INTRODUCTION — The causes of scrotal pain will be reviewed here. The evaluation of scrotal pain or swelling and causes of scrotal swelling are discussed separately. (See "Evaluation of nontraumatic scrotal pain or swelling in children and adolescents" and "Causes of painless scrotal swelling in children and adolescents".)
DIFFERENTIAL DIAGNOSIS — The spectrum of conditions that affect the scrotum and its contents ranges from incidental findings to pathologic causes that require expeditious diagnosis and treatment (eg, testicular torsion, testicular cancer). The most common causes of acute scrotal pain in children and adolescents include testicular torsion, torsion of the appendix testis, and epididymitis (table 1). In one review of 238 consecutive boys, ages 0 to 19 years, who presented with acute scrotal pain to a children's hospital over a two-year period, 16 percent had testicular torsion, 46 percent had torsion of the appendix testis, and 35 percent had epididymitis .
TESTICULAR TORSION — Testicular torsion is the most important and potentially serious of the acute processes affecting the scrotal contents because it may result in the loss of the testicle.
Normal testicular anatomy is depicted in the figure (figure 1). Intravaginal torsion results from inadequate fixation of the testis to the tunica vaginalis through the gubernaculum testis. The most common abnormality associated with testicular torsion is known as the "bell clapper" deformity: the testicle lacks the normal attachment to the tunica vaginalis (permitting increased mobility) and rests transverse within the scrotum (figure 2) . The bell clapper deformity may be bilateral and predisposes to testicular torsion.
If fixation of the lower pole of the testis to the tunica vaginalis is insufficiently broad-based or absent, the testis may torse (twist) on the spermatic cord (figure 3). The twisting of the spermatic cord within the tunica vaginalis causes venous compression and subsequent edema of the testicle and cord with ultimate ischemia of the testicle caused by arterial occlusion [2,3].
Neonatal testicular torsion, which is extravaginal, is discussed separately. (See "Neonatal testicular torsion".)
Testicular torsion has two peak incidences: a small one in the neonatal period and a large one during puberty, but it can occur at any age. The incidence is estimated to be 1 in 4000 in males younger than 25 years old . Approximately 65 percent of cases occur in boys between the ages of 12 and 18 years [5,6]. The increased incidence during adolescence is thought to be secondary to the increasing weight of the testes during pubertal development .
Clinical presentation — Patients classically present with an abrupt onset of severe testicular or scrotal pain, usually of less than 12 hours' duration [2,8-10]. Nearly 90 percent of patients may have associated nausea and vomiting [11,12]. The pain can be isolated to the scrotum or may radiate to the lower abdomen [5,7]. The pain is constant unless the testicle is torsing and detorsing. A typical presentation, particularly in children, is for the patient to awaken with scrotal pain in the middle of the night or in the morning. Many boys report a previous episode of pain [2,5,7,13]. However, a significant minority of males with testicular torsion may present with abdominal pain and not initially report testicular pain. This presentation emphasizes the importance of a complete genito-urinary examination in all males with abdominal pain.
On physical examination, the scrotum may be edematous, indurated and erythematous and the affected testis usually is tender, swollen, and slightly elevated because of shortening of the cord from twisting (picture 1). The testis may be lying horizontally, displacing the epididymis from its normal posterolateral position. A reactive hydrocele may also be present.
The cremasteric reflex (elevation of the testis in response to stroking of the upper inner thigh) is absent in nearly all cases of torsion, but it also may be absent in boys without torsion, particularly if they are younger than six months [8,9,14-17].
Prehn reported that elevation of the scrotal contents relieves the pain in patients with epididymitis and aggravates or has no effect on the pain in patients with testicular torsion . However, Prehn sign is not a reliable distinguishing feature between torsion and other diagnoses in children [13,18].
