluation scrotal "ain or s%ellin) and causes o6 scrotal s%ellin) are discussed se"arately( 9See DE&aluation o6 scrotal "ain or s%ellin) in children and adolescentsD and D4auses o6 "ainless scrotal s%ellin) in children and adolescentsD(: 0ES0$42!AR 0ORS$O3 5 0esticular torsion is the most dramatic and "otentially serious o6 the acute "rocesses a66ectin) the scrotal contents 'ecause it may result in the loss o6 the testicle( 3ormal testicular anatomy is de"icted in the 6i)ure 96i)ure -:( $ntra&a)inal torsion results 6rom inade7uate 6i8ation o6 the testis to the tunica &a)inalis throu)h the )u'ernaculum testis( 0he most common a'normality associated %ith testicular torsion is kno%n as the D'ell cla""erD de6ormity* the testicle lacks the normal attachment to the tunica &a)inalis 9"ermittin) increased mo'ility: and rests trans&erse %ithin the scrotum 96i)ure +: B+C( 0he 'ell cla""er de6ormity may 'e 'ilateral and "redis"oses to testicular torsion(

$6 6i8ation o6 the lo%er "ole o6 the testis to the tunica &a)inalis is insu66iciently 'road> 'ased or a'sent, the testis may torse 9t%ist: on the s"ermatic cord 96i)ure .:( 0he t%istin) o6 the s"ermatic cord %ithin the tunica &a)inalis causes &enous com"ression and su'se7uent edema o6 the testicle and cord %ith ultimate ischemia o6 the testicle caused 'y arterial occlusion B+,.C( 3eonatal testicular torsion, %hich is e8tra&a)inal, is discussed se"arately( 9See D3eonatal testicular torsionD(: 0esticular torsion has t%o "eak incidences* a small one in the neonatal "eriod and a lar)e one durin) "u'erty, 'ut it can occur at any a)e( 0he incidence is estimated to 'e - in @,,, in males youn)er than +A years old B@C( A""ro8imately ?A "ercent o6 cases occur in 'oys 'et%een the a)es o6 -+ and -; years BA,?C( 0he increased incidence durin) adolescence is thou)ht to 'e secondary to the increasin) %ei)ht o6 the testes durin) "u'ertal de&elo"ment B1C( 4linical "resentation 5 Patients classically "resent %ith an a'ru"t onset o6 se&ere testicular or scrotal "ain, usually o6 less than -+ hours= duration B+,;,<CE ho%e&er, in)uinal or lo%er a'dominal "ain may 'e the "resentin) com"laint B-,C( 3early <, "ercent o6 "atients may ha&e associated nausea and &omitin) B--,-+C( 0he "ain can 'e isolated to the scrotum or may radiate to the lo%er a'domen BA,1C( 0he "ain is constant unless the testicle is torsin) and detorsin)( A ty"ical "resentation, "articularly in children, is 6or the "atient to a%aken %ith scrotal "ain in the middle o6 the ni)ht or in the mornin)( Many 'oys re"ort a "re&ious e"isode o6 "ain B+,A,1,-.C( Ho%e&er, one study re"orted only ; "ercent o6 the "atients %ith torsion had a history o6 "ain in the "ast B;C( On "hysical e8amination, the scrotum may 'e edematous, indurated and erythematous and the a66ected testis usually is tender, s%ollen, and sli)htly ele&ated 'ecause o6 shortenin) o6 the cord 6rom t%istin)( 0he testis may 'e lyin) horiFontally, dis"lacin) the e"ididymis 6rom its normal "osterolateral "osition( A reacti&e hydrocele may also 'e "resent( 0he cremasteric re6le8 9ele&ation o6 the testis in res"onse to strokin) o6 the u""er inner thi)h: is a'sent in nearly all cases o6 torsion, 'ut it also may 'e a'sent in 'oys %ithout torsion, "articularly i6 they are youn)er than si8 months B;,<,-@>-1C( Prehn re"orted that ele&ation o6 the scrotal contents relie&es the "ain in "atients %ith e"ididymitis and a))ra&ates or has no e66ect on the "ain in "atients %ith testicular torsion BAC( Ho%e&er, Prehn si)n is not a relia'le distin)uishin) 6eature 'et%een torsion and other dia)noses BA,-.,-;C( $ntermittent torsion 5 $ntermittent testicular torsion, characteriFed 'y acute and intermittent shar" testicular "ain and scrotal s%ellin), %ith ra"id resolution 9%ithin seconds to a 6e% minutes: and lon) inter&als %ithout sym"toms, should 'e considered in all 'oys %ith a history o6 such scrotal "ain and s%ellin) %ithout other identi6ia'le causes B-<,+,C( $n one re&ie% o6 A, "atients %ith intermittent testicular torsion, +? "ercent re"orted nausea or &omitin), and +- "ercent re"orted that the "ain a%akened them 6rom slee" B+,C(

