Paediatric Testicular Pain

Differential

• Testicular torsion
• Torsion of testicular appendage
• Incarcerated hernia
• Epididymo-orchitis
• Testicular or epididymal rupture
• Hydrocoele
• Varicocoele
• Idiopathic scrotal oedema
• Tumour/leukaemia

Testicular torsion

• Peaks in neonates and adolescents age 13-16
• Presentation
  • Sudden onset unilateral testicular pain, usually constant
  • May follow minor trauma
  • Associated nausea and vomiting
  • In neonate – Painless, smooth testicular enlargement
• Examination
  • Discoloured hemiscrotum, very tender and swollen
  • High-riding and horizontal
  • Absent cremasteric reflex
  • Reactive hydrocoele may be evident
  • Impaired gait
  • Neonate – Does not transilluminate. Dark colour
  • 20% have fever

TWIST score

• Testicular swelling – 2 points
• Hard testicle – 2 points
• Absent cremasteric reflex – 1 point
• Nausea or vomiting – 1 point
• High-riding testicle – 1 point
• 0/7 = Not torsion (100% sensitive)
• 1-5 = Moderate risk  USS (35% risk of torsion)
• 6 or higher = High risk  Surgical exploration (66% risk of torsion)
  • Unless Tanner 1 or 2 may undergo USS first as less likely

TWIST score algorithm

Incarcerated hernia

• Presentation
  • Intermittent inguino-scrotal swelling
  • Pain ++
  • Worse with crying
  • If nausea and vomiting, consider bowel obstruction
• Strangulated hernia = impaired blood supply
• Incarcerated = Irreducible
• Examination
  • Firm, tender, irreducible inguinoscrotal swelling
• Reduction is necessary – surgical consult

Torsion hydatid

• Torsion of the testicular appendage
• Peaks age 11
• Difficult to distinguish from testicular torsion
• Presentation
  • 1-2 days gradual onset with focal tenderness and no nausea/vomiting
• Examination
  • Focally tender upper pole of testis
  • Testis itself is not tender
  • Blue dot sign – Necrotic appendage seen through skin
  • Reactive hydrocoele may be evident
• Surgical consult for exploration in most cases
• Conservative Rx with scrotal support, analgesia and ice usually relieves symptoms in 7-10 days

Epididymo-orchitis

• Very rare pre-puberty (unless underlying structural abnormality with recurrent UTI)
• Seen in adolescents with STI
• Presentation
  • Insidious, fever, urinary symptoms, urethral discharge
  • May have had recent instrumentation e.g. catheter
  • Mumps orchitis presents 4-6 days after parotitis
• Examination
  • Red, swollen hemiscrotum
  • Posterolateral testicular tenderness
  • Pyuria
  • Tenderness improves with testicular elevation
• Management
  • Urine first pass for MCS and PCR for STI
  • IV BenPEN 60mg/kg IV q6h + Gent 7mg/kg daily if unwell
  • PO bactrim 0.5mL/kg BD (8/40 mg/mL)
  • Slow to resolve

Testicular or epididymal rupture

• Scrotal trauma e.g. handlebars, saddle, sports
• Delayed onset scrotal pain and swelling
• Examination
  • Tender, swollen testis
  • Bruising
  • Oedema
  • Haematoma or haematocoele
• Surgical review in all testicular trauma unless testis clearly felt to be normal without significant tenderness

Hydrocoele

• Patent processus vaginalis with subsequent fluid accumulation
• 1-2% of boys born with this
• May fluctuate or be reducible
• Systemically well
• May be reactive to torsion, trauma, tumour or epididymitis
• Examination
  • Soft, non-tender, swelling adjacent to testicle
  • Testis normal and non-tender
  • Trans-illuminates
• Management
  • Resorb and tunica vaginalis closes in 90% by 2 yo
  • Consider surgical repair if present after 2 yo

Varicocoele

• Peripubertal males with abnormally enlarged spermatic cord veins
• Predominantly left-sided
• Bag of worms above testicle
• Non-tender
• More prominent with standing
• Refer to surgical OPD – consider OT if symptomatic or impaired testicular growth

Tumor/leukaemia

• Can be painful if rapidly growing, associated with haemorrhage or infarction
• Painless, unilateral, hard scrotal swelling
• Leukaemia infiltration may be bilateral
• Need high index of suspicion

Last Updated on November 9, 2021 by Andrew Crofton