Evaluation of the Acute Scrotum

Clinical opinion based on the history and physical examination is exceedingly important. Although diagnostic techniques are available, most diagnoses can be made by the pediatric urologist without their use. In the differential diagnosis testicular torsion is the most important. Other common diagnoses include: non-bacterial epididymoorchitis, torsion of the testicular or epididymal appendages, trauma. incarcerated inguinal hernia and hydrocele. Less common diagnoses include epididymitis associated with a urinary tract infection (or, in older children, a sexually transmitted disease), insect bites to the scrotum, idiopathic scrotal edema, scrotal fat necrosis, Henoch-Schonlein purpura, testis tumor and abuse.

HISTORY

The child’s age is relevant, as testicular torsion is much more common around puberty. Trauma can be the cause of painful swelling of the testicle, but trauma can also be the cause of a testicular torsion so that a history of trauma does not rule out testicular torsion.

A history of hydrocele (patent processus vaginalis) at birth or delayed descent of the testis may predispose to an inguinal hernia or testicular torsion. Testicular swelling secondary to incarceration of an inguinal hernia is more commonly seen in the very young. Previous inguinal surgery does not preclude the development of a testicular torsion. Testicular torsion has been observed both following inguinal herniorrhaphy and previous fixation for torsion.

A history of similar episodes of short-lived testicular pain may suggest intermittent torsion and spontaneous detorsion. Testicular torsion has also been reported to occur in family members.

The presence of urinary symptoms may be relevant as epididymitis or orchitis, or both may be bacterial and associated with a urinary tract infection. In addition, there may be systemic symptoms such as fever, abdominal pain, nausea or vomiting, or possibly a past history of urinary tract infections, urologic instrumentation, surgery or trauma. Most inflammatory disorders of the testicle in the pediatric group, however, are not associated with a bacterial infection but due to a virus, trauma or reflux of urine down the vas.

PHYSICAL EXAM

The patient is examined in a gentle, reassuring manner and in a warm environment. Observation of the abdomen and genitalia is carried out while taking the history. A relaxed scrotum suggests a less severe process. Before the groin and scrotal contents are examined, an attempt is made to elicit the cremasteric reflex, first on the non-involved side. Although not diagnostic, the presence of an active ipsilateral cremasteric reflex strongly suggests that the diagnosis is not torsion.

The scrotum is then observed to determine the degree of swelling and erythema. If the scrotal skin is light, the blue dot sign of an infarcted testicular or epididymal appendage may be seen.

Palpation begins in the groins to exclude an incarcerated hernia. Next, an attempt is made to palpate the cords. A thickened, tender spermatic cord suggests a testicular torsion (spermatic cord torsion) while tenderness alone may indicate epididymitis.

The contralateral testis is always examined first and then the involved testis. An infarcted appendage toward the upper pole of the testis is suggested by localized tenderness.

The boy should also be examined standing so that the lie of the testicles can be examined. An elevated testis again is suggestive of torsion.

Neonates with torsion are generally free of distress and exhibit few signs. The scrotum is characteristically swollen, discolored and without discomfort on palpation. The presence of a cremasteric reflex is not helpful in the neonate, unlike in the older child, as newborns do not possess an active cremasteric reflex.

Many disorders can present as scrotal pathology in the neonate. These disorders include hernias, hydroceles and several testicular or paratesticular problems other than torsion: tumor, ectopic spleen, ectopic adrenal tissue, epididymitis or scrotal abscess. Idiopathic testicular infarction probably represents a spontaneous detorsion. Ruptured varicocele and scrotal hemangioma have also been described. In addition, intra-abdominal pathology has been implicated such as incarcerated hernia (containing bowel or bladder), meconium peritonitis or any other inflammatory intraperitoneal process which can migrate into the scrotum by means of the patent processus vaginalis. In addition, intraperitoneal hemorrhage, perforated appendix and intussusception have presented in such a manner.

In newborns who have had placement of ventricular peritoneal shunts, migration of the shunt into the scrotum has been described. Shunts may also cause hydroceles.

DIAGNOSTIC STUDY

If testicular torsion is suspected, urgent surgical management is indicated, although manual detorsion may be carried out with or without local anesthesia. Complete detorsion may not be assured. Furthermore, spermatogonia are destroyed after four hours of complete arterial occlusion. Therefore, time is of the essence and additional diagnostic studies may compromise testicular salvage for the sake of clinching the diagnosis. Therefore, if there is any doubt we recommend urgent exploration. We suggest that it is better to have a viable testis and a diagnosis of epididymitis after surgery than an infarcted testis though accurately diagnosed torsion through various diagnostic studies.

Diagnostic studies that have been used are the Doppler stethoscope, radionuclide scanning of the testicles using 99AMP technetium, high resolution color Doppler ultrasound and MRI.

TREATMENT

Scrotal exploration with detorsion of the involved testicles and intrascrotal fixation with a similar procedure performed on the non-involved testicle are indicated, as there is a high chance of this happening at some later date to the contralateral testicle.

Neonatal testicular torsion occurs infrequently. The majority are unilateral and extravaginal (includes the tunica vaginalis) with torsion of the entire spermatic cord and covering structures, unlike torsion in the pubertal children which are intravaginal. However, some in the neonate can be intravaginal. Several bilateral neonate testicular torsions have been described with several of them being asynchronous. Associated abnormalities or predisposing factors have been speculated on but none clearly implicated. It has been postulated that an early intrauterine torsion could result in complete atrophy by the time of birth and present as “the vanishing testis syndrome”.

Prompt exploration is mandated with retention of all but a necrotic (dead) testis and contralateral fixation. After administration of a general anesthetic, a midline scrotal incision is made. The involved scrotal side is then opened to deliver the testicle. The testicle is untwisted; and if it regains its blood supply, it is secured to the wall of the scrotum. A similar procedure is performed on the other testicle to prevent it from twisting at a later date.

Anesthesia for neonatal exploration in the first 24-48 hours of life should be of little concern in the appropriate setting despite the complex transition from fetal to extra-uterine circulation. Postoperative observation with an apnea monitor is important.

In the neonate the surgical approach to the involved testicle can be either trans-scrotal or inguinal.

Recently, there have been concerns regarding the immunobiology of testicular torsion and the possible effects on the contralateral testicle. Despite some concern regarding the data from animal studies, follow-up in humans appears to support a lack of adverse effects on the contralateral testicle by ipsilateral testicular torsion whether the testicle is removed, or deformed and retained.