Physical 6indin)s o6 intermittent testicular torsion may include horiFontal or &ery mo'ile testes, anterior e"ididymis, or 'ulkiness o6 the s"ermatic cord 6rom "artial t%istin) B-<,+,C( 0hese 6indin)s are usually "resent to &aryin) de)rees on "hysical e8amination( Ho%e&er, the clinical and radio)ra"hic e&aluations o6 some 'oys %ith intermittent torsion may 'e normal, hi)hli)htin) the im"ortance o6 immediate 6ollo%>u" 6or recurrent or %orsenin) "ain( Boys %ith intermittent com"laints and normal e&aluation at the time o6 "resentation should ha&e a 6ollo%>u" e&aluation %ithin se&en days unless "ain recurs sooner( 2n6ortunately, intermittent testicular torsion most o6ten lea&es no clinical trace, 'ut on those occasions %hen intermittent testicular torsion is sus"ected, consultation %ith or re6erral to urolo)y is recommended( Dia)nosis 5 0he dia)nosis o6 testicular torsion can 'e made clinically, as descri'ed a'o&e( One study 6ound that the a'sence o6 i"silateral cremasteric re6le8, skin chan)es and the "resence o6 nausea and or &omitin) are most consistently "redicti&e o6 torsion B+-C( Radiolo)ic e&aluation 9a color Do""ler ultrasound or nuclear scan o6 the scrotum: should 'e undertaken i6 the certainty o6 the dia)nosis is in 7uestion and the "er6ormance o6 ima)in) studies %ill not si)ni6icantly delay treatment( Demonstration o6 decreased testicular "er6usion %ith either o6 these scans is consistent %ith testicular torsion( Decreased testicular "er6usion also can 'e seen in some "atients %ith a lar)e hydrocele, a'scess, hematoma, or scrotal hernia B-+C( 3e)ati&e scans 9ie, normal or increased testicular 6lo%: may occur rarely B<,-<C, usually %ith s"ontaneous detorsion and "artial or intermittent torsion B-<C( 0he Do""ler ultrasound can discern testicular and e"ididymal siFe, scrotal 6luid, scrotal %all thickenin), enlar)ed a""endi8 testis, and arterial 6lo% in the testis and e"ididymis( 0he re"orted sensiti&ity and s"eci6icity o6 Do""ler ultrasound in the detection o6 testicular torsion ran)e 6rom ?< to -,, "ercent and 11 to -,, "ercent, res"ecti&ely B;,++> +1C( 0he use6ulness o6 Do""ler ultrasound is limited in small "re"u'ertal testes %ith lo%er 'lood 6lo%( 0he nuclear scan measures testicular "er6usion( 0he re"orted sensiti&ity and s"eci6icity o6 scinti)ra"hy are -,, "ercent and <1 "ercent, res"ecti&ely B+.,+1C( Mana)ement 5 0he dia)nosis o6 testicular torsion, %hether clinically or radio)ra"hically made, re7uires immediate consultation %ith an urolo)ist 9ta'le -:( 0he treatment 6or a torsed testicle that remains &ia'le in&ol&es sur)ical detorsion and 6i8ation 9orchio"e8y: o6 'oth testes( Orchiectomy is "er6ormed i6 the testicle is non&ia'le( 0he &ia'ility o6 a torsed testicle is de"endent u"on the duration and com"leteness o6 torsion( 0y"ical rates o6 &ia'ility accordin) to duration o6 torsion ha&e 'een descri'ed as 6ollo%s BA,1,-.C* Detorsion %ithin @ to ? hours 5 -,, "ercent &ia'ility Detorsion a6ter -+ hours 5 +, "ercent &ia'ility Detorsion a6ter +@ hours 5 , "ercent &ia'ility

