See: [RCH acute scrotal pain](https://www.rch.org.au/clinicalguide/guideline_index/Acute_scrotal_pain_or_swelling/), [[Testicular torsion]]
#paeds #tables
# scrotal pain +/- swelling
| | **Testicular torsion** | **Irreducible hernia** | **Torsion of testicular appendage** | **Epididymo-orchitis** | **Trauma eg testicular or epididymal rupture** |
| ---------------------- | -------------------------------------------------------------------------------------------------------------------- | ------------------------------------------------- | --------------------------------------------------- | ---------------------------------------------------------- | ---------------------------------------------- |
| Typical age group | Pubertal(and rarelyneonates) | Infants | Pre-pubertal <br>(7-12 years) | <2 years and post-pubertal <br>(rarely pre-pubertal) | - |
| Pain | **Severe**<br><br>Usually sudden onset<br><br>May radiate to iliac fossa or thigh<br><br>May be painless in neonates | **Irritable** | Usually sudden onset <br>Usually minimal at rest | Sudden or subacute onset <br>May improve with elevation | May be delayed |
| Swelling | **Yes** | Yes <br><br>May extend to scrotum | Yes | Yes | May be delayed |
| Fever | Unusual | Unusual | Unusual | Common | Unusual |
| Nausea and vomiting | Common (90%) | Common | Uncommon | Uncommon | Uncommon |
| Dysuria or discharge | No | No | No | Common | No |
| Gait | **Impaired** | - | - | - | - |
| Position of testis | **High riding or horizontal** | - | Normal | - | - |
| Palpation | **Tender** <br>Thickened spermatic cord | Firm and tender <br>**Swelling not reducible** | Focal tenderness of upper pole of testis | Tender postero-lateral testis | Tender |
| Oedema crosses midline | No | No | No | Possible | Possible |
| Discoloration | Red/blue <br>Dark in neonate | - | Blue dot sign | Red | Bruising<br><br>(consider causes, eg NAI) |
| Cremasteric reflex | Usually absent | Usually present | Usually present | Usually present | Usually present |
| Reactive hydrocele | Possible | No | No | Possible | Possible |
## atraumatic testicular pain (Jana table)
| Diagnosis | supporting features |
| ---------------------------------------------------- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- |
| [[Testicular torsion]] | - sudden onset a/w exercise or exertion<br>- absent cremasteric reflex |
| epididymo-orchitis | - a/w fevers, STI risk factors<br>- *Prehn's sign* (physical lifting of the testicles relieves the pain of epididymitis but not pain caused by testicular torsion; less specific than doppler) |
| torted testicular appendage<br>(Hydatid of Morgagni) | - more common in teens / adolescence <br>- visible blueish "dot" discolouration of scrotal appendage<br>- point tenderness just below upper anterior border of testicle<br>- may be pain-free at rest |
| referred pain<br>(eg renal stone or inguinal hernia) | - haematuria<br>- flank to groin / testicular pain |
| femoral hernia | - palpation of hernia with cough<br>- absent bowel movements if strangulated / incarcerated |
note, hydrocele is usually not painful
# painless swelling
| | **Hydrocele** | **Varicocele** | **Idiopathic scrotal oedema** | **Tumour/ <br>leukaemia** |
| ------------------ | --------------------------------------- | ----------------------------------------- | --------------------------------------------------------- | --------------------------------------------------------------- |
| Typical age group | Infants | Peri-pubertal | 3-7 years | 1-8 years |
| Fever | Unusual | Unusual | Unusual | Possible |
| Palpation | Soft <br>Non-tender <br>Fluctuant | "Bag of Worms" <br>Occasionally tender | Non-tender <br>May have low-grade discomfort | Hard <br>Non-tender <br>May be painful if rapidly growing |
| Swelling pattern | Scrotal | Predominantly left-sided | Can extend across midline and into perineum, groin, penis | Unilateral or bilateral |
| Discoloration | No | No | Bland, purplish | No |
| Transilluminable | Brightly | No | No | No |
| Reactive hydrocele | - | No | No | Possible |
# treatment
| **Diagnosis** | **Management** |
| --------------------------------------- | -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- |
| **Testicular torsion** | If suspected, or cannot be confidently excluded: <br>Urgent surgical review <br>Fasting or clear fluids until surgical review <br>Provide adequate analgesia |
| **Irreducible hernia** | Urgent surgical review <br>Fasting or clear fluids until surgical review <br>Consider a nasogastric tube on free drainage if bowel obstruction is suspected <br>Provide adequate analgesia |
| **Torsion of testicular appendage** | May be difficult to distinguish from testicular torsion <br>Requires surgical exploration if unable to confidently exclude testicular torsion <br>Once diagnosis confirmed, treatment is supportive, with [analgesia](https://www.rch.org.au/clinicalguide/guideline_index/Acute_pain_management/) and rest <br>Pain should resolve in 2-10 days |
| **Trauma** | Surgical review for all testicular trauma, unless the testis is clearly felt to be normal and without significant tenderness<br><br>**In cases of suspected child abuse presenting with testicular or scrotal trauma, see [Child abuse](https://www.rch.org.au/clinicalguide/guideline_index/Child_Abuse_Guideline/ "Child abuse")** [](https://www.rch.org.au/clinicalguide/guideline_index/Child_abuse__Additional_resources/) |
| **Suspected epididymo-orchitis** | [Antibiotics](https://www.rch.org.au/clinicalguide/guideline_index/Local_Antimicrobial_Guidelines/) - IV if systemically unwell/young infant, oral if well <br>Second episode - renal tract ultrasound and urological review <br>Slow to resolve. May have weeks of gradually subsiding scrotal discomfort and swelling |
| **Hydrocele** | Spontaneous resolution in the first year; 90% by 2 years <br>Consider outpatient surgical referral for repair if present after 2 years of age |
| **Varicocele** | Refer to surgical outpatients |
| **Idiopathic scrotal** <br>**oedema** | Scrotal oedema can occur in setting of systemic disease eg nephrotic syndrome <br>If idiopathic, resolves spontaneously over 1-5 days. No intervention required |
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# OSCE
#OSCE
- [RMH 2024 - testicular pain](x-devonthink-item://DBD1F2AD-B0AE-47EE-B89E-2B4854CCE710)
## Teach a resident
DDx:
- torsion (tx <6 hours)
- epididymo-orchitis
- non-testicle (eg renal colic, hernia)
Health advocacy:
- graded assertiveness if registrar wants USS for high-risk torsion
- knowledge of "ischaemic time"
- advocate exploration in OT
- if unsuccessful then escalate to consultant
USS utility:
- POCUS can rule-in torsion but cannot exclude