Chapter 61

#### Key Points

1. The most common causes of pediatric acute scrotal pain and swelling are torsion of the testis and torsion of the testicular or epididymal appendages.

2. Intravaginal testicular torsion, which is associated with abnormal fixation of the testicle within the tunica vaginalis, is most common at puberty. Extravaginal testicular torsion results from twisting of the spermatic cord proximal to the scrotal tunica vaginalis and is thought to occur during descent of the testicle into the scrotum and is seen in the newborn period.

3. There are numerous causes for acute scrotal swelling, but the most important objective is determining and promptly treating any condition that may destroy the testicle. There is approximately a 6-hour window before irreversible ischemic damage occurs.

4. Testicular appendages are mullerian duct remnants on the superior pole of the testis and the epididymal appendages are Wolffian duct remnants. Torsion of the appendages can mimic spermatic cord torsion. Torsion of the appendages is more likely in later childhood. Tenderness of the upper pole of the testicle only, especially with a firm, tender nodule present is characteristic of a torsed appendix testis. The “blue dot” sign is pathognomonic for torsion of an appendage, but is not seen in all cases.

5. A thorough history and physical exam is typically sufficient for determining an operative intervention for the acute scrotum. The absence of a cremasteric reflex is a good indicator of torsion of the cord. In acute epididymitis, the cremasteric reflex is present. Additional studies, including radiography, should be used in cases to confirm the diagnoses of nontorsion.

6. Nonoperative management is aimed at treating the underlying cause. Torsion of the testicular appendages is often nonsurgical and it is treated medically with analgesics, however, if pain persists, surgical exploration is indicated.

7. Suspected testicular torsion requires immediate surgical intervention. While manual detorsion may be attempted, surgical exploration is still indicated. Exploration of the contralateral hemiscrotum should be carried out as it is common to identify a bell-clapper deformity. Fixation of the contralateral testis is recommended to prevent subsequent torsion.

8. A median raphe incision is used with delivery and detorsion of the affected testicle. The contralateral testicle, and if a viable ipsilateral testicle remains, is pexed with nonabsorbable sutures between the tunica albuginea and the scrotal wall. Orchiectomy should be performed if the affected testicle is obviously necrotic.

9. Urgent exploration is not necessary in perinatal torsion when the scrotum is blue and edematous at birth, indicating ischemia has been present for weeks or days. Controversy regarding prompt exploration of the contralateral testis remains. If symptoms have just occurred, exploration is indicated when the infant's anesthetic and overall general condition has been considered.

10. The differential diagnosis of the acute scrotum represents myriad conditions. The astute clinician must determine the need for immediate surgical intervention versus nonoperative treatment in a timely manner to salvage the viable testicular tissue.

#### Disease Pathophysiology

Acute scrotal swelling can occur as a result of many conditions. These include ...

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