10.1.1.546.6206 Bedah
10.1.1.546.6206 Bedah
10.1.1.546.6206 Bedah
Because acute scrotal pain, swelling, and/or inflammation are a potential surgical
emergency, prompt and accurate diagnosis is crucial. The 3 most common etiologies of
acute scrotal pain in the pediatric age group are epididymitis, torsion of the appendix testis,
and testicular torsion. There are numerous other causes of scrotal pain, which include
hernia, hydrocele, trauma, Henoch-Schonlein purpura, idiopathic scrotal edema, and
neoplasm, but only testicular torsion requires emergent surgery. History and physical
examination, along with adjunctive imaging, can provide important keys to the diagnosis.
This article reviews the differential diagnosis and management of the acute scrotal pain in
the pediatric population, specifically focusing on testicular torsion, epididymitis, and
torsion of the appendix testis.
Clin Ped Emerg Med 10:38-44 © 2009 Elsevier Inc. All rights reserved.
38 1522-8401/$ - see front matter © 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.cpem.2009.01.010
Testicular torsion, torsion of appendix testis, & epididymitis 39
case series, only 16 patients had an ultrasound performed Kadish and Bolte [5] and in 38 (92.7%) of 41 patients with
preoperatively. Of these, 9 had demonstration of increased torsion in the study of Karmazyn et al [6]. The presence of
flow to the epididymis. Only 3 were diagnosed operatively a diffusely tender testicle was not explicitly reported in the
with epididymitis; 3 others had torsion of the appendix testis other 2 studies.
[4]. This suggests that ultrasound findings alone may In addition, patients with torsion were more likely to
overdiagnose epididymitis. present earlier and have an abnormal testicular orientation
than patients with epididymitis [3,5,6]. With the exception
of the Rabinowitz study in which the methodology is
Testicular Torsion unclear, these studies are all retrospective. In the
Torsion of the testicle results from twisting of the spermatic Karmazyn and Ciftci studies, it is not clear who was
cord, which then compromises the blood supply. Torsion may documenting the physical examination findings and how
occur extravaginally (twisting proximal to the tunica patients were classified if no physical examination findings
vaginalis) or intravaginally (twisting within the tunica were charted. Lastly, Karmazyn produced a clinical scoring
vaginalis). Extravaginal torsion occurs in the perinatal age system in which a patient receives one point for each of the
group and makes up a small percentage of the total number of following findings: pain less than 6 hours, diffusely tender
cases of testicular torsion. Intravaginal torsion occurs in older testicle, and absent or decreased cremasteric reflex. Of the
children and is believed to be due to abnormal fixation of the 30 patients in his series who had 0 points or none of the
testis within the tunica vaginalis. In either case, the resulting findings, none had testicular torsion [6]. A prospective
ischemia can lead to changes in testicular morphology, sperm validation of this scoring system is necessary before any
formation, or even complete testicular loss. recommendations can be made regarding its use in ruling
Pediatric testicular torsion has a bimodal age presenta- out testicular torsion.
tion with a small peak in neonates and a second larger
peak in peripubertal children. Peripubertal children
The Role of Imaging
classically present with nausea, vomiting, and severe Because history and physical examination are not entirely
acute testicular pain, whereas infants with prenatal torsion reliable in diagnosing testicular torsion, many studies have
typically are asymptomatic with a hard firm testicle [8]. examined the use of ultrasound as an adjunctive tool. The
The remainder of this section will be devoted to a published sensitivity of color Doppler ultrasonography for
discussion of torsion outside infancy. Neonatal torsion diagnosing testicular torsion has a wide range of 63% to
will be addressed separately. 100% with a specificity of 80% to 100% [5,6,8,9,11-15].
These studies primarily used the absence of preserved
blood flow to diagnose torsion. However, in multiple case
Physical Findings and Historical Clues to series, there are examples of torsion with preserved blood
Testicular Torsion flow on ultrasound, accounting for the lowered sensitivity
Various studies have compared the clinical presentation of in some of the case series [12,16-18].
epididymitis, torsion of the appendix testis, and testicular Figure 1 is an example of preserved testicular flow on
torsion to distinguish between the 3. Four separate scrotal ultrasound in a 16-year-old boy who presented to
retrospective studies have shown that an absent or
decreased cremasteric reflex is the most sensitive physical
examination sign for diagnosing testicular torsion [10]. A
positive or normal cremasteric reflex is seen when the
testicle retracts after light stroking of the inner ipsilateral
thigh. In separate studies by Rabinowitz [10] and Kadish
and Bolte [5], the cremasteric reflex was absent in 100% of
patients (56 and 13 patients, respectively) with torsion.
