A testy diagnostic dilemma: the acute scrotum

July 2004

The acute painful swollen testicle in the prepubertal child presents the clinician with a most urgent diagnostic challenge. Missing or delaying the diagnosis may frequently potentially lead to loss of the testicle. However, not every acute scrotum that swells is destined for testicular destruction.

In the prepubertal male, the physician must differentiate among the following: torsion of the testicle, torsion of the appendage of the testicle, orchitis (sometimes due to Henoch-Schönlein purpura or Kawasaki disease), hydrocele with an incarcerated hernia, traumatic hydrocele or epididymitis. Of these, an incarcerated hernia and full torsion of the testicle, which is in many series the most common diagnosis of acute scrotum, are medical emergencies. And surgery must be performed immediately to salvage the torsed testicle or incarcerated bowel, respectively.

Two case vignettes

An infant presents to the office with irritability and refusal to eat. He is afebrile and cries upon any movement of his body. You perform a complete examination and find that his tympanic membrane is full of pus, he has some moderate rhinorrhea and the right testicle is moderately swollen and painful enough to elicit tears with any palpation or motion. His genitourinary examination is otherwise normal.

You do not want to panic the mother, but you must act with alacrity and decisiveness. The acute otitis media can cause irritability, yet a surgical emergency is likely staring at you in the genitourinary tract. I recently encountered the above findings in the following two vignettes.

Case vignette 1: A 3-month-old developed an acute tender reddened scrotum; the inguinal ring also felt tight and the redness appeared to extend slightly into the inguinal area as well. In another twist, the child had a history of hydrocele since birth. He was seen in the emergency department the night before with vomiting and poor appetite, and the family was reassured that the hydrocele was not the problem. However, the mother persisted that something was wrong with her child. When the cranky child returned the next day to the office, the hydrocele was unchanged, and he was afebrile but quite fussy. The small hernia connected to the hydrocele was not reducible. The child was promptly sent to pediatric surgery. Diagnostic imaging, which was not performed, would have only delayed the time to the operating room. The incarcerated hernia was corrected; several centimeters of strangulated bowel were resected; and the child received a week of parenteral antibiotics. A surgical emergency – almost approaching a disaster.

Case vignette 2: A 4-month-old child presented to the office with a similar acute scrotum – his hydrocele was tense, mildly reddened and painful with motion (figure 1). No hernia was discerned. I promptly picked up the phone and scheduled the child for an immediate Doppler-flow ultrasound of the testicles. The radiologist read the ultrasound equivocally, but noted that the flow to the testicle appeared normal bilaterally and that the right epididymis might be swollen. Because of some persistent concern about torsion of the testis, radiologic equivocation and the potential gravity of this physical finding, the child was referred to the pediatric urologist. He confirmed the findings of a swollen epididymis and a normal flow to the testicle. He prescribed trimethoprim-sulfamethoxazole for acute epididymitis. A nervous physician — anxiety-ridden about the potential for a disaster.

In the first scenario, despite the obvious finding of an emergency — an acute scrotum — the clinician must ascertain a complete history, asking, for example, whether the child has a prior history of hydrocele, mumps vaccination, exposure to parainfluenza or mumps virus and especially acute trauma. A cursory but thorough examination also is essential as the first case demonstrates.

Torsion of the entire testicle or the appendage of the testicle, which both result from an anatomical abnormality, are the most common diagnoses reported from series of children with spontaneous acute scrotum. But epididymitis may account for the diagnosis in 8% to 41% of boys.

Epididymitis usually results from an inflammatory reaction of the epididymis to a multitude of infectious agents and occasionally from underlying urinary tract abnormality or trauma.

Postpuberty

In the postpubertal male, most cases of epididymitis are sexually acquired and are caused by Chlamydia trachomatis and gonococcus. Predisposing conditions for the prepubertal male with epididymitis include ectopic ureter, ectopic vas deferens or urethral fistula. Thus, a complete urinalysis and urine culture should always be performed. This association also led clinicians to believe that epididymitis was caused by either coliforms or Pseudomonas. However, in contrast to the adolescent, in one series of prepubertal children from Israel, epididymitis was often associated serologically with Mycoplasma, enterovirus and adenovirus. Surprisingly, no antibiotics were administered to 42 males in this series with acute epididymitis and a normal urinalysis. Each was treated only with ibuprofen and tight underclothing. (Oops, in our Case 2.) Remember also that orchitis does not usually cause a reactive hydrocele; is usually associated with mumps, parainfluenza and other viruses; and is not treated with antibiotics.

Take-home messages

As I stress to acolytes, always listen carefully to the mother in your office. Most have a sixth sense built into their system for serious or major problems with their child. More often than not, they will be right.

Doppler flow ultrasound is the definitive test of choice for the acute scrotum. But, rarely, the “appropriate diagnostic test” may not be the best initial course of action. You might be better off sending the “acute” child immediately to the surgeon.

Despite reasonable diagnostic information in children with a rare malady, you too might need calm reassurance from your expert surgeon or specialist as well.

Antibiotics are probably not necessary in a prepubertal child with uncomplicated epididymitis and a normal urinalysis. Treat instead with ibuprofen and restrictive underclothing (an athletic supporter for infants?).

For more information:

• Lau P, Anderson PA, Giacomantonio JM, Schwarz RD. Acute epididymitis in boys: are antibiotics indicated? Br J Urol. 1997;79:797-800.
• Mushtaq I, Fung M, Glasson MJ. ANZ J Surg. 2003;73:55-58.
• Likitnukul S, McCracken GH, Nelson JD, et al. Epididymitis in children and adolescents. A 20-year retrospective study. Am J Dis Child. 1987;141:41-44.
• Raheja R, Pantuck AJ, Fleisher MH. Is diagnosis of bacterial epididymitis by doppler scrotal ultrasonography misleading? Infect Urol. 2000;13:121-123.

• Stan L. Block, MD, has a pediatric practice in Bardstown, Ky., and is a member of the Infectious Diseases in Children Editorial Advisory Board.