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  • Acute scrotal pain is usually caused by testicular torsion, epididymitis, or torsion of the appendix testis, and should be considered a surgical emergency until proven otherwise.

  • Epididymitis is often caused by viral infections; however, bacterial urinary tract infections must be evaluated for in young children, and sexually transmitted disease should be considered in adolescents.

  • Persistent scrotal swelling and a “bag-of worms” appearance indicates possible obstruction from tumor.

  • Priapism can be divided into two mechanisms: low-flow or ischemic as in sickle cell vaso-occlusion and high-flow or engorgement, which can occur with trauma.


Acute scrotal pain and swelling in children have many causes; however, in most cases the emergency physician (EP) can determine the etiology by the history and physical examination and by considering the age of the patient. Scrotal swelling may be painful or painless. The most common diagnoses for an acute scrotum are testicular torsion, torsion of the appendix testis or epididymis, and epididymitis, but includes a number of other things as well (Table 86-1). In all cases, the possibility of a surgical emergency must be considered and the evaluation and management must proceed accordingly. Color Doppler ultrasound is the examination of choice for imaging scrotal pathology.

TABLE 86-1Differential Diagnosis of Scrotal Pain in Children8


Testicular torsion has a bimodal incidence, with the first peak in the neonatal period and a second in adolescence, although can occur at any age.1,2 Torsion of the testes is a urologic emergency and results in a significant amount of legal action against EPs for missed diagnosis. The EP must suspect this diagnosis in any child with complaint of scrotal pain or signs of scrotal swelling on physical examination.

The classic description of the anatomic abnormality associated with torsion is the “bell-clapper” deformity that is often bilateral and causes the testes to have a horizontal lie within the ...

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