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Evaluation of nontraumatic scrotal pain or swelling in children and adolescents

Evaluation of nontraumatic scrotal pain or swelling in children and adolescents
Literature review current through: Jan 2024.
This topic last updated: Jul 19, 2022.

INTRODUCTION — The evaluation of nontraumatic scrotal pain or swelling in children and adolescents will be discussed here.

The causes of scrotal pain and swelling are discussed separately, as is the evaluation of scrotal trauma in children. (See "Causes of scrotal pain in children and adolescents" and "Causes of painless scrotal swelling in children and adolescents" and "Scrotal trauma in children and adolescents".)

CLINICAL ANATOMY — The scrotum contains the testicles and portions of the spermatic cords. It provides two discrete cavities for the testicles. These cavities connect at the median raphe, a scrotal projection that extends from the dorsum of the penis to the anus. The layers of the scrotum include the skin and the dartos, a muscular layer that provides the septum for the two scrotal cavities and forms the outermost fascial layer of the scrotum (figure 1 and figure 2).

The tunica vaginalis on each side of the scrotum encompasses the anterior two thirds of the testicle and holds the testicle and its appendages, epididymis, spermatic cord, and associated nerve, artery, and venous vessels (figure 3). Within the tunica vaginalis is a potential space in which fluid from a variety of sources may accumulate. The testicle itself has an additional covering called the tunica albuginea that maintains its oval contour. Additional testicular coverings include the infundibuliform fascia, cremaster muscle, and intercrural fascia. The epididymis usually is positioned posterolaterally to the testicle and must be differentiated from an abnormal mass. The spermatic cord, which consists of the testicular vessels and the vas deferens, is connected to the base of the epididymis near the top of the testicle.

Because the left spermatic cord is longer than the right, the left scrotum and testicle typically hang lower than the right.

EVALUATION — Evaluation of scrotal pain or swelling begins with a careful history and physical examination. Based upon these findings, further ancillary studies such as Doppler ultrasonography and urine testing establish the diagnosis.

History — A detailed history in a boy with scrotal pain or swelling can help to narrow the differential diagnosis and lead to a more focused examination [1]:

In patients with testicular or scrotal pain, what is the onset, location, severity, and timing of pain? The description of pain can help identify specific causes (see "Causes of scrotal pain in children and adolescents"):

Abrupt onset of severe testicular pain suggests testicular torsion or torsion of testicular or epididymal appendages (table 1) [2]. Testicular torsion is a surgical emergency. (See "Causes of scrotal pain in children and adolescents", section on 'Testicular torsion'.)

Acute abdominal pain associated with decreased appetite, nausea, and/or vomiting can be nonspecific but may represent referred pain associated with testicular torsion. In addition, some adolescents may not report scrotal pain because of modesty or embarrassment) [3]. (See "Emergency evaluation of the child with acute abdominal pain".)

Acute scrotal pain in association with flank pain and hematuria suggests a renal stone, which may cause referred pain to the scrotum. (See "Kidney stones in children: Clinical features and diagnosis", section on 'Pain'.)

Gradual onset of testicular pain is more characteristic of epididymitis. Sexual activity may be associated with epididymitis in postpubertal males. Epididymitis also occurs in prepubertal and non-sexually active males, but less frequently. (See "Causes of scrotal pain in children and adolescents", section on 'Epididymitis'.)

Subacute or chronic pain with urination in a boy with scrotal pain suggests urethritis, epididymitis, or a urinary tract infection. (See "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis" and "Etiology and evaluation of dysuria in children and adolescents", section on 'Infectious causes'.)

Subacute or chronic scrotal pain in patients with difficulty voiding and/or incontinence may indicate referred pain to the scrotum from an intraabdominal, pelvic, or rectal mass; or a neurologic problem, including a lesion of the spinal cord. (See "Clinical manifestations and diagnosis of central nervous system tumors in children", section on 'Spinal tumors'.)

In patients without pain, is there a history of change in testicular or scrotal size? If so, what is the onset of this change? Does scrotal size vary with time of day, position, or Valsalva maneuver? Such changes are suggestive of communicating hydrocele (with or without an inguinal hernia) or varicocele (table 2). These conditions and other causes of scrotal swelling are discussed separately. (See "Causes of painless scrotal swelling in children and adolescents".)