Sur)ery ne&er should 'e delayed on the assum"tion o6 non&ia'ility 'ased on a clinical estimate o6 duration o6 torsion( Some "atients %ith a "rolon)ed "eriod o6 sym"toms may ha&e had intermittent torsion or a "artial torsion and testicles that are sal&a)ea'le( 0he contralateral hemiscrotum ty"ically is e8"lored durin) sur)ery 'ecause the 'ell cla""er de6ormity usually is 'ilateral( E8"loration "ermits 6i8ation o6 the contralateral testis to "re&ent 6uture torsion B+,A,-.,+;C( Some authors re"ort decreased 6ertility a6ter unilateral testicular torsion %hen the testis is le6t in situ B+<>.+C, "ossi'ly 'ecause o6 immune>mediated dama)e to the contralateral testis B.-,..,.@C( Ho%e&er, no e&idence o6 decreased 6ertility or anti>s"erm anti'odies %as 6ound in one study o6 "re"u'ertal 'oys %ith testicular torsion B.AC, and the 6ertility issue remains contro&ersial( Manual detorsion 5 Manual detorsion o6 the torsed testicle may 'e considered i6 the child "resents 'e6ore scrotal s%ellin) de&elo"s B-+,.?,.1C( 2nless there are e8tenuatin) circumstances 9ie, de6initi&e care is hours a%ay:, the "rocedure should ty"ically 'e "er6ormed 'y clinicians e8"erienced in the techni7ue, and only a6ter a""ro"riate sedation and anal)esia ha&e 'een administered B-+C( 9See DProcedural sedation in children outside o6 the o"eratin) roomD(: 0he classic teachin) is that the testis usually rotates medially and is detorsed 'y rotatin) it out%ard to%ard the thi)h( Ho%e&er, in a retros"ecti&e analysis o6 +,, consecuti&e 'oys a)ed -; months to +, years %ho under%ent sur)ical e8"loration 6or testicular torsion, lateral rotation %as "resent in one>third o6 cases B.;C( Success6ul detorsion is su))ested 'y relie6 o6 "ain, lo%er "osition o6 the testis in the scrotum, and return o6 normal arterial "ulsations detected %ith a Do""ler stethosco"e B-+C( Sur)ical e8"loration is necessary e&en a6ter clinically success6ul manual detorsion 'ecause orchio"e8y must 'e "er6ormed to "re&ent an additional e"isode B.;C( 3eonatal testicular torsion 5 3eonatal testicular torsion is discussed se"arately( 9See D3eonatal testicular torsionD(: 0ORS$O3 O 0HE APPE3D$G 0ES0$S OR APPE3D$G EP$D$DHM$S 5 0he a""endi8 testis is a small &esti)ial structure on the anterosu"erior as"ect o6 the testis 9an em'ryolo)ic remnant o6 the MIllerian duct system: 96i)ure @:( $t measures a'out ,(. cm( 0he a""endi8 e"ididymis is a &esti)ial remnant o6 the #ol66ian duct that is located at the head o6 the e"ididymis( 0he "edunculated sha"e o6 these a""enda)es "redis"oses them to torsion, %hich can "roduce scrotal "ain that ran)es 6rom mild to se&ere( 0orsion o6 the a""endi8 testis or a""endi8 e"ididymis 96i)ure @: occurs most commonly in 'oys 'et%een 1 and -+ years o6 a)e B.<C( 4linical "resentation 5 0he "ain o6 torsion o6 the a""endi8 testis or a""endi8 e"ididymis is o6 sudden onset, like the "ain o6 testicular torsion( Physical e8amination o6 'oys %ith torsion o6 the a""endi8 testis or e"ididymis ty"ically demonstrates a nontender testicle and a tender localiFed mass that is "al"a'le, usually at

the su"erior or in6erior "ole( 0he a""endi8 may 'e )an)renous or 'lack and a""ears throu)h the scrotum as the D'lue dot si)nD 9"icture -:( A normal cremasteric re6le8 may 'e "resent, and a reacti&e hydrocele may 'e "al"ated( Blood 6lo% to the a66ected testis is normal or increased and can 'e demonstrated on Do""ler ultrasound or nuclear scan B+C( Dia)nosis 5 0he dia)nosis o6 torsion o6 the a""endi8 testis or a""endi8 e"ididymis can 'e made clinically, as descri'ed a'o&e( Do""ler ultrasound or nuclear scan may 'e hel"6ul in cases %here testicular torsion cannot other%ise 'e e8cluded( 0esticular ultrasound %ill sho% the torsed a""enda)e as a lesion o6 lo% echo)enicity %ith a central hy"oecho)enic area B@,C( 4olor Do""ler re&eals normal 'lood 6lo% to the testis %ith an occasional increase on the a66ected side, "ossi'ly due to in6lammation( Do""ler may 'e less accurate in a "re"u'ertal "atient 'ecause o6 lo%er 'aseline testicular "er6usion( Radionuclide ima)in) denotes a Dhot dotD si)n at the torsed a""enda)e( Ho%e&er, this 6indin) is unrelia'le i6 the sym"toms are less than 6i&e hours old and %ill 'e seen in only @A "ercent o6 "atients %hose sym"toms ha&e lasted A to +@ hours B@-C( Mana)ement 5 0he mana)ement o6 a torsed a""endi8 testis or a""endi8 e"ididymis is su""orti&e, %ith anal)esics, 'ed rest, and scrotal su""ort to hel" alle&iate s%ellin) 9ta'le -:( 0he "ain should resol&e in A to -, days( Sur)ery 9remo&al o6 the testicular a""endi8: is reser&ed 6or "atients %ho ha&e "ersistent "ainE the contralateral hemiscrotum need not 'e e8"lored BA,-.,@+C( EP$D$DHM$0$S 5 $n6lammation o6 the e"ididymis is kno%n as e"ididymitis 96i)ure A:( E"ididymitis occurs more 6re7uently amon) late adolescents, 'ut also occurs in youn)er 'oys %ho deny se8ual acti&ity B1,;,-.C( Se&eral 6actors may "redis"ose "ost"u'ertal 'oys to de&elo" su'acute e"ididymitis, includin) se8ual acti&ity, hea&y "hysical e8ertion, and direct trauma 9e), 'icycle or motorcycle ridin):( Bacterial e"ididymitis in "re"u'ertal 'oys is associated %ith structural anomalies o6 the urinary tract B@.>@AC( Amon) se8ually acti&e males, chlamydia is the most common micro'ial a)ent, 6ollo%ed 'y 3( )onorrhea, E( coli, and &iruses( Or)anisms that less commonly cause e"ididymitis include 2rea"lasma, Myco'acterium, and cytome)alo&irus, or cry"tococcus in "atients %ith H$J in6ection( $n6ectious e"ididymitis in "re"u'ertal 'oys and adolescents %ho are not se8ually acti&e may 'e caused 'y Myco"lasma "neumoniae, entero&iruses, or adeno&iruses B@?C( Bacterial in6ection a""ears to 'e uncommon in such "atients( As an e8am"le, an o'ser&ational study o6 <1 cases o6 e"ididymitis %ho had urine cultures 6ound that only @ "ercent had a 'acterial in6ection and, in "atients %ith "ositi&e urine cultures, the or)anisms isolated 6re7uently %ere not sensiti&e to commonly "rescri'ed em"iric anti'iotics B@1C( 4linical "resentation 5 Patients %ith e"ididymitis may "resent %ith acute or su'acute onset o6 "ain and s%ellin) isolated to the e"ididymis B@AC( A history o6 6re7uency,

