Saving Balls 101: The Acute Scrotum

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Early diagnosis of testicular torsion will save a ball…

An 8 year old presents with right testicular pain. What are your differential diagnoses and why?

 

Peak Age Frequency Comments
Torsion appendix testis Prepubertal (9-11 years) 60%
Torsion testis Neonatal; puberty 30%
Epididymo-orchitis Infancy < 10% Look for underlying urinary tract abnormality
Idiopathic Scrotal Oedema 5-6 years < 10% Testes are non-tender
Trauma MAY be red herring

 

The AGE of the boy with the acute scrotum is the biggest clue to the diagnosis. (see table)

Although testicular torsion is commoner in pubertal boys and neonates, it can strike at any age.

Even though torsion of appendix testis may be the commonest cause of an acute scrotum in the paediatric age group, TESTICULAR torsion should still be the #1 differential, as it is so important not to miss it.

I am always asking myself: “Why is it NOT testicular torsion?” If I can’t answer that satisfactorily, that boy is going to theatre.


Torsion of appendix testis

Why commoner in boys aged 9-11?

Torsion of the appendix testis is generally at the age where the boy is about to hit puberty – the oestrogen surge that precedes testosterone will stimulate the mesonephric (aka Mullerian aka “female”) remnant that is the appendix testis (aka hydatid of Morgagni), which engorges and twists on its narrow stalk. 

How to distinguish from testicular torsion?

Testicular appendage torsion Testiscular torsion
Onset usually slower / more insidious – longer history of pain (eg on/off for 1-2 days) Onset usually quite sudden
May have associated vomiting
Comfortable if sitting still, with legs apart(usually looks fairly happy playing on iPad or iPhone, until we approach) More commonly in pain all the time
Tender over upper poleRest of testis may be non-tender Tender all over testis
May be able to see Blue Dot signCremasteric reflex may be present Testis may be riding higher, or horizontal lie.

Torsion of appendix testis presenting late (i.e. after 2-3 days) may be associated with significant hydrocele that will obliterate all the distinguishing features listed above, and make it almost impossible to distinguish from testicular torsion.

What treatment is required?

 

Usually seek diagnostic  confirmation with Surgical Registrar.

If you’re not sure it is NOT testicular torsion, urgent referral for scrotal exploration.

If you (or we) are sure it is torsion of appendix testis:

If pain is not controlled on oral analgesia, theatre to excise the torted appendix testis.

If pain is controlled on paracetamol/ibuprofen, discharge with education as to natural history of appendage torsion, and advice to return if pain gets worse. May be useful to rest up, to minimise oedema in scrotum.


Testicular torsion

This diagnosis must be considered in all cases.

Symptoms as above

Clinical signs can be subtle or obvious.

Trap for young players:

Beware intermittent torsion – there may be no signs as the testis may have de-torted. Boys with recurrent pain that sounds like torsion should be referred to a surgeon for consideration of non-urgent scrotal exploration, especially if there is horizontal lie!

Beware undescended testes – they are at higher risk of torsion. The patient will have an empty scrotum, and a painful lump in the groin…


Perinatal torsion

How is it different to usual torsion?

The torsion usually happens in the perinatal period (i.e. can be antenatal, or early postnatal period).

It is usually extravaginal torsion – i.e. the tunica vaginalis is not yet adherent to the surrounding scrotal tissue.

It is classically described as PAINLESS.

The testis is usually dead by the time of diagnosis/operation.

The other side is at risk of metachronous torsion (timing is variable).

 The aim is to save the other ball, as the affected one is usually unsalvageable.

How to recognise it?

perinatal torsion

We usually get referrals from the Nursery, but occasionally parents will bring in their neonate to Emergency with one large purple hemiscrotum.

Look for asymmetry of the testes/hemiscrotum. The hemiscrotum is enlarged or indurated, but not always tender.


Idiopathic scrotal oedema

idiopathic scrotal oedema

This can be almost thought of as cellulitis of the scrotum.

As the name suggests, most of the time we do not know the cause. Sometimes there is a small scratch or insect bite in the scrotal area. It tends to affect pre-schoolers.

It tends to start as a small spot and then involves the whole hemiscrotum – from the base of the penis to the perineum, and even laterally to the inguinal area, and sometimes both hemi-scrotum.

Importantly, the testes are NOT tender.

The scrotal skin itself is indurated, oedematous, red and tender.

If you can reach the testis through unaffected skin (sometimes from the non-affected scrotum), you will find that it is not tender, and you can safely exclude torsion.


Epididymo-orchitis

This would be amongst the last on my list of differential diagnoses, and not one I would confer easily.

It tends to affect the very young or very old paediatric patient.

In the middle age range (2–12 years), the vas is narrow, and no semen is produced, so there are fewer instances of epididymitis.

In older post-pubertal boys, epididymitis can occur due to reflux of secretions up a wide vas. Sexual contact also needs to be taken into consideration.

In the infant with epididymitis, urinary tract anomalies need to be excluded e.g. ureteric anomalies. In this age group, I would confirm the diagnosis with urine culture, and obtain a renal tract ultrasound.

 

References:

Gutti JM, Murphy JP. Current management of the acute scrotum. Seminars of Pediatric Surgery, 2007; 16(1): 58-63

 

Part 2 of Saving Balls 101: inguinoscrotal masses will be coming soon.

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About 

Camille Wu is a paediatric surgeon based at Sydney Children’s Hospital.

Author: Camille Wu

Camille Wu is a paediatric surgeon based at Sydney Children’s Hospital.