Has the patient had fever? Fever suggests orchitis due to infections such as coxsackie virus, mumps, or brucellosis. Fever is also seen in some patients with epididymitis. (See "Causes of scrotal pain in children and adolescents", section on 'Orchitis' and "Causes of scrotal pain in children and adolescents", section on 'Epididymitis'.)

Physical examination — The patient and/or parents should receive a brief overview of the genital examination before the examination is begun. A parent/caregiver and/or chaperone should be present for the examination if the patient and/or examiner prefers. Uninterrupted privacy must be guaranteed during the examination. The patient's undergarments should be removed, and a gown or towel (held by the patient) should be offered to alleviate any embarrassment.

For most aspects of the examination, the patient should be standing. The examiner can sit or stand. Some patients with severe pain may not tolerate standing and require evaluation in the supine position. The evaluation of patients with scrotal pain or swelling should include a detailed examination of the abdomen, inguinal region, and genitalia, including the testes, epididymis, spermatic cord, scrotal skin, penis, and cremasteric reflex.

In addition to the genital examination, abdominal and rectal examinations are indicated if clinical suspicion exists for an abdominal or rectal mass, metastatic visceral disease, spinal cord lesion, or prostatitis.

Genital examination

Inspection — The first step is to inspect the penis, pubic hair (postpubertal males), and inguinal area while the patient is standing. The examiner should notice the presence or absence of any ulcers, papules, urethral discharge, piercings, tattoos, pubic hair infestation, or lymphadenopathy. Ulcers, papules, discharge, and lymphadenopathy may suggest a sexually transmitted infection. Piercings and tattoos may provide a portal of entry for skin and soft tissue infection. Erythema or discoloration of the scrotum may occur in patients with testicular torsion or an incarcerated inguinal hernia. (See "Sexually transmitted infections: Issues specific to adolescents", section on 'STI clinical patterns' and "Body piercing in adolescents and young adults", section on 'Localized infection'.)

The left testicle usually lies slightly lower than the right testicle. The position of the testicles (eg, high versus low and horizontal versus vertical) should be evaluated; a high-riding testicle with a horizontal lie raises concern for testicular torsion, as does a left testicle that is higher than the right testicle.

Patients with varicoceles (nonpainful swelling that feels like a "bag of worms") on standing or with a Valsalva maneuver should also be examined in the supine position. This maneuver will help to differentiate idiopathic from secondary varicocele. Idiopathic varicocele usually is more prominent in the upright position and disappears when the patient is supine, whereas secondary varicocele usually does not get much smaller with change in position from upright to supine. (See "Causes of painless scrotal swelling in children and adolescents", section on 'Varicocele'.)

Palpation — The examiner should palpate the entire testicular surface by gently rolling it between his or her thumb and forefingers. The testicle should have the consistency of a hard-boiled egg. The epididymis should be palpated in the posterolateral position and followed to the spermatic cord (figure 3).

The examiner should note any swelling or tenderness along any of these structures; if swelling is noted, transillumination may help to determine if it is cystic or solid in nature. Transillumination is performed by placing a light source at the base of the scrotum. Fluid-filled masses (eg, hydrocele or spermatocele) will transfer the light and cause the scrotum to glow; solid masses (eg, torsed testicle) will not.

Prehn reported that elevation of the scrotal contents relieves the pain in patients with epididymitis and aggravates or has no effect on pain in patients with testicular torsion. However, Prehn sign is not a reliable distinguishing feature between testicular torsion, epididymitis, and other diagnoses in children. (See "Causes of scrotal pain in children and adolescents", section on 'Clinical presentation'.)

Cremasteric reflex — The cremasteric reflex should be assessed by stroking the upper thigh while observing the ipsilateral testis. A normal response is cremasteric contraction with elevation of the testis. The reflex is present in the majority of healthy boys between the ages of 30 months and 12 years; it is less consistently present in infants and teenagers [4]. The reflex is almost always absent in patients with testicular torsion, which may help to distinguish this condition from other causes of scrotal pain (table 1) [5]. (See 'Diagnostic approach' below.)

Ancillary studies — The initial laboratory and radiologic studies that help to differentiate among causes of scrotal pain or swelling vary according to the presentation [1]:

Testicular pain — Testicular torsion is one of the prime concerns in pediatric patients with testicular pain. Emergency evaluation and color Doppler ultrasonography is indicated to delineate anatomy, assess perfusion, and identify or exclude testicular torsion (algorithm 1). The approach to testicular torsion is discussed in detail separately. (See "Causes of scrotal pain in children and adolescents", section on 'Testicular torsion'.)