Although absence of the cremasteric reflex did not confirm
the diagnosis of torsion, in these 2 studies, the presence of
the cremasteric reflex effectively ruled it out. However, 2
other studies have failed to reproduce 100% sensitivity for
this examination finding. Karmazyn et al [6] reported that
only 28 (90.3%) of 31 of patients with torsion in their case
series had an absent or decreased cremasteric reflex, and
Ciftci et al [3] demonstrated that an absent cremasteric
reflex had a 92% sensitivity in diagnosing 36 patients with
torsion. Another finding that performed well was the
presence of a diffusely tender testicle. This finding was Figure 1 Testicular ultrasound in missed torsion case demonstrat-
present in 13 of 13 patients with torsion in the study of ing presence of flow.
40 S. Yin, J.L. Trainor
Testicular Salvage Rates stratified prenatal from postnatal torsion, one of the 3
Early surgical exploration with restoration of blood flow infants had a testicle that was salvageable [31]. It
clearly improves the rate of testicular salvage. Visser and remains to be seen whether this infant will have long-
Heyns [26] examined both the salvage and late atrophy term atrophy of the salvaged testicle. In another study, 4
rate in 2 meta-analyses of 1140 patients from 22 case series of 10 neonates with postnatal torsion had testicular
and 535 patients in 8 case series. In their meta-analysis, salvage. The authors were able to follow the 4 salvaged
exploration within 6 hours yielded a testicular salvage rate patients at 6 months of age and noted normal growth of
of higher than 90%, which then dropped consistently to the testes [34]. Given this low published salvage rate,
approximately 20% at 24 to 48 hours. This same analysis one might infer that there is a delay in presentation for
found the testicular atrophy rate to approach 0% when postnatal torsion. Even so, an infant with a normal
salvaged within 6 hours and higher than 70% when testicular examination result at birth who then presents
salvaged at more than 24 hours. The methodology used in with an acute scrotal pain should be surgically explored
conducting this meta-analysis is unclear, but the results immediately. The role of ultrasound in diagnosing
appear consistent with other published rates [4,27]. Testes neonatal torsion is controversial, with some authors
salvaged greater than 8 hours after presentation showed a reporting 100% sensitivity with experienced operators
significant decrease in postpubertal size and exocrine and others acknowledging false-negative as well as false-
function [28]. All evidence indicates that surgical explora- positive results. Blood flow to the neonatal testis may be
tion and repair should be done as quickly as possible. A difficult to evaluate with Doppler ultrasonography even
small but significant percentage of late presenters can be when present and normal [32-34].
salvaged so urologic consultation should not be deferred
Manual Detorsion
for patients with late presentations.
Because of the urgency involved in restoring blood flow
to the affected testis, manual detorsion has been
Neonatal Torsion suggested as a treatment modality for torsion outside
Traditionally, neonatal torsion has been treated as a single the neonatal period. Traditionally, torsion of the testicle
entity. Recently, there have been efforts in the literature to was thought to occur primarily in a medial direction so
change the terminology to encompass 2 distinct entities: that an attempt at detorsion would involve twisting the
(1) in utero or prenatal torsion and (2) postnatal torsion affected testis in a lateral direction in a maneuver similar
[29]. Approximately 70% to 80% of perinatal torsion is to opening a book. Numerous studies have demon-
prenatal [30,31]. Prenatal torsion is almost universally strated good success rates ranging from 68% to 86%
unsalvageable. Brandt et al [29] showed that 23 of 23 with manual detorsion [35-37]. However, caution should
patients presenting with an abnormal scrotal examination be observed before attempting this technique. Sessions et
result at birth and surgically explored had no viable or al [35] observed that 54 (33%) of 162 of torsions
salvageable testes. The case series published by Kaye et al occurred in a lateral direction. Therefore, manual
[31] and John et al [32] found that 13 of 13 and 24 of 24 manipulation to the lateral direction in many patients
testes were unsalvageable, respectively. would worsen the degree of torsion. Immediate relief of
However, Pinto et al [30] were able to salvage 2 of 30 symptoms is described with successful manual detorsion;
testicles in neonates with torsion. Both of these patients therefore, increasing severity of symptoms with
were explored within 6 hours of diagnosis, and salvage was attempted detorsion may be an indication that lateral
defined as no testicular atrophy at 1 year of age. One of torsion is present.
