Acute enlargement or pain in the scrotal area is an important clinical sign as it may signal a surgical emergency. Boys with either of these symptoms need to be seen promptly because of the risk of testicular torsion. Testicular torsion may result in infarction of the testis in 6–12 hours if there is progressive obstruction to the blood supply.
The key questions that direct and inform the management are:
• whether this is a painless or painful problem
• whether it is associated with localized or generalized swelling.
Scrotal pain
a. Spermatic cord torsion
Torsion is the most important cause of scrotal pain. It is most common in early puberty, but can occur at any age. An unusual attachment of the testis within the tunica vaginalis results in the testis lying transversely and this predisposes to twisting. Clinically there is an abrupt onset of pain in the testicle often after trauma or exercise.
The pain is sharp and is often accompanied by systemic symptoms such as nausea and vomiting. On examination there is a high riding, tender testicle which is made more uncomfortable by elevation. There is a knot of blood vessels at the upper margin, which may be confused with epididymitis. Classically, there is an absent cremasteric reflex on the affected side. If the torsion is allowed to continue, there is increasing scrotal edema and inflammation, which obscure the landmarks.
If there are strong clinical signs of torsion then surgical exploration is indicated. The purpose of surgery is to untwist the affected testicle and anchor the opposite testicle (orchidopexy). Imaging studies are done only when the clinician is sure that torsion does not exist and is seeking supporting evidence. Imaging investigations can be either a nuclear testicular scan or color Doppler sonography. Either is acceptable though sonography is less sensitive.
b. Torsion of the testicular appendage
There are five vestigial appendages associated with the testis. Torsion can occur of any of them, usually in boys aged 7–12 years. The onset of pain is slow and milder than torsion of the spermatic cord. There are no systemic symptoms but usually only slight swelling of the testis. There may be a bluish discoloration in the upper scrotum (‘blue dot sign’). A nuclear scan will show increased blood flow in the upper region, which can be confused with epididymitis. The treatment is usually analgesia, bed rest and scrotal elevation.
c. Epididymo-orchitis
This condition occurs more commonly in adults and adolescents and is generally rare in children. Inflammation of the epididymi can be viral (adenovirus, mumps or Epstein-Barr virus) or occasionally bacterial in association with anatomical problems of the urinary tract. The possibility of spermatic cord torsion must be considered. Urinalysis may show mild pyuria. A nuclear scan will show increased blood flow to the epididymis. Treatment is supportive. Antibiotics directed to common urinary pathogens are used when bacterial infection is suspected.
d. Trauma
Trauma to the scrotum is usually a precisely remembered event in a boy’s life. If there is no history, another cause should be sought for scrotal pain. The mechanism of injury is often straddle type such as falling astride a bicycle bar. It is generally rare in prepubertal children because of the small size and mobility of the testes. There is often overlying bruising and, if severe enough, a traumatic hematocele. Surgical evacuation may be required if there is a significant collection of blood. In milder cases, cold compresses and analgesics suffice.
e. Other causes
The vasculitic process of Henoch-Schönlein purpura can involve the spermatic cord and testicle causing acute pain and swelling. Children typically have a purpuric rash on the buttocks and legs, which is diagnostic. Treatment in most circumstances consists of rest and pain relief, although severe testicular swelling may be an indication for steroid treatment.
An incarcerated inguinal hernia can also cause acute scrotal pain. There is often a history of intermittent groin swelling, which improves spontaneously. On examination a hernia is detected and cannot be reduced manually. If allowed to persist it can look very much like an acute torsion of the testis with systemic symptoms. Imaging with Doppler sonography or testicular scan can help clarify the cause. Surgical exploration and treatment is required.
Painless scrotal swelling
a. Hydrocele
Hydrocele is a collection of fluid between the tunica vaginalis and the testicle. In the first year of life the process vaginalis often closes and the hydrocele resolves. It often presents as a clear, bluish swelling in the region of the testicle. If it shrinks with gentle pressure, then there is a hernia component. Surgery is not usually advised before 1 year of age since many spontaneously resolve. If the hydrocele persists, or if there is a hernia component present, then surgery is recommended.
b. Varicocele
This is a collection of enlarged spermatic cord veins. It is more common in adolescents and on the left side. It is most obvious in the standing position and occasionally causes pain, especially with exertion. In most cases surgery is not required unless there are symptoms of atrophy of the testes (which is rare).
c. Other causes
An uncomplicated reducible inguinal hernia can cause intermittent testicular swelling. This often requires elective surgical repair because of the risk of incarceration. Acute scrotal edema is a form of urticaria. It starts in the scrotal area and can extend posteriorly. The cause of this is unknown but may include an insect bite allergic reaction, cellulitis or contact dermatitis. Almost all children with this condition are prepubertal. Treatment is symptomatic.
