Causes of scrotal pain in children and adolescents
- Joel S Brenner, MD, MPH
Joel S Brenner, MD, MPH
- Associate Professor, Sports Medicine and Adolescent Medicine
- Eastern Virginia Medical School
- Aderonke Ojo, MD
Aderonke Ojo, MD
- Associate Professor of Pediatric Emergency Medicine
- Baylor College of Medicine
- Section Editors
- Amy B Middleman, MD, MPH, MS Ed
Amy B Middleman, MD, MPH, MS Ed
- Section Editor — Adolescent Medicine
- Professor of Pediatrics, Chief of Adolescent Medicine
- University of Oklahoma Health Sciences Center
- Gary R Fleisher, MD
Gary R Fleisher, MD
- Editor-in-Chief — Adult and Pediatric Emergency Medicine
- Section Editor — Pediatric Signs and Symptoms
- Egan Family Foundation Professor
- Harvard Medical School
- Laurence S Baskin, MD, FAAP
Laurence S Baskin, MD, FAAP
- Section Editor — Pediatric Urology
- Frank Hinman, Jr., MD, Distinguished Professorship in Pediatric Urology
- Chief Pediatric Urology
- Professor of Urology and Pediatrics
- UCSF Benioff Children's Hospital
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
The spectrum of conditions that affect the scrotum and its contents ranges from incidental findings to pathologic events that require expeditious diagnosis and treatment (eg, testicular torsion, testicular cancer). The most common causes of acute scrotal pain in children and adolescents include testicular torsion, torsion of the appendix testis, and epididymitis. In one review of 238 consecutive boys, ages 0 to 19 years, who presented with acute scrotal pain to a children's hospital over a two-year period, 16 percent had testicular torsion, 46 percent had torsion of the appendix testis, and 35 percent had epididymitis .
The causes of scrotal pain will be reviewed here. The evaluation of scrotal pain or swelling and causes of scrotal swelling are discussed separately. (See "Evaluation of scrotal pain or swelling in children and adolescents" and "Causes of painless scrotal swelling in children and adolescents".)
Testicular torsion is the most dramatic and potentially serious of the acute processes affecting the scrotal contents because it may result in the loss of the testicle. Normal testicular anatomy is depicted in the figure (figure 1).
Intravaginal torsion results from inadequate fixation of the testis to the tunica vaginalis through the gubernaculum testis. The most common abnormality associated with testicular torsion is known as the "bell clapper" deformity: The testicle lacks the normal attachment to the tunica vaginalis (permitting increased mobility) and rests transverse within the scrotum (figure 2) . The bell clapper deformity may be bilateral and predisposes to testicular torsion.
If fixation of the lower pole of the testis to the tunica vaginalis is insufficiently broad-based or absent, the testis may torse (twist) on the spermatic cord (figure 3). The twisting of the spermatic cord within the tunica vaginalis causes venous compression and subsequent edema of the testicle and cord with ultimate ischemia of the testicle caused by arterial occlusion [2,3].
- Lewis AG, Bukowski TP, Jarvis PD, et al. Evaluation of acute scrotum in the emergency department. J Pediatr Surg 1995; 30:277.
- Kass EJ, Lundak B. The acute scrotum. Pediatr Clin North Am 1997; 44:1251.
- Tumeh SS, Benson CB, Richie JP. Acute diseases of the scrotum. Semin Ultrasound CT MR 1991; 12:115.
- Williamson RC. Torsion of the testis and allied conditions. Br J Surg 1976; 63:465.
- Edelsberg JS, Surh YS. The acute scrotum. Emerg Med Clin North Am 1988; 6:521.
- Rohn RD. Male genitalia: Examination and findings. In: Comprehensive Adolescent Health Care,, Friedman SB, Fisher M, Schonberg SK, et al. (Eds), Mosby-Year Book, St. Louis 1998. p.1078.
- Anderson MM, Neinstein LS. Scrotal disorders. In: Adolescent Health Care: A Practical Guide, Neinstein LS. (Ed), Williams & Wilkins, Baltimore 1996. p.464.
- Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics 1998; 102:73.
- Karmazyn B, Steinberg R, Kornreich L, et al. Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys. Pediatr Radiol 2005; 35:302.
- Petrack EM, Hafeez W. Testicular torsion versus epididymitis: a diagnostic challenge. Pediatr Emerg Care 1992; 8:347.
