The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this guideline.

Inguinal, Scrotal and Genital Problems in Reviewed by Carl Kuschel and Philip
Morreau (Paediatric Surgery)
Neonates
June
2006

Hydrocoele Inguinal Hernia Undescended Testes Testicular Torsion

Torsion of the Testicular
Penile Torsion "Buried" Penis Hypospadias
Appendages
Microphallus Other Causes

1. Examination after birth frequently reveals abnormalities in the inguinal, scrotal,

or genital regions.
2. Some of these abnormalities require urgent attention; others require non-urgent
referral, or parental reassurance.

Problem Description Clinical findings Management

Hydrocoele Persistence of 1. Swelling in the 1. Reassurance
the processus scrotum 2. Surgical review if
vaginalis results 2. Can be unilateral still present at 18 months
in peritoneal or bilateral or diagnostic uncertainty
fluid in the 3. Skin may have at any age
scrotum around bluish
the testis or discolouration if
spermatic cord large
4. Can fluctuate in
size (if
communicating)
5. Has a distinct
upper margin
6. Transilluminates
7. Non-tender
8. Rare in females
9. Careful
examination to ensure
that testis is present and
that there is no inguinal
hernia

Inguinal Swelling in 1. Inguinal swelling 1. If reducible and

inguinal region (can extend to the infant in NICU – non-
hernia (can extend to scrotum in males or labia urgent surgical referral for
scrotum in in females) surgical repair prior to
males, or to 2. Difficult to define discharge
labia in the upper margin 2. If reducible and
females) of the swelling infant at home –
secondary to (unlike hydrocoeles discuss with
persistence of a ) surgical registrar
wide processus 3. Usually reducible (will usually be
vaginalis, with 4. Will be firm and repaired within 1-2
herniation of tender if weeks)
bowel (or, in incarcerated 3. If
females, the 5. May transilluminate incarcerated, urgent surg
ovary) ical referral

More common
in premature
infants

More common
in infants with
raised intra-
abdominal
pressure
Undescended May affect 2% 1. The scrotum may 1. If possible intersex
testes of males. be smooth and disorder, refer to
(cryptorchidis underdeveloped or may theambiguous genitalia
m) Testes should look normal guideline
be in the 2. Assess penile size 2. For males with
scrotum by and any undescended
birth/term. In abnormalities testes, refer to
these infants a (note:undescende paediatric surgical
testis can be d testes clinic
said to be and hypospadias in 3. If remain
undescended dicates anintersex undescended,
by 3 months disorder till proven orchidopexy usually
otherwise) performed within the first
In preterm 3. Examine infant for year. If associated with
infants this can other abnormalities a hernia refer as
be confidently (association with other per hernia guidelines
diagnosed by 6 syndromes, e.g. Smith-
months post Lemli-Opitz, Oto-Palato-
delivery Digital, Prune Belly
Syndrome)
Testicular In neonates, 1. Tender, red firm 1. Urgent
torsion typically and enlarged testis referral to paediatric
perinatal in 2. Will not surgery
origin transilluminate 2. Imaging
3. Usually unilateral (ultrasound with Doppler)
Is also (but can be may be useful but should
associated bilateral) not delay surgical referral
with undescend 4. Differential
ed testes includes testicular tumour

Torsion of the May 1. May see a blue dot 1. Urgent

testicular mimic testicular (ecchymosis) on the referral as per torsion
appendages torsion. scrotum with no ultrasound

Testicular
appendages are
only palpable
when torsion
has occurred
Penile torsion Counterclockwis 1. Median raphe of 1. Non-urgent referral
e (usually) the penis spirals to the to paediatric surgery
rotation of the meatus
penile shaft, 2. May be associated
with meatus with hypospadias
pointing
obliquely
“Buried” penis Penile shaft is 1. Penis is buried 1. Non-urgent referral
hidden under under the suprapubic fat to paediatric surgery
the pre-penile pad
skin 2. Ensure penile
length is normal

Hypospadias See hypospadias guideline

Microphallus See ambiguous genitalia guideline
Other causes A range of other conditions may cause scrotal swelling including:
of groin/
scrotal 1. Ectopic or strangulated gonads
swelling 2. Varicocoele (not in neonates)
3. Intra-abdominal (e.g. adrenal) haemorrhage
4. Pneumoperitoneum
5. Calcifications following healed meconium peritonitis
6. Testicular tumour
 7. Epididymitis (in association with UTI)

Diagnosis and Treatment of the Acute Scrotum

LARIS E. GALEJS, MAJ, USAF, MC

U.S. Air Force Medical Center, Wright-Patterson Air Force Base

Dayton, Ohio

EVAN J. KASS, M.D.