Urinalysis and urine culture should also be performed. Pyuria can occur in epididymitis but is unusual in testicular torsion or torsion of the appendix testis or appendix epididymis.

Evaluation for sexually transmitted infections in adolescent patients who have findings consistent with sexually transmitted epididymitis (tenderness and swelling of the epididymis, which may be accompanied by signs of urethritis) 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.

Painless scrotal swelling — Most patients with painless scrotal swelling can have the underlying cause determined by history and physical examination (algorithm 2). Doppler ultrasonography is indicated to further investigate a solid mass. Ultrasonography may occasionally be helpful to confirm the finding of a spermatocele. (See "Causes of painless scrotal swelling in children and adolescents", section on 'Diagnosis'.)

DIAGNOSTIC APPROACH — The diagnostic approach to scrotal pain or swelling can be divided according to the predominant symptom:

Scrotal pain – The diagnostic approach and the clinical findings that point to the cause of scrotal pain are provided in the algorithm and table (algorithm 1 and table 1) and discussed in detail separately. (See "Causes of scrotal pain in children and adolescents".)

Nonpainful scrotal swelling – The diagnostic approach and clinical findings that help identify the likely cause of nonpainful scrotal swelling are provided in the algorithm and table (algorithm 2 and table 2) and discussed in detail separately. (See "Causes of painless scrotal swelling in children and adolescents".)

An experienced clinician can often make an accurate diagnosis based upon a careful history and physical examination. However, advances in color Doppler imaging of the scrotum have made this modality a useful adjunct during evaluation of the painful or swollen scrotum.

Painful scrotum — The most common causes of acute scrotal pain in children and adolescents are testicular torsion (a surgical emergency), incarcerated inguinal hernia (a surgical emergency), torsion of the appendix testis or epididymis, and epididymitis. Other causes include trauma, immunoglobulin A vasculitis (IgAV; Henoch-Schönlein purpura [HSP]), orchitis, and referred pain. The evaluation and management of scrotal trauma is discussed separately. (See "Scrotal trauma in children and adolescents".)

The nontraumatic, painful scrotum requires a rapid diagnostic approach (algorithm 1). When clinical findings are definitive for testicular torsion (ie, acute onset of severe testicular pain in association with nausea or vomiting, absent cremasteric reflex, and testicular tenderness and swelling on physical examination with 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. Experienced clinicians may attempt manual detorsion under sedation while awaiting arrival of the consulting surgeon. (See "Causes of scrotal pain in children and adolescents", section on 'Manual detorsion'.).

In most cases, the clinical findings will not be definitive for or against a testicular torsion, and an emergency Doppler ultrasound of the scrotum should be obtained with emergency surgical consultation reserved for patients with documented torsion. (See "Causes of scrotal pain in children and adolescents", section on 'Diagnosis'.)

In the same way, an incarcerated hernia commonly presents in infancy with irritability accompanied by a firm, discrete, inguinal mass that may extend into the scrotum. The mass is tender, and overlying skin is edematous with erythema or duskiness. Vomiting and/or abdominal distensions indicates prolonged incarceration with bowel obstruction. The clinician should attempt reduction, which may be facilitated by pain control (eg, intranasal or intravenous fentanyl) and local measures (cold therapy to the groin for several minutes and reverse Trendelenburg position) (figure 4 and figure 5). (See "Inguinal hernia in children", section on 'Manual reduction'.).

If reduction is unsuccessful, the clinician should emergently consult a surgeon to provide definitive management. The surgeon will attempt manual reduction, occasionally with sedation. Inability to reduce an incarcerated hernia is an indication for reduction in the operating room. For patients in whom reduction is successful, timely follow-up with a surgeon with pediatric urologic expertise should be arranged for elective repair. (See "Inguinal hernia in children", section on 'Incarcerated inguinal hernia'.)

Patients with testicular tenderness but equivocal clinical features for, or low likelihood of, testicular torsion should undergo urinalysis and prompt Doppler ultrasound of the scrotum. The three most common etiologies of testicular pain (testicular torsion, torsion of appendix testes or epididymal appendage, and epididymitis) are typically differentiated by a combination of history, physical examination, and these ancillary studies (table 1). Resolved testicular torsion is an important consideration in a boy with testicular pain but normal physical examination and ancillary studies. These patients warrant anticipatory guidance and follow-up with a pediatric urologist. (See "Causes of scrotal pain in children and adolescents", section on 'Intermittent torsion'.)

