DR. VIVEK M. REGE
PEDIATRIC SURGEON & PEDIATRIC UROLOGIST
ACUTE SWELLING & PAIN IN SCROTAL REGION
This is one condition that requires a quick decision and urgent surgery. The
usual story is that of a boy who comes home from school or from playing
with a pain in the scrotal region. The onset may have been while the boy was
playing or even more often while sitting. There may be some history of
trauma, which may lead to the parents to assume that pain is due to direct
trauma only. However, the boy must be thoroughly questioned to find out
when did the pain actually start, has it remained the same, increased, or
decreased and disappeared. Check if the boy is having any urinary problem
like burning or painful micturition prior to the pain. Also, one must check
for swelling and redness on one side of the scrotum. Thus a boy presenting
Acute scrotal swelling
with pain and swelling on one side of the scrotum has to be given immediate
therapy since there are 2 possibilities. The first is Testicular torsion that
requires urgent surgery to untwist the torsion; the other is epididymo orchitis
that requires purely non surgical therapy.
HURKISONDAS HOSPITAL
B J WADIA HOSPITAL FOR CHILDREN
WOCKHARDT HOSPITAL
MOBILE- 98210 52680
Website: www.addlifesurgikids.com
DR. VIVEK M. REGE
PEDIATRIC SURGEON & PEDIATRIC UROLOGIST
Testis
Epididymis
Cord
Normal structures
Testicular torsion – the cause is a congenital anomaly wherein, the
testis after descending into the scrotum is not fixed in place and is mobile.
The testis is free to rotate along its long axis – this in turn leads to a twisting
of the blood vessels of the testis and cutting off of the blood supply to the
testis. As this progresses, the total blood supply of the testis is cut off
leading to gangrene or infarction of the testis. This makes the testis atrophy
and loose all functions. The twists can be of various degrees i.e. 180 degrees,
360 degrees – thus it may be one full turn or 2 or more turns. Obviously,
more the twists the faster the loss of blood supply. Additionally, the time
interval from the occurrence of the torsion and its relief is also very
important. If corrected within 6 hours – still about 10% of testis can loose
their functions; this can increase to 90 % if the time interval goes more than
24 hours. This then is the reason for urgent intervention and untwisting of
the torsion. This is also the reason for showing the proper doctor as soon as
possible.
Torsion of testis – showing an infarcted
black testis – requiring an orchiectomy
HURKISONDAS HOSPITAL
B J WADIA HOSPITAL FOR CHILDREN
WOCKHARDT HOSPITAL
MOBILE- 98210 52680
Website: www.addlifesurgikids.com
DR. VIVEK M. REGE
PEDIATRIC SURGEON & PEDIATRIC UROLOGIST
Epididymo orchitis (EO) – This is an infective inflammatory
condition secondary to urinary infection. Retrograde infection from the
urethra via the vas deferens to the epididymis and testis. The infection and
subsequent inflammation lead to pain and swelling in the testicular region
very similar to that in torsion. The infection could also have come to the
epididymis from the normal blood flow. Rarely there may be an abnormal
upper urinary tract anomaly and presents as epididymo orchitis.
Perineal abscess with secondary scrotal swelling
Differentiating the two is very difficult clinically. However, a detailed
history with a proper examination may help if the child allows. Usually, a
small child with severe pain will scream just looking at the doctor and
examination will not be possible very easily. Some of the things that may
help during examination are – check if there is more swelling posteriorly
with thickening of the epididymis, suggestive of EO. At times the pain is not
very severe and gradually supporting and lifting the epididymis with the
palm of the hand may give relief to the child again a sign of inflammation.
Another clinical sign that may help is eliciting the Cremasteric reflex by
stroking the medial side of the upper thigh. If this results in a positive reflex,
the testis gets pulled upwards due to the contraction of the cremaster muscle,
it means that the cremaster can function as it is not twisted. Thus, positive
cremasteric reflex, usually rules out torsion. On the other hand absence of
the reflex does not necessarily mean only torsion as the inflammation and
edema due to the infection can temporarily make the cremaster inactive.
