Assessment

Any acute scrotal swelling requires immediate surgical assessment for torsion of the testis or strangulated inguinal hernia, which are surgical emergencies.


Differential Diagnosis

Note: This table describes typical features. In practice it is often difficult to be certain of the diagnosis clinically ie. sometimes the diagnosis may only be made by surgical exploration.


Diagnosis Suggestive features on history Suggestive features on examination
Torsion of the testis Sudden onset testicular pain and swelling; occasionally nausea, vomiting. Note: pain may be in the iliac fossa Discolouration of scrotum; exquisitely tender testis, riding high
Torsion of the appendix testis (hydatid of Morgagni) More gradual onset of testicular pain Focal tenderness at upper pole of testis; "blue dot" sign – necrotic appendix seen through scrotal skin Note: Difficult to distinguish from testicular torsion
Epididymoorchitis Onset may be insidious; fever, vomiting, urinary symptoms; rare in pre-pubertal boys, unless underlying genitourinary anomaly, when associated with UTI. Red, tender, swollen hemiscrotum; tenderness most marked posteriolateral to testis. Pyuria may be present.
Incarcerated inguinal hernia History of intermittent inguinoscrotal bulge, with associated irritability Firm, tender, irreducible, inguinoscrotal swelling
Idiopathic scrotal oedema Swelling noted but child not distressed Bland violaceous oedema of scrotum, extending into perineum + penis; testes not tender
Hydrocele Swollen hemiscrotum in well, settled baby Soft, non-tender swelling adjacent to testis; transilluminates brightly.
Henoch Schonlein purpura Painful scrotal oedema, with purpuric rash over scrotum. May have associated vasculitic rash of buttocks and lower limbs, arthritis, abdominal pain with GI bleeding, and nephritis May be difficult to distinguish from testicular torsion in absence of other features
Testicular or epididymis rupture Scrotal trauma eg. straddle injury, bicycle handlebars, sports injury. Delayed onset of scrotal pain and swelling. Tender swollen testis. Bruising, oedema, haematoma, or haematocele may be present.

Investigation

Check urinalysis, and send sample for M & C. Neither Doppler ultrasound nor blood tests are useful.

Management

Early surgical consultation is vital, as delay in scrotal exploration and detorsion of a torted testis will result in testicular infarction within 8-12 hours. Keep the child fasted.

Specific management of other causes depends on the diagnosis:

  • Suspected torsion of the appendix testis usually requires surgical exploration.
  • Incarcerated inguinal hernia must be reduced or the contents of the hernia may become gangrenous.
  • Epididymoorchitis should be managed with antibiotics once a suitable urine sample has been sent. Young infants or systemically unwell children should be admitted for i.v. antibiotics (eg. amoxycillin and gentamicin). Most patients can be successfully managed as out-patients, with co-trimoxazole. Adolescents with epididymoorchitis should have a meatal swab for chlamydia and gonococcus.
  • Idiopathic scrotal oedema usually resolves spontaneously over a couple of days. No intervention is required
  • Hydroceles will often resorb and the tunica vaginalis closes spontaneously in the first year. If still present at 2 years, surgical referral should be made for consideration of repair.
  • Henoch Schonlein purpura Check urinalysis and blood pressure. These children need close paediatric surveillance as abdominal pathology can be quite severe acutely, and nephritis may develop in the convalescent period.