Testicular pain or swelling, often referred to as the acute scrotum, can have a number of causes. Testicular torsion represents a surgical emergency because the likelihood of testicular salvage diminishes with the duration of torsion. Therefore, the family physician must act quickly to identify or exclude this condition in any patient who presents with an acute scrotum. This article reviews an approach to the diagnosis and treatment of the acute scrotum.
History
The history and physical
examination can significantly narrow the differential diagnosis of an acute
scrotum, if not establish the exact cause. None of the conditions responsible
for acute scrotal pain or swelling has a single pathognomonic finding, but the
combined background information and physical findings frequently suggest the
correct diagnosis.
The age of the patient is important. Testicular torsion is most common in neonates and postpubertal boys, although it can occur in males of any age. Schönlein-Henoch purpura and torsion of a testicular appendage typically occur in prepubertal boys, whereas epididymitis most often develops in postpubertal boys.
The onset and duration of pain must be carefully determined. Testicular torsion usually begins abruptly, as if a switch has been flipped. The pain is severe, and the patient often appears uncomfortable. Moderate pain developing gradually over a few days is more suggestive of epididymitis or appendiceal torsion. With either of these conditions, the patient may appear relatively comfortable except when examined.
Physical Examination
A general abdominal
examination should be performed, with particular attention given to flank
tenderness and bladder distention. Next the inguinal regions should be examined
for obvious hernias and any swelling or erythema. The spermatic cord in the groin
may be tender in a patient with epididymitis but typically is not tender in a
patient with testicular torsion.
The genital
examination begins with inspection of the scrotum. The two sides should be
assessed for discrepancies in size, degree of swelling, presence and location
of erythema, thickening of the skin and position of the testis. Unilateral
swelling without skin changes suggests the presence of a hernia or hydrocele.
The duration of symptoms is also relevant. A high-riding testis with an abnormal (transverse) lie may suggest torsion, but this diagnosis is unlikely if pain has been present for over 12 hours and the scrotum has a normal appearance. In both epididymitis and testicular torsion, the affected hemiscrotum typically displays significant erythema and swelling after 24 hours.
Diagnostic Studies
Urinalysis should be
performed to rule out urinary tract infection in any patient with an acute
scrotum. Pyuria with or without bacteria suggests infection and is consistent
with epididymitis. Based on our experience, a white blood cell count is not helpful
and should not be routinely obtained.
Until recently, no
imaging studies were useful in confirming the cause of an acute scrotum.
Immediate surgical exploration was thus the standard approach when torsion was
suspected. However, studies conducted in the past few years have shown
that only 16 to 42 percent of boys with an acute scrotum have testicular
torsion.
In an effort to
improve diagnostic accuracy and avoid needless surgery, both nuclear medicine
imaging and sonography have been performed in patients with an acute scrotum.
Unfortunately, Doppler stethoscopes and conventional gray-scale ultrasonography
have not been useful and therefore should not be used. Nuclear testicular flow
studies can be helpful; however, they often require too much time and thus have
fallen into disfavor.
