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.