Intermittent torsion — Intermittent testicular torsion is characterized by the sudden onset of acute and intermittent sharp testicular pain, with rapid resolution (within seconds to a few minutes) and long intervals without symptoms, and should be considered in all boys with a history of such scrotal pain and/or swelling without other identifiable causes [19,20].
In one review of 50 patients with intermittent testicular torsion, 26 percent reported nausea or vomiting, and 21 percent reported that the pain awakened them from sleep . Physical findings of intermittent testicular torsion may include horizontal or very mobile testes, anterior epididymis, or bulkiness of the spermatic cord from partial twisting [19,20]. These findings are usually present to varying degrees on physical examination. However, the clinical and radiographic evaluations of some boys with intermittent torsion may be normal, highlighting the importance of immediate follow-up for recurrent or worsening pain.
All boys suspected to have intermittent testicular torsion should have an ultrasound that includes imaging of the spermatic cord. Although the testes may have normal architecture and flow, in some cases views of the cord show a whirlpool sign or a pseudomass. Boys with intermittent complaints, normal physical examination, and an unremarkable ultrasound of the testis spermatic cord at the time of presentation should have a follow-up evaluation within seven days unless pain recurs sooner. Ultrasound for intermittent torsion is at best 75 percent sensitive, and the diagnosis of this condition remains clinical .
Diagnosis — The diagnosis of testicular torsion can be made clinically. Thus, when clinical findings are strongly suggestive for testicular torsion (eg, acute onset of severe testicular pain in association with nausea or vomiting with findings of absent cremasteric reflex, testicular tenderness with swelling and high-riding or transverse position (picture 1)), the clinician should promptly consult a surgeon with pediatric urologic expertise to evaluate the patient and make a decision regarding operative exploration and repair.
Observational studies suggest that clinical findings may reliably identify testicular torsion and can be used to make decisions regarding Doppler ultrasound imaging and urology consultation [22-24]. In a prospective study of 338 children with an acute scrotum evaluated at a single institution, the TWIST score for testicular torsion was derived :
●Nausea or vomiting: 1 point
●Testicular swelling: 2 points
●Hard testis on palpation: 2 points
●High-riding testis: 1 point
●Absent cremasteric reflex: 1 point
During derivation, a score ≥5 diagnosed testicular torsion with sensitivity 76 percent, specificity 100 percent, and positive predictive value 100 percent (prevalence of torsion, 15 percent). A score ≤2 excluded testicular torsion with a sensitivity 100 percent, a specificity 82 percent, and a negative predictive value 100 percent (95% CI 98-100 percent). The prediction model had an area under the curve (AUC) for the receiver-operator curve (ROC) of 0.98 (near perfect test performance). A retrospective validation of this score in 116 children seen for an acute scrotum at a different institution and included in the derivation study found similar results .
Two subsequent prospective validations of the TWIST score (combined total of nearly 400 males) continue to report high discrimination (AUC 0.82 to 0.95) [23,24]. In a study performed in a pediatric tertiary care emergency department, the TWIST score was most accurate in pubertal patients (Tanner stage 3 to 5) .
Taken together, these studies support the practice of early surgical consultation for children in whom testicular torsion is strongly suspected based upon history and physical examination rather than performing imaging (eg, high TWIST score of ≥5 to 6). Although TWIST score has demonstrated the ability to predict testicular torsion with a high negative predictive value, further validation is needed before it is routinely used to exclude testicular torsion without a confirmatory ultrasound.
Role of imaging — In most cases, the clinical findings will be equivocal for a testicular torsion. In these patients, when available on-site, a color Doppler ultrasound of the scrotum should be obtained, and emergency surgical consultation reserved for documented testicular torsion or continued diagnostic uncertainty (eg, equivocal ultrasound findings). Demonstration of decreased testicular perfusion or twisting of the spermatic cord is consistent with testicular torsion . Decreased testicular perfusion also can be seen in some patients with a large hydrocele, abscess, hematoma, or scrotal hernia . Negative ultrasound (ie, normal or increased testicular flow) may occur rarely in patients eventually diagnosed with testicular torsion [9,19], usually with spontaneous detorsion and partial or intermittent torsion .
