Acute Testicular Disorders

John M. Gatti; J. Patrick Murphy

doi:10.1542/pir.29-7-235

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John M. Gatti, MD*
J. Patrick Murphy, MD^†

^*Associate Professor, University of Missouri at Kansas City School of Medicine; Director, Minimally Invasive Urology, Children's Mercy Hospital, Kansas City, Kan
^†Professor, University of Missouri at Kansas City School of Medicine; Chief, Section of Urology, Children's Mercy Hospital, Kansas City, Kan

Objectives

After completing this article, readers should be able to:

Describe the appropriate evaluation and management of the acute scrotum.
Discern testicular torsion from other, less urgent conditions that may mimic it.
Discuss the importance of prompt diagnosis and treatment of testicular torsion for gonadal salvage.

Introduction

Acute scrotal pain with or without swelling and erythema in the child or adolescent male should be treated as an emergent condition. The differential diagnosis includes: torsion of the spermatic cord, appendix testis or epididymis, epididymitis/orchitis, hernia, hydrocele, trauma, sexual abuse, tumor, idiopathic scrotal edema (dermatitis/insect bite), cellulitis, and vasculitis (Henoch–Schönlein purpura). Most of the conditions are nonemergent, but the prompt diagnosis and treatment of torsion of the spermatic cord is imperative to avoid permanent ischemic damage to the testicle. The most common causes of acute scrotal pain are testicular (spermatic cord) torsion and torsion of the rudimentary vestigial appendages of the testicle or epididymis. The child's age suggests the cause of the acutely painful scrotum because torsion of the appendix testes/epididymis is more common in prepubertal boys and spermatic cord torsion occurs more frequently in adolescents and newborns.

Testicular Torsion

Torsion of the testicle results from twisting of the spermatic cord, which compromises testicular blood supply. The number of twists determines the amount of vascular impairment, although generally a 4- to 8-hour window exists before significant ischemic damage occurs that can affect long-term testicular morphology and sperm formation. Testicular torsion is a true surgical emergency. Adolescent males tend to present beyond the “golden” 4- to 8-hour period, but urgent surgical treatment is indicated because viability of the testis is difficult to predict.

Two types of testicular torsion may occur. Extravaginal torsion results from twisting of the cord proximal to the tunica vaginalis. This mechanism occurs perinatally during descent of the testicle before the scrotal investment of …