Acute scrotum
Key points
Main differentials of acute scrotum:
Testicular torsion - surgical emergency, requires urgent exploration, should be done on site if possible - transfer if patients should only be in exceptional circumstances
Torsion of the hydatid of Morgagni - very common in children, exploration is warranted if unable to exclude testicular torsion
Epididymitis - more likely in children with urological abnormalities e.g. vesicoureteric reflux. Amiodarone can cause epididymitis. Exploration is warranted if unable to exclude testicular torsion
Nerve supply to testis and scrotum:
L1-2 > iliohypogastric, ilioinguinal, genitofemoral nerves
S2-4 > pudendal nerve
T10-L1, S2-4 > Autonomic supply (pain can be referred to abdomen)
Examination for abdominal pain in boys should always include testicular examination
Blood supply to the testis:
Aorta > gonadal artery
Superior vesical artery > Deferential artery (artery to the vas)
Inferior epigastric artery > cremasteric artery
Pampiniform plexus > gonadal vein > renal vein (left), IVC (right)
Standard scenario
Child presents with acute scrotum
Torsion excluded clinically - USS may have role
Unable to exclude torsion - book for urgent scrotal exploration
Options for fixation in torsion:
Non-absorbable sutures (usually 3-point)
Absorbable sutures (usually 3-point)
Sutureless fixation (Dartos pouch/Jaboulay)
No evidence for a particular methods superiority over others
Follow up to check for atrophy if torsion reduced
Offer prosthetic at a later date near end of or after puberty if orchidectomy performed
Special scenario - Chronic orchalgia
Differentials:
Intermittent testicular torsion
Epididymitis secondary to renal tract abnormality
History, exam and urine dip to differentiate
If pain worse when passing urine - may suggest refluxing vas - advise hydration
If likely intermittent torsion - offer fixation
If investigations normal or ongoing pain after fixation
Check for depression/anxiety, refer to pain team
Special scenario - acute scrotum in a neonate
Differentials:
1. Torsion
2. Tumour
Contralateral synchronous torsion is a major risk - would render patient anorchic
Investigation and exploration should be on urgent basis as contralateral torsion can occur within hours
If noted at birth - Can be antenatal torsion/vascular accident - unlikely salvage
Get urgent USS for ?yolk sac tumour
If no USS available or equivocal findings - explore urgently through groin + contralateral scrotal exploration if torsion
If previously normal testis - urgent exploration as normal + contralateral if torsion
Do dartos pouch fixation only as likely extra-vaginal torsion
Fixation sutures may cause problems with thin scrotal skin
2018 JPS Meta Analysis - Neonatal torsion
Approx 7% bilateral torsion, 4% were asynchronous
Extravaginal predominant
Approx 7% salvage rate overall - 2/196 were perinatal
Page edited by Mrs Charnjit Seehra BSc November 2024
References
Patel AP. Anatomy and physiology of chronic scrotal pain. Transl Androl Urol. 2017 May;6(Suppl 1):S51-S56. doi: 10.21037/tau.2017.05.32. PMID: 28725619; PMCID: PMC5503924.
Boam T, Kiely D, Peeraully R, Jancauskaite M, Fraser N. Outcomes following emergency fixation of torted and non-torted testes. J Pediatr Urol. 2021 Aug;17(4):538.e1-538.e8. doi: 10.1016/j.jpurol.2021.05.016. Epub 2021 May 25. PMID: 34103229.
PSTRN, BURST, A national survey of practice for the emergency fixation of testis. Ann R Coll Surg Engl. 2024 Feb 16. doi: 10.1308/rcsann.2023.0101. Epub PMID: 38362750.
Monteilh C, Calixte R, Burjonrappa S. Controversies in the management of neonatal testicular torsion: A meta-analysis. J Pediatr Surg. 2019 Apr;54(4):815-819. doi: 10.1016/j.jpedsurg.2018.07.006. Epub 2018 Aug 8. PMID: 30098810.