Private Pathology: Acute Scrotal Swelling in Children and Adolescents
Author: Joel Fein, MD, Assistant Professor of Pediatrics, The University of Pennsylvania School of Medicine, Attending Physician, Division of Emergency Medicine, The Children’s Hospital of Philadelphia, PA.
Peer Reviewer: Steven G. Rothrock, MD, FACEP, Department of Emergency Medicine, Orlando Regional Medical Center & Arnold Palmer’s Hospital for Women and Children, Orlando, FL; Clinical Assistant Professor, Division of Emergency Medicine, University of Florida College of Medicine, Gainesville, FL.
For various reasons, boys with scrotal complaints are often vague about their symptoms. It is often not until these symptoms become severe, or the parent notices an abnormality during the routine care of the child, that these children come to medical attention. For example, some boys with scrotal pathology will complain only of abdominal pain, nausea, or vomiting. All children with abdominal complaints require a complete genital examination during the course of their visit.
The differential diagnosis of scrotal swelling or pain includes structural abnormalities, infections, inflammatory processes, and traumatic injuries. Boys with scrotal complaints in the ED will benefit greatly from a physician with working know-ledge of the potential diagnoses in patients with this complaint. Some of these entities are common, such as testicular torsion, or rare, such as Familial Mediterranean Fever. A systematic approach to the history and physical examination will help clinicians narrow the differential diagnosis considerably, rapidly initiate treatment, and reduce parental and patient anxiety. In patients with testicular torsion, expedience in diagnosis, treatment, and consultation could mean the difference between a viable and non-viable testicle.
Scrotal swelling in a child may signify a surgical emergency or a benign variant of normal anatomy. A review of almost 400 boys with acute scrotal pain revealed that 38% had testicular torsion, 31% had epididymitis or orchitis, 24% had torsion of the appendix testis, and the remainder had idiopathic pathology or normal findings.1 The consultation with a surgical specialist and the application of appropriate diagnositc technologies is often necessary to arrive at a definitive diagnosis. Nevertheless, the differential diagnosis can be effectively narrowed through astute questioning and an ordered, comprehensive physical examination.
The Editor
During fetal development, each testicle descends from the abdominal cavity into the scrotal sac, carrying with it the spermatic cord. (See Figure 1.) The external portions of the cord are derived from abdominal wall structures, including muscle, fat, and fascial layers. The dense, fibrous covering of the testicle is called the tunica albuginea, the outer layer of which is an outpouching of the peritoneum called the tunica vaginalis. The tunica vaginalis surrounds the testicle on three sides, allowing for fixation of the testicle to the scrotal wall posteriorly in the scrotum. Proceeding internally to externally, the layers surrounding the testicle include the tunica albuginea, the tunica vaginalis, internal spermatic fascia, cremasteric muscle, external spermatic fascia, Colles fascia, and dartos muscle. The cremasteric and testicular arteries travel inside the spermatic cord along with the vas deferens and the spermatic (pampiniform plexus of) veins. The epididymis is located on the posterior and lateral aspect of the testicle, arching over the superior pole. Many testicular appendages exist as vestigial structures in the scrotum.
Normally, the testicle lies longitudinally in the scrotal sac, and the left testicle lies slightly lower than the right.
Whether or not scrotal swelling is painful can considerably limit the potential diagnoses. (See Table 1.) Younger patients may not complain of pain, but the parents may notice a wide based gait or general irritability. The patient’s age can also suggest a diagnosis: Testicular torsion, as well as the infectious causes of scrotal swelling, are most common in the second decade of life, whereas vasculitis causing scrotal pathology is more common during the first decade.
If the area is painful, it is important to ask about the timing, severity, and location of the pain. Is voiding painful, or is there a penile discharge? Is there a fever, nausea, or vomiting? Are there any existing urological abnormalities, or has there been prior urinary tract infections, urological instrumentation, or surgery? Finally, does the patient or caretaker recall any trauma to that region?
If the area is not painful, how long has the swelling been there? Has it been noted to resolve and recur? If so, is there a body position that exacerbates or relieves the symptom? Are any other parts of the body swollen?
Remember that the child with scrotal pathology often presents with lower abdominal or groin pain. Any patient with a history of abdominal pain should have a genital examination performed. Conversely, it is important to examine the abdomen of all patients with scrotal pain to evaluate peritoneal inflammation, intestinal obstruction, and abdominal masses.