- Tunnessen WW Jr. Scrotal swelling. In: Signs and Symptoms in Pediatrics, 3rd, Lippincott, Williams & Wilkins, Philadelphia 1999. p.606.
- Perron CE. Pain: Scrotal. In: Textbook of Pediatric Emergency Medicine, 5th, Fleisher GR, Ludwig S, Henretig FM. (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.525.
- Pillai SB, Besner GE. Pediatric testicular problems. Pediatr Clin North Am 1998; 45:813.
- Caldamone AA, Valvo JR, Altebarmakian VK, Rabinowitz R. Acute scrotal swelling in children. J Pediatr Surg 1984; 19:581.
- Rabinowitz R. The importance of the cremasteric reflex in acute scrotal swelling in children. J Urol 1984; 132:89.
- Nelson CP, Williams JF, Bloom DA. The cremasteric reflex: a useful but imperfect sign in testicular torsion. J Pediatr Surg 2003; 38:1248.
- Caesar RE, Kaplan GW. The incidence of the cremasteric reflex in normal boys. J Urol 1994; 152:779.
- Jefferies MT, Cox AC, Gupta A, Proctor A. The management of acute testicular pain in children and adolescents. BMJ 2015; 350:h1563.
- Stillwell TJ, Kramer SA. Intermittent testicular torsion. Pediatrics 1986; 77:908.
- Eaton SH, Cendron MA, Estrada CR, et al. Intermittent testicular torsion: diagnostic features and management outcomes. J Urol 2005; 174:1532.
- Munden MM, Williams JL, Zhang W, et al. Intermittent testicular torsion in the pediatric patient: sonographic indicators of a difficult diagnosis. AJR Am J Roentgenol 2013; 201:912.
- Srinivasan A, Cinman N, Feber KM, et al. History and physical examination findings predictive of testicular torsion: an attempt to promote clinical diagnosis by house staff. J Pediatr Urol 2011; 7:470.
- Barbosa JA, Tiseo BC, Barayan GA, et al. Development and initial validation of a scoring system to diagnose testicular torsion in children. J Urol 2013; 189:1859.
- Kalfa N, Veyrac C, Lopez M, et al. Multicenter assessment of ultrasound of the spermatic cord in children with acute scrotum. J Urol 2007; 177:297.
- Lam WW, Yap TL, Jacobsen AS, Teo HJ. Colour Doppler ultrasonography replacing surgical exploration for acute scrotum: myth or reality? Pediatr Radiol 2005; 35:597.
- Paltiel HJ, Connolly LP, Atala A, et al. Acute scrotal symptoms in boys with an indeterminate clinical presentation: comparison of color Doppler sonography and scintigraphy. Radiology 1998; 207:223.
- Baker LA, Sigman D, Mathews RI, et al. An analysis of clinical outcomes using color doppler testicular ultrasound for testicular torsion. Pediatrics 2000; 105:604.
- Yazbeck S, Patriquin HB. Accuracy of Doppler sonography in the evaluation of acute conditions of the scrotum in children. J Pediatr Surg 1994; 29:1270.
- Kass EJ, Stone KT, Cacciarelli AA, Mitchell B. Do all children with an acute scrotum require exploration? J Urol 1993; 150:667.
- Nussbaum Blask AR, Bulas D, Shalaby-Rana E, et al. Color Doppler sonography and scintigraphy of the testis: a prospective, comparative analysis in children with acute scrotal pain. Pediatr Emerg Care 2002; 18:67.
- Sheldon CA. Undescended testis and testicular torsion. Surg Clin North Am 1985; 65:1303.
- Bartsch G, Frank S, Marberger H, Mikuz G. Testicular torsion: late results with special regard to fertility and endocrine function. J Urol 1980; 124:375.
- Krarup T. The testes after torsion. Br J Urol 1978; 50:43.
- Mastrogiacomo I, Zanchetta R, Graziotti P, et al. Immunological and clinical study of patients after spermatic cord torsion. Andrologia 1982; 14:25.
- Williamson RC, Thomas WE. Sympathetic orchidopathia. Ann R Coll Surg Engl 1984; 66:264.
- Harrison RG, Lewis-Jones DI, Moreno de Marval MJ, Connolly RC. Mechanism of damage to the contralateral testis in rats with an ischaemic testis. Lancet 1981; 2:723.
- Zanchetta R, Mastrogiacomo I, Graziotti P, et al. Autoantibodies against Leydig cells in patients after spermatic cord torsion. Clin Exp Immunol 1984; 55:49.
