Acutely painful Scrotum Torsion of a testicular appendage most common Torsion of the testes most important

Clinically - Severe pain in the scrotum Testicular appendage hydatid of morgagni (torsion) Early stages: blue/black pea sized swelling - extremely tender to touch - may be seen through the skin of the scrotum near the upper pole of the testes - palpation of the testis itself causes no discomfort later: A reactive hydrocele develops - tenderness becomes more generalised - difficult to distinguish from a torsion of the testis Testis (torsion) Both the testis and the epididymis are exquisitely tender (unless necrosis has already occurred) - Drawn up into the neck of the scrotum - Slightly swollen - Cord may be palpably thickened - Later; will become red and oedematous; making it hard to differentiate between acute epididymitis Older boys - pain radiated to the ipsilateral iliac fossa - may be associated with nausea and vomiting - may be confused with appendicitis (thus; important to always examine the scrotum in boys presenting with lower abdominal pain) Treatment urgent surgical exploration of the scrotum is required to untwist the testis and epididymis and to suture both testes to prevent subsequent torsion Necrotic testis should be removed A torted and infarcted testicular appendix should be removed NB: Testicular necrosis occurs within 8 hours - U/S and NM tests are of little value as they can be misleading. Epididymo-orchitis unusual in children; most often seen in the first year of life - may signify an underlying structural abnormality of the urinary tract Ix: - renal U/S - MCUG - Urinalysis expect leukocytes and bacteria