Assessment
Any acute scrotal swelling requires immediate surgical assessment for torsion of the testis or strangulated inguinal hernia, which are surgical emergencies.
Differential Diagnosis
Note: This table describes typical features. In practice it is often difficult to be certain of the diagnosis clinically ie. sometimes the diagnosis may only be made by surgical exploration.
| Diagnosis | Suggestive features on history | Suggestive features on examination |
|---|---|---|
| Torsion of the testis | Sudden onset testicular pain and swelling; occasionally nausea, vomiting. Note: pain may be in the iliac fossa | Discolouration of scrotum; exquisitely tender testis, riding high |
| Torsion of the appendix testis (hydatid of Morgagni) | More gradual onset of testicular pain | Focal tenderness at upper pole of testis; "blue dot" sign – necrotic appendix seen through scrotal skin Note: Difficult to distinguish from testicular torsion |
| Epididymoorchitis | Onset may be insidious; fever, vomiting, urinary symptoms; rare in pre-pubertal boys, unless underlying genitourinary anomaly, when associated with UTI. | Red, tender, swollen hemiscrotum; tenderness most marked posteriolateral to testis. Pyuria may be present. |
| Incarcerated inguinal hernia | History of intermittent inguinoscrotal bulge, with associated irritability | Firm, tender, irreducible, inguinoscrotal swelling |
| Idiopathic scrotal oedema | Swelling noted but child not distressed | Bland violaceous oedema of scrotum, extending into perineum + penis; testes not tender |
| Hydrocele | Swollen hemiscrotum in well, settled baby | Soft, non-tender swelling adjacent to testis; transilluminates brightly. |
| Henoch Schonlein purpura | Painful scrotal oedema, with purpuric rash over scrotum. May have associated vasculitic rash of buttocks and lower limbs, arthritis, abdominal pain with GI bleeding, and nephritis | May be difficult to distinguish from testicular torsion in absence of other features |
| Testicular or epididymis rupture | Scrotal trauma eg. straddle injury, bicycle handlebars, sports injury. Delayed onset of scrotal pain and swelling. | Tender swollen testis. Bruising, oedema, haematoma, or haematocele may be present. |
Investigation
Check urinalysis, and send sample for M & C. Neither Doppler ultrasound nor blood tests are useful.
Management
Early surgical consultation is vital, as delay in scrotal exploration and detorsion of a torted testis will result in testicular infarction within 8-12 hours. Keep the child fasted.
Specific management of other causes depends on the diagnosis:
- Suspected torsion of the appendix testis usually requires surgical exploration
- Incarcerated inguinal hernia must be reduced or the contents of the hernia may become gangrenous
- Epididymoorchitis should be managed with antibiotics once a suitable urine sample has been sent. Young infants or systemically unwell children should be admitted for i.v. antibiotics (eg. amoxycillin and gentamicin). Most patients can be successfully managed as out-patients, with co-trimoxazole. Adolescents with epididymoorchitis should have a meatal swab for chlamydia and gonococcus
- Idiopathic scrotal oedema usually resolves spontaneously over a couple of days. No intervention is required
- Hydroceles will often resorb and the tunica vaginalis closes spontaneously in the first year. If still present at 2 years, surgical referral should be made for consideration of repair
- Henoch Schonlein purpura Check urinalysis and blood pressure. These children need close paediatric surveillance as abdominal pathology can be quite severe acutely, and nephritis may develop in the convalescent period