School-aged and adolescent boys are typically reticent about having their genitals examined. The child with a painful scrotum is even more anxious that the examination will cause increased pain. The physical examination of these patients must therefore collect as much data as possible before the area is manipulated. The approach is best taken "from outside inward." (See Table 2.) First, note the location of any swelling or discoloration. Often, one can determine the lie of each testicle without touching the patient. This is admittedly more difficult if the swelling is severe. If one testicle is riding much higher than the other, or it lies in a transverse rather than a longitudinal axis, testicular torsion must be considered. Remember that the left testicle ordinarily sits lower in the scrotum than does the right testicle. The cremasteric reflex should be performed next, because the reflex may extinguish after palpation. To perform this reflex, swipe the inner thigh with a fingertip or pen. In the normal condition, cremaster muscle contraction causes a brisk elevation of the ipsilateral testicle. Contraction of the dartos muscle and movement of the scrotal sac without obvious testicular movement is not considered a positive cremasteric reflex. Comparison between sides is helpful, although edema or discoloration of the scrotum may limit one’s ability to detect a positive reflex. In addition, repeated attempts often diminish the reflex.
Two large series of boys and adolescents with acute scrotal pain found that more than 50% without torsion had a cremasteric reflex, while none with testicular had a cremasteric reflex.2,3 Thus, the presence of a cremasteric reflex provides strong evidence that a testicular torsion is absent although the absence of a cremasteric reflex does not prove that torsion is present. Furthermore, rare cases of torsion in children with a cremasteric reflex have been reported.4
After the cremasteric reflex is performed, one can palpate the scrotum. Palpate the scrotal wall, the anterior testicle, the posterior testicle and epididymis, and any other masses in the scrotal sac. Palpate the spermatic cord, and compare the sides for thickness. If one area of the testicle is more tender than another, the location may suggest a diagnosis of torsion of the appendix testis (described below), epididymitis, or a scrotal mass. It is useful to compare testicular sizes to each other. Pre-existing size discrepencies can often be confirmed by either the patient or a parent. A large testicle that is painful suggests a traumatic injury, whereas a painless one suggests a hydrocele. Scrotal masses are identified as either separate or indistinguishable from the testicle. A compliant, easily distinguishable mass may be a hernia, while a discrete, non-painful mass that is inseparable from the testicle suggests a testicular tumor. Prehns sign is a relief of pain when the testis is manually elevated in the scrotum. This sign is thought to be positive in cases of epididymitis and negative (no relief of pain) in cases of testicular torsion. However, even in the most experienced hands this sign is inaccurate and should not be relied upon to distinguish these diagnoses.5
Other physical examination findings can point toward specific diagnoses of scrotal pathology. The blue dot sign, a blue tinge to the skin overlying the anterior portion of the testicle, may signify torsion of the appendix testis. The presence of parotitis suggests mumps orchitis. A purpuric rash below the waistline may signify Henloch Schonlein Purpura (HSP), while a constellation of findings that include rash, conjunctivitis, mucous membrane lesions, and lymphadenopathy may suggest Kawasaki disease.
Radiologic studies can be performed in consultation with the surgical specialist and are necessary only for patients with a swollen scrotum in whom the diagnosis is unclear after history and physical examination. It should be emphasized that certain disorders (esp. testicular torsion) require emergent surgical exploration and repair, and that radiologic procedures may delay appropriate intervention and increase the risk of losing a testicle. Both sonography and scintography explore the quality of blood flow to the testicle and surrounding structures. High-resolution sonography with color Doppler is a readily available and accurate method of diagnosing torsion and epididymitis in adolescent and adult patients. Recent efforts have been made to apply this technique to younger children as well.6,7 However, because the testicular arteries are small in prepubertal children, Doppler flow studies are more difficult to interpret.8 Therefore, technitium 99m pertechnetate scintography remains the primary radiologic tool in the young child with a painful, swollen scrotum. Doppler flow imaging holds promise as the technology and skills with this technique are improving. One study found that Doppler sonography was 89% sensitive and 100% specific in correctly identifying scrotal pathology.7 Conversely, handheld Doppler stethoscope devices produce results that are difficult to interpret.9 These devices are least accurate 8-12 hours after torsion, because hyperemia of the torsed area can give false-positive readings. False-negative readings are also possible.10 The technique may be most helpful in evaluating the success of a detorsion procedure, if flow is detected in a testicle that previously had no flow.11 The clinician should be discouraged from using the handheld Doppler stethoscope to alter his or her management in a patient with scrotal swelling.
