The enlarged, tender, and discolored scrotum in infants and children may present a major diagnostic dilemma. An acute scrotum is defined as an acute painful swelling of the scrotum or its contents accompanied by local signs and general symptoms (Figure 1). This includes a myriad of diagnostic possibilities, the treatment of which varies from skillful observation only to emergency surgical intervention. The correct diagnosis is essential to avoid irreversible testicular injury. To avoid this injury a torsion of the testis must not go unrecognized; however, other conditions must also be considered. Causes of an acute scrotum are listed in Table 1.
Accurate history and physical examination, along with appropriate tests, are exceedingly important in making an early diagnosis to preserve testicular function. A systematic approach to the evaluation of management of the acute scrotum will be discussed along with the clinical features, diagnostic techniques, and therapy.
Torsion of the testicle is the one diagnosis that cannot be missed if gonadal preservation is to be a reality. It is also one of the most common causes of the acute scrotum in children and is either extravaginal or intravaginal.
Extravaginal torsion is found exclusively in neonates and presents at or shortly after birth (Figure 2). It involves a twist of the spermatic cord above the tunica vaginalis, thus cutting off the blood supply (Figure 3). Most of these present as a swollen, red or bluish-red scrotum unilaterally with variable amount of edema. Usually examination by transillumination will distinguish extravaginal torsion from a hydrocele and allow proper diagnosis. Despite a variety of articles indicating a viable testes, most of these are nonviable at exploration. Recent reports refer to a contralateral defect being found; thus, the surgeon should consider contralateral orchiopexy (Figure 4). It is felt that this represents an intrauterine event which ultimately ends in orchiectomy in most cases.
Causes off an Acute Scrotum
Figure 2. The acute scrotum in the neonate.
Figure 4. Abnormal contralateral findings in a patient with extravaginal torsion.
Figure 1. Acute scrotum in a young boy due to torsion of the testis.
Figure 3. Extravaginal torsion of the testis in a neonate.
Figure 5. Postpuberal testicular torsion.
Intravaginal torsion involves twisting of the testis within the tunica vaginalis. This is called "bell-clapper" deformity due to the lack of posterior attachment of the testis to the scrotum, thus allowing for potential twists and subsequent vascular compromise. This type of torsion can occur any time in life but usually is more common in the prepubertal and postpuberal male (Figure 5).
Figure 6. Normal scrotal radionuclide scan.
Figure 7. Scrotal scan revealing left photopenic area due to torsion.
These patients present with a history of pain with either acute or insidious onset that radiates to the groin. They may report episodes that resolve but most have not had similar symptoms. If there have been prior episodes with resolution and no therapy, the diagnosis is strongly suggestive of torsion of the testis. Patients may have nausea with or without vomiting and abdominal pain, but rarely fever. The abdominal pain may in fact be the chief complaint, leading one to not consider scrotal pathology. There are no complaints of urinary symptoms.
Physical examination reveals clearly unilateral edema and erythema of varying degrees in most patients. There is induration on palpation along with exquisite tenderness that in children may not allow for a complete exam, thus the epdidymis may be difficult to palpate. It is always important to check the contralateral testes to discern that they are in the proper vertical position. Prehn's sign (relief of pain on elevation) is not reliable enough in children to put any credence in it. Many try to use it to differentiate between epididymitis and torsion. If the diagnosis cannot be ruled out by the above findings and further testing, torsion of the testis or spermatic cord is a surgical emergency.
Figure 8. Scrotal scan with increased flow due to epididymitis.
Figure 9. Scrotal ultrasound with acute hydrocele.
Noninvasive testing has been used to differentiate torsion from epididymitis when there are overlapping signs and symptoms. Its use depends on availability to the clinician on a 24-hour basis and expertise in use and interpretation. Also, the size of the pediatric patient may preclude the use of certain tests.
Testicular radionuclide scan is the most commonly used adjunctive test (Figure 6). It reveals diminished or absent blood flow to the hemiscrotum as opposed to increased or lack of decrease with epididymitis (Figures 7 and 8). The accuracy depends on the technique of doing the test, size of the patient (cooperation), and the stage of the pathologic process. In the later stages there may be reactive hyperemia at the periphery of the testis, thus creating the picture of increased flow. If it is performed on younger patients (ie, small children), it is less accurate. Overall, if there is doubt about the diagnosis, this test is appropriate because it can be done within a few hours of the onset of symptoms. If these conditions cannot be met, the patient should undergo exploration to be certain of the diagnosis without additional delay.
