Paediatrics: Testicular torsion

Testicular torsion

Testicular torsion must be excluded in a child with acute scrotal pain. The peak incidence occurs around 12yrs, but it can occur at any age.

•   Congenital testicular torsion: rare perinatal event. Newborn infant has a hard, painless scrotal mass. Testis has invariably infarcted and exploration is not necessary, nor is fixation of the opposite testis. The pathology is torsion of the spermatic cord outside the tunica vaginalis.

•   Torsion outside the perinatal period: the result of an abnormally mobile mesentery of the testis inside the tunica vaginalis. This anomaly is bilateral and allows the gonad to twist on its vascular pedicle.

Presentation

•   Sudden onset severe scrotal pain, often associated with nausea and vomiting.

•   Tender testis.

•   Overlying scrotal skin may be reddened and oedematous.

Treatment

•   Immediate scrotal exploration is mandatory to salvage the testis, which should then be fixed to prevent recurrence.

•   The contralateral testis should also be fixed.

Differential diagnosis of acute scrotal pain

Testicular torsion

•   Sudden onset pain, swelling, and nausea

•   Testis is very tender, and may lie transversely in scrotum

•   Scrotal skin may be red

Torted hydatid

•   Gradual onset of less severe pain; no nausea

•   Focal tenderness at upper pole of testis

•   Torted hydatid may be visible through scrotal skin as a pea-sized blue/black swelling

Epididymo-orchitis

•   Insidious onset of dysuria and fever

·  Usually associated with a urinary tract infection

•   Red tender scrotum

Testicular trauma 

History obvious and there are signs of trauma/ haematocele 

Idiopathic scrotal oedema

•   Child is well

•   Scrotal skin is cellulitic but the testes are not tender

The condition settles spontaneously within a few days