A complete blood count (CBC) is neither sensitive nor specific for any of the diagnoses listed in the evaluation of the swollen scrotum. In general, children with torsion of the spermatic cord and epididymitis are more likely to have a total leukocyte count of greater than 10,000/mm3, compared to children with torsion of the appendix testis.1 However, this test should not be used to rule in or rule out the diagnosis.
Urinalysis can be helpful in diagnosing epididymitis if urine leukocytes are present. However, only 30% of patients with epididymitis have an abnormal urinalysis.1 In younger patients with epididymitis, urine culture often reveals coliform organisms.12 A patient with traumatic injuries to the perineum or scrotum who has red blood cells evident in his urinalysis should be evaluated by a surgical subspecialist or undergo radiologic assessment of his genitourinary tract. If the injury is primarily to the groin area, a retrograde urethrogram may be necessary to evaluate damage to the urethra. If the mechanism of injury is more diffuse, as in a motor vehicle accident, then renal injury must be suspected and evaluated.
Testicular torsion is a surgical emergency. Twisting of the spermatic cord on its own axis initially leads to venous congestion. If not rapidly corrected, the arterial supply to the testicle will eventually be compromised and infarction will ensue. The majority of patients with testicular torsion have a congenital condition called the bell clapper deformity. In this condition, the tunica vaginalis completely envelopes the testicle, thereby preventing fixation of the testicle posteriorly in the scrotum and predisposing the patient to testicular torsion. Since the testicle and spermatic cord twist in relation to the tunica vaginalis, this is termed intravaginal torsion. Although the deformity is bilateral, symptoms usually occur unilaterally. The left testicle is more commonly affected because the left spermatic cord is usually longer.
Two thirds of the cases of testicular torsion occur between the ages of 12 and 18 years, and torsion rarely occurs in patients younger than 8 or older than 35 years. Unfortunately, adolescent males are more likely to present for medical care later in the disease process than do adult patients.13
The patient with testicular torsion will complain of relatively sudden onset, severe scrotal pain with associated nausea or vomiting (in up to 42%). Coexistent inguinal and abdominal pain occur in up to 40% of patients with thigh pain also reported. Varying review have noted a previous similar episode of scrotal pain with spontaneous resolution in 11-50% of patients.14 The pain may initially be located in the abdomen, thigh, or groin. Similar episodes may have occurred previously and spontaneously resolved. In addition, a history of minor trauma to the abdomen or groin area may be noted. A history of trauma does not, therefore, preclude the diagnosis of testicular torsion. Physical examination reveals a swollen scrotum with the affected testicle high riding in a transverse lie. Because the nerves and arteries supplying cremasteric muscle are located inside the spermatic cord, the cremasteric reflex will invariably be absent in nearly all testicular torsion. However, the absence of this reflex does not by itself confirm the diagnosis.15 The testicle is excruciatingly tender, although further examination and delineation of the exact location of the tenderness is often difficult in children. Edema and discoloration of the scrotum are late and ominous findings of testicular torsion.
Suspicion of testicular torsion mandates immediate surgical or urological consultation. Laboratory and radiographic analysis are not often helpful in diagnosing testicular torsion and should never delay definitive management. Both color Doppler sonography and testicular scintography have been used by surgical subspecialists to clarify the diagnosis of torsion in patients with a confusing clinical picture. A scan that demonstrates no flow to the affected testicle argues strongly for the diagnosis of testicular torsion.6 However, color Doppler flow studies can be misleading in patients with late presentation of testicular torsion because inflammation of the scrotal tissues can mimic adequate blood flow to the testicle.16
Prior to the arrival of the surgical specialist, the emergency physician may attempt manual detorsion. When torsion occurs, the superior pole of the testicle frequently twists medially, toward the contralateral thigh.17 In the manual detorsion procedure, one holds the affected testicle between thumb and forefinger and untwists 360° toward the ipsilateral thigh. (See Figure 2.) Rapid relief of pain and swelling should ensue. If relief is noted, the testicle should be rotated another 360° or more, since the usual twist is 720°.17 Because testicles can potentially torse in the opposite direction, the direction can be reversed if more pain or swelling occurs after the initial maneuver. Sedation and analgesia may be warranted in order to facilitate the detorsion procedure. Surgical correction (bilateral orchiopexy) is still necessary after this maneuver; however, the emergency detorsion procedure can help salvage the affected testicle. The prognosis of testicular torsion is directly related to the time between onset of symptoms and detorsion. Almost all torsed testicles will be viable if detorsed within three hours of symptom onset, one-half to three-quarters within eight hours, one-fifth within 24 hours, and almost none after 24 hours.18,19 (See Figure 3.)
