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Scrotal pain is one of the most common urologic emergencies seen in boys. Although many causes of scrotal pain may not require an immediate organ-preserving procedure, some causes can lead to rapid and permanent loss of testicular function without timely intervention. Thus, the clinician must identify patients who need emergent diagnostic and/or therapeutic procedures, and those who need observation and reassurance.

Testicular Torsion

Testicular torsion should be considered in children with acute scrotal pain, as torsion is a urologic emergency. The estimated incidence of torsion in the U.S. is 4.5 per 100,000 children.1 Testicular torsion has a bimodal age presentation, with one peak in the immediate neonatal period and another peak during early puberty. Because the testicle of neonates with prenatal torsion is not salvageable, many urologists agree neonates can be taken to the operating room on a semielective basis to decrease the risk of anesthesia. However, in perinatal torsion, the contralateral side may also be torsed, even without abnormal physical examination findings or an abnormal US.2

Most boys with testicular torsion present between 12 and 18 years of age. Classically, the pain is abrupt in onset and severe and is usually associated with nausea or vomiting. The testicle is extremely painful, and often the patient will walk with a wide-based gait to minimize the contact of the scrotum to the thigh. There is often a preceding history of a sports activity or even minor trauma to the area, which may mislead the clinician into considering the traumatic causes of scrotal pain. Upon further history, the patient may recall episodes of previous scrotal pain that rapidly resolved without intervention, which may represent intermittent torsion with spontaneous detorsion. Episodes of intermittent torsion may predispose a patient to acute complete testicular torsion.3

Classic physical examination findings of testicular torsion include a swollen, tender, high-riding testis, with an abnormal transverse lie. The absence of the cremasteric reflex on the affected side is common with acute torsion, although not absolutely diagnostic, as other scrotal processes may also result in an absent cremasteric reflex.

Doppler US is the diagnostic imaging study of choice, with radionuclide imaging a distant second. If the time to obtain diagnostic imaging may lead to delay of surgical intervention, advocate for emergent surgical exploration by a urologist, rather than waiting for an imaging study to be completed. Time is especially critical if the duration of symptoms is <6 hours, as the salvage rate is excellent in such cases. Beyond 6 hours, the salvage rate becomes progressively worse, and after 48 hours of symptoms, the salvage rate is essentially zero. Thus, for patients presenting with equivocal signs of torsion or who have had pain for >6 hours, a Doppler US may be indicated. Doppler US can visualize blood flow to the testis. In acute torsion, Doppler demonstrates an enlarged testis with decreased or absent flow compared with the unaffected ...

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