Adolescent Urology: Acute Scrotum, Varicoceles, and Delayed Puberty

Bruce J. Schlomer

I. ACUTE SCROTUM

Acute scrotum is defined by clinical presentation involving acute onset of scrotal pain and can include scrotal swelling, abnormal testis examination such as hardness or abnormal lie, or tenderness on examination of scrotal contents. The differential diagnosis for acute scrotum is quite broad. The most common diagnoses include torsion of the appendix testis, testicular torsion, and bacterial epididymitis (Table 17-1). The keys to correct diagnosis are clues in history, age of patient, physical examination, urine analysis findings, and scrotal ultrasound if needed.

A. Torsion of Appendix Testis or Epididymis

Torsion of the appendix testis or appendix epididymis typically presents in childhood before puberty and is the most common cause for acute scrotum in prepubertal males (Fig. 17-1). The pain can come on gradually but also can present rather acutely. On examination, the affected side typically has moderate to severe tenderness; inflammation or induration in epididymis can be appreciated along with tenderness localizing to epididymis; and the testis/epididymis can become very swollen and hard with overlying reddish change to the skin. The “blue dot” sign, which is not commonly seen, describes a dark-colored area or dot near the upper pole of the testis, which corresponds to the appendix testis or epididymis that has torsed.

Scrotal ultrasound typically shows increased vascular flow to the epididymis and occasionally an avascular area near the epididymis which is the torsed appendix. A urine analysis is normal. A diagnosis of “epididymitis” is often assigned based on ultrasound findings. While there is inflammation in the epididymis, this is not a bacterial infection. Pain and induration typically improve over 2 to 4 weeks and treatment is supportive with ibuprofen, limiting activity, and ice packs if needed.

B. Testicular Torsion

Testicular torsion most commonly presents in the neonatal period or peripubertal period. Neonatal testicular torsion typically presents at birth with a swollen, red, and hard scrotum. The pathology is extravaginal torsion of the spermatic cord. Management is somewhat controversial but options include immediate orchiectomy and contralateral orchiopexy, delayed contralateral orchiopexy, and observation. Asynchronous contralateral extravaginal torsion in the neonatal period is very rare, but the effects are devastating and this often drives families and urologists to proceed with immediate orchiectomy and contralateral orchiopexy.

The most common type of testicular torsion is intravaginal torsion. This type of testis torsion is the most common cause for acute scrotum in the peripubertal age range. The pathology involves twisting of the
spermatic cord inside the tunica vaginalis and resultant ischemia to the testis. A bell-clapper deformity predisposes to intravaginal testicular torsion and may be present bilaterally. Presenting symptoms and signs include acute scrotal pain, very tender testis, abnormal lie or high-riding testis, hard testis, absent cremasteric reflex, nausea/vomiting, and scrotal swelling.

TABLE 17-1 Distinguishing Testicular Torsion from Epididymitis

	Testicular Torsion	Epididymitis
Incidence	Accounts for 50-60% of acute scrotum cases in adolescents and 25% to 30% of cases in all pediatric patients.	Accounts for 20% of acute scrotum cases in adolescents, and less than 1% in prepubertal boys.
History	Acute onset of scrotal pain. The patient can usually state the exact time the pain began. Patients may or may not be sexually active. Urethral discharge usually not present. Usually not associated with voiding complaints. Nausea and vomiting are often present.	Gradual onset of pain. Patients are usually sexually active. Urethral discharge may be present: thin and watery suggests chlamydia; thick and purulent suggests gonorrhea. Dysuria may be present.
Physical Examination	Patients appear uncomfortable and in distress. High-riding testis. Absence of cremasteric reflex is usually found. Testis is hard and can be swollen. Overlying edema and scrotal redness suggests longer course of torsion.	Early: An enlarged and tender epididymis that is distinct from testis. Later: Entire testis and epididymis swollen and tender. No distinction between epididymis and testis. Most adolescents present later making it difficult to distinguish epididymitis from testis torsion.
Laboratory	Urinalysis negative. Scrotal ultrasound with absence of blood flow to testis. Heterogeneous parenchyma suggests longer-standing torsion.	Urinalysis usually reveals numerous leukocytes. Nucleic acid amplification tests positive for gonorrhea or chlamydia. Scrotal ultrasound with hyperemia of epididymis and testis

The diagnosis of testicular torsion should be highly suspected in a peripubertal male with acute scrotal pain and some or all of the other findings. An ultrasound is usually obtained to confirm the diagnosis with high sensitivity and specificity. If the diagnosis is highly suspected, the patient should be taken to surgery without allowing any delay for an ultrasound. However, many centers can obtain an ultrasound very rapidly and confirm the diagnosis without significant delay.

FIG. 17-1 Location of appendix testis and appendix epididymis.

The treatment for testis torsion in peripubertal period is emergent scrotal exploration, detorsion of testis, contralateral orchiopexy, and either ipsilateral orchiopexy or orchiectomy depending on viability of testis. Manual detorsion can be attempted to relieve ischemia but is not reliably successful. Rotating the testis laterally (opening a book) is initially recommended or under ultrasound guidance (Fig. 17-2). After around 6 hours of torsion, the risk for nonviability or subsequent testis atrophy increases significantly and after 24 hours, the risk for complete atrophy is 100% and orchiectomy is typically recommended. The decision to perform orchiectomy depends on how long the torsion has been present, intraoperative appearance of testis, and preoperative discussions with the family and patient. If the testis has a dark purple or black appearance that does not improve within 30 minutes of being detorsed, or there is no significant intraparenchymal blood flow on intraoperative Doppler ultrasound, or there is no significant intraparenchymal blood flow if the testis is incised, then orchiectomy is recommended.

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