Orchitis and testicular tumor are less frequent diagnoses in boys with scrotal pain. Orchitis often presents with bilateral testicular pain and may be accompanied by systemic manifestations of the underlying infection (eg, mumps, coxsackie virus, or brucellosis) (see "Mumps" and "Brucellosis: Epidemiology, microbiology, clinical manifestations, and diagnosis"). Most testicular malignancies or metastatic testicular tumors do not cause testicular pain and present as unilateral swelling. However, rarely, rapid tumor growth with distension of the tunica albuginea, tumor necrosis, or hemorrhage can cause pain. Physical examination and ultrasound will often demonstrate a discrete testicular mass. (See "Clinical manifestations, diagnosis, and staging of testicular germ cell tumors", section on 'Clinical manifestations'.)

Mild to moderate scrotal wall tenderness with rash may be seen with IgAV (HSP) and Kawasaki disease. These entities are readily identified by other manifestations. Patients with IgAV typically have palpable purpura without thrombocytopenia or coagulopathy. Other findings may include joint pain, abdominal pain, and renal disease (see "IgA vasculitis (Henoch-Schönlein purpura): Clinical manifestations and diagnosis"). In addition to rash, patients with Kawasaki disease typically have three or more of the following: high fever of >4 days duration, bilateral bulbar conjunctival injection with perilimbic swelling, oral mucous membrane changes, peripheral extremity changes (eg, erythema of the palms and soles and/or swelling of the hands and feet), or cervical lymphadenopathy with at least one node >1.5 cm in diameter. (See "Kawasaki disease: Clinical features and diagnosis".)

Boys who have acute onset of scrotal pain without local inflammatory signs, tenderness, or a mass on examination may be suffering from referred pain to the scrotum. The conditions that may cause referred scrotal pain are diverse and include urolithiasis, appendicitis, lumbar or sacral nerve compression due to a mass lesion, or postherniorrhaphy nerve pain. (See "Causes of scrotal pain in children and adolescents", section on 'Referred pain'.)

Swollen scrotum without pain — In patients with a swollen, nonpainful scrotum, a careful general and genital examination typically provides the diagnosis (algorithm 2). The clinician should first determine if there is generalized edema. Bilateral scrotal swelling accompanied by generalized edema and/or ascites identifies systemic edema due to conditions such as nephrotic disease, liver disease, protein-losing enteropathy, or heart failure. (See "Pathophysiology and etiology of edema in children".)

Next, the testicle should be palpated to determine if it is of normal size and shape. The presence of a discreet, ovoid, firm testicular mass is suggestive of a primary testicular tumor or malignant infiltration in patients with leukemia or lymphoma. Transillumination is variable depending upon whether a reactive hydrocele is present. (See "Clinical manifestations, diagnosis, and staging of testicular germ cell tumors", section on 'Clinical manifestations' and "Overview of the clinical presentation and diagnosis of acute lymphoblastic leukemia/lymphoma in children".)

During evaluation for a hernia, unilateral scrotal swelling that is reducible through the external inguinal ring indicates an indirect inguinal hernia. (See "Inguinal hernia in children".)

On further inspection, mild to moderate scrotal wall swelling with rash and minimal tenderness may occur with IgAV (HSP) and Kawasaki disease. These entities are readily identified by other manifestations. Patients with IgAV typically have palpable purpura without thrombocytopenia or coagulopathy. Other findings may include joint pain, abdominal pain, and renal disease (see "IgA vasculitis (Henoch-Schönlein purpura): Clinical manifestations and diagnosis"). In addition to rash, patients with Kawasaki disease typically have three or more of the following: high fever of >4 days duration, bilateral bulbar conjunctival injection with perilimbic swelling, oral mucous membrane changes, peripheral extremity changes (eg, erythema of the palms and soles and/or swelling of the hands and feet), or cervical lymphadenopathy with at least one node >1.5 cm in diameter. (See "Kawasaki disease: Clinical features and diagnosis".)

Bilateral soft scrotal wall swelling with pruritus suggests allergic scrotal edema secondary to an insect bite or other allergen. Soft scrotal swelling and redness without pruritus is seen in children with idiopathic scrotal edema. Typical patients are school-age boys who have a history of atopy and no reported pruritus, inciting event, or infection [6]. The swelling resolves in two to three days and may recur in up to 10 percent of individuals.

At this point in the evaluation, transillumination and change in size with a Valsalva maneuver helps to differentiate the remaining etiologies:

Varicocele – Varicoceles do not transilluminate, and the spermatic cord has a "bag of worms" texture (figure 6). The varicocele may increase or only be palpable during Valsalva maneuver or with standing. Varicoceles that do not get smaller in the supine position warrant further evaluation as discussed separately. (See "Causes of painless scrotal swelling in children and adolescents", section on 'Varicocele'.)

Hydrocele – A hydrocele is a cystic scrotal fluid collection that transilluminates. A hydrocele that communicates with the peritoneal cavity may increase in size during the day or with the Valsalva maneuver. A noncommunicating hydrocele does not change in size or shape with crying or straining. Acute appearance of a hydrocele warrants further investigation as discussed in detail separately. (See "Causes of painless scrotal swelling in children and adolescents", section on 'Hydrocele'.)

Spermatocele – A spermatocele (epididymal cyst) is a painless, fluid-filled cyst of the head (caput) of the epididymis that may contain nonviable sperm. It transilluminates superior to the testis and can be palpated as distinct from the testis (figure 7). Spermatoceles do not change in size with Valsalva. Asymptomatic spermatoceles do not warrant intervention. (See "Causes of painless scrotal swelling in children and adolescents", section on 'Spermatocele (epididymal cyst)'.)

In a significant proportion of patients, transillumination will not be definitive. For these cases, an ultrasound should be obtained.

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 topics (see "Patient education: Hydrocele (The Basics)" and "Patient education: Varicocele (The Basics)")

SUMMARY AND RECOMMENDATIONS

Evaluation – The evaluation of nontraumatic scrotal pain or swelling should begin with a focused history and a complete genital examination. (See 'History' above and 'Physical examination' above.)

Diagnostic approach – The diagnostic approach depends upon the suspected diagnosis and whether pain is present.

Nontraumatic painful scrotum – The nontraumatic painful scrotum requires a rapid diagnostic approach (algorithm 1). (See 'Painful scrotum' above.)

-Testicular torsion (high likelihood based on presentation) – When clinical findings are definitive for testicular torsion (ie, acute onset of severe testicular pain in association with nausea or vomiting, absent cremasteric reflex, and testicular tenderness and swelling on physical examination with high-riding or transverse position) (picture 1), the clinician should obtain an emergency consultation from a surgeon with pediatric urologic expertise to evaluate the patient and make a decision regarding operative exploration and repair. (See "Causes of scrotal pain in children and adolescents", section on 'Management'.)

Experienced clinicians may attempt manual detorsion under sedation while awaiting arrival of the consulting surgeon. (See "Causes of scrotal pain in children and adolescents", section on 'Manual detorsion'.)

-Testicular tenderness (equivocal presentation or low likelihood of testicular torsion) – Patients with testicular tenderness but equivocal clinical features for, or low likelihood of, testicular torsion should undergo urinalysis and prompt Doppler ultrasound of the scrotum. (See 'Painful scrotum' above.)

The three most common etiologies of testicular pain (testicular torsion, torsion of appendix testes or epididymal appendage, and epididymitis) are typically differentiated by a combination of history, physical examination, color Doppler ultrasonography, urinalysis, and, for patients with pyuria, testing for sexually transmitted diseases (table 1). (See "Causes of scrotal pain in children and adolescents".)

-Incarcerated inguinal hernia – An incarcerated hernia commonly presents in infancy with irritability accompanied by a firm, discrete, inguinal mass that may extend into the scrotum. The mass is tender, and overlying skin is edematous with erythema or duskiness. Vomiting and/or abdominal distensions indicate prolonged incarceration with bowel obstruction. The clinician should attempt reduction, which may be facilitated by pain control (eg, intranasal or intravenous fentanyl) and local measures (cold therapy to the groin for several minutes and reverse Trendelenburg position) (figure 4 and figure 5). If reduction is unsuccessful, the clinician should promptly consult a surgeon with pediatric urologic expertise to provide definitive management. (See "Inguinal hernia in children", section on 'Incarcerated inguinal hernia'.)

Swollen, nonpainful scrotum – In patients with a swollen, nonpainful scrotum, a careful genital examination typically provides the diagnosis (algorithm 2). (See 'Swollen scrotum without pain' above.)

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