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Introduction

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Acute scrotal pain in infancy and adolescence should be regarded as torsion of the testis until proved otherwise.

Text, page 1218

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Scrotal pain in males can occur in all age groups but the child or adolescent with acute scrotal pain often poses a diagnostic challenge. Serious problems include testicular torsion, strangulation of an inguinoscrotal hernia, a testicular tumour and a haematocele, all of which require surgical intervention.

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Key facts and checkpoints

  • Torsion of the testis is not the most common cause of acute scrotal pain in childhood and adolescence, but it is the most important.1

  • Torsion is also a feature of young men younger than 25 years.

  • Testicular pain can be referred to the abdomen.

  • Torsion of the testis should form part of the differential diagnosis in a boy or young man who is vomiting and has intense pain in the lower abdominal quadrant inguinal region.

  • The loss of a testicle from torsion, an avoidable problem, is a real ‘time bomb’ and a common reason for litigation for medical negligence.

  • The clinical picture of epididymo-orchitis can mimic torsion of the testis so closely that in most boys and young men the diagnosis should be made only at surgical exploration.1

  • An abnormality predisposing to torsion of the testis is usually present bilaterally; the opposite testis should also be fixed to prevent torsion (orchidopexy).

  • Torsion must be corrected as soon as possible to reduce the chance of gangrene and loss of the testis.

  • Suspect self-correcting testicular torsion in repeated episodes of severe spontaneously resolving pain. Refer for possible orchidopexy.

  • Suspect abscess formation if epididymo-orchitis does not settle with a reasonable course of antibiotics. Surgical drainage may be necessary.

  • A varicocele can cause testicular discomfort—examine the patient in the standing position.

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The clinical approach

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History

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It is important to determine whether there were any pre-existing predisposing factors or history of trauma.

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Key questions

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  • Have you noticed any burning of urine or penile discharge?

  • Have you had an injury to your scrotal region such as being struck by a baseball, cricket ball or falling astride something?

  • Have you travelled overseas recently?

  • Have you been aware of a lump in your testicle or groin?

  • Have you had an illness lately and have you noticed swelling of the glands in your neck or near your ear (i.e. screening for mumps)?

  • Do you have back pain or have you injured your back?

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Examination

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Both sides of the scrotum must be examined and contrasted. Inguinal and femoral hernial orifices, the spermatic cord, testis and epididymis must be checked on both sides. The size, lie and elevation in the scrotum of the testis should be assessed, as should the cremasteric reflex. This is done by stroking or pinching the medial thigh, and considered positive if the testicle ...

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