The Doppler ultrasound can discern testicular and epididymal size, scrotal fluid, scrotal wall thickening, enlarged appendix testis, twisting of the spermatic cord, and arterial flow in the testis and epididymis. The reported sensitivity and specificity of Doppler ultrasound in the detection of testicular torsion ranges from 69 to 100 percent and 77 to 100 percent, respectively [8,26-32]. Point-of-care ultrasound by a properly trained and experienced operator may also achieve high sensitivity and specificity in selected patients [33,34].
However, the usefulness of Doppler ultrasound is limited in small prepubertal testes with lower blood flow. Furthermore, scrotal ultrasounds may occasionally show present but diminished blood flow to the testis and epididymis, or even increased blood flow to the epididymis as the result of reperfusion if a testis has either spontaneously or manually detorsed . In these patients, other ultrasonography findings (eg, "whirlpool sign" of the spermatic cord, redundant or torsed spermatic cord with preserved blood flow, or abnormal testicular lie) can assist with the diagnosis . However, the importance of a careful history and physical examination as well as a clear understanding of the possible limitations in interpreting imaging studies cannot be overstated.
The nuclear scan measures testicular perfusion. The reported sensitivity and specificity of scintigraphy are 100 percent and 97 percent, respectively [27,31]. However, a nuclear scan takes several hours to perform and is typically not available quickly enough to permit timely operative detorsion and orchiopexy. For these reasons, Doppler ultrasound has supplanted the nuclear scan as the test of choice for testicular torsion.
Management — The diagnosis of testicular torsion, whether made clinically or radiographically, requires immediate consultation with a urologist (table 2).
The treatment for a torsed testicle that remains viable involves surgical detorsion and fixation (orchiopexy). Orchiectomy is performed if the testicle is nonviable. The viability of a torsed testicle is dependent upon the duration and completeness of torsion. Typical rates of viability according to duration of torsion have been described as follows [5,7,13,36]:
●Detorsion within 4 to 6 hours: 97 to 100 percent viability
●Detorsion after 12 hours: 20 to 61 percent viability
●Detorsion after 24 hours: 0 to 24 percent viability
Surgery never should be delayed on the assumption of nonviability based upon a clinical estimate of duration of torsion. Some patients with a prolonged period of symptoms may have had intermittent torsion or a partial torsion and testicles that are salvageable.
For patients with testicular torsion, the contralateral hemiscrotum usually is explored during surgery and bilateral orchiopexy performed [2,5,13,37]. However, the necessity of bilateral orchiopexy has been questioned. In one retrospective, multicenter observational study of over 1500 older adolescents and young adults with testicular torsion, immediate contralateral orchiopexy (ICLO) was associated with significantly higher postoperative complications, primarily hematoma and delayed wound healing, compared with propensity-matched patients who received ipsilateral scrotal exploration alone . Long-term risk of recurrent testicular torsion was not significantly different in patients with ICLO versus no ICLO (0.3 and 0.7 percent, respectively). However, confirmation of these findings in randomized controlled trials is needed.
Some authors report decreased fertility after unilateral testicular torsion when the testis is left in situ [39-42], possibly because of immune-mediated damage to the contralateral testis [41,43,44]. However, no evidence of decreased fertility or antisperm antibodies was found in one study of prepubertal boys with testicular torsion , and the fertility issue remains controversial.
Manual detorsion — We suggest that children and adolescents with testicular torsion based upon clinical findings or documented on ultrasound undergo an attempt at manual detorsion prior to surgery if emergency operative care is not rapidly available (figure 4). Manual detorsion of the torsed testicle can restore blood flow while the patient awaits surgical correction and increases the probability of testicular salvage [12,46-48]. As an example, in an observational study of 133 patients (median age 16 years) with testicular torsion, successful manual detorsion (72 patients) was associated with a testicular salvage rate of 97 percent compared with 75 percent salvage in patients in whom detorsion was not attempted or was not successful . Delay in presentation and surgical wait time did not differ significantly between the groups although median time to surgery was greater than three hours in both groups.