Testicular torsion may also occur in neonates. Extravaginal torsion differs from intravaginal torsion in that the testicle, spermatic cord, and the tunica vaginalis twist during the descent of the testicle, resulting in testicular atrophy. Because this condition is asymptomatic, it is often detected during surgical exploration for cryptorchidism.20 If the testicle partially descended prior to the event, the physical examination of the neonate may reveal a painless, firm scrotal mass with mild erythema or edema of the scrotal skin.21 Treatment for extravaginal torsion is unilateral orchiectomy, since the testicle is always non-viable at the time of diagnosis. In contrast to intravaginal torsion, there is no bell clapper deformity, therefore, contralateral orchiopexy is not required.
Torsion of the Appendix Testis
There are a number of vestigial appendages connected to the testis and epididymis; however, none have any ongoing functional importance. Twisting of an appendage on its pedicle can result in tissue ischemia and concomitant pain and swelling of that area of the scrotum. The appendix that is located on the superior pole of the testis is a vascular connective tissue remnant of the Mullerian duct, and is the most common appendage to torse. This occurs most often in school-aged children and early adolescents, and rarely over the age of 20 years.22 In one series of 171 patients who required surgical exploration for acute scrotal pain, 25% had torsion of a testicular appendage.23 Right and left sides are affected equally as often. The child complains of either sudden or gradual onset of scrotal pain, with no nausea, vomiting, or fever. The pain is usually less severe than that of testicular torsion. Physical examination reveals a normally positioned testicle in a mildly swollen or erythematous scrotum. The cremasteric reflex should be brisk unless swelling is severe, and tenderness will be present on the anterior and/or lateral pole of the testicle. The "blue dot sign" signifies the appearance of a hemorrhagic appendix testis visible through the scrotal wall and is a specific but not sensitive indicator of this condition. One study of 100 boys hospitalized for acute scrotal pain found that the blue dot sign was present in seven of 32 cases of torsion of the testicular appendages.5 In the symptomatic child, however, it is admittedly difficult to differentiate torsion of the appendix testis and testicular torsion. Laboratory analysis is unhelpful in the diagnosis of torsion of the appendix testis. However, scintography and Doppler studies may reduce the need for surgical exploration by documenting adequate blood flow to the testicle.24 Doppler flow sonography in a patient with torsion of the appendix testis reveals a circular mass of increased echogenicity with a central hypoechoic region adjacent to the testicle.25
If the diagnosis can be secured, management of torsion of the appendix testis is not surgical, but rather expectant and palliative. The appendix will likely autoamputate with no known sequelae, and pain management is accomplished with oral analgesics and bedrest. If the pain persists over weeks, the appendix may be ischemic but not infarcted. In this case, surgical removal of the appendix testis may be necessary.26
Epididymitis is an inflammation of the epididymis, most often caused by infection. If the inflammation spreads to the testicles, the resulting epididymo-orchitis can be difficult to differentiate from other testicular pathology such as testicular torsion or primary orchitis.27 Although epididymitis is usually due to a sexually transmitted organism, prepubertal patients may be infected with coliform bacteria such as pseudomonas, Escherichia coli, or enterococcus. Although uncommon, other organisms such as Streptococcus pneumoniae, Salmonella sp., Shigella sp., Mycobacterium tuberculosis, and Brucella sp. have been reported.24 Urologic abnormalities, prior urologic instrumentation, and imperforate anus predispose younger patients to epididymitis. A negative urine culture in young boys with epididymitis argues strongly against the presence of a urologic anomaly. In a study of 25 patients with epididymitis in whom a urine culture was obtained, Siegel et al demonstrated that a negative culture predicted normal urologic anatomy 100% of the time (95%, CI 78,100).12 On the other hand, the presence of fever, leukocytosis, or pyuria was less helpful in determining the presence of a urologic abnormality in these patients.