- Puri P, Barton D, O'Donnell B. Prepubertal testicular torsion: subsequent fertility. J Pediatr Surg 1985; 20:598.
- Garel L, Dubois J, Azzie G, et al. Preoperative manual detorsion of the spermatic cord with Doppler ultrasound monitoring in patients with intravaginal acute testicular torsion. Pediatr Radiol 2000; 30:41.
- Cornel EB, Karthaus HF. Manual derotation of the twisted spermatic cord. BJU Int 1999; 83:672.
- Sessions AE, Rabinowitz R, Hulbert WC, et al. Testicular torsion: direction, degree, duration and disinformation. J Urol 2003; 169:663.
- Fisher R, Walker J. The acute paediatric scrotum. Br J Hosp Med 1994; 51:290.
- Boettcher M, Bergholz R, Krebs TF, et al. Differentiation of epididymitis and appendix testis torsion by clinical and ultrasound signs in children. Urology 2013; 82:899.
- Baldisserotto M. Scrotal emergencies. Pediatr Radiol 2009; 39:516.
- Melloul M, Paz A, Lask D, et al. The pattern of radionuclide scrotal scan in torsion of testicular appendages. Eur J Nucl Med 1996; 23:967.
- Flanigan RC, DeKernion JB, Persky L. Acute scrotal pain and swelling in children: a surgical emergency. Urology 1981; 17:51.
- Merlini E, Rotundi F, Seymandi PL, Canning DA. Acute epididymitis and urinary tract anomalies in children. Scand J Urol Nephrol 1998; 32:273.
- Siegel A, Snyder H, Duckett JW. Epididymitis in infants and boys: underlying urogenital anomalies and efficacy of imaging modalities. J Urol 1987; 138:1100.
- Likitnukul S, McCracken GH Jr, Nelson JD, Votteler TP. Epididymitis in children and adolescents. A 20-year retrospective study. Am J Dis Child 1987; 141:41.
- Somekh E, Gorenstein A, Serour F. Acute epididymitis in boys: evidence of a post-infectious etiology. J Urol 2004; 171:391.
- Santillanes G, Gausche-Hill M, Lewis RJ. Are antibiotics necessary for pediatric epididymitis? Pediatr Emerg Care 2011; 27:174.
- Haynes BE, Bessen HA, Haynes VE. The diagnosis of testicular torsion. JAMA 1983; 249:2522.
- Gislason T, Noronha RF, Gregory JG. Acute epididymitis in boys: a 5-year retrospective study. J Urol 1980; 124:533.
- Schalamon J, Ainoedhofer H, Schleef J, et al. Management of acute scrotum in children--the impact of Doppler ultrasound. J Pediatr Surg 2006; 41:1377.
- Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64:1.
- Updated recommended treatment regimens for gonococcal infections and associated conditions -- United States, April 2007. www.cdc.gov/std/treatment/2006/GonUpdateApril2007.pdf (Accessed on April 18, 2007).
- Committee on Infectious Diseases. The use of systemic fluoroquinolones. Pediatrics 2006; 118:1287.
- Lau P, Anderson PA, Giacomantonio JM, Schwarz RD. Acute epididymitis in boys: are antibiotics indicated? Br J Urol 1997; 79:797.
- Ioannides AS, Turnock R. An audit of the management of the acute scrotum in children with Henoch-Schonlein Purpura. J R Coll Surg Edinb 2001; 46:98.
- Green MG. The genitalia. In: Pediatric Diagnosis: Interpretatino of Symptoms and Signs in Children and Adolescents, 6th, WB Saunders, Philadelphia 1998. p.101.
- McGee SR. Referred scrotal pain: case reports and review. J Gen Intern Med 1993; 8:694.
- Méndez R, Tellado M, Montero M, et al. Acute scrotum: an exceptional presentation of acute nonperforated appendicitis in childhood. J Pediatr Surg 1998; 33:1435.
- TESTICULAR TORSION
- Clinical presentation
- - Intermittent torsion
- - Role of imaging
- - Manual detorsion
- Neonatal testicular torsion
- TORSION OF THE APPENDIX TESTIS OR APPENDIX EPIDIDYMIS
- Clinical presentation
- Clinical presentation
- OTHER CAUSES
- Incarcerated inguinal hernia
- Henoch-Schönlein purpura (IgA vasculitis)
- Referred pain
- Nonspecific scrotal pain
- INFORMATION FOR PATIENTS