Scrotal Pain (Acute)
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Population Covered By The Guidance
This pathway provides guidance for the imaging investigation of male patients with acute scrotal pain.
Date reviewed: April 2018
Date of next review: October 2023
Published: June 2018
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Images
Teaching Points
Teaching Points
- There are many causes of acute scrotal pain. Torsion of the testis, epididymo-orchitis and torsion of the testicular appendage are the most common
- If torsion is suspected following history and physical examination, imaging should not delay urgent surgical exploration
- The viability of a torted testicle declines significantly with time, up to 100% salvageable within 6 hours, but almost none are salvageable at 24 hours
- Negative surgical exploration is preferable to a missed diagnosis because all imaging studies have a false negative rate
- Epididymo-orchitis is the most common cause of scrotal pain in adolescents and adults and is diagnosed clinically. Ultrasound is indicated if there is concern about a scrotal abscess or after failure to respond to treatment
- Doppler ultrasound is only indicated in equivocal cases or where there is a low suspicion for torsion on clinical evaluation. Other causes for scrotal pain can also be demonstrated on ultrasound
References
References
Date of literature search: March 2018
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Davenport M. ABC of general surgery in children. Acute problems of the scrotum. BMJ : British Medical Journal. 1996;312(7028):435-7. (Level II evidence). View the reference
- Dunne PJ, O'Loughlin BS. Testicular torsion: time is the enemy. Aust N Z J Surg. 2000;70(6):441-2. (Level II evidence). View the reference
- Makela E, Lahdes-Vasama T, Rajakorpi H, Wikstrom S. A 19-year review of paediatric patients with acute scrotum. Scand J Surg. 2007;96(1):62-6. (Level II evidence). View the reference
- Tekgül S, Dogan HS, R. Kocvara, Nijman JM, Radmayr C, Stein R, et al. EAU guideline on paediatric urology. European Association of Urology. 2017 (Guideline). View the reference
- Baker LA, Sigman D, Mathews RI, Benson J, Docimo SG. An analysis of clinical outcomes using color doppler testicular ultrasound for testicular torsion. Pediatrics. 2000;105(3 Pt 1):604-7. (Level II evidence). View the reference
- Bowlin PR, Gatti JM, Murphy JP. Pediatric testicular torsion. Surg Clin North Am. 2017;97(1):161-72. (Review article). View the reference
- Al Shakarchi J, Bowley D, Hendrickse C. Guidelines for the management of acute scrotal pain in children. Heart of England NHS Foundation Trust. 2011 View the reference
- Kaplan G. Testicular torsion BMJ Best Practice; 2018. (Review article). View the reference
- Hartman MS, Leyendecker JR, Friedman B, Fulgham PF, Heller MT, Hosseinzadeh K, et al. Acute onset of scrotal pain - without trauma, without antecedent mass. American College of Radiology ACR Appropriateness Criteria. 2014 (Guideline). View the reference
- National Institute for Health and Care Excellence. Management of paediatric torsion. 2015. (Guideline). View the reference
- Murphy FL, Fletcher L, Pease P. Early scrotal exploration in all cases is the investigation and intervention of choice in the acute paediatric scrotum. Pediatr Surg Int. 2006;22(5):413-6. (Level II evidence). View the reference
- Lopez RN, Beasley SW. Testicular torsion: potential pitfalls in its diagnosis and management. J Paediatr Child Health. 2012;48(2):E30-2. (Review article). View the reference
- Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013;88(12):835-40. (Review article). View the reference
- Wilbert DM, Schaerfe CW, Stern WD, Strohmaier WL, Bichler KH. Evaluation of the acute scrotum by color-coded Doppler ultrasonography. J Urol. 1993;149(6):1475-7. (Level II evidence). View the reference
- Suzer O, Ozcan H, Kupeli S, Gheiler EL. Color Doppler imaging in the diagnosis of the acute scrotum. Eur Urol. 1997;32(4):457-61. (Level II evidence). View the reference
- Burks DD, Markey BJ, Burkhard TK, Balsara ZN, Haluszka MM, Canning DA. Suspected testicular torsion and ischemia: evaluation with color Doppler sonography. Radiology. 1990;175(3):815-21. (Level III evidence). View the reference
- Altinkilic B, Pilatz A, Weidner W. Detection of normal intratesticular perfusion using color coded duplex sonography obviates need for scrotal exploration in patients with suspected testicular torsion. J Urol. 2013;189(5):1853-8. (Level II evidence). View the reference
- Horstman WG, Middleton WD, Melson GL. Scrotal inflammatory disease: color Doppler US findings. Radiology. 1991;179(1):55-9. (Level II-III evidence). View the reference
- Guthrie JA, Fowler RC. Ultrasound diagnosis of testicular tumours presenting as epididymal disease. Clin Radiol. 1992;46(6):397-400. (Level II evidence). View the reference
- Allen TD, Elder JS. Shortcomings of color Doppler sonography in the diagnosis of testicular torsion. J Urol. 1995;154(4):1508-10. (Level IV evidence). View the reference
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