their patients likely had postnatal torsion and was Another potential pitfall of manual detorsion is failure to
diagnosed at 21 hours of life. The other patient was completely untwist the cord, because torsion may involve
diagnosed at birth [30]. Management of prenatal torsion multiple revolutions. In the study by Sessions et al [35] in
remains controversial in the urologic literature, with some which 70 patients underwent orchiectomy for torsion, the
authors recommending immediate exploration and others median amount of rotation observed was 540°, with a
recommending observation or delayed exploration range of 180° to 1080°. One manual rotation will reduce
[29,33]. In the emergency department, immediate urologic the torsion by 180° to 360°. This may cause a significant
consultation is recommended for any newborn infant reduction in pain if some blood flow is restored, but it may
presenting with suspected torsion. not result in complete resolution. Hence, manual detorsion
In contrast to infants with prenatal torsion, infants is not a substitute for exploration and fixation. Manual
with postnatal torsion tend to present with the classic detorsion with the aid of ultrasound is likely the most
signs of acute inflammation (erythema, swelling, and prudent approach because ultrasound can provide infor-
tenderness). However, the parental complaint may be mation about the direction of twist as well as evidence of
increased fretfulness or irritability. The outcome of successful detorsion. This requires either expertise in use
postnatal torsion may not be as bleak as that seen in of bedside ultrasound or immediate availability of radio-
prenatal cases. In a recent case series that specifically logic assistance.
42 S. Yin, J.L. Trainor
respectively. Torsion of the appendix testis makes up about ultrasonography alone. The true incidence and etiology
91% to 95% of torsed appendices [20]. of pediatric epididymitis remains to be determined.
The presentation of torsion of a testicular appendage can However, a school-aged child with a normal urinalysis
be similar to testicular torsion or epididymitis. Patients and a negative urine culture who is diagnosed with
typically present with sudden onset of pain. These patients epididymitis via ultrasound is unlikely to have a bacterial
are more likely to have isolated tenderness to the superior illness or require antibiotic treatment.
pole of the testicle than patients with testicular torsion or
epididymitis [5]. In the study by Kadish and Bolte [5], References
patients with torsion of the appendix testis presented in a 1. Williamson RC. Torsion of the testis and allied conditions. Br J Surg
similar time frame to patients with testicular torsion. In 1976;63:465.
addition, they were more likely to have a normal lie [5], 2. Varga J, Zivkovic D, Grebeldinger S, et al. Acute scrotal pain in
although in one study, this did not reach statistical children—ten years' experience. Urol Int 2007;78:73-7.
3. Ciftci AO, Senocak ME, Cahit Tanyel F, et al. Clinical predictors for
significance because of the small number of patients, and
differential diagnosis of acute scrotum. Eur J Pediatr Surg 2004;14:
in another study, there was no statistical analysis done on 333-8.
the differences [3]. 4. Mushtaq I, Fung M, Glasson MJ. Retrospective review of paediatric
The “blue dot” sign commonly described in textbooks patients with acute scrotum. ANZ J Surg 2003;73:55-8.
is present in a minority of cases of torsion of the 5. Kadish HA, Bolte RG. A retrospective review of pediatric patients with
epididymitis, testicular torsion, and torsion of testicular appendages.
testicular appendage. In one case series, the blue dot sign
Pediatrics 1998;102:73-6.
was noted in only 3 (23%) of 13 patients [5]. This may 6. Karmazyn B, Steinberg R, Kornreich L, et al. Clinical and sonographic
be due to the time of presentation and progression of criteria of acute scrotum in children: a retrospective study of 172
disease process at that point. Early on in the torsion boys. Pediatr Radiol 2005;35:302-10.