William Beaumont Hospital

Royal Oak, Michigan

Testicular torsion must be considered in any patient who complains of acute scrotal pain and swelling.
Torsion of the testis is a surgical emergency because the likelihood of testicular salvage decreases as the
duration of torsion increases. Conditions that may mimic testicular torsion, such as torsion of a testicular
appendage, epididymitis, trauma, hernia, hydrocele, varicocele and Schönlein-Henoch purpura, generally
do not require immediate surgical intervention. The cause of an acute scrotum can usually be established
based on a careful history, a thorough physical examination and appropriate diagnostic tests. The onset,
character and severity of symptoms must be determined. The physical examination should include
inspection and palpation of the abdomen, testis, epididymis, scrotum and inguinal region. Urinalysis
should always be performed, but scrotal imaging is necessary only when the diagnosis remains unclear.
Once the correct diagnosis is established, treatment is usually straightforward.

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 (Figure 1).

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 (Table 1).

Patient with Acute Scrotum

FIGURE 1. Protocol for the diagnosis and treatment of the acute scrotum.

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.

The physician needs to be aware that an embarrassed child may state that he has lower abdominal or inguinal
pain rather than scrotal pain. A child may also minimize his symptoms out of fear. Therefore, the history
should be corroborated with the parents' observation of the child's behavior.

TABLE 1
Diagnosis of Selected Conditions Responsible for the Acute Scrotum
 Onset of Cremasteric
Condition symptoms Age Tenderness Urinalysis reflex Treatment

Testicular Acute Early Diffuse Negative Negative Surgical

torsion puberty exploration

Appendiceal Subacute Prepubertal Localized to Negative Positive Bed rest and

torsion upper pole scrotal
elevation

Epididymitis Insidious Adolescence Epididymal Positive or Positive Antibiotics

negative

A history of trauma does not exclude the diagnosis of testicular torsion. Scrotal trauma incurred during sports
activities or rough, boisterous play often causes severe pain of short duration. Pain that persists for more than
one hour after scrotal trauma is not normal and merits investigation to rule out testicular rupture or acute
torsion. Pain that resolves promptly after scrotal trauma only to recur gradually a few days later suggests
traumatic epididymitis.
 Information should always be obtained about prior
occurrence of pain. When asked, many patients with
torsion describe previous episodes of similar pain that
lasted only a short time and resolved spontaneously.
Acute on-and-off pain suggests intermittent torsion with
spontaneous detorsion.

Finally, a general urologic and surgical history should be

obtained. Neurologic problems, congenital genitourinary
anomalies and urethral instrumentation can predispose
patients to urinary tract infections and thus epididymitis.

Physical Examination
The physician can often assess the severity of pain by
observing the patient before beginning the physical
examination. Is the patient writhing in pain or lying
comfortably? Does he talk with friends or family? Is he
able to ambulate without discomfort?

A general abdominal examination should be performed,

FIGURE 2. Anatomy of the normal (right) testis
and spermatic cord.
tender in a patient with testicular torsion.
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

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.

The cremasteric reflex should always be assessed. This reflex is elicited by stroking or gently pinching the skin
of the upper inner thigh while observing the scrotum. A normal response is contraction of the cremasteric
muscles on the ipsilateral side with unilateral elevation of the testis. One study found that the cremasteric
1

reflex was intact in 100 percent of boys 30 months to 12 years of age but was not consistently normal in
infants and teenagers. The cremasteric reflex is rarely intact in patients with testicular torsion but is usually
present in patients with torsion of a testicular appendix.
2
A thorough testicular examination requires a knowledge of testicular landmarks. An illustration of normal
anatomy of the testis is presented in Figure 2. The testis is best examined by grasping it between the thumb
and the first two digits. The epididymis should be palpable as a soft, smooth ridge posterolateral to the testis.
The testes are normally the same size.

In early torsion, the entire testis is swollen and tender, and is larger than the unaffected testis (Figure 3).
Tenderness limited to the upper pole suggests torsion of a testicular appendage, especially when a hard,
tender nodule is palpable in this region. A small bluish discoloration, known as the "blue dot sign," may be
visible through the skin in the upper pole. This sign is virtually pathognomonic for appendiceal torsion when
tenderness is also present.

In early epididymitis, the epididymis exhibits tenderness and induration, but the testis itself is not tender.
Swelling to the degree that the epididymis is no longer palpable can indicate torsion if the symptoms have
been present for only a few hours. With both appendiceal torsion and epididymitis, loss of testicular
landmarks occurs later in the clinical course.