●Grasp the testicle and rotate it within the scrotum outward towards the thigh (medial to lateral) one or two full 360 degree turns (figure 4).
●Prompt relief of pain lower position of the testis in the scrotum, and return of arterial flow on Doppler ultrasound suggests detorsion . If Doppler ultrasound is not rapidly available, then a Doppler stethoscope can also be used to detect the return of arterial pulsations in the affected testis.
●If there is no relief or pain worsens, try rotating the testicle in the opposite direction (lateral to medial).
●Prepare the patient for surgical exploration and orchiopexy; prompt urologic consultation should occur for all patients.
The classic teaching is that the testis usually rotates medially and is detorsed by rotating it outward toward the thigh. However, in a retrospective analysis of 200 consecutive boys aged 18 months to 20 years who underwent surgical exploration for testicular torsion, lateral rotation was present in one-third of cases .
Surgical exploration is necessary even after clinically successful manual detorsion because partial torsion is frequently present and orchiopexy must be performed to prevent an additional episode [48,50].
Neonatal testicular torsion — Neonatal testicular torsion is discussed separately. (See "Neonatal testicular torsion".)
TORSION OF THE APPENDIX TESTIS OR APPENDIX EPIDIDYMIS — The appendix testis is a small vestigial structure on the anterosuperior aspect of the testis (an embryologic remnant of the Müllerian duct system) (figure 5). It measures about 0.3 cm. The appendix epididymis is a vestigial remnant of the Wolffian duct that is located at the head of the epididymis. The pedunculated shape of these appendages predisposes them to torsion, which can produce scrotal pain that ranges from mild to severe. Torsion of the appendix testis or appendix epididymis (figure 5) occurs most commonly in boys between 7 and 12 years of age .
Clinical presentation — The pain of torsion of the appendix testis or appendix epididymis is of sudden onset, like the pain of testicular torsion.
Physical examination of boys with torsion of the appendix testis or epididymis typically demonstrates a nontender testicle and a tender localized mass that is palpable, usually at the superior or inferior pole . In some patients, the torsed testicular tissue may be gangrenous or black and appear through the scrotum as the "blue dot sign" (picture 2).
A normal cremasteric reflex may be present, and a reactive hydrocele may be palpated. Blood flow to the affected testis is normal or increased and can be demonstrated on Doppler ultrasound or nuclear scan [2,52].
Diagnosis — The diagnosis of torsion of the appendix testis or appendix epididymis can be made clinically, as described above. Doppler ultrasound or nuclear scan may be helpful in cases where testicular torsion cannot otherwise be excluded.
Testicular ultrasound will show the torsed appendage as a lesion of low echogenicity with a central hypoechogenic area . Color Doppler reveals normal blood flow to the testis with an occasional increase on the affected side, possibly due to inflammation. Doppler may be less accurate in a prepubertal patient because of lower baseline testicular perfusion.
Radionuclide imaging denotes a "hot dot" sign at the torsed appendage. However, this finding is unreliable if the symptoms are less than five hours old and will be seen in only 45 percent of patients whose symptoms have lasted 5 to 24 hours .
Management — The management of a torsed appendix testis or appendix epididymis is supportive, with analgesics, bed rest, and scrotal support to help alleviate swelling (table 2). The pain should resolve in 5 to 10 days. Surgery (removal of the testicular appendix) is reserved for patients who have persistent pain; the contralateral hemiscrotum need not be explored [5,13,55].
