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  • Acute scrotal pain is usually caused by testicular torsion, epididymitis, or torsion of the appendix testis.
  • Testicular torsion is the most serious common cause of acute scrotal pain in children. Pain is abrupt and severe. Prompt urologic consultation must be obtained in each case.
  • Torsion of an appendix is usually less severe and localized.
  • Epididymitis is caused by urinary tract infections in young children and by sexually transmitted disease in older children and adolescents. Antibiotic treatment is based on age and presentation.
  • Color Doppler ultrasound is the diagnostic test of choice for evaluation of the acute scrotum.
  • A genitourinary examination should be performed on all children with abdominal or genitourinary complaints, as signs and symptoms may be nonspecific and abdominal pain may be caused by testicular torsion, inguinal hernia, epididymitis, and, rarely, testicular tumor.
  • The emergency department can reduce up to 95% of inguinal hernias.
  • Varicoceles are generally benign and most are left sided; however, persistent scrotal swelling and a “bag of worms” appearance indicates possible obstruction from tumor.
  • With normal growth and stretching of the prepuce, it will become retractable in 90% of children by the age of 6 years.
  • The evaluation of children with paraphimosis must begin by establishing that the children have not been circumcised and by eliminating the possibility of hair tourniquet syndrome. Treatment is manual reduction of the prepuce over the glans penis.
  • Priapism can be divided into two mechanisms: low flow or ischemic as in sickle cell vasoocclusion and high flow or engorgement.


Acute scrotal pain and swelling in children has many causes; in most cases the emergency physician (EP) can determine the etiology by the history and physical examination and by considering the age of the patient. Scrotal swelling may be painful or painless (Table 82–1). The most common diagnoses for an acute scrotum are testicular torsion, torsion of the appendix testis or epididymis, and epididymitis. In all cases, the possibility of a surgical emergency must be considered and the evaluation and management must proceed accordingly. Color Doppler ultrasound is the examination of choice for imaging scrotal pathology.

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Table 82-1. Causes of Scrotal Swelling in Children

Testicular Torsion


Testicular torsion can occur anytime from infancy to adulthood. Its incidence is bimodal, first in the neonatal period and with peak incidence in adolescence.1,2 Torsion of the testes is a urologic emergency and results in a significant amount of legal action against EPs for missed diagnosis. The EP must suspect this diagnosis in any child with complaint of scrotal pain ...

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