event, arterial flow to the appendage continues, whereas 7. Anderson PAM, Giacomantonio JM. The acutely painful scrotum in
children: review of 113 consecutive cases. Can Med Assoc J 1985;132:
venous egress is interrupted. This leads to a swollen
1153-5.
appendage filled with deoxygenated blood. Before edema 8. Lewis AG, Bukowski TP, Jarvis PD, et al. Evaluation of acute scrotum
of the scrotal skin develops, this swollen appendage may in the emergency department. J Pediatr Surg 1995;30:277-82.
be visible as the blue dot beneath the skin. As the 9. Gunther P, Schenk JP, Wunsch R, et al. Acute testicular torsion in
inflammatory process continues, scrotal edema interferes children: the role of sonography in the diagnostic workup. Eur Radiol
2006;16:2527-32.
with the visibility of the swollen appendage, and the
10. Rabinowitz R. The importance of the cremasteric reflex in acute
once-visible sign is lost. scrotal swelling in children. J Urol 1984;132:89-90.
Patients with torsion of the testicular appendage can be 11. Patriquin HB, Yazbeck S, Trinh B, et al. Testicular torsion in infants
treated supportively once testicular torsion has been and children: diagnosis with Doppler sonography. Radiology 1993;
excluded. Nonsteroidal antiinflammatory drugs are recom- 188:781-5.
12. Bentley DF, Ricchiuti DJ, Nasrallah PF, et al. Spermatic cord torsion
mended, as well as limitation of activity to minimize pain.
with preserved testis perfusion: initial anatomical observations. J Urol
In addition, scrotal support with a pediatric athletic 2004;172:2373-6.
supporter or tight-fitting brief-style underwear can mini- 13. Kalfa N, Veyrac C, Lopez M, et al. Multicenter assessment of
mize mobility of the testicle and hence pain. Patients can ultrasound of the spermatic cord in children with acute scrotum. J
experience torsion of an appendix multiple times because Urol 2007;177:297-301.
14. Lam WW, Yap T, Jacobsen AS, et al. Colour Doppler ultrasonography
of the potential presence of multiple appendages.
replacing surgical exploration for acute scrotum: myth or reality?
Pediatr Radiol 2005;35:597-600.
15. Baker LA, Sigman D, Mathews RI, et al. An analysis of clinical
Summary outcomes using color Doppler testicular ultrasound for testicular
Any child presenting with an acute scrotal pain should be torsion. Pediatrics 2000;105:604-7.
16. Allen TD, Elder JS. Shortcomings of color Doppler sonography in the
treated as if they have a potential surgical emergency.
diagnosis of testicular torsion. J Urol 1995;154:1508-10.
Testicular torsion, epididymitis, and torsion of the 17. Kalfa N, Veyrac C, Baud C, et al. Ultrasonography of the spermatic
appendix testis are the 3 most common nontraumatic cord in children with testicular torsion: impact on the surgical
causes of acute scrotal pain. Prompt diagnosis is crucial to strategy. J Urol 2004;172:1692-5.
avoid ischemic injury to the testicle. Physical examination 18. Arce JD, Cortes M, Vargas JC. Sonographic diagnosis of acute
spermatic cord torsion. Pediatr Radiol 2002;32:485-91.
findings combined with adjunctive imaging can usually
19. Eaton SH, Cendron MA, Estrada CR, et al. Intermittent testicular
provide the correct diagnosis. Imaging alone, however, torsion: diagnostic features and management outcomes. J Urol 2005;
cannot reliably exclude testicular torsion, and the emer- 174:1532-5.
gency physician should seek urologic consultation in the 20. Dogra VS, Bhatt S, Rubens DJ. Sonographic evaluation of testicular
presence of concerning history or physical examination torsion. Ultrasound Clin 2006;1:55-6.
21. Stillwell TJ, Kramer SA. Intermittent testicular torsion. Pediatrics
findings, even when testicular blood flow appears to be
1986;77:908-11.
preserved. The use of high-resolution ultrasonography to 22. Livne PM, Sivan B, Karmazyn B, et al. Testicular torsion in the
identify twists in the spermatic cord may ultimately prove pediatric age group: diagnosis and treatment. Pediatr Endocrinol Rev
to be a better diagnostic test than color Doppler 2003;2:128-33.
