Key points
- Testicular torsion is a surgical emergency – testis viability can diminish considerably six hours after symptom onset.
- A presumptive diagnosis of testicular torsion should be made promptly on history and examination alone.
- USS and bloods are not routinely required (may delay diagnosis and be falsely negative).
- All boys with acute scrotal pain, or unexplained abdominal pain, require a scrotal examination.
- Urgent surgical review is required if testicular torsion cannot be excluded or an alternate explanation for symptoms cannot be made.
- If no paediatric surgical service onsite, the first point of call for suspected testicular torsion cases should be the General Surgical or Urological services. If no onsite Surgical services, contact Retrieval Services Queensland (RSQ) to arrange urgent transfer.
Purpose
This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) with acute scrotal pain in Queensland.
This guideline has been developed by senior ED clinicians and Paediatricians across Queensland, with input from Paediatric Surgery, Queensland Children’s Hospital, Brisbane. It has been endorsed for use across Queensland by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.
Introduction
Acute scrotal pain is a common surgical emergency in boys. While it usually occurs in post-pubertal boys, it can be seen in a range of ages from neonates to young men. A number of diagnoses can present with acute scrotal pain including testicular torsion and irreducible inguinal hernia which require time-critical diagnosis to avoid permanent harm.
Emergent | Urgent | Other |
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Assessment
The primary aim of the assessment is to identify testicular torsion to enable emergent management. A standardised, rapid clinical evaluation with careful attention to the features on history and clinical examination can differentiate between the potential causes for acute scrotal pain.
History
History taking should include specific questioning on:
- pain including onset and location, referred pain
- systemic symptoms including nausea, vomiting, dizziness
- trauma
- urinary symptoms (sexual history in older males)
Keep in mind boys may be reluctant to volunteer scrotal symptoms because of embarrassment and reluctance to be examined.
Examination
Careful physical examination of the scrotum (with a chaperone) should focus on signs of testicular torsion.
Diagnosis
History | Examination |
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The presence or absence of a single sign cannot exclude testicular torsion. |
History | Examination |
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Condition | Clinical features |
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Scrotal trauma |
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Epididymo-orchitis (EDO) |
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Testicular tumours |
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Vasculitis |
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Condition | Description and epidemiology | Clinical features |
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Appendix testis torsion |
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Hydrocele |
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Varicocele |
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Idiopathic scrotal oedema |
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Referred pain |
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Investigations
Delays to detorsion increase the risk of testicular infarction.
Investigations (including scrotal USS) are NOT routinely required for presumptive testicular torsion
- pyuria on urinalysis does not exclude testicular torsion
- normal scrotal USS in boys does not exclude testicular torsion (80-85% sensitive)
- scrotal USS recommended only on specialist advice
If after clinical exam testicular torsion in deemed unlikely, other non-emergent diagnosis of acute scrotal pain may be considered.
Investigations for diagnosis of non-emergent conditions | |
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EDO |
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Scrotal trauma |
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Varicocele |
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*Polymerase chain reaction
Management
Testicular torsion
Resolution of torsion is usually required within six hours to avoid permanent harm.
Testis viability is directly related to the time to detorsion and the number of twists in the spermatic cord. Delays to diagnosis of testicular torsion (PDF) (access via QH intranet) have resulted in permanent harm.
Boys with presumptive testicular torsion require surgical exploration and, if necessary, orchidopexy. Testes may still be salvageable for up to 24 hours. The fastest treatment will always be onsite. The first point of call should be Paediatric surgical, General Surgical or Urological services. If no onsite Surgical services, contact RSQ to arrange urgent transfer to the nearest suitable facility. Patients >12 years old do not need a paediatric surgeon. (See position statement from the Royal Australasian College of Surgeons).
Urgent referral to the Surgical or Urological service (onsite or via RSQ) is required for the boys with presumptive testicular torsion or acute scrotal pain where testicular torsion is unable to be excluded.
Irreducible inguinal hernia
Boys with incarcerated inguinal hernia require urgent surgical review and reduction in theatre.
Immediate referral to Paediatric Surgical service is required for irreducible inguinal hernia.
Other diagnoses
The management for differential diagnoses is as follows:
- EDO – antibiotics as per local guidelines. May be IV or oral depending on the patient’s age, comorbidities and severity of illness. If complicated by abscess formation, consider referral to Surgical service for drainage.
- Varicocele – consider referral to Surgical service as may need surgical intervention, especially if causing pain, or impairing testicular growth.
- Hydrocele – most (90%) resolve by two years of age. Consider referral to Surgical service if persists past two years of age.
- Scrotal trauma – refer to Surgical service unless examination of the testis is normal and there is no evidence of significant scrotal swelling.
- Appendix testis torsion – if confirmed, can usually be managed with analgesia as an outpatient, although some boys with persisting pain or inflammation may require excision of the appendix testis.
Escalation and advice outside of ED
Clinicians can contact the services below to escalate the care of a paediatric patient as per local practices. Transfer is recommended if the child requires a higher level of care.
