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High-Yield Facts

  • Acute scrotal pain is usually caused by testicular torsion, epididymitis, or torsion of the appendix testis.

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

Testicular Pain/Scrotal Masses

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 (Table 85-1). The most common diagnoses for an acute scrotum are testicular torsion, torsion of the appendix testis or epididymis, and epididymitis. 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 85-1Causes of Scrotal Pain or Swelling in Children

Testicular Torsion

Testicular torsion has a bimodal incidence, with the first peak in the neonatal period and a second in adolescence.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 scrotal sac (Fig. 85-1). The abnormal testicular attachments to the tunica vaginalis allow the testis to twist along with the spermatic cord and the testicular artery; the vascular supply is compromised and the testis will necrose. After 4 to 6 hours of continuous pain, the salvage rate is 96%, but drops to 20% after 12 hours of pain, and below 10% at 24 hours.1 Torsion may be intermittentand therefore the duration of symptoms may not necessarily predict the viability of the testis.


Bell-clapper deformity in testicular torsion results from the twisting of the spermatic cord and causes the testis to be elevated, with a horizontal lie. The lack of fixation of the tunica vaginalis ...

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