dysuria, urethral dischar)e, andKor 6e&er may 'e "resent B+,;,-+C( On "hysical e8amination, the a66ected testis has a normal &ertical lieE the scrotum may 'e red and "archment>like 9althou)h this is an uncommon 6indin):E scrotal edema is "resent in at least A, "ercent o6 cases B;,-,,--C( Sometimes an in6lammatory nodule is 6elt %ith an other%ise so6t, nontender e"ididymis( $n contrast to "atients %ith testicular torsion, "atients %ith e"ididymitis usually ha&e a normal cremasteric re6le8 9i6 they ha&e a one under normal conditions: B+,;C( Patients %ith e"ididymitis may e8"erience "ain relie6 %ith ele&ation o6 the testis 9Prehn si)n:, 'ut this is not a relia'le marker 6or e"ididymitis BA,-.,-;C( Patients %ith e"ididymitis may ha&e leukocytosis and "yuriaE ho%e&er, urinalysis may 'e normal( 2rine culture o6ten is ne)ati&e( $n one retros"ecti&e study o6 "atients %ith acute scrotal "atholo)y, only -A "ercent o6 those %ith e"ididymitis had a "ositi&e urinalysis 9L-, %hite 'lood cells "er hi)h>"o%er 6ield: B;C( Earlier studies re"orted "ositi&e urinalysis in +@ to A< "ercent o6 "atients %ith e"ididymitis B@@,@;C( Dia)nosis 5 0he dia)nosis o6 e"ididymitis can 'e made clinically as descri'ed a'o&e( Ho%e&er, i6 the dia)nosis is uncertain, Do""ler ultrasono)ra"hy or nuclear scan may 'e hel"6ul, re&ealin) increased 'lood 6lo% to the a66ected e"ididymis B@,,@<C( A urinalysis and urine culture should 'e o'tained in all "atients %ith e"ididymitis( $n addition, the 4enters 6or Disease 4ontrol 94D4: recommend that "ro&iders o'tain the 6ollo%in) studies in "atients %ho ha&e 6indin)s consistent %ith se8ually transmitted e"ididymitis BA,C* Gram>stained smear and culture o6 urethral e8udates or intraurethral s%a' s"ecimen, or 3ucleic acid am"li6ication tests 6or 3( )onorrhea and 4( trachomatis, and 2rine culture and 6irst &oid urine 6or leukocytes Sy"hilis and H$J testin) Mana)ement 5 0reatment &aries accordin) to the se&erity o6 the case at "resentation and sus"ected etiolo)y 9ta'le -:( 0reatment 6or se8ually transmitted e"ididymitis includes anti'iotics BA,C, anal)esics, scrotal su""ort, ele&ation, and 'ed rest in the acute "hase BA,C( $t is e7ually im"ortant to assure that the se8ual "artner )ets treatment i6 a se8ually transmitted disease is sus"ected as the etiolo)y( 0he dia)nosis and treatment re)imen should 'e ree&aluated i6 there is no im"ro&ement a6ter three days o6 thera"y BA,C(

6irst>line treatment re)imen recommended 'y the 4D4 %hen the most likely cause is chlamydia or )onorrhea includes ce6tria8one 9+A, m) $M in one dose: plus do8ycycline 9-,, m) PO t%ice a day 6or -, days: BA,,A-C( Muinolones are no lon)er recommended 6or the treatment o6 e"ididymitis i6 3( )onorrhoeae is sus"ected 'ecause o6 increasin) resistance o6 3( )onorrhoeae to these a)ents(

or acute e"ididymitis most likely caused 'y enteric or)anisms or %ith ne)ati&e )onococcal culture or nucleic acid am"li6ication test, o6lo8acin 9.,, m) PO t%ice a day 6or -, days: or le&o6lo8acin 9A,, m) PO once daily 6or -, days: may 'e used BA-C(