44 S. Yin, J.L. Trainor
23. Paltiel HJ, Connolly LP, Atala A, et al. Acute scrotal symptoms in boys 35. Sessions AE, Rabinowitz R, Hulbert WC, et al. Testicular torsion:
with an indeterminate clinical presentation: comparison of color direction, degree, duration and disinformation. J Urol 2003;169:
Doppler sonography and scintigraphy. Radiology 1998;207:223-31. 663-5.
24. Nussbaum Blask AR, Bulas D, Shalaby-Rana E, et al. Color Doppler 36. Garel L, Dubois J, Azzie G, et al. Preoperative manual detorsion of the
sonography and scintigraphy of the testis: a prospective, comparative spermatic cord with Doppler ultrasound monitoring in patients with
analysis in children with acute scrotal pain. Pediatr Emerg Care 2002; intravaginal acute testicular torsion. Pediatr Radiol 2000;30:41-4.
18:67-71. 37. Cornel EB, Karthaus HF. Manual derotation of the twisted spermatic
25. Wu HC, Sun SS, Kao A, et al. Comparison of radionuclide imaging cord. Br J Urol Int 1999;83:672-4.
and ultrasonography in the differentiation of acute testicular torsion 38. Haecker FM, Hauri-Hohl A, von Schweinitz D. Acute epididymitis in
and inflammatory testicular disease. Clin Nucl Med 2002;27:490-3. children: a 4-year retrospective study. Eur J Pediatr Surg 2005;15:
26. Visser AJ, Heyns CF. Testicular function after torsion of the spermatic 180-6.
cord. Br J Urol Int 2003;92:200-3. 39. Tracy CR, Steers WD, Costabile R. Diagnosis and management of
27. Makela E, Lahdes-Vasama T, Rajakorpi H, et al. A 19-year review of epididymitis. Urol Clin N Am 2008;35:101-8.
paediatric patients with acute scrotum. Scand J Surg 2007;96:62-6. 40. Chiang MC, Chen HW, Fu RH, et al. Clinical features of testicular
28. Bartsch G, Frank S, Margerger H, et al. Testicular torsion: late results torsion and epididymo-orchitis in infants younger than 3 months. J
with special regard to fertility and endocrine function. J Urol 1980; Pediatr Surg 2007;42:1574-7.
124:375-8. 41. Lau P, Anderson PA, Giacomantonia JM, et al. Acute epididymitis in
29. Brandt MT, Sheldon CA, Wacksman J, et al. Prenatal testicular boys: are antibiotics indicated? Br J Urol 1997;79:797-800.
torsion: principles of management. J Urol 1992;147:670-2. 42. Somekh E, Gorenstein A, Serour F. Acute epididymitis in boys:
30. Pinto KJ, Noe HN, Jerkins GR. Management of neonatal testicular evidence of a post-infectious etiology. J Urol 2004;171:391-4.
torsion. J Urol 1997;158:1196-7. 43. Al-Taheini KM, Pike J, Leonard M. Acute epididymitis in children: the
31. Kaye JD, Levitt SB, Friedman SC, et al. Neonatal torsion: a 14-year role of radiologic studies. Urology 2008;71:826-9.
experience and proposed algorithm for management. J Urol 2008;179: 44. Merlini E, Rotundi F, Seymandi PL, et al. Acute epididymitis and
2377-83. urinary tract anomalies in children. Scand J Urol Nephrol 1998;32:
32. John CM, Kooner G, Mathew DE, et al. Neonatal testicular torsion-a 273-5.
lost cause? Acta Paediatr 2008;97:502-4. 45. Siegel A, Snyder H, Duckett JW. Epididymitis in infants and boys:
33. Yerkes EB, Robertson FM, Gitlin J, et al. Management of perinatal underlying urogenital anomalies and efficacy of imaging modalities. J
torsion: today, tomorrow or never? J Urol 2005;174:1579-83. Urol 1987;138:1100-3.
34. Sorensen MD, Galansky SH, Striegl AM, et al. Perinatal extravaginal 46. Cappele O, Liard A, Barret E, et al. Epididymitis in children: is further
torsion of the testis in the first month of life is a salvageable event. investigation necessary after the first episode? Eur Urol 2000;38:
Urology 2003;62:132-4. 627-30.