The testis may be elevated to elicit Prehn's sign. Lack of pain relief (negative sign) may contribute to the
diagnosis of testicular torsion.

If torsion is suspected, manual detorsion can be attempted by

rotating the testis away from the midline. Dramatic resolution of
pain as a result of this maneuver confirms the diagnosis of
torsion and eliminates the need for urgent surgical exploration.
However, the patient should still be referred for elective
orchiopexy.

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
3-5

FIGURE 3. Testicular torsion. 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
6
testicular flow studies can be helpful; however, they often require too much time and thus have fallen into
disfavor.

Color Doppler ultrasonography is being used increasingly in the evaluation of suspected testicular torsion. At
our institution, this modality has become the preferred imaging technique for evaluating the acute scrotum
(Figures 4, 5 and 6).

Color Doppler ultrasonography is noninvasive and has a diagnostic accuracy at least equal to that of nuclear
scanning. It can semiquantitatively characterize blood flow, and it can distinguish intratesticular and scrotal
wall flow. It can also be used to assess other pathologic conditions involving the scrotum.
7-9

Proper technique is essential. When color Doppler examinations are not performed correctly, studies can be
false positive or false negative. The color Doppler equipment should be calibrated to demonstrate blood flow
in the normal testis first. Then the abnormal testis should be examined without altering the settings on the
machine. For flow measurements, the Doppler cursor must be be positioned within the testis. When normal
or increased flow is demonstrated, torsion is excluded.

We recommend surgical exploration when a technically adequate color Doppler ultrasonogram cannot be
obtained or when blood flow to the testis is found to be diminished or absent. It may not be possible to
10

demonstrate a Doppler signal in the small testes of some young boys. In this situation, the clinical findings
alone are used in deciding whether surgical exploration is required.

We recently reviewed a series of 243 boys who presented to our institution with an acute scrotum. Immediate
surgical exploration was performed in 14 patients, and screening ultrasound examination was used in 229
patients. The overall incidence of testicular torsion was 19 percent. On color Doppler examination, blood
flow was absent in 45 patients. Surgical exploration confirmed testicular torsion in these patients. One of the
two patients with decreased blood flow had testicular torsion; the other had torsion of the appendix testis.
The color Doppler examination showed increased or normal blood flow in 182 patients. None of these
patients later developed testicular atrophy, which would have indicated misdiagnosed torsion. Color Doppler
ultrasonography also correctly diagnosed incarcerated hernias, varicoceles, hematomas and testicular
ruptures.

FIGURE 4. Color Doppler

Treatment ultrasonogram showing acute
torsion affecting the left testis in a
Spermatic Cord Torsion 14-year-old boy who had acute
The "bell clapper" deformity is one underlying cause of testicular torsion pain for four hours. Note
in older children. In this deformity, the testicle lacks a normal attachment decreased blood flow in the left
testis compared with the right
to the tunica vaginalis and therefore hangs freely. As a result, the
testis.
spermatic cord can twist within the tunica vaginalis (intravaginal torsion).

When the history and physical examination strongly suggest that testicular torsion is present and the duration
of pain is less than 12 hours, urgent surgical intervention is indicated. No imaging studies are required
because they may delay treatment and thereby jeopardize testicular survival. When pain has been present for
more than 12 hours or the diagnosis is unclear, color Doppler ultrasound examination can be helpful in
making clinical decisions. It is important to remember that most patients with an acute scrotum do not have
testicular torsion.

Surgery is performed to correct torsion in the affected testis and to anchor the other testis (orchiopexy) to
prevent future torsion, which otherwise occurs in most patients with contralateral torsion. Surgical
exploration can usually be accomplished through a single, small midline incision in the scrotal raphe. Clearly
necrotic testes must be removed. Viable testes should be fixed with nonabsorbable sutures.

Testicular torsion can also occur perinatally if the entire testis complex has not yet fused to the scrotum. In
this type of torsion, the testis, spermatic cord and tunica vaginalis twist en bloc (extravaginal torsion).
Clinically, extravaginal torsion appears as an asymptomatic swelling of the scrotum. Erythema or a bluish
discoloration of the scrotum is also frequently seen.

The management of perinatal torsion remains controversial. Some surgeons advocate a nonoperative
approach because of the poor potential for testicular salvage. Others, ourselves included, argue that leaving a
neonatal testis in place may have adverse effects on the contralateral testis and note that cases of bilateral
neonatal torsion have been reported. However, we do not perform surgery urgently unless the neonate has
11

clear documentation of a normal examination at birth and subsequently experiences testicular torsion.

