Acute Scrotum - Paediatrics

Acute Scrotum

·        Must examine the genitalia of every boy who presents with acute lower abdominal pain (may not localise to testis)

·        In descending order of frequency, causes of an acute scrotum are:

o  Torsion of the appendix testis

o  Testicular torsion 

o  Idiopathic scrotal oedema. Symmetric swelling, no testicular tenderness. May include penis, inguinal and perineal regions. Exclude torsion

o  Rarely, epididymo-orchiditis

·        Management of torsion: 

o  High probability: short duration and negative urinalysis ® surgery

o  Low probability: longer duration and positive urinalysis ® ?Doppler US for ¯blood flow

Torsion of Appendix Testis

·        Most commonly caused by Hydatid of Morgagni (Mullerian duct remnant) at top of testis 

·        Peak incidence at 10 – 12 years. Oestrogen stimulates enlargement of the remnants ® predisposes to torsion 

·        Symptoms range from minimal inflammation to florid, swollen hemi-scrotum indistinguishable from testicular torsion

·        Urgent surgical referral

Testicular Torsion

·        Testes are covered by tunica vaginalis – has parietal and visceral surface (like lungs in pleura)

·        Testis rotates on its chord within parietal tunica vaginalis

·        Once torsion has occurred in one, more likely in another

·        < 6 hours will probably not cause infarct

·        Two peaks for incidence: 

o  Neonatal: Testis usually dead by diagnosis. May not operate (will atrophy). May „pex‟ contralateral side to prevent torsion 

o  Age 13 – 15: History and presentation variable. Surgical emergency. If testis viable, untwist and fix. Fix contra-lateral side 

·        Need to remove a torted testis, otherwise he will develop autoantibodies for spermatozoa ® infertility of other testis

Epididymo-Orchitis

·        Very rare in children.  Two peaks

o  Newborn, with underlying urinary tract anomaly.  Do US and MCU.  MSU to rule out infection 

o  In 13+ due to reflux up the vas ® infection/inflammation

·        Mumps orchitis does not occur in pre-pubertal boys