Doppler ultrasound has been used in older patients but as a rule is not used often in younger ones due to the size of the patient, inadequate cooperation, and lack of sufficient expertise in certainty of the diagnosis. When appropriate it allows quick evaluation of blood flow, but for most children it delays diagnosis or treatment rather than supplementing it. Also, if there is spontaneous derotation of the torsed testicle there will be a normal study. Scrotal ultrasound will be discussed below as it relates to other causes of acute scrotum (Figure 9).
Epididymitis is also a common cause of the acute scrotum in children. Like torsion, it may present with pain but is usually insidious in onset over several days. It is associated with edema and erythema, the severity of which depends on the time course. Early in the course the enlarged epididymis can be palpated but, as progression occurs, may be obscured by surrounding edema. Unlike torsion it is not usually associated with gastrointestinal symptoms. There may be a fever but it is highly variable. Urinary symptoms are not uncommon (ie, dysuria, dribbling, or frequency). The urinalysis may reveal pyuria.
The causes of epididymitis can be bacterial, viral, traumatic, chemical, associated with systemic disease, or idiopathic (Table 2). Bacterial epididymitis is the most common and is frequently due to coliforms. StaphykMKcus has also been reported as an agent. Viral cases are represented by those that resolve without antibiotic therapy. Preceding trauma has caused epididymitis, in which case the history aids the diagnosis.
Postpuberal causes include venereal organisms such as Neisseria gtmorrheae or Chlamydia tnchomatis. In these cases, there may be associated urethral discharge that can be cultured and smeared. Since these are sexually transmitted diseases, the partner needs to be evaluated and treated as well. In infants, Hemophilis influenzae type B has also been reported.
In patients with either bacterial or chemical causes an effort should be made to evaluate the urinary tract for congenital anomalies. These patients obviously will require not only treatment of the infection but also correction of the underlying anomaly (Figures 10 and 11). Various systemic disorders such as HenochSchönlein purpura may present with a vasculitic process involving the epididymis; others include sarcoidosis and Kawasaki syndrome. The presence of the disease should raise suspicion in these patients. There are also the children who present with the acute scrotal epididymitis for which no etiology can be identified. Some may require biopsy for diagnosis.
Microorganisms Associated With Clinical Epididymitis
Orchitis presents less frequently but appears similar to epididymitis except epididymis is not usually involved. These patients may have exquisite pain secondary to swelling of the testis. Mumps orchitis is the best known cause but there is a wide variety of viruses and pygenic organisms that cause this entity. Often there is associated hydrocele although it is not appreciated initially due to edema. The testis is usually swollen, unlike with epididymitis where early on only the epididymis is swollen. Mumps orchitis usually presents approximately four to six days after parotitis and, interestingly, is usually unilateral.
Figure 10. Acute scrotum in patient with imperforate anus and rectourethral fistula.
Figure 11. Intraoperative findings of epididymitis.
Figure 12. Torsion of appendix testis.
Figure 13. Typical idiopathic scrotal edema.
TORSION OF TESTICULAR APPENDAGES
Torsion of testicular appendages is more common in younger pediatric patients (Figure 12). Although it has a less severe impact on the patient, the findings on presentation may make the differential with testicular torsion difficult enough to warrant emergency exploration. Torsion of testicular appendages accounts for a significant percentage of the cases of the acute scrotum in younger patients. It presents early with insidious onset but progresses to the full-blown syndrome if seen later. The exam differs from that for epididymitis in being localized in tenderness to the upper pole of testis or epididymis. The presence of a so-called "blue dot" sign is pathognomic of this entity, representing the necrotic appendage beneath the skin. Unlike testicular torsion, if the diagnosis is certain it can be observed along with analgesics only. However, if due to edema and erythema, torsion of the testes cannot be ruled out. Emergency exploration should be carried out to clarify the diagnosis and excise the appendage. In cases where conservative observation and analgesic therapy is followed, the clinical process may be prolonged.
IDIOPATHIC SCROTAL EDEMA
Although a well substantiated cause has not been found, idiopathic scrotal edema has become recognized as a real entity. It is manifested by onset of unilateral or bilateral edematous scrotum with erythema (Figure 13). Usually there is minimal tenderness that may extend out of the scrotum despite a normal testis on palpation. It has a self-limiting course if left alone over several days. In most cases, laboratory tests are normal. Again, if uncertainty leads to exploration, the testis and the epididymis are normal with findings of edematous skin only. There is no indication for antibiotic therapy.
The previously discussed torsion of the testis or testicular appendage and epididymitis along with idiopathic scrotal edema account for the overwhelming majority of cases of acute scrotum in children. However, there are other causes of which the pediatrician should be aware (Table 1).