$t should 'e noted that do8ycycline is not a""ro&ed 6or use in children youn)er than the a)e o6 ei)ht years and that 6luoro7uinolones are not a""ro&ed 6or use in "atients youn)er than -; years o6 a)e %hen other e66ecti&e alternati&es are a&aila'le BA+C( 0he treatment o6 e"ididymitis in "re"u'ertal 'oys de"ends u"on %hether they ha&e an associated urinary tract in6ection( 0hose %ho ha&e "yuria, "ositi&e urine cultures, or underlyin) risk 6actors 6or urinary tract in6ection should 'e treated em"irically %ith anti'iotics that co&er coli6orms and achie&e ade7uate le&els in e"ididymal tissues 9e), trimetho"rim>sul6ametho8aFole, ce"hale8in: B-+C( Additional e&aluation o6 'oys %ith urinary tract in6ection is discussed se"arately( 9See DAcute mana)ement, ima)in), and "ro)nosis o6 urinary tract in6ections in in6ants and children older than one monthD, section on =$ma)in)= (: 0he treatment o6 non'acterial e"ididymitis is su""orti&e and includes scrotal su""ort, rest, 3SA$Ds, and "ossi'ly anti'iotics BA.C( O0HER 4A2SES 0rauma 5 $t is not uncommon 6or 'oys and men to su66er minor e"isodes o6 scrotal traumaE only rarely does a se&ere testicular injury result, usually 'ecause o6 com"ression o6 the testis a)ainst the "u'ic 'ones 6rom a direct 'lo% or straddle injury( 0he s"ectrum o6 injuries can ran)e 6rom a hematocele 9hematoma in the tunica &a)inalis: to an intratesticular hematoma to disru"tion o6 the tunica al'u)inea causin) testicular ru"ture( 4olor Do""ler ultrasono)ra"hy can accurately dia)nose the e8tent o6 injury( 0esticular ru"ture re7uires sur)ical re"air( !esser injuries are mana)ed accordin) to the clinical se&erity and o6ten can 'e treated nono"erati&ely( $ncarcerated in)uinal hernia 5 Herniation o6 'o%el or omentum into the scrotum can "resent %ith "ain and a scrotal mass 9"icture +:( Bo%el sounds may 'e audi'le in the scrotum( 9See DO&er&ie% o6 in)uinal hernia in childrenD(: Henoch>SchNnlein "ur"ura 9$)A &asculitis: 5 Henoch>SchNnlein "ur"ura 9HSP B$)A &asculitis 9$)AJ:C: is a systemic &asculitis syndrome characteriFed 'y nonthrom'ocyto"enic "ur"ura, arthral)ia, renal disease, a'dominal "ain, )astrointestinal 'leedin), and occasionally scrotal "ain( $n one re&ie% o6 <. 'oys %ith HSP 9$)AJ:, ++ had scrotal in&ol&ement BA@C( 0he onset o6 scrotal "ain may 'e acute or insidious( $n 'oys %ho lack other characteristic 6indin)s o6 HSP 9$)AJ:, sono)ra"hy can usually distin)uish HSP 9$)AJ: 6rom testicular torsion( 0reatment o6 HSP 9$)AJ: is su""orti&e( 9See DMana)ement o6 Henoch>SchNnlein "ur"ura 9$)A &asculitis:D(: Orchitis 5 Jiral 9mum"s, ru'ella, co8sackie, echo&irus, lym"hocytic choriomenin)itis &irus, "ar&o&irus: and 'acterial 9'rucellosis: in6ections can cause orchitis in children and adolescents BAAC( 4linical mani6estations may include scrotal s%ellin), "ain, and tenderness %ith erythema and shininess o6 the o&erlyin) skin, althou)h the "resentation may 'e more se&ere( 9See a""ro"riate to"ic re&ie%s:(

