The adolescent with a painful scrotum

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Date: Mar. 2000
From: Contemporary Pediatrics(Vol. 17, Issue 3)
Publisher: Intellisphere, LLC
Document Type: Article
Length: 3,690 words

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A painful or swollen scrotum is a potential emergency. Be sure you know how to distinguish testicular torsion from less urgent problems.

The painful or acutely swollen scrotum requires accurate and timely assessment. An adolescent with these symptoms should be examined promptly and thoroughly, looking particularly for the signs of torsion and epididymitis reviewed here. This article is a companion piece to our overview of the male genital examination, which appeared in Contemporary Pediatrics last July.

Who gets what?

Case studies of patients with acute scrotal pain indicate varying etiologies for the condition. A review of the charts of 387 inpatients with acute scrotal pain showed that in all children under 6 years old the problem was testicular torsion, as it was in half the patients 7 to 12 years of age. The remaining cases were caused by torsion of an intrascrotal appendage. In 13- to 18-year-old patients, 76% had testicular torsion, 16% had torsive appendages, and 8% had epididymitis. In 80% of 19- to 24-year-olds, the cause of pain was epididymitis.

In another review of multiple surgical admissions and hospital patients, testicular torsion accounted for acute scrotal pain in approximately 42% of children. This review combined 211 cases from four different case series. Patients ranged in age from 2 to 18 years. Other diagnoses were torsion of an appendage in 29%, epididymitis in 22%, and orchitis in 3%. [1] A more recent study looked at 238 patients--infants, children, and adolescents up to 19 years old--who came to the emergency room in a children's hospital. Sixteen percent of boys had testicular torsion, 35% epididymitis, and 46% torsion of an intrascrotal appendage. [2]

Testicular torsion

Testicular torsion is a twisting of the testis and spermatic cord that results in venous obstruction, progressive edema, arterial compromise, and, eventually, testicular infarction. It is a surgical emergency: A delay in diagnosis of only four to six hours may result in abnormal testicular function, and a delay of more than six hours often leads to removal of the testicle. Testicular torsion is the most common cause of testicular loss in young males. The risk of developing torsion by age 25 is estimated to be about one in 160. [3]

There are two types of torsion, defined by their relationship to the tunica vaginalis: extravaginal and intravaginal. Extravaginal torsion occurs primarily in neonates or occasionally in utero and accounts for less than 10% of all cases of torsion. It occurs when the gubernaculum and testicular tunics are not completely attached to the scrotal wall and involves a complete twisting of the scrotal contents (testis, epididymis, and tunica vaginalis) on the spermatic cord. Extravaginal torsion usually causes little distress, and the testicular salvage rate is poor. Intravaginal torsion, twisting of the testis within the tunica vaginalis, accounts for 90% of all cases of torsion and nearly all cases in children older than 2 years. While it may happen at any age, two thirds of cases occur in boys between 12 and 18 years, with incidence peaking at...

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Gale Document Number: GALE|A62110388