Scrotal Pain, Acute
Kate Kraft
INTRODUCTION
When evaluating a patient with acute scrotal pain, testicular torsion should be considered the diagnosis until proven otherwise. Testicular torsion is the only condition in the differential diagnosis of acute scrotum that absolutely requires emergent surgical intervention. This complaint must be evaluated in an emergency setting; telephone consultation for such symptoms is dangerous because valuable time may be wasted, leading to testicular loss. One in every 4,000 males less than 25 years of age will develop testicular torsion. The incidence is bimodal, although testicular torsion can occur at any age. A peak incidence is seen in the first few days of life and again at puberty. Between 16% and 42% of boys and young adults presenting with acute scrotal pain to a hospital emergency department prove to have testicular torsion. This represents a surgical emergency because irreversible ischemic injury can occur after 4 hours, and testicular viability decreases significantly beyond 6 hours from the onset of pain. Therefore, patients presenting with this complaint must be given high priority in an acute-care setting.
DIFFERENTIAL DIAGNOSIS OF ACUTE/SUBACUTE SCROTUMAnatomic
Testicular torsion
Torsion of the appendix testis
Torsion of the appendix epididymis
Inguinal hernia
Hydrocele
Inflammatory
Epididymitis
Epididymo-orchitis
Trauma
Insect bite
Inflammatory vasculitis (Henoch-Schönlein purpura)
Idiopathic scrotal edema
Others
Dermatologic lesions
Varicocele
Tumor
Ureteral colic (referred pain)
Nonurogenital pathology (e.g., musculoskeletal)
DIFFERENTIAL DIAGNOSIS
Common Causes
Testicular torsion, torsion of the testicular appendices, and epididymitis account for approximately 95% of all acute scrotum cases. In one study, almost 70% of all cases of acute scrotal pain were classified as either a testicular torsion or torsion of the appendix testis.
Testicular Torsion
Testicular torsion results from a complete twist of the testis on its vascular pedicle. The resulting ischemia produces pain that can be constant or colicky. The sudden onset of pain is often accompanied by nausea and vomiting. The testis in question is pulled up high in the scrotum (secondary to the twists in the spermatic cord). In majority of the cases, no cremasteric reflex can be elicited. Since the cremasteric reflex is not always present, especially in older males, absence of a cremasteric reflex does not invoke a diagnosis of testicular torsion.
Testicular torsion may be extravaginal or intravaginal. Extravaginal torsion occurs almost exclusively in neonates and accounts for approximately 10% of testicular torsion. It results from twisting of the tunica vaginalis and testis before complete descent into the scrotum and fusion of the tunica to the scrotal wall. The majority of testicular torsion cases are intravaginal in which the testis rotates freely within the tunica vaginalis. This occurs due to a congenital anatomic malpositioning of the testis, termed the bell-clapper deformity. A normal testis and its blood supply are attached to the tunica vaginalis posteriorly. However, with the bell-clapper deformity, no such posterior attachment exists to anchor the testis and prevent it from twisting completely around the spermatic cord. Establishing this diagnosis early is crucial, for the situation presents a surgical emergency; the longer the delay in diagnosis, the lower the chances for testicular salvage.
Torsion of the Testicular Appendices
Torsion of the testicular appendices results when these tiny vestigial remnants twist around their base and become ischemic. The typical presentation is characterized by a gradual onset of pain, and patients often note significant scrotal swelling and erythema secondary to a reactive hydrocele. The appetite is unaffected, and nausea and vomiting are rare. It is often possible to elicit a strong cremasteric reflex, which greatly aids in distinguishing this condition from torsion of the testis. If the patient presents early on, point tenderness is noted on the upper outer pole. Some patients have a “blue-dot sign” on the scrotum. Once the diagnosis is established, treatment consists of nonsteroidal anti-inflammatories and rest. Over a 1-week period, 90% to 95% of these patients improve with no need for further treatment. In about 5% to 10% of cases, the appendix torses intermittently, and surgical excision of the appendix testis is warranted.
Epididymitis
This diagnosis is extremely rare in the prepubertal boy. A true bacterial epididymitis in a prepubertal boy is usually secondary to a structural anomaly of the genitourinary tract. In the adolescent male, the usual causes of bacterial epididymitis
are chlamydia and gonorrhea. However, at times the adolescent male may present with a normal urinalysis and a tender, inflamed epididymis. Often these patients present following a period of heavy physical exertion such as weight lifting. It is believed that reflux of sterile urine via the prostatic ducts under pressure sets up inflammation within the epididymis. Regardless of etiology, the diagnosis of epididymitis is established by the history and physical findings. The onset of pain is slow, and the appetite is preserved. A history of urethral discharge and/or dysuria may be noted. The physical examination demonstrates a nontender testis with a large and very tender epididymis palpable posteriorly. If a bacterial process is suspected, appropriate therapy with antibiotics should be prescribed. Noninfectious epididymitis should be treated with scrotal support, limited physical activity, and nonsteroidal anti-inflammatory medications until symptoms improve.
are chlamydia and gonorrhea. However, at times the adolescent male may present with a normal urinalysis and a tender, inflamed epididymis. Often these patients present following a period of heavy physical exertion such as weight lifting. It is believed that reflux of sterile urine via the prostatic ducts under pressure sets up inflammation within the epididymis. Regardless of etiology, the diagnosis of epididymitis is established by the history and physical findings. The onset of pain is slow, and the appetite is preserved. A history of urethral discharge and/or dysuria may be noted. The physical examination demonstrates a nontender testis with a large and very tender epididymis palpable posteriorly. If a bacterial process is suspected, appropriate therapy with antibiotics should be prescribed. Noninfectious epididymitis should be treated with scrotal support, limited physical activity, and nonsteroidal anti-inflammatory medications until symptoms improve.
Hernia/Hydrocele
Patients may present with an incarcerated hernia that produces significant pain. The hernia sac represents an extension of the peritoneal cavity, which can cause pain when suddenly entrapped. The findings of an enlarged scrotum that transilluminates in conjunction with a thickened inguinal bulge provide evidence for a patent processus vaginalis. This allows for peritoneal fluid to roll down and pool within the scrotum. The testis is not tender in this setting. On occasion, the patent processus vaginalis expands from a small tunnel that only allows for passage of fluid to a much larger diameter that enables bowel or omentum to herniate into the sac. Presence of bowel or omentum produces a thicker spermatic cord. On occasion, the bowel or omentum becomes inflamed, causing pain and becoming more difficult to reduce. At this point, surgical consultation is required.
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