Patients %ith orchitis are treated sym"tomatically %ith 'ed rest, nonsteroidal antiin6lammatory a)ents, su""ort o6 the in6lamed testis, and ice "acks( 9See DE"idemiolo)y, clinical mani6estations, dia)nosis and mana)ement o6 mum"sD, section on =0reatment= (: Re6erred "ain 5 Boys %ho ha&e the acute onset o6 scrotal "ain %ithout local in6lammatory si)ns or a mass on e8amination may 'e su66erin) 6rom re6erred "ain to the scrotum( 0he "recise incidence o6 re6erred "ain is unclear( 0he conditions that may cause re6erred scrotal "ain are di&erse, re6lectin) the anatomy o6 the three somatic ner&es that tra&el to the scrotum* the )enito6emoral, ilioin)uinal, and "osterior scrotal ner&es BA?C( Retrocecal a""endicitis is an im"ortant 9al'eit uncommon: cause o6 re6erred scrotal "ain in children and adolescents BA1C( Re"orted causes o6 re6erred "ain in adults include a'dominal aortic aneurysm, urolithiasis, lo%er lum'ar or sacral ner&e root im"in)ement, retrocecal a""endicitis, retro"eritoneal tumor, and "ostherniorrha"hy "ain BA?C( 9See DAcute a""endicitis in children* 4linical mani6estations and dia)nosisD (: 3ons"eci6ic scrotal "ain 5 Sometimes older 'oys and youn) teena)ers "resent %ith com"laints o6 mild scrotal "ain and a com"letely normal "hysical e8amination( 0hese characteristics make testicular torsion and other "atholo)ic conditions hi)hly unlikely( $ma)in) o6 such "atients is not usually necessary( 0hey should 'e instructed to return 6or immediate e&aluation i6 the "ain increases in se&erity or is associated %ith testicular s%ellin)( $3 ORMA0$O3 OR PA0$E30S 5 2"0oDate o66ers t%o ty"es o6 "atient education materials, O0he BasicsP and OBeyond the Basics(P 0he Basics "atient education "ieces are %ritten in "lain lan)ua)e, at the Ath to ?th )rade readin) le&el, and they ans%er the 6our or 6i&e key 7uestions a "atient mi)ht ha&e a'out a )i&en condition( 0hese articles are 'est 6or "atients %ho %ant a )eneral o&er&ie% and %ho "re6er short, easy>to>read materials( Beyond the Basics "atient education "ieces are lon)er, more so"histicated, and more detailed( 0hese articles are %ritten at the -,th to -+th )rade readin) le&el and are 'est 6or "atients %ho %ant in>de"th in6ormation and are com6orta'le %ith some medical jar)on( Here are the "atient education articles that are rele&ant to this to"ic( #e encoura)e you to "rint or e>mail these to"ics to your "atients( 9Hou can also locate "atient education articles on a &ariety o6 su'jects 'y searchin) on O"atient in6oP and the key%ord9s: o6 interest(:

to"ic 9see DPatient in6ormation* E"ididymitis 90he Basics:D:

S2MMARH 5 0he clinical "resentations, dia)nosis, and mana)ement o6 the most common causes o6 testicular or scrotal "ain in children and adolescents are descri'ed a'o&e 9ta'le + and ta'le -:( 0he di66erential dia)nosis o6 acute scrotal "ain "rimarily includes testicular torsion, torsion o6 the a""endi8 testis, and e"ididymitis( 0esticular torsion )enerally "resents %ith the a'ru"t onset o6 se&ere "ain( 0he testicle may lie trans&ersely in the scrotum and 'e retractedE the cremasteric re6le8 is ty"ically a'sent( 0esticular torsion is an emer)encyE timely dia)nosis and

treatment are &ital 6or sur&i&al o6 the testis( At the time o6 dia)nosis it is reasona'le to attem"t manual detorsion( 9See a'o&e(:

o6 the a""endi8 testis also "resents %ith the a'ru"t onset o6 "ain, 'ut the "ain ty"ically is less se&ere than in testicular torsion( Pain is localiFed to the re)ion o6 the a""endi8 testis 9anterosu"erior:, and a D'lue dotD si)n may 'e a""arent at the same location 9"icture -:( 0reatment may 'e sym"tomatic, or the a""endi8 testis may 'e sur)ically e8cised( 9See a'o&e(:

Patients %ith e"ididymitis may "resent %ith acute or su'acute onset o6 "ain and s%ellin) isolated to the e"ididymis( A history o6 6re7uency, dysuria, urethral dischar)e, andKor 6e&er may 'e "resent( 0he a66ected testis has a normal &ertical lieE scrotal edema o6ten is "resent( 0reatment de"ends on the se&erity o6 illness and the sus"ected etiolo)y( 9See a'o&e(: $n rare cases, retrocecal a""endicitis may cause re6erred scrotal "ain in children and adolescents( $n these "atients, "rimary scrotal or testicular "atholo)y %ill 'e a'sent( 2se o6 2"0oDate is su'ject to the Su'scri"tion and !icense A)reement(

!e%is AG, Buko%ski 0P, Jar&is PD, et al( E&aluation o6 acute scrotum in the emer)ency de"artment( J Pediatr Sur) -<<AE .,*+11( Qass EJ, !undak B( 0he acute scrotum( Pediatr 4lin 3orth Am -<<1E @@*-+A-( 0umeh SS, Benson 4B, Richie JP( Acute diseases o6 the scrotum( Semin 2ltrasound 40 MR -<<-E -+*--A( #illiamson R4( 0orsion o6 the testis and allied conditions( Br J Sur) -<1?E ?.*@?A( Edels'er) JS, Surh HS( 0he acute scrotum( Emer) Med 4lin 3orth Am -<;;E ?*A+-(

