The term “acute scrotum” covers a few condition that cause scrotal swelling, pain and inflammation. In many some cases these diseases cannot be differentiated without surgical exploration of the scrotum. The concept of diagnostic exploration of all cases of “acute scrotum” is widely accepted in pediatric urology in Cracow, Poland. In my opinion experienced pediatric urologist/surgeon does not have to stick to this “rule”, if only can be sure it is not testicular torsion. Still, this is not a kind of responsibility that GPs should try to take on themselfs.
The symptoms of acute scrotum are generalized or more localized pain in the scrotum, oedema, reddish discoloration and hardening of scrotal contents. Sometims the testis lies high in the scrotum, is immobilized, there is pain in the groin and vommiting.
The conditions responsible for this are:
1. Testicular torsion – the most sesious disease from this group. Usually after 4-6 hours of impaired blood supply testicular tissue is irreversibly damaged. If surgery is performed earlier the testis has great chance of recovering. The condition usually affects newborns and later adolescents and adults. The neonatal torsion can be obscured be hydrocoele, which is common in this age group, but in this case is just secondary reaction for necrosis.
2. Torsion and necrosis of Morgagni appendix. Appendices of epidydymis and testis are remnants of blind ending seminal ducts in a form of small polip-like structures 1-4mm in lenght. Spontaneous torsion of them leads to necrosis of this small fragment of tissue and secondary local inflammatory reaction. It usually happens between 6 and 12 yo, in younger boys then testicular torsion, thogh it is a roule of thumb. The spectrum of symptoms is really wide- from light localized of small palpated ball (nectrotic appendix) vahishing in 2-3 days to great scrotalm pain, oedema and reddening persistens for weeks in not treated surgically. It can be treated conservatively in most cases, but it should be decision on pediatric urologist or surgeon. In more fouurishing cases it can be difficult to distinguish it from testicular torsion without exploration. Besides, removing necrotic appendix can make recovery much faster in these cases.
3. Inflammation of testis or epidydymis – these are usually of infectious background, sometimes facilitated by urethral stenosis (secondary to penile surgery) and reflux of urine into ductus defferens. They can be treated with antibiotics, if only we can be 100% sure it is not testicular torsion. These conditions may appear in any age, but is quite distinctive phenomenon in neonatal age.
4. trauma, haematoma and testicular rupture
5. Oncological conditions (leukemia)
In some cases common testicular hydrocoele, especially worsened during any infection, must be taken into consideration.
The most usefull diagnostic tools are medical history, palpation and ultrasound with power dopler which shows lack of blood flow (torsion of testis) or increased blood flow (inflammation) in comparision of other testis. Must be remembered that ultrasound alone can be misleading.
All cases of acute scrotum should be consulted by pediatric urologis or surgeon. They should not be treated by GPs. Surgical intervention is simple and last 15-30minutes. It is final diagnostic tool, allaws us to remove necrotic testis or Morgagni appendix, or de-rotate and fix the testis if it required . Scrotal pain or discomfot after the procedure is not intensive and lasts usually one day. There is no need for prolonged hospital stay usually. Scrotal haematoma and oedema happens sometimes, may last for a couple of weeks, but has no impact on final effect.
Information for parents about testicular torsion and related conditions can be found on official webpage of European Society of Pediatric Urology here.