EPIDIDYMITIS — Inflammation of the epididymis is known as epididymitis (figure 6). Epididymitis occurs more frequently among older adolescents but also occurs in younger boys who deny sexual activity [7,8,13]. Several factors may predispose postpubertal boys to develop subacute epididymitis, including sexual activity, heavy physical exertion, and direct trauma (eg, bicycle or motorcycle riding). Bacterial epididymitis in prepubertal boys is associated with structural anomalies of the urinary tract [56-58].
Among post-pubertal and sexually active males, chlamydia is the most common sexually transmitted infection, followed by N. gonorrhea. E. coli, and viruses are other common pathogens. Organisms that less commonly cause epididymitis include Ureaplasma, Mycobacterium, and cytomegalovirus, or, in patients with HIV infection, cryptococcus.
Infectious epididymitis in prepubertal boys and adolescents who are not sexually active may be caused by Mycoplasma pneumoniae, enteroviruses, or adenoviruses . Bacterial infection appears to be uncommon in such patients . As an example, an observational study of 97 cases of epididymitis who had urine cultures found that only 4 percent had a bacterial infection and, in patients with positive urine cultures, the organisms isolated frequently were not sensitive to commonly prescribed empiric antibiotics .
Clinical presentation — Patients with epididymitis may present with acute or subacute onset of pain and swelling isolated to the epididymis . A history of frequency, dysuria, urethral discharge, and/or fever may be present [2,8,12,52]. On physical examination, the affected testis has a normal vertical lie; the scrotum may be red and parchment-like (although this is an uncommon finding); scrotal edema is present in at least 50 percent of cases [8,10,11]. Sometimes an inflammatory nodule is felt with an otherwise soft, nontender epididymis.
In contrast to patients with testicular torsion, patients with epididymitis usually have a normal cremasteric reflex (if they have one under normal conditions) [2,8]. Patients with epididymitis may experience pain relief with elevation of the testis (Prehn sign), but this is not a reliable marker for epididymitis [5,13,62].
When epididymitis is suspected, the patient should provide a urinalysis and urine culture. Evaluation for sexually transmitted infections in adolescent patients who have findings consistent with sexually transmitted epididymitis is also appropriate. As in the adult male, options include rapid molecular testing, nucleic acid amplification testing of urethral discharge and/or nucleic acid amplification testing of urine, Gram stain of urethral discharge (if present), and/or culture. (See "Acute scrotal pain in adults", section on 'Clinical features and diagnosis'.)
Patients with epididymitis may have pyuria; however, urinalysis may be normal. Urine culture often is negative. In one retrospective study of patients with acute scrotal pathology, only 15 percent of those with epididymitis had a positive urinalysis (>10 white blood cells per high-power field) . Earlier studies reported positive urinalysis in 24 to 59 percent of patients with epididymitis [57,63].
Diagnosis — The diagnosis of epididymitis can be made clinically as described above. However, if the diagnosis is uncertain, Doppler ultrasonography or nuclear scan may be helpful, revealing increased blood flow to the affected epididymis [52,53,64].
A urinalysis and urine culture should be obtained in all patients with epididymitis. In addition, the United States Centers for Disease Control (CDC) recommend that providers obtain the following studies in patients who have findings consistent with sexually transmitted epididymitis :
●Gram-stained smear and culture of urethral exudates or intraurethral swab specimen, or
●Nucleic acid amplification tests for N. gonorrhea and C. trachomatis, and
●Urine culture and first void urine for leukocytes
●Syphilis and HIV testing
Management — Treatment varies according to the severity of the case at presentation and suspected etiology (table 2):
●Sexually transmitted infection (STI) – Treatment for sexually transmitted epididymitis includes antibiotics, analgesics, scrotal support, elevation, and bed rest in the acute phase . It is equally important to assure that the sexual partner gets treatment if an STI is suspected. The diagnosis and treatment regimen should be reevaluated if there is no improvement after three days of therapy. Most data regarding safety and efficacy are extrapolated from late adolescents and young adults. Guidelines for the treatment of specific STIs are regularly updated by the Centers for Disease Control and Prevention (CDC) .