Pre-pubertal boys (8-12 years) and post-pubertal boys (greater than 12 years) presenting with presumptive testicular torsion do not routinely require treatment at a paediatric facility unless there are paediatric-specific concerns. Transfer may result in time-critical delays to surgery and a detrimental outcome for the patient. This is reinforced in the Position Paper “Surgery in Children” published by the Royal Australasian College of Surgeons.
Child requiring time-critical care
Diagnoses requiring time-critical care:
- confirmed or suspected testicular torsion
- irreducible inguinal hernia
Resolution of testicular torsion is usually required within SIX hours to avoid permanent harm.
Diagnosis | Contact |
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Possible testicular torsion | Onsite Paediatric Surgical/ General Surgical / Urology service as per local practice. If no onsite service, contact Retrieval Services Queensland (RSQ) on 1300 799 127 to coordinate urgent transfer for definitive care. RSQ (access via QH intranet) |
Irreducible inguinal hernia | Paediatric Surgical Service onsite or via Retrieval Services Queensland (RSQ). If no onsite service, contact Retrieval Services Queensland (RSQ) on 1300 799 127 to coordinate urgent transfer for definitive care. |
Child requiring non-time-critical care
Reason for contact | Who to contact |
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Advice (including management, disposition or follow-up) | Follow local practices. Options:
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Referral | First point of call is the onsite/local paediatric surgical service |
Inter-hospital transfers
Do I need a critical transfer? |
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Request a non-critical inter-hospital transfer |
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Non-critical transfer forms |
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Disposition
When to consider discharge from ED
Boys who have been assessed and have no evidence of serious surgical or infectious pathology can be safely discharged home. In these boys, 48-72 hours of rest, supportive underwear and NSAIDs will help decrease inflammation and pain. Oral hydration and the management of constipation (if present) are worthwhile to address the underlying cause.
On discharge, advise parents to seek medical attention (GP or ED) if pain is persisting or increasing.
Follow-up
- Not routinely required.
When to consider admission
Requirement for admission will be determined by the relevant specialist service.
Related documents
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- McBride, CA and Patel, B, (2017), ‘Acutely painful scrotum: Tips, traps, tricks and truths’, J Paediatr Child Health, 53:1054-1059.
- Srinivasan, A, et al, (2011), ‘History and physical examination findings predictive of testicular torsion: an attempt to promote clinical diagnosis by house staff’, J Pediatr Urol, 7(4):470-4.
- Bowlin, PR, Gatti, JM, Murphy, JP, (2017), ‘Pediatric Testicular Torsion’, Surg Clin N Am, 97:161-172.
- Jefferies, MT, et al, (2015), ‘The management of acute testicular pain in children and adolescents’, BMJ, 350:h1563.
- Sharp, VJ, Kieran, K., Arlen, AM, (2013), ‘Testicular Torsion: Diagnosis, Evaluation, and Management’, Am Fam Physician, 88(12):835-840.
- Heurn, L, Pakarinen, MP, Wester, T., (2014), ‘Contemporary management of abdominal surgical emergencies in infants and children’, BJS 101:e24-e33.
- Mellick, LB, (2011), ‘Torsion of the Testicle: It Is Time to Stop Tossing the Dice’, Pediatric Emergency Care 28(1):80-85.
- DaJusta, D, et al, (2013), ‘Contemporary Review of Testicular Torsion: New Concepts, Emerging Technologies and Potential Therapeutics’, J Pediatr Urol, 9(6):723-30.
- Drlik, M, Kocvara, R., (2013), ‘Torsion of spermatic cord in children: A review’, J Pediatr Urol 9(3):259-266.
- Royal Children’s Hospital, Melbourne, Australia, Clinical Practice Guideline on Acute Scrotal Pain or Swelling, Last Revised Feb 2017, cited Nov 2017, Available from: https://www.rch.org.au/clinicalguide/
- Patient Safety Communique No.6/2017. Testicular Torsion https://qheps.health.qld.gov.au/__data/assets/pdf_file/0022/1400278/psc-ttortion.pdf (PDF)
- Position Paper, “Surgery in Children” published by the Royal Australasian College of Surgeons https://umbraco.surgeons.org/media/1666/2017-05-04_pos_fes-pst-055_surgery_in_children.pdf (PDF)
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Document ID: CHQ-GDL-60001
Version number: 3.0
Supersedes: 2.0
Approval date: 01/06/2022
Effective date: 01/06/2022
Review date: 01/06/2026
Executive sponsor: Executive Director Medical Services
Author/custodian: Queensland Emergency Care Children Working Group
Applicable to: Queensland Health medical and nursing staff
Document source: Internal (QHEPS) + External
Authorisation: Executive Director Clinical Services
Keywords: Scrotal pain, testicular torsion, epididymo-orchitis, abdominal pain, paediatric, emergency, guideline, children, CHQ-GDL-60001
Accreditation references: NSQHS Standards (1-10): 1, 8
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This guideline is intended as a guide and provided for information purposes only. View full disclaimer.
Last updated: October 2023