Emergency Department Management of Acute Scrotal Pain in Pediatric Patients

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Publication Date: October 2024 (Volume 21, Number 10)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-B Credits. CME expires 10/01/2027.

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Abstract

Testicular torsion is a urologic emergency, accounting for up to 15% of cases of acute scrotal pain. Rapid recognition and management are essential to ensure viability of the testis. Doppler ultrasound can be used to confirm the diagnosis of testicular torsion; however, recent studies suggest that a more judicious use of ultrasound may be safe, decrease delays in surgical management, and avoid unnecessary utilization of resources. This issue reviews the epidemiology and historical and physical examination findings of testicular torsion and other common causes of acute scrotal pain. The existing literature is reviewed and recommendations are provided to guide the emergency clinician in appropriate management and disposition of boys with acute scrotal pain.

Case Presentations

A previously healthy 13-year-old boy with 3 hours of lower abdominal and groin pain presents to your rural community ED…

• The boy has no fever, dysuria, or hematuria. He is not sexually active and denies trauma. He has vomited twice.
• On examination, the boy appears uncomfortable and rates his pain as 9/10. His abdomen is soft, with mild lower left quadrant tenderness. A testicular examination is notable for a swollen, erythematous, high-riding left testicle that feels indurated compared to the right testicle. You cannot elicit a cremasteric reflex on either the right or the left.
• You begin to consider your management priorities…

A 15-year-old boy presents with left testicle pain that started a few hours ago...

• The boy denies fever, nausea, vomiting, dysuria, or penile discharge. He rates his pain as 8/10, and he looks very uncomfortable.
• You are able to elicit a cremasteric reflex on the left. His left scrotum is swollen, erythematous, and tender to palpation. The testicle is not hard or high-riding. You are very suspicious for testicular torsion and are surprised that there is a cremasteric reflex present.
• You wonder how reliable this reflex is in ruling testicular torsion in or out. You consider the utility of manual detorsion in this patient and whether ultrasound should be obtained first…

An 8-year-old boy presents to your community ED at 3 AM with right testicle pain for 3 days.…

• There is no history of trauma. The patient reports his pain is 4/10 and worse with walking. The boy’s mother says he has been walking “funny.” The boy denies nausea or vomiting.
• A cremasteric reflex is positive bilaterally. The right hemiscrotum is normal, with no redness or swelling. The testicle is not hard or high-riding, and there is mild tenderness to palpation. The boy does not appear uncomfortable.
• The TWIST score for this child is 0. You wonder how often testicular torsion occurs in prepubertal boys. You do not have ultrasound staff available at this time of night, and you consider whether an ultrasound is always necessary to rule out torsion, especially when the TWIST score is 0...

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