●Other etiologies (STI testing negative) – For acute epididymitis in adolescents with negative STI testing and most likely caused by enteric organisms STI testing, ofloxacin (300 mg PO twice a day for 10 days) or levofloxacin (500 mg PO once daily for 10 days) may be used .
The treatment of epididymitis in prepubertal boys depends upon whether they have an associated urinary tract infection. Those who have pyuria, positive urine cultures, or underlying risk factors for urinary tract infection should be treated empirically with antibiotics that cover coliforms and achieve adequate levels in epididymal tissues (eg, trimethoprim-sulfamethoxazole, cephalexin) [12,60]. Antibiotics are not necessary in prepubertal boys with negative urinalysis and no STI [60,61]. The treatment of nonbacterial epididymitis is supportive and includes scrotal support, rest, and nonsteroidal antiinflammatory drugs (NSAIDs) . Additional evaluation of boys with urinary tract infection is discussed separately. (See "Urinary tract infections in infants older than one month and children less than two years: Acute management, imaging, and prognosis", section on 'Imaging'.)
Trauma — It is not uncommon for boys and men to suffer minor episodes of scrotal trauma; only rarely does a severe testicular injury result, usually because of compression of the testis against the pubic bones from a direct blow or straddle injury. The spectrum of injuries can range from a hematocele (hematoma in the tunica vaginalis) to an intratesticular hematoma to disruption of the tunica albuginea causing testicular rupture. Color Doppler ultrasonography can accurately diagnose the extent of injury. Testicular rupture requires surgical repair. Lesser injuries are managed according to the clinical severity and often can be treated nonoperatively. (See "Scrotal trauma in children and adolescents".)
Incarcerated inguinal hernia — Herniation of bowel or omentum into the scrotum can present with pain and a scrotal mass (picture 3). Bowel sounds may be audible in the scrotum. (See "Inguinal hernia in children".)
Immunoglobulin A vasculitis (IgAV; Henoch-Schönlein purpura [HSP]) — IgAV (HSP) is a systemic vasculitis syndrome characterized by nonthrombocytopenic purpura, arthralgia, renal disease, abdominal pain, gastrointestinal bleeding, and occasionally scrotal pain. In one review of 93 boys with IgAV (HSP), 22 had scrotal involvement . The onset of scrotal pain may be acute or insidious. In boys who lack other characteristic findings of IgAV (HSP), sonography can usually distinguish IgAV (HSP) from testicular torsion. Treatment of IgAV (HSP) is supportive. (See "IgA vasculitis (Henoch-Schönlein purpura): Management".)
Orchitis — Viral (mumps, rubella, coxsackie, echovirus, lymphocytic choriomeningitis virus, parvovirus) and bacterial (brucellosis) infections can cause orchitis in children and adolescents. Clinical manifestations may include scrotal swelling, pain, and tenderness with erythema and shininess of the overlying skin, although the presentation may be more severe. Mumps epididymo-orchitis may occur, especially in unimmunized pubertal and post-pubertal males . (See "Mumps", section on 'Orchitis or oophoritis'.)
Patients with viral orchitis are treated symptomatically with bed rest, nonsteroidal antiinflammatory agents (NSAIDs), support of the inflamed testis, and application of cold packs to the scrotum. Males with brucellosis and orchitis require antibiotic treatment, as discussed separately. (See "Brucellosis: Treatment and prevention".)
Referred pain — Boys who have the acute onset of scrotal pain without local inflammatory signs or a mass on examination may be suffering from referred pain to the scrotum. The precise incidence of referred pain is unclear. The conditions that may cause referred scrotal pain are diverse, reflecting the anatomy of the three somatic nerves that travel to the scrotum: the genitofemoral, ilioinguinal, and posterior scrotal nerves . Retrocecal appendicitis is an important (albeit uncommon) cause of referred scrotal pain in children and adolescents . Reported causes of referred pain in adults include abdominal aortic aneurysm, urolithiasis, lower lumbar or sacral nerve root impingement, retrocecal appendicitis, retroperitoneal tumor, and postherniorrhaphy pain . (See "Acute appendicitis in children: Clinical manifestations and diagnosis".)