The child with epididymitis will experience moderate-to-severe scrotal pain and swelling of one or both sides of the scrotum. Some children with epididymitis complain of abdominal and groin pain rather than scrotal pain. The onset of pain is usually more gradual than that of torsion although up to 30% have an acute onset of pain.26,14 Fever, nausea, and vomiting are uncommon. Dysuia is commonly present. However, the absence of dysuria or discharge does not preclude the diagnosis of epididymitis. Physical examination reveals a swollen scrotum with testicle in normal location and axis. A reactive hydrocele may be present. The cremasteric reflex should be intact but may be blunted because of swelling. Tenderness is usually located posterior and superior to the testicle; however, it may involve the entire testicle in late infection. The penile discharge caused by Chlamydia trachomatis infection is clear and thin, while that caused by Neisseria gonorrhea is white and thick. Only one-third of patients with epididymitis have greater than 10 leukocytes per high power field on urinalysis.1 The clinical features in the patient with scrotal pain, which, if present, strongly suggest the diagnosis of epididymitis, are presented in Table 3. If necessary, further information can be obtained through Color Doppler flow imaging. In the normal patient, epididymal vascularity will not be evident. Therefore, the presence of epididymal vascularity is helpful in diagnosing an inflammatory process. Occasionally, this study will reveal testicular ischemia due to compression of venous outflow by an edematous epididymis.8 The key clinical features that differentiate testicular torsion, torsion of the appendix testis, and epididymitis are presented in Table 4.
Treatment of epididymitis should be guided toward eradicating the causative organism. In sexually active adolescents, treat for Neisseria gonorrhea and Chlamydia trachomatis. The common regimen is one dose of ceftriaxone 250 mg IM and doxycycline 100 mg bid po for 7 days. One may also choose to treat with cefixime 800 mg po and azithromycin 1g po, both one time doses.As with any child who has a sexually transmitted disease, serological evaluation for syphilis and treatment of the patient’s sexual partners should be undertaken in these cases. In younger patients and those who are not sexually active, trimethoprim-sulfamethoxazole should be given to treat coliform organisms. These patients require further evaluation for urological abnormalities. Symptomatic relief can be obtained from anti-inflammatory medications and bedrest. Rare complications include testicular infarction, infertility due to atrophy, chronic epididymitis, and epididymal abscess formation.
Orchitis is less common than epididymitis and is rare in younger children. It is usually due to a viral infection. The most common of these, mumps, occurs in the winter and spring and is usually unilateral.21 Mumps orchitis usually follows the parotitis by 4-8 days and lasts between four and 10 days. Other organisms that cause orchitis include coxsackie virus, adenovirus, and Epstein-Barr virus. The patient will often show other stigmata of these infections prior to the gradual onset of testicular pain. Physical examination reveals a swollen scrotum and testicle in normal position, a brisk cremasteric reflex, and enlarged testicles that are diffusely tender. If the epididymis is also tender, differentiation between epididymitis and orchitis may be difficult. Urinalysis is usually normal in patients with orchitis. In patients where scrotal swelling makes a thorough physical examination difficult, scintography or Doppler flow imaging may be useful in distinguishing orchitis from testicular torsion. In the absence of other viral signs and symptoms, the patient should also be evaluated for epididymitis as mentioned above. Although sterility is uncommon after an episode of orchitis, some testicular atrophy is apparent in 30-50% of patients, and 10% of patients experience impaired fertility. The management of orchitis is symptomatic: bedrest, scrotal support, ice packs, and analgesia.
The vasculitides that cause scrotal swelling commonly present in the first decade of life and include Henoch-Schonlein Purpura (HSP), Kawasaki disease, and Familial Mediterranean Fever (FMF).