Rohn RD( Male )enitalia* E8amination and 6indin)s( $n* 4om"rehensi&e Adolescent Health 4are,, riedman SB, isher M, Schon'er) SQ, et al( 9Eds:, Mos'y>Hear Book, St( !ouis -<<;( "(-,1;( Anderson MM, 3einstein !S( Scrotal disorders( $n* Adolescent Health 4are* A Practical Guide, 3einstein !S( 9Ed:, #illiams R #ilkins, Baltimore -<<?( "(@?@(
Qadish HA, Bolte RG( A retros"ecti&e re&ie% o6 "ediatric "atients %ith e"ididymitis, testicular torsion, and torsion o6 testicular a""enda)es( Pediatrics -<<;E -,+*1.( QarmaFyn B, Stein'er) R, Qornreich !, et al( 4linical and sono)ra"hic criteria o6 acute scrotum in children* a retros"ecti&e study o6 -1+ 'oys( Pediatr Radiol +,,AE .A*.,+( Petrack EM, Ha6eeF #( 0esticular torsion &ersus e"ididymitis* a dia)nostic challen)e( Pediatr Emer) 4are -<<+E ;*.@1(

0unnessen ## Jr( Scrotal s%ellin)( $n* Si)ns and Sym"toms in Pediatrics, .rd, !i""incott, #illiams R #ilkins, Philadel"hia -<<<( "(?,?( Perron 4E( Pain* Scrotal( $n* 0e8t'ook o6 Pediatric Emer)ency Medicine, Ath, leisher GR, !ud%i) S, Henreti) M( 9Eds:, !i""incott #illiams R #ilkins, Philadel"hia +,,?( "(A+A(
Pillai SB, Besner GE( Pediatric testicular "ro'lems( Pediatr 4lin 3orth Am -<<;E @A*;-.( 4aldamone AA, Jal&o JR, Alte'armakian JQ, Ra'ino%itF R( Acute scrotal s%ellin) in children( J Pediatr Sur) -<;@E -<*A;-( Ra'ino%itF R( 0he im"ortance o6 the cremasteric re6le8 in acute scrotal s%ellin) in children( J 2rol -<;@E -.+*;<( 3elson 4P, #illiams J , Bloom DA( 0he cremasteric re6le8* a use6ul 'ut im"er6ect si)n in testicular torsion( J Pediatr Sur) +,,.E .;*-+@;( 4aesar RE, Qa"lan G#( 0he incidence o6 the cremasteric re6le8 in normal 'oys( J 2rol -<<@E -A+*11<( Haynes BE, Bessen HA, Haynes JE( 0he dia)nosis o6 testicular torsion( JAMA -<;.E +@<*+A++( Still%ell 0J, Qramer SA( $ntermittent testicular torsion( Pediatrics -<;?E 11*<,;( Eaton SH, 4endron MA, Estrada 4R, et al( $ntermittent testicular torsion* dia)nostic 6eatures and mana)ement outcomes( J 2rol +,,AE -1@*-A.+( Srini&asan A, 4inman 3, e'er QM, et al( History and "hysical e8amination 6indin)s "redicti&e o6 testicular torsion* an attem"t to "romote clinical dia)nosis 'y house sta66( J Pediatr 2rol +,--E 1*@1,( !am ##, Ha" 0!, Jaco'sen AS, 0eo HJ( 4olour Do""ler ultrasono)ra"hy re"lacin) sur)ical e8"loration 6or acute scrotum* myth or realityS Pediatr Radiol +,,AE .A*A<1( Paltiel HJ, 4onnolly !P, Atala A, et al( Acute scrotal sym"toms in 'oys %ith an indeterminate clinical "resentation* com"arison o6 color Do""ler sono)ra"hy and scinti)ra"hy( Radiolo)y -<<;E +,1*++.( Baker !A, Si)man D, Mathe%s R$, et al( An analysis o6 clinical outcomes usin) color do""ler testicular ultrasound 6or testicular torsion( Pediatrics +,,,E -,A*?,@( HaF'eck S, Patri7uin HB( Accuracy o6 Do""ler sono)ra"hy in the e&aluation o6 acute conditions o6 the scrotum in children( J Pediatr Sur) -<<@E +<*-+1,( Qass EJ, Stone Q0, 4acciarelli AA, Mitchell B( Do all children %ith an acute scrotum re7uire e8"lorationS J 2rol -<<.E -A,*??1( 3uss'aum Blask AR, Bulas D, Shala'y>Rana E, et al( 4olor Do""ler sono)ra"hy and scinti)ra"hy o6 the testis* a "ros"ecti&e, com"arati&e analysis in children %ith acute scrotal "ain( Pediatr Emer) 4are +,,+E -;*?1( Sheldon 4A( 2ndescended testis and testicular torsion( Sur) 4lin 3orth Am -<;AE ?A*-.,.( Bartsch G, rank S, Mar'er)er H, MikuF G( 0esticular torsion* late results %ith s"ecial re)ard to 6ertility and endocrine 6unction( J 2rol -<;,E -+@*.1A( Qraru" 0( 0he testes a6ter torsion( Br J 2rol -<1;E A,*@.(