Torsion of Testicular Appendages

The appendix testis, a müllerian duct remnant located at the superior pole of the testicle, is the most common
appendage to undergo torsion. The epididymal appendix, located on the head of the epididymis, is a wolffian
duct remnant and may also become twisted. Torsion of either appendage produces pain similar to that
experienced with testicular torsion, but the onset is more gradual. Color Doppler ultrasonography
demonstrates increased blood flow.

Torsion of a testicular appendage may be misinterpreted as epididymitis. However if the urinalysis is normal,
no antibiotic therapy is required. Management entails several days of bed rest and scrotal elevation in an effort
to minimize inflammation and edema. Normal activity may both worsen and prolong the symptoms.
Nonsteroidal anti-inflammatory drugs (NSAIDs) and analgesics generally are not helpful and thus are not
routinely used. The inflammation usually resolves within a week, although the testicular examination may not
be completely normal for several weeks.
 FIGURE 5. Color Doppler
ultrasonogram showing late torsion
affecting the right testis in a 16-year-
old boy who had pain for 24 hours.
Note increased blood flow around the
right testis but absence of flow within
the substance of the testis.
FIGURE 6. Color Doppler
ultrasonogram showing inflammation
(epididymitis) in a 16-year-old boy
who had pain in the left testis for 24
hours. Note increased blood flow in
and around the left testis.

Epididymitis or Orchitis
Epididymitis in adolescents and young adults is often related to sexual activity and does not present with a
urinary tract infection. In prepubertal boys, however, epididymitis is almost always associated with a urinary
tract anomaly. Any episode of epididymitis and urinary tract infection should be investigated with a
12

renal/bladder sonogram and a voiding cystourethrogram to rule out structural problems.

Treatment includes empiric antibiotic therapy until the results of a urine culture are known. If the culture is
negative, the symptoms are most likely due to abacterial epididymitis caused by urine reflux. Bed rest and
scrotal elevation are often helpful. NSAIDs and analgesics can be used to alleviate symptoms. As with
appendiceal torsion, the pain and swelling generally resolve within a week. Resolution of epididymal
induration may require several weeks.

Scrotal Trauma
The likelihood of testicular salvage
Severe testicular injury is uncommon and usually results from diminishes with the duration of torsion.
either a direct blow to the scrotum or a straddle injury. Damage
occurs when the testis is forcefully compressed against the pubic
bones. A spectrum of injuries may occur.

Traumatic epididymitis is a noninfectious inflammatory condition that usually occurs within a few days after a
blow to the testis. Treatment is similar to that for nontraumatic epididymitis.
Scrotal trauma can also result in intratesticular hematoma, hematocele or laceration of the tunica albuginea
(testicular rupture). Color Doppler ultrasonography is the imaging technique of choice. Surgical referral is
13

required because testicular rupture requires immediate drainage and repair. Hematomas and hematoceles are
managed on an individual basis.

Other Causes
Acute idiopathic scrotal edema is another possible cause of an acute scrotum. This condition is characterized
by the rapid onset of significant edema without tenderness. Erythema may be present. The patient is usually
afebrile, and all diagnostic tests are negative. The etiology of this condition remains unclear. Treatment
consists of bed rest and scrotal elevation. Analgesics are rarely needed.

Schönlein-Henoch purpura, a systemic vasculitic syndrome of uncertain etiology, is characterized by

nonthrombocytopenic purpura, arthralgia, renal disease, abdominal pain, gastrointestinal bleeding and,
occasionally, scrotal pain. The onset can be acute or insidious. Hematuria may be present. The syndrome has
14

no specific treatment.

Inguinal hernia should be suspected in a child who has a history

Every patient with acute scrotal pain
of intermittent groin swelling. If the diagnosis is unclear, should be evaluated for torsion.
ultrasound examination can be helpful. An incarcerated or
strangulated hernia requires urgent surgical intervention, whereas
a reducible hernia should be repaired electively.

A hydrocele occurs because of a patent processus vaginalis. The hydrocele can seal off, trapping peritoneal
fluid around the testis, or it can persist and dilate, possibly causing bowel herniation. Most hydroceles resolve
spontaneously. Therefore, an infant with a hydrocele and no evidence of a hernia is usually just observed for
the first one or two years of life. If the hydrocele persists beyond this time, surgical repair through the groin is
recommended.

Occasionally, a varicocele causes mild to moderate scrotal discomfort. No changes in the scrotal skin occur,
but the affected hemiscrotum may have a full appearance. On physical examination, a varix is palpable as a
"bag of worms" above a palpably normal testis and epididymis. Referral to a urologist is prudent because
varicoceles can affect both testicular growth and fertility.
15