Scrotal involvement in HSP was first reported in the original description of this illness by Allen et al29 and occurs in approximately 30% of patients with HSP.30 Genital involvement usually follows the skin, joint, and intestinal symptoms by several days; however, it occasionally begins simultaneously. The pain can be scrotal or testicular in origin and lasts up to one week.30 Surgical management is rarely necessary; however, testicular torsion has rarely been noted to occur during the course of HSP.31 Radionuclide imaging will reveal increased perfusion to the affected site, compared to the decreased perfusion noted with testicular torsion.32
Children with Kawasaki disease may complain of mild-to-moderate scrotal pain. The perineal rash involves the scrotal walls rather than the testicle and usually accompanies the conjunctivitis, mucous membrane lesions, and lymphadenopathy seen in the acute phase of the illness. Some patients with Kawasaki disease may have swelling of the epididymis as well.28
In contrast to children with Kawasaki disease and HSP, children with FMF may complain of scrotal pain even before the final diagnosis is recognized. FMF is a genetic disease that affects Sephardic Jews, Turks, Armenians, and Middle Eastern Arabs. The illness is characterized by acute attacks of serositis, as well as the possibility of renal amyloidosis. Granulocytic infiltration causes inflammation of the spermatic cord and/or the epididymis. Children present with the gradual onset of unilateral, red, painful scrotal swelling along with fever, leukocytosis, and an elevated sedimentation rate (ESR).33 Testicular pathology is rare but should be considered in the absence of fever or if the onset of pain is sudden.34
Isolated traumatic injury to the scrotum is most often due to a direct blow to the genital region, either intentional or sports-related.35 While most injuries due to direct, blunt trauma to the testicles are minor, injuries due to motor vehicle accidents can be more severe. Injury occurs as the testicles are crushed between the offending object and the pubic symphysis. Blood collections within the tunica albuginea or tunica vaginalis can compress the testicle and result in testicular atrophy.36 The tunica albuginea and dartos muscle, the cremasteric reflex, and the inherent mobility of the testicles can help protect the testicles from injury.37 Because these protective mechanisms are absent in patients with undescended testicles, these patients are at a higher risk for more severe damage after blunt abdominal trauma. Testicular torsion may follow minor trauma to the region, and this diagnosis must be excluded in any patient with testicular pain regardless of the preceding history.
Traumatic injuries to the testicle include, in ascending order of severity, contusion, hematoma, rupture, and dislocation. Testicular contusions cause pain but do not alter the physical examination of the scrotum. The pain will resolve within a few days, and even occasionally during the physician visit. Treatment is bedrest, ice, scrotal support, and analgesia. Testicular hematomas, on the other hand, are more painful and create a mass effect in the scrotum. If the hematoma is large enough, it can compromise testicular blood flow. Ultrasonography is a useful adjunct in deciding whether or not the patient requires surgical intervention. Testicular rupture is caused by a tear in the tunica albuginea and must be diagnosed and surgically treated promptly if the testicle is to be preserved. The patient with testicular rupture may complain of nausea or vomiting. The testicle is enlarged and ill defined, and the scrotum is tender, tense, and ecchymotic. A sonogram that detects a hematocele (blood in the layers of the tunica vaginalis) is highly suspicious for testicular rupture.38 Dislocation of the testicle is an uncommon injury that can follow major trauma and may accompany injuries such as pelvic or proximal femur fractures. The scrotum may be swollen or tender but surprisingly emptythe testicle may be located in the groin. Surgery is necessary to reduce and pex the testicle in position.
All patients with hematoceles, symptomatic hematomas, testicular rupture, or testicular dislocation require immediate attention.37 It has been noted that surgical exploration within three days of injury can reduce the need for orchiectomy, shorten hospitalization, and relieve disability.39 As a rule, any patient with persistent pain or massive swelling of the scrotum after traumatic injury should be seen by a surgical subspecialist. Patients in whom the pain resolves quickly and the physical examination is normal may be referred for follow-up but need not undergo radiologic or surgical evaluation in the acute setting.
Inguinal Hernia. Inguinal hernias occur in 1-5% of the pediatric population.40 The majority of hernias in children are indirect, in that the abdominal viscera pass through a congenitally patent processus vaginalis and exit the internal inguinal ring into the scrotum. In contrast, a direct hernia penetrates the external inguinal ring due to a weakness in the muscular layers that make up the floor of the inguinal canal (Hesselbach’s triangle). Indirect hernias are more common on the right side. They can occur at any age; however, almost all will occur before the fifth decade of life, and 40% are obvious by 6 months of age.41 Premature infants have a relatively high incidence of inguinal hernia. The passage of peritoneal contents down the inguinal canal can be incomplete or complete. An incomplete hernia generates a lump in the groin, whereas a complete hernia generates a mass in the scrotal sac. This mass will be separate from the testicle and epididymis and may feel sausage shaped. If the mass is not separate from the testicle, there is a chance that it is actually a hydrocele rather than a hernia. This is an important distinction to make, because the manual reduction of a hydrocele is not recommended. The presence of bowel sounds in the scrotum strongly suggests a diagnosis of inguinal hernia; however, their absence does not exclude the diagnosis. Additionally, the spermatic cord on the side of the hernia may be thickened due to the presence of peritoneum and/or bowel in that location. A hydrocele of the spermatic cord may, however, result in a similarly thickened cord. Transillumination of the scrotal sac can occur in patients with either hernia or hydrocele and should not be used as a differentiating sign. (See Table 5.)
