Acute Scrotum Algorithm

  • The general approach to acute scrotal pain is to work-up the patient for testicular torsion by first risk stratifying them based on age group, history and physical.
    • Based on the patient’s pre-test probability → call GU emergently or obtain testicular U/S.
  • The U/S will also help in the evaluation of other serious causes of testicular pain such as appendage torsion and epididymitis.

  • The etiology of acute scrotal pain varies among different age groups, the most common being: (Journal of Pediatric Surgery 1995;30(2):277-82)
    • 0-1 yo: Testicular torsion
    • 3-13 yo: Appendage torsion
    • 13 yo: Epididymitis
Acute Scrotum Algorithm
Acute Scrotum Algorithm

Rule Out Testicular Torsion


  • Age
    • Torsion can occur at any age, and up to 39% of cases occur in adulthood (J Urol 1990;143:62)
    • Adults with torsion may have a lower salvage rate (likely because of the severity of cord twisting) (J Urol 2002;167:2109)
  • Presentation of Testicular Torsion
    • Acute scrotal pain – Sudden/severe pain
    • Systemic symptoms (N/V)
    • Nonspecific/abdominal pain
  • Pitfall: Intermittent Testicular Torsion (torsion-detorsion)
    • Intermittent Testicular Torsion should be considered in patients who present with recurrent, rapid onset, severe pain with spontaneous resolution.
    • Hyperperfusion of testis can occur after detorsion or intermittent torsion and give a false diagnosis of epididymitis on U/S.
    • Whirlpool sign (caused by twisting of the spermatic cord) on spermatic cord imaging can help identify these patients along with horizontal lie of the testis (J Ultrasound Med 2006;25:563-574)
    • Horizontal lie of testis is the only physical exam finding significantly associated with bell clapper deformity (Spec 100%) (J Urology 2005;174:1532-35)
    • GU should be contacted if intermittent torsion suspected for future surgical fixation to prevent future pain and infarction.

Physical Exam for Testicular Torsion

  • Cremaster reflex (J Urol 1984;132(1):89-90)
    • Most sensitive physical exam finding is the cremasteric reflex (sensitivity100%) in one series of 245 patients
    • If you see scrotum rising when you stroke the inner thigh → less likely there is torsion (other series have confirmed these findings)
    • Disclaimer: Cannot rely solely on presence of reflex, must interpret in context of other clinical findings.
    • Absence of cremasteric reflex is meaningless, kids normally lack this reflex.
  • High riding testicle
  • Horizontal lie

Salvage rates for Torsion (Am Fam Physician 2006;74:1739-43)

  • <6 hours: 90-100%
  • 2-24 hours: 36-50%
  • >24 hours: 0-10%

Diagnostic work up for Testicular Torsion

  • Based on pre-test probability of torsion
    • Definite Torsion: GU consult for emergent evaluation, especially if <4hours
    • Indeterminate: U/S +/- GU consulting

  • Color Doppler U/S
    • Sensitivity and specificity to diagnose torsion across multiple studies are 85-100% and 75-100%, respectively. (J Urol 2004;172:1692-1695)
    • U/S is not perfect in ruling-out torsion and multiple studies have shown false negatives → must look for intra-testicular (not peripheral) flow
    • Pitfall: Emergent surgical exploration should still be considered for those at high risk for torsion despite negative U/S
  • Cord Imaging:
    • Rotated spermatic cord “whirlpool sign” is a highly sensitive and specific sign for torsion, especially when vascular flow is present on Doppler U/S.
  • Manual detorsion
    • Procedure: Detorse from inside to out → like opening a book
    • 30-80% success rate
    • If successful, relief of ischemia can convert a urologic emergency into an elective surgical procedure and will salvage the testes

Rule Out Torsion Mimics

  • Epididymitis
  • Appendage Torsion

1. Epididymitis

Clinical Presentation of Epididymitis

  • Age: post-pubertal boys
  • Insidious onset: slowly progressive pain
  • UTI symptoms / pyuria
  • Tender epididymis with swelling/induration
  • Prehn sign (physical lifting of the testicles relieves the pain of epididymitis but not pain caused by testicular torsion)

Etiology of Epididymitis

  • Varies by age groups
    • Pre-pubertal: Chemical irritation secondary to reflux of sterile urine (STD? → child abuse?)
    • Young males: STD
    • Older male: STD vs urinary pathogens (reflux from BPH)
  • Special Case:Child with Epididymitis? (J Urol. 1987;138:1100-3)
    • Will need GU follow up for upper tract imaging and VCUG (voiding cystourethrogram) because of the known association with urinary tract pathology

Work-up for Epididymitis

  • Urine Neisseria gonorrhoeae/Chlamydia trachomatis (CT/GC)
  • US – shows preserved/increased testicular blood flow

Treatment of Epididymitis (based on age group)

• Empiric antibiotics to cover most likely etiology (STD vs urinary pathogens)
• Children: Antibiotics against coliforms
• Adults: Neisseria gonorrhoeae/Chlamydia +/- coliforms

2. Appendage Torsion

  • Clinical Presentation of Appendage Torsion
    • Age: pre-pubertal boys
    • Acute scrotal pain
    • Physical exam: Blue dot sign, tender nodule on upper pole

  • Work up for Appendage Torsion
    • Clinical diagnosis
    • US – Low echogenic area with central hypoechogenicity
  • Treatment of Appendage Torsion
    • Conservative: Rest, ice, anti-inflammatories → slow recovery and pain may last weeks to months
    • Surgical: excision of appendix testes → not necessary but is safe and pts can resume activity in days

Rule out Other Causes

  • Hernia
  • Fournier’s gangrene
  • Hydrocele
  • Acute Idiopathic scrotal edema
  • HSP (Henoch-Schonlein Purpura)
  • Trauma
  • Varicocele
  • Referred pain (nephrolithiasis, appy etc…)

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