Strangulated inguinal hernia is usually readily defined with definite inguinal mass unless only the omentum is strangulated. Pediatric patients with testicular tumors present with pain and enlargement of the scrotum. In cases where trauma has occurred secondarily, discoloration may be present due to hemorrhage into the tumor. Scrotal ultrasound is helpful in these cases along with a testicular scan. HenochSchönlein purpura is noted for causing acute scrotum in younger boys. It is usually associated with a petechial rash and other signs; however, be aware that torsion also may occur with the same scrotal findings. Once again, if there is any doubt, a testicular scan should be done.
Figure 14. Flow diagram of management of boy with acute scrotal swelling.
Primary scrotal trauma can present with edema and erythema for which definite history may or may not be obtainable. An insect bite is a typical example. If trauma involves the abdomen there may be concomitant bluish discoloration that represents blood from the peritoneal cavity finding its way through the patent processus into the scrotum as a secondary hematocele. Similarly, children with an intra-abdominal source for sepsis may also present with an acute pyocele in the scrotum. The physical examination of the abdomen should give a clue as to the etiology.
The pediatric acute scrotum can be a diagnostic dilemma. The history, physical examination, and appropriate tests are important. The correct diagnosis will be arrived at if the systematic approach is remembered (Figure 14). In cases where testicular torsion cannot be ruled out (such as an epididymitis or torsion of the appendix testis where torsion of the testis is mimicked), the patient will need scrotal exploration, it is hoped that with further availability of scanning and expertise by pediatric surgeons the false negative exploration will decrease in number. Remember, occasionally a patient will require scrotal exploration with biopsy of the epididymis to delineate the underlying cause. In most cases of epididymitis, effort should be made to identify the cause by culture of urine, urethral discharge, or appropriate fluid from the epididymis. Urological evaluation will be necessary in the younger boys, particularly those with recurrent episodes, to mie out congenital anomalies. Only by following this systematic approach can clinicians hope to preserve gonadal function and achieve best care of their patients.
1. Anderson PAM. Giacomantonio JM: The acutely painful scrotum in children: Review of II) consecutive cases. Can Med Assoc i 1985; 132:115).
2. Bickerstaff Kl. Sethta K, Mûrie JA: Doppler ultrasonography in the diagnosis of acute scrotal pain. BrJ San: 1988; 75:238.
3. ClaJamone AA. Valvo JR. Altebarmakian VK, et al: Acute scrotal swelling in children. J Püdiatr Surg 1984; 19:581.
4. Cranston DW, Moisey CU: The management of acute scrotum pain. BrJ Surg 1983: 70:505.
5. Dunn EK. Macchia RJ. Chauhan PS, et al: Scintiscan for acute intrascroral conditions. CIm Nucl Med 1986: 11:381.
6. Evans JP. Snyder HMcC: Idiopathic scrotal edema. Uwbgy 1977: 9:549.
7. Fonkalsnid EW: Testicular uruksccnt and torsion. PeJiuir Clin North Am 1987; 34:1305.
8. Hemalatha W. RickwwJ ? MK: The diagnosis and management of acute scrotal conditions in boys. J Urul 1981; 53:455.
9. Hitch DC. GiJday DL. Sbandirne B. et ah A new approach ft» the diagnosis of testicular torsion. J FWuirr Surg 1976; 11:537.
10. Krone KD. Cam.ll BA: Scrotal ultrasound. Radiol CUn North Am 1985; 23:121.
11. Lin YC, King DR, Birken GA, et al: Acute scrotum due to Haemophilus influenzae type b. J IWiW Surg 1988; 23:183.
12. Likitnukul S, McCracken OH Jt. Nelson JD. Votteler TP: Epididymitis in children and adolescents. Am J Db CMi 1987; 141:41.
13. Melekos M. Ashach HW, Markou SA: Etiology of acute scrotum in 100 boys with regard to age distribution. J Urol 1988; 139:1023.
14. Sarria A. Olivan G. Fleta J. et al: The Pediatrie Forum. Am J Dis CkM 1988; 142:810.
15. Sharer WC: Acute scrotal pathokißy· Surg CIm Nor* Am 1982: 62:955.
16. Son KA. KofT SA: Evaluation and management of acute scrotum, ftim Gm 1985; 12:637.
17. Wilson-Story D-. Scrotal swellings in the under 5s. Ardi Dis Child 1987; 62:50.
Causes off an Acute Scrotum
Microorganisms Associated With Clinical Epididymitis