The diagnosis and treatment of the acute scrotum in children and adolescents

Testicular scanning: evaluating the acute scrotum in the clinical setting

In a retrospective study of patients with acute scrotal pain presenting to the hospitals of Southern Illinois University School of Medicine from January 1982 until September 1987, determination was made of the appropriate use of testicular scan for definitive diagnosis. Though the testicular scan is a highly sensitive and specific examination in the identification of testicular torsion, we believe its routine use in clinical practice is limited. Appropriate utilization of the examination requires its use in high-risk groups with equivocal physical findings or in patients with unusual presentations of age, anatomy, or neurologic deficit. The scan if used for routine screening of the acute scrotum would result in needless delays and unjustifiable expense when it is mandatory that the treatment be immediate surgical exploration.

Intermittent torsion: association with horizontal lie of the testicle

The importance of making an early diagnosis of intermittent testicular torsion cannot be over-emphasized. We report on 3 patients with recurrent episodes of severe testicular pain but who were pain-free at evaluation. All 3 patients were found to have a horizontal lie of the symptomatic testicle and a normal vertical axis in the contralateral asymptomatic testicle. Scrotal exploration revealed a bell-clapper deformity in all 3 patients. A history of recurrent scrotal pain and horizontal testicular lie, even in the absence of pain at the time of physical examination, is a strong indication for exploration and bilateral testicular fixation.

Indications for conservative management of acute scrotal pain in children

Forty-three boys who presented with acute scrotal pain were studied retrospectively. Of these, 40 had torsion of scrotal contents. Torsion of testicular appendages, a self limiting condition, tended to present later than testicular torsion (P = 0.002). The testis was saved in all 11 cases of testicular torsion explored within 12h of the onset of pain but orchidectomy was required in four who presented later. In 11 cases, a torted testicular appendage diagnosed as a tender nodule was found on examining the upper pole of the testis. The remaining 14 cases of torted appendage were diagnosed at operation because testicular torsion could not be excluded due to scrotal swelling. Most (12) of this operated group were not seen until 3 days after the onset of pain. This study suggested that urgent operation was unnecessary in those in whom a tender nodule was found (pathognomonic of a torted appendage) and in those presenting after more than 24h of pain with scrotal erythema and oedema. The likely diagnosis in the latter case is a torted appendage and in cases of torsion of the testis there is no prospect of salvage at this stage. These guidelines were applied to a group of 20 boys studied prospectively. In eight, all with less than 24h of pain, immediate exploration was undertaken and testicular torsion was confirmed in six. The remaining 12 fulfilled the criteria for conservative management and were observed. All had normal testes at late review. Careful clinical assessment in boys with scrotal pain indicates which cases may be treated by non-operative management without fear of losing a salvageable testis.

The effect of unilateral experimental testicular torsion on spermatogenesis and fertility

Significant subfertility exists in patients following unilateral testicular torsion, implying bilateral testicular disease. Immunological activation has been detected after experimental torsion and the present study sought to demonstrate immunologically mediated effects on contralateral spermatogenesis following experimental torsion, as well as quantifying ipsilateral damage. Early and late effects of torsion on bilateral spermatogenesis were studied at 1 and 6 months in 10 groups each containing 20 rats. Gross and histological examination, direct immunofluorescence tests, vas deferens counts and copulation studies were performed. Severe ipsilateral damage was noted, even after brief torsion periods. No contralateral testicular effects, immunological or otherwise, were observed. Ipsilateral damage after torsion may have been underestimated. There is no damage to contralateral testicular exocrine function following unilateral experimental torsion.

Torsion of scrotal contents in children

One hundred and forty consecutive cases of torsion of scrotal contents were reviewed retrospectively. There were 95 cases of torsion of the testicular appendage and 45 cases of testicular torsion. Testicular torsion was more common on the left and patients tended to present earlier with more systemic upset in the form of vomiting, abdominal and groin pain than patients with torsion of a testicular appendage. Pathognomic features of examination were an elevated or ectopic testis in 50% of cases of testicular torsion and a palpable tender blue nodule in 21% of cases of torsion of a testicular appendage. We believe that it is often possible to distinguish between these two conditions and, where this is possible, a trial of conservative management is justified for torsion of a testicular appendage.

Diagnosis and management of testicular torsion: pitfalls and perils

When a patient presents with acute scrotal pain and physical findings do not permit confident exclusion of testicular torsion, the initial step in management is immediate consultation with a urologist, pediatric surgeon, or general surgeon. Scrotal imaging is fallible and takes time that may be critical to salvage of the testis. Manual detorsion may be indicated when specialty support is not immediately available, but even if this technique is apparently successful, the patient should be transferred to specialty care without delay.