Nonspecific scrotal pain — Sometimes older boys and young teenagers present with complaints of mild scrotal pain and a completely normal physical examination. These characteristics make testicular torsion and other pathologic conditions highly unlikely. Imaging of such patients is not usually necessary. They should be instructed to return for immediate evaluation if the pain increases in severity or is associated with testicular swelling.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Epididymitis (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Differential diagnosis – The differential diagnosis of acute scrotal pain primarily includes testicular torsion, torsion of the appendix testis, and epididymitis. Important distinguishing features are provided in the table (table 1). (See 'Differential diagnosis' above.)
●Testicular torsion – Testicular torsion requires rapid recognition and emergency intervention to prevent testicular necrosis. The most common abnormality associated with testicular torsion, the "bell clapper" deformity, refers to lack of the normal attachment of the testicle to the tunica vaginalis that permits increased mobility and a more transverse orientation within the scrotum (figure 2) compared with a normal testicle (figure 1).
•Clinical presentation and diagnosis – Testicular torsion is an emergency; timely diagnosis and surgical treatment are vital for survival of the testis. Testicular torsion generally presents with the abrupt onset of severe pain that is often associated with nausea or vomiting. The testicle may lie transversely in the scrotum and be retracted; the cremasteric reflex is typically absent (table 1). However, some pediatric patients with testicular torsion may have lesser degrees of pain or intermittent testicular pain. Imaging of the scrotum with color Doppler ultrasound may be an important study to establish the diagnosis depending upon the clinical presentation (see 'Clinical presentation' above and 'Diagnosis' above):
-Findings strongly suggest testicular torsion – Obtain emergency urology consultation prior to imaging; color Doppler ultrasound of the scrotum may also be obtained if the performance of imaging will not significantly delay treatment.
-Findings equivocal for testicular torsion (majority of patients) – Proceed with color Doppler ultrasound; obtain emergency urology consultation for documented testicular torsion or in patients with continued diagnostic uncertainty.
•Management – The operative treatment for a torsed testicle that remains viable involves surgical detorsion and fixation (orchiopexy) of both testes. Indications for surgery as determined by a urologist are provided in the table (table 2). Orchiectomy is performed if the testicle is nonviable. (See 'Management' above.)
If emergency operative care is not rapidly available, we suggest that children and adolescents with testicular torsion based upon clinical findings or ultrasound undergo an attempt at manual detorsion prior to surgery (Grade 2C). (See 'Manual detorsion' above.)
●Torsion of the appendix testis or appendix epididymis – Torsion of the appendix testis also presents with the abrupt onset of pain, but the pain typically is less severe than in testicular torsion. Pain is localized to the region of the appendix testis (anterosuperior), and a "blue dot" sign may be apparent at the same location (picture 2). Treatment may be symptomatic, or the appendix testis may be surgically excised. (See 'Torsion of the appendix testis or appendix epididymis' above.)
●Epididymitis – Patients with epididymitis may present with acute or subacute onset of pain and swelling isolated to the epididymis. A history of frequency, dysuria, urethral discharge, and/or fever may be present. The affected testis has a normal vertical lie; scrotal edema often is present. Treatment depends on the severity of illness and the suspected etiology. (See 'Epididymitis' above.)
●Other causes – Other causes of scrotal pain in children and adolescents include scrotal trauma, an incarcerated inguinal hernia, immunoglobulin A vasculitis (Henoch-Schönlein purpura), orchitis, and, less commonly, referred pain from a retrocecal appendicitis or lower lumbar or sacral nerve root impingement. (See 'Other causes' above.)
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