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.

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

Investigations

If after clinical exam testicular torsion in deemed unlikely, other non-emergent diagnosis of acute scrotal pain may be considered.

*Polymerase chain reaction

Management

Testicular torsion

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.

Child requiring non-time-critical care

Inter-hospital transfers

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

• Patient Safety Communique No.6/2017. Testicular Torsion [PDF] (access via QH intranet)
• Position Paper “Surgery in Children” published by the Royal Australasian College of Surgeons [PDF]