A hernia is rarely painful unless it is incarcerated. Children with indirect hernias will more commonly experience incarceration of the hernia sac than will adults. In this context, the hernia must be manually or surgically reduced before strangulation of bowel occurs. Strangulation of bowel may result in fever, leukocytosis, hematochezia, and testicular swelling.42 Caution should be taken in reducing inguinal hernias in patients with evidence of strangulation. However, there is no evidence that the presence of bowel obstruction in the absence of signs of strangulation precludes manual reduction of an inguinal hernia.43 Reduction of an inguinal hernia can be facilitated by placing the patient in the Trendelenberg position, applying ice to the affected area, and providing analgesia and muscle relaxation. During this procedure, it is important to first place downward traction on the mass to allow a direct pathway back through the internal inguinal ring. One hand applies pressure to the inguinal canal while the other hand applies slow, persistent pressure to the mass to "milk out" the gas and contents of the bowel.42 Often, the hernia will initially reduce slowly and then suddenly "pop" back in at a certain point. The area must be inspected to assure that there is no longer bowel present in the scrotum or at the internal inguinal ring. If the hernia is completely reduced and the pain resolves, operative management can occur as a scheduled rather than emergent procedure.
Hydrocele. A hydrocele is a collection of fluid between the layers of the tunica vaginalis. This can be a congenital condition or may be secondary to infection, trauma, torsion, or tumor. In a congenital hydrocele, the presence or absence of flow through the processus vaginalis determines whether the hydrocele can communicate with the peritoneum. Communicating hydroceles decrease in size when the patient is recumbent and therefore will be more noticeable in an ambulating patient at the end of the day. Congenital hydroceles are painless. The testicle often cannot be palpated separately from the mass, and one can usually palpate a normal spermatic cord above the hydrocele. Both a communicating hydrocele and an indirect inguinal hernia are related to a patent processus vaginalis. Therefore, what seems like a hydrocele can contain a small component of hernia, and transillumination of a scrotal mass does not rule out the presence of an inguinal hernia. Closed aspiration of a hydrocele could result in bowel perforation and infection and is therefore not recommended. Sonography is helpful in differentiating hernias and hydroceles, as well as detecting secondary causes such as tumor. Referral to a surgical subspecialist is warranted for secondary hydroceles or congenital hydroceles that persist after the first 1-2 years of life. Some physicians argue that communicating hydroceles should be removed sooner due to the risk of hernia development.
Varicocele. The venous return of the left spermatic vein courses through the renal vein, whereas the right spermatic vein returns directly through the inferior vena cava. Valvular incompetence of the spermatic vein can result in dilation of the pampiniform plexus. Varicoceles occur in 10-15% of adolescent and adult males and occur invariably on the left side.44 A varicocele is generally asymptomatic. However, it can cause some minor discomfort and, if large, can contribute to testicular atrophy and infertility. Physical examination reveals a bluish discoloration in the scrotum that feels like a "bag of worms" on palpation. Varicoceles that do not recede when the patient is lying supine, or those that are present on the right side, raise concern for situs inversus or causes of venous obstruction such as renal tumor, renal vein thrombosis, or vena caval obstruction. These patients should be referred for further evaluation. Referral to a surgical subspecialist has also been suggested for a varicocele associated with a testicle that is smaller in size by at least 20% compared to the contralateral testicle; however, this is less useful in a prepubescent child.26,48 Although ligation of the varicocele can result in improved testicular growth in adolescents, it is unclear whether this is true in adults.46,47 In infertile adults, semen analysis is used to determine the deleterious effects of a varicocele. In the adolescent patient, however, infertility is not always documented, and semen samples are more difficult to obtain. Some authors, therefore, suggest that the response to luteinizing hormone-releasing hormone be part of the evaluation of adolescents with varicoceles.48
Spermatocele. A spermatocele is a cyst within the testicle, efferent duct, or epididymis. They may be multiple and bilateral, less than one centimeter in diameter, and can transilluminate. Since they contain sperm, spermatoceles occur only in post-pubertal males. In general, no further evaluation or treatment is necessary if the diagnosis is secure. Radiological and surgical evaluation is necessary only if the cyst is very large, painful, or if testicular tumor is suspected.