Mastro)iacomo $, Tanchetta R, GraFiotti P, et al( $mmunolo)ical and clinical study o6 "atients a6ter s"ermatic cord torsion( Androlo)ia -<;+E -@*+A( #illiamson R4, 0homas #E( Sym"athetic orchido"athia( Ann R 4oll Sur) En)l -<;@E ??*+?@( Harrison RG, !e%is>Jones D$, Moreno de Mar&al MJ, 4onnolly R4( Mechanism o6 dama)e to the contralateral testis in rats %ith an ischaemic testis( !ancet -<;-E +*1+.( Tanchetta R, Mastro)iacomo $, GraFiotti P, et al( Autoanti'odies a)ainst !eydi) cells in "atients a6ter s"ermatic cord torsion( 4lin E8" $mmunol -<;@E AA*@<( Puri P, Barton D, O=Donnell B( Pre"u'ertal testicular torsion* su'se7uent 6ertility( J Pediatr Sur) -<;AE +,*A<;( Garel !, Du'ois J, AFFie G, et al( Preo"erati&e manual detorsion o6 the s"ermatic cord %ith Do""ler ultrasound monitorin) in "atients %ith intra&a)inal acute testicular torsion( Pediatr Radiol +,,,E .,*@-( 4ornel EB, Qarthaus H ( Manual derotation o6 the t%isted s"ermatic cord( BJ2 $nt -<<<E ;.*?1+( Sessions AE, Ra'ino%itF R, Hul'ert #4, et al( 0esticular torsion* direction, de)ree, duration and disin6ormation( J 2rol +,,.E -?<*??.( isher R, #alker J( 0he acute "aediatric scrotum( Br J Hos" Med -<<@E A-*+<,( Baldisserotto M( Scrotal emer)encies( Pediatr Radiol +,,<E .<*A-?( Melloul M, PaF A, !ask D, et al( 0he "attern o6 radionuclide scrotal scan in torsion o6 testicular a""enda)es( Eur J 3ucl Med -<<?E +.*<?1( lani)an R4, DeQernion JB, Persky !( Acute scrotal "ain and s%ellin) in children* a sur)ical emer)ency( 2rolo)y -<;-E -1*A-( Merlini E, Rotundi , Seymandi P!, 4annin) DA( Acute e"ididymitis and urinary tract anomalies in children( Scand J 2rol 3e"hrol -<<;E .+*+1.( Sie)el A, Snyder H, Duckett J#( E"ididymitis in in6ants and 'oys* underlyin) uro)enital anomalies and e66icacy o6 ima)in) modalities( J 2rol -<;1E -.;*--,,( !ikitnukul S, Mc4racken GH Jr, 3elson JD, Jotteler 0P( E"ididymitis in children and adolescents( A +,>year retros"ecti&e study( Am J Dis 4hild -<;1E -@-*@-( Somekh E, Gorenstein A, Serour ( Acute e"ididymitis in 'oys* e&idence o6 a "ost>in6ectious etiolo)y( J 2rol +,,@E -1-*.<-( Santillanes G, Gausche>Hill M, !e%is RJ( Are anti'iotics necessary 6or "ediatric e"ididymitisS Pediatr Emer) 4are +,--E +1*-1@( Gislason 0, 3oronha R , Gre)ory JG( Acute e"ididymitis in 'oys* a A>year retros"ecti&e study( J 2rol -<;,E -+@*A..( Schalamon J, Ainoedho6er H, Schlee6 J, et al( Mana)ement o6 acute scrotum in children>>the im"act o6 Do""ler ultrasound( J Pediatr Sur) +,,?E @-*-.11( 4enters 6or Disease 4ontrol and Pre&ention, #orko%ski QA, Berman SM( Se8ually transmitted diseases treatment )uidelines, +,,?( MM#R Recomm Re" +,,?E AA*-(

2"dated recommended treatment re)imens 6or )onococcal in6ections and associated conditions >> 2nited States, A"ril +,,1( %%%(cdc()o&KstdKtreatmentK+,,?KGon2"dateA"ril+,,1("d6 9Accessed on A"ril -;, +,,1:(
4ommittee on $n6ectious Diseases( 0he use o6 systemic 6luoro7uinolones( Pediatrics +,,?E --;*-+;1( !au P, Anderson PA, Giacomantonio JM, Sch%arF RD( Acute e"ididymitis in 'oys* are anti'iotics indicatedS Br J 2rol -<<1E 1<*1<1( $oannides AS, 0urnock R( An audit o6 the mana)ement o6 the acute scrotum in children %ith Henoch> Schonlein Pur"ura( J R 4oll Sur) Edin' +,,-E @?*<;(

Green MG( 0he )enitalia( $n* Pediatric Dia)nosis* $nter"retatino o6 Sym"toms and Si)ns in 4hildren and Adolescents, ?th, #B Saunders, Philadel"hia -<<;( "(-,-(
McGee SR( Re6erred scrotal "ain* case re"orts and re&ie%( J Gen $ntern Med -<<.E ;*?<@( MUndeF R, 0ellado M, Montero M, et al( Acute scrotum* an e8ce"tional "resentation o6 acute non"er6orated a""endicitis in childhood( J Pediatr Sur) -<<;E ..*-@.A(

0o"ic ?@@? Jersion ?(,