Thus there is no active and definitive method of clinically differentiating one
from the other.
HURKISONDAS HOSPITAL
B J WADIA HOSPITAL FOR CHILDREN
WOCKHARDT HOSPITAL
MOBILE- 98210 52680
Website: www.addlifesurgikids.com
DR. VIVEK M. REGE
PEDIATRIC SURGEON & PEDIATRIC UROLOGIST
There is one investigation that may help to a certain extent. A Color
Doppler study for the blood supply to the testis will show no blood flow in
case of Torsion but excess blood flow in EO. However, this is based on
many factors like, the person doing the study (experience). The time from
onset when the study is done, after 6-9 hours, there is an excess blood flow
around the testicular region and could be mistaken for EO and the boy is
conserved with poor result and the testis is atrophic and functionless later in
life.
Inguinal swelling with acute pain – torsion of undescended testis
THERAPY
The dilemma in such a case is assuming the cause to be EO, the
treatment is medical; however, if the diagnosis is then found to be torsion,
the testis is lost permanently. On the other hand, if the child is operated on
assuming it is torsion and it turns out to be EO, then the operation would
have been unnecessary and unindicated. In this type of a case my philosophy
is, when in doubt, assume all cases are torsion of the testis and operate the
child to look for the torsion of testis. This operation is undertaken after a
full detailed explanation of the pros and cons to the parents of the boy, their
consent is taken. The advantages of this approach no torsion will be missed
or remain uncorrected after the child is brought to the surgeon for opinion
and advice; there is no wastage of valuable time for searching traveling to
and from a Sonologist who will be doing the Doppler study and not being
HURKISONDAS HOSPITAL
B J WADIA HOSPITAL FOR CHILDREN
WOCKHARDT HOSPITAL
MOBILE- 98210 52680
Website: www.addlifesurgikids.com
DR. VIVEK M. REGE
PEDIATRIC SURGEON & PEDIATRIC UROLOGIST
definitely sure about the final diagnosis based on the interpretation of the
study. It is better to explore and find that the diagnosis is EO rather than
conserve, treat medically and later find this was a case of torsion.
In cases of torsion – the testis is explored, untwisted, and observed.
The color, consistency, pulsations are looked for to confirm that the testis is
viable. After confirming that the testis is alright, it is reposited into the
scrotum and fixed in position with a stitch going through the testis and the
skin of the scrotum to prevent a recurrence of the torsion. Even more
important, the opposite side testis must always be fixed at the same sitting
with a suture. This is done because, the same congenital anomaly that was
responsible for torsion on one side, may be present on the opposite side, and
fixing the opposite side testis would prevent torsion from occurring on that
side in the future. This is very important to remember.
In case of EO, an oral broad spectrum antibiotic is started for the
infective pathology, additionally, an anti-inflammatory drug is begun to take
care of the inflammation and the edema. Elevation of the scrotum with local
cold compresses are also started. This therapy is continued till the swelling
and tenderness begin to recede. More important in these cases is to
investigate the child for urological defects after the episode settles. A
complete urinary tract investigation must include Ultrasound for kidneys,
ureters and bladder, a MCU to look for reflux, obstruction of the lower
urinary tract, and an IVP to look for anomalies of the upper urinary system
like double or ectopic ureters etc.
HURKISONDAS HOSPITAL
B J WADIA HOSPITAL FOR CHILDREN
WOCKHARDT HOSPITAL
MOBILE- 98210 52680
Website: www.addlifesurgikids.com
DR. VIVEK M. REGE
PEDIATRIC SURGEON & PEDIATRIC UROLOGIST
HURKISONDAS HOSPITAL
B J WADIA HOSPITAL FOR CHILDREN
WOCKHARDT HOSPITAL
MOBILE- 98210 52680
Website: www.addlifesurgikids.com