A 17-year-old male came to clinic with a 3 week history of what he described as intermittent left testicular pain. It occurred only during the day and would occur randomly, lasting for a few seconds to a few minutes. The pain occurred mainly in the lower abdomen but would come into the upper scrotal area. He described it as a pressure-type pain not a stabbing/cutting pain. He said there was no inguinal masses. He denied sexual activity, masturbation, trauma, or excessive exertion. He denied any inguinal swelling, swelling or erythema of the scrotum, testes or penis and no penile discharge. He was an athlete who wore compression clothing but not a protective cup or athletic supporter. The review of systems showed no fever, chills, nausea, emesis, constipation, diarrhea or dysuria.
The pertinent physical exam showed normal vital signs and growth parameters. His genitourinary examination showed Tanner V pubertal changes with no skin changes, erythema or edema. There was no specific swelling in the inguinal area. His left testicle was slightly higher than the right and was oriented longitudinally. There was no tenderness of the testicle, the epididymis or the anterior or superior area of the testicle. The spermatic cord had no “bag of worms.” Palpation of the area of the inguinal ring re-created the pain. No specific “silk-bag” sign or bulging could be appreciated but the ring seemed slightly larger/looser on the left than on the right. There was a normal cremesteric reflex on both sides. The pallus was normal without discharge. The diagnosis of a probable indirect inguinal hernia with referred intermittent pain was made.
The work-up included a normal urinalysis and screening for sexually transmitted infections that were normal. The patient was referred to a general surgeon and given instructions on when to seek care sooner if the pain intensified or changed.
Most inguinal hernias are indirect (i.e. the hernia passes through the internal inguinal ring and down the inguinal canal); only 2% of all hernias in children are direct hernias (i.e. the hernia directly protrudes through the floor of the inguinal canal). Indirect inguinal hernias occur in about 1-5% of infants. They occur on the right side (60%), left side (30%) and bilaterally (10%) and they are more common in premature infants of both sexes. The male : female ratio of inguinal hernias is 4-8 : 1.
The chief complaint of testicular or scrotal pain always raises concerns. The acute scrotum generally has pain, edema, erythema and warmth. Although acute scrotum is considered a surgical emergency because of the need to treat testicular torsion promptly, most cases are nonemergent. The most common causes of acute scrotum are torsion of the appendix testis or epididymitis depending on the study. One 18 year retrospective of surgically confirmed cases found 9.8% of all urological surgical admissions were for acute scrotum. Of these, 74.7% were for torsion of the appendix testis, 8.4% were for testicular torsion, 5.8% were for tunica vaginalis inflammation, 3.7% were for epididymitis, and 7.2% were for other causes.
Prompt referral to urology for evaluation and treatment of an acute scrotum should be made. Ultrasound evaluation can be helpful to aid with diagnosis particularly determining how much blood flow there is to the testes. Other ultrasonic findings can include edema of the epididymis (for epididymitis),
The differential diagnosis of testicular/scrotal pain includes:
- Testicular torsion – usually has unilateral severe scrotal pain and may be associated with nausea, emesis, elevation of testes, absence of cremesteric reflex, horizontal positioning of testes, and scrotal edema. Occurs most often in neonates and adolescent boys.
- Epididymitis – usually has an insidious onset, painful epididymis, and normal placement of testes and cremesteric reflex. It may also be associated with scrotal edema or have dysuria. Common pathogens in younger males are adenovirus, enterovirus and Mycoplasma. In adolescents, Neisseria gonorrhea and Chlamydia trachomatis may occur. E. coli is also common if there are associated anatomic abnormalities.
- Torsion of the appendix testis – occurs often in school age boys, and has painful superior area point tenderness. There may be a blue-dot sign.
- Torsion of embryonic remnant of testis or epididymis
- Tunica vaginalis swelling
- Orchitis – classically associated with mumps virus but also associated with sexually transmitted diseases or HIV.
- Fournier gangrene
- Testicular infarction
- Testicular tumor – usually painless
- Hydrocoele – usually painless
- Varicoele – usually painless
- Referred pain
- Irritation of innervation of the genitourinary structures – ilioinguinal, iliohypogastric, genitofemoral, pudendal
- Henoch Schonlein purpura
- Skin problems – rash, insect bites
Questions for Further Discussion
1. What testing should be considered for an acute scrotum?
2. What is the time period over which a testicle may become non-viable if there is testicular torsion?
3. What is the treatment for epididymitis?
- Symptom/Presentation: Pain
- Age: Teenager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at MedlinePlus for this topic: Testicular Disorders.
To view current news articles on this topic check Google News.
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Yang C Jr, Song B, Liu X, Wei GH, Lin T, He DW. Acute scrotum in children: an 18-year retrospective study. Pediatr Emerg Care. 2011 Apr;27(4):270-4.
Boettcher M, Bergholz R, Krebs TF, Wenke K, Treszl A, Aronson DC, Reinshagen K. Differentiation of epididymitis and appendix testis torsion by clinical and ultrasound signs in children. Urology. 2013 Oct;82(4):899-904.
Munden MM, Williams JL, Zhang W, Crowe JE, Munden RF, Cisek LJ. Intermittent testicular torsion in the pediatric patient: sonographic indicators of a difficult diagnosis. Am J Roentgenol. 2013 Oct;201(4):912-8.
Van Heurn LW, Pakarinen MP, Wester T. Contemporary management of abdominal surgical emergencies in infants and children. Br J Surg. 2014 Jan;101(1):e24-33.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital