The acute scrotum: suggested disposition and treatment

Testicular torsion

Indications for surgery:

Suggestive history or physical examination

Similar episodes >2 weeks ago

No flow or spermatic cord knot by Doppler ultrasound

Diagnostic uncertainty^¶

Treatment:

Definitive: surgery

Temporizing: trial of manual detorsion

Torsion of appendage

Admission criteria:

Testicular torsion excluded

Severe pain

Pain refractory to trial of analgesics and conservative management

Treatment:

Analgesics

Rest

Acute epididymitis

Admission criteria:

Testicular torsion excluded

Severe pain

Immunocompromised

Not tolerating oral medications or noncompliant

Treatment:

Children:

If pyuria >3 WBC/hpf or positive culture, or if underlying GU abnormality:

Antibiotic course against coliforms*

If no pyuria and negative culture:

Antibiotics not required

Extensive evaluation not required

Sexually active adolescents:

Heterosexual: empiric antibiotics (chlamydia, GC)^Δ

Homosexual: empiric antibiotics (chlamydia, GC and coliforms)^Δ

* Antibiotic choices include: Trimethoprim (TMP)-sulfamethoxazole (6-12 mg TMP component/kg per day divided every 12 hours) or cephalexin (25-50 mg/kg per day divided every 6-8 hours).
¶ Refer to the 2015 Sexually Transmitted Diseases Guidelines from the Centers for Disease Control and Prevention available at their website.
Δ Significant overlap in clinical fndings and diagnostic studies may occur for testicular torsion, torsed appendage, or acute epididymitis. Exploratory surgery may ultimately be necessary to determine the etiology of scrotal pain.

Adapted with permission from:
Burgher, SW. Acute scrotal pain. Emerg Med Clin North Am 1998; 16:781.

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The acute scrotum: suggested disposition and treatment