Scrotal Pain (Acute)

Pathway

Images

Image Gallery Note: These images open in a new page
1		Epididymo-Orchitis Image 1 (Ultrasound): Swelling of the right epididymis with associated mild orchitis. Doppler images (not shown here) demonstrate increased vascularity.
2		Testicular Tumour Image 2 (Ultrasound): Solid and cystic lesion with thick walls and marked vascularity in some areas. The appearances are consistent with a tumour.
3a		Testicular Tumour Image 3a: Orchidectomy specimen showing complete replacement of the normal testicular parenchyma with the classical "cut-potato" appearance of a seminoma. The tunica albuginea is intact.
3b		Image 3b (H&E, x2.5): Histological section of a seminoma showing groups of malignant cells with large nuclei and prominent nucleoli. There are also intervening fibrous bands with an infiltrate of lymphocytes and plasma cells.
4a		Testicular Tumour Image 4a (H&E, x2.5): Orchidectomy specimen showing a teratoma with areas of cyst formation and haemorrhage.
4b		Image 4b (H&E, x2.5): Histological section of a teratoma (non-seminomatous germ cell tumour) showing hyaline cartilage and islands of columnar epithelium.

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

1. 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
2. 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
3. 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
4. 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
5. 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
6. Bowlin PR, Gatti JM, Murphy JP. Pediatric testicular torsion. Surg Clin North Am. 2017;97(1):161-72. (Review article). View the reference
7. 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
8. Kaplan G. Testicular torsion BMJ Best Practice; 2018. (Review article). View the reference
9. 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
10. National Institute for Health and Care Excellence. Management of paediatric torsion. 2015. (Guideline). View the reference
11. 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
12. 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
13. 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
14. 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
15. 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
16. 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
17. 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
18. 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
19. 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
20. 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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