Testicular Neoplasm. Testicular neoplasms are rare but serious causes of scrotal swelling in childhood and adolescence. Germ-cell testicular cancer is the most common solid organ tumor in males between 15 and 35 years of age.49 The incidence is dramatically increased in a patient with an undescended testicle, especially if it is in an intraabdominal location. Bleeding into a tumor can cause pain and swelling in that area. However, most tumors are detected by self-examination and are painless, hard, irregular masses indistinguishable from the testicle. Occasionally, paraneoplastic phenomena such as gynecomastia result from b-hcg or estrogen secretion. Surgical and oncological referral are required for these testicular masses. The prognosis for these patients is favorable if the neoplasm is detected and treated early. In the pre-adolescent child, germ-cell tumors are rare, but other neoplasms such as leukemia or lymphoma must be considered if the patient has painless scrotal swelling.
Acute idiopathic Scrotal Edema. Redness and swelling of dartos tunic and overlying skin can occur with no concomitant pathology of the scrotal contents. Acute idiopathic scrotal edema (AISE) usually occurs during the first decade of life; however, there have been occasional reports in adults.50 Children with AISE often come to medical attention after the parent notices the redness and swelling of the scrotal sac during bathing or dressing. The findings are bilateral in approximately 50% of patients.51 A violaceous hue may be noted, and mild pain may be present. The process can extend to the penis, groin, thighs, and abdomen.52 The cremasteric reflexes are intact. The testicle, epididymis, and prostate are all nontender; however, the spermatic cord may be edematous. The etiology of AISE is thought to be allergic, but in most cases there is no specific allergen identified.51 In the face of a normal testicular examination, treatment includes only observation for resolution of symptoms within a few days. Antihistamines have been used with some success, but no controlled trials exist supporting this therapy.52
The child with a swollen scrotum is at risk for having serious pathology that could endanger his life or the opportunity for future progeny. The physician who performs the initial evaluation on such a child must be familiar with the common presentations of testicular torsion, genital infection, scrotal masses, and traumatic injuries. While the need for sugical consultation or referral in these patients is common, the initial evaluation and management typically begins in the office or emergency department. In this article, a logical and ordered diagnostic approach to this complaint is presented.
References
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CME Questions
32. All of the following historical factors are helpful in evaluating the child with a swollen scrotum except:
A. the patient complains of nausea and vomiting.
B. the patient does not have scrotal pain.
C. there is a family history of testicular torsion.
D. there is a history of prior urological instrumentation.
33. The most sensitive non-radiological finding in a patient with testicular torsion is:
A. unilateral scrotal swelling.
B. absent cremasteric reflex.
C. tender testicle.
D. normal urinalysis.
E. testicle riding lower on the left than on the right.
34. All of the following scrotal masses require urgent evaluation except:
A. painless, hard lump that cannot be separated from the the right testicle.
B. painful, swollen testicle after a direct blow to the area.
C. waxing and waning hydrocele in an infant.
D. right sided varicocele.
E. left sided spermatocele.
35. Appropriate antimicrobial therapy for a 15-year-old boy with epididymitis includes:
A. trimethoprim-sulfamethoxazole.
B. amoxicillin.
C. ceftriaxone and doxycycline.
D. no antimicrobial therapy necessary.
36. The following statement is true regarding torsion of the appendix testis:
A. it occurs most commonly in adolescents and young adults.
B. the blue dot sign is almost always present.
C. it rarely requires surgical intervention if diagnosed with certainty.
D. it occurs more commonly on the left side.
E. it is associated with future infertility.
37. Scrotal lesions that require surgical intervention include:
A. hematocele.
B. testicular torsion that has completely resolved after manual reduction.
C. incarcerated inguinal hernia.
D. all of the above.
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