SCROTAL SWELLING AND

PAIN IN CHILDREN

Presented by
Dr munir suwalem
S.H.O
Peadiatric surgery
B.M.C
Benghazi - libya
 The Scrotum is a cutaneous pouch which
contains the testes and parts of the spermatic
cords. It is divided on its surface into two lateral
portions by a ridge or raph,

which is continued forward to the under surface of

the penis, and backward, along the middle line of
the perineum to the anus
the scrotum consists of two layers ,the outer layer
is integument and the inner layer is dartos
tunic, which divides the scrotal pouch into two
cavities for the testes,
 Vessels and Nerves.
The arteries supplying the coverings of the testes
are: the superficial and deep external pudendal
branches of the femoral, the superficial perineal
branch of the internal pudendal, and the cremasteric
branch from the inferior epigastric. The veins follow
the course of the corresponding arteries.
The lymphatics end in the inguinal lymph glands.
The nerves are the ilioinguinal and lumboinguinal
branches of the lumbar plexus, the two superficial
perineal branches of the internal pudendal nerve, and
the pudendal branch of the posterior femoral
cutaneous nerve.
 The function of the scrotum appears to be to
keep the temperature of the testes slightly
lower than that of the rest of the body.

the temperature should be one or two

degrees Celsius below body
temperature (around 37 degrees Celsius or
99 degrees Fahrenheit);

higher temperatures may be damaging

to sperm count.
CLASSIFICATION
scrotalswelling is usually
classified as:

Painful or painless

Acute or chronic
 Acute scrotal swelling with pain
Torsion of spermatic cord
Torsion of appendix testis

Acute epididymitis-orchitis

Trauma

Insect bite

Thrombosis of spermatic vein

Fat necrosis

inguinal Hernia(incarcerated)

Folliculitis

Henoch-Schnlein purpura
 Scrotal swelling without pain

Tumor

Idiopathic scrotal edema

Hydrocele

Inguinal
Hernia
Henoch-Schnlein purpura
 Chronic scrotal swelling

Hydrocele

InguinalHernia
Varicocele

Spermatocele

Sebaceous cyst

Tumor
EPIDEMIOLOGY
Prevalence

Inguinal
hernias and hydroceles are the
most common causes of scrotal swelling.

Testiculartorsion occurs in 1:4000 boys.

Varicoceles are present in 15% of male
adolescents and adults.
EPIDEMIOLOGY
Age
Hernias can occur at any age but are more
common in premature infants.
Testicular torsion most commonly occurs
between the ages of 12 and 18 years.
Idiopathic scrotal edema affects children < 14
years.
Acute inflammation of the epididymis or testis,
including mumps orchitis, can occur at any age
but is uncommon before adolescence.
Varicoceles are usually asymptomatic and are
usually detected between 10 and 15 years of
age.
MECHANISM
Acute scrotal swelling with pain
Torsion of the testicle
Twisting of the spermatic cord, with
resulting compromise of the blood supply
to the testis

Torsion of the appendix testis

When the appendix testis
torses, inflammation and swelling of the
testis and epididymis ensue, causing
testicular pain and scrotal erythema.
MECHANISM
Acute epididymitis-orchitis usually after UTI
Results from an anomaly of the urinary tract,
either congenital or acquired:

Renalduplications and posterior urethral valves

are among the more common anomalies.

Withintermittent catheterization, the condition

can occur from retrograde passage of bacteria
back from ejaculatory ducts at the level of the
prostate to the testis and epididymis.
 MECHANISM
Henoch-Schnlein purpura
Systemic vasculitis that can cause abdominal and
joint pain , May involve the scrotal wall in a minority
of cases
Trauma

A similar appearance can follow a difficult breech

delivery
Severe blunt trauma affecting the scrotal contents
Scrotal skin disease

Insect bites, folliculitis, and allergic dermatitis may

cause erythema and edema of the scrotal wall.
MECHANISM
Scrotal swelling without pain
Hernias and hydroceles
Most are caused by persistent patency of the
processus vaginalis
Layers of the processus vaginalis condense
late in gestation or early postnatally.
Obliteration of the processus vaginalis only
around the testis leads to an indirect inguinal
hernia with protrusion of fluid (or other contents)
through the internal ring to the end of the pouch
and potentially to the scrotum.
MECHANISM

Communicating hydrocele occurs when fluid

travels through a processus vaginalis into the
tunica vaginalis around the testis.

Scrotal hydrocele occurs after complete

obliteration proximally with patency distally.

Hydroceles of the cord occur when the

processus vaginalis obliterates proximally and
distally, leaving a patent area in the midportion
with retained fluid.
MECHANISM
Varicoceles

A predilection for the left side exists,

reflecting anatomy of the left gonadal vein
entering the left renal vein at a right
angle.

The right gonadal vein enters the vena

cava directly at an angle, precluding
reflux of venous blood.
HISTORY
Acute scrotal swelling with pain
Torsion of the testicle

Acute onset of constant, severe scrotal pain

aggravated by physical activity
Nausea and vomiting may occur.
Possible history of incidental antecedent scrotal
trauma, but pain usually occurs during rest or
sleep
Neonatal testicular torsion Can exhibit at
delivery as a nontender hard scrotal mass
HISTORY
Torsion of the appendix testis
Onset of pain and swelling is commonly acute but
can be progressive, usually occurring during rest.
Pain can be severe, but nausea and vomiting are
less common than with testicular torsion.
Acute epididymitis-orchitis

History can reveal acute or more protracted onset

of pain.
The patient may have fever or dysuria or pyuria
Epididymal inflammation may arise after scrotal
trauma.
HISTORY
Henoch-Schnlein purpura
Onset may be insidious or acute, producing a
variable degree of erythema and edema.
In more severe cases, the process may involve
the testis and epididymis, mimicking testicular
torsion.

Focalfat necrosis
Can exhibit with scrotal pain and swelling,
usually after trauma in an obese boy
HISTORY
Trauma

History (eg, injury from zipper entrapment of

scrotal skin) can be definitive.

Mumps orchitis
Rarely occurs in isolation; pain and swelling
usually occur within a week after parotitis.

Scrotalskin disease
History may be of limited utility.
HISTORY
Scrotal swelling without pain
Inguinalhernias and hydroceles
Hernia
Swelling expands with increases in
intraabdominal pressure (eg, crying,
bowel movements, coughing).
The parent or child often reports the
swelling to be smallest in the morning
and largest late in the day.
HISTORY
Hydrocele Whether the hydrocele is acute or
whether the scrotum has been chronically
enlarged is often unclear.

The patient may have a history of trauma to the

scrotum that stimulates production of serous
fluid.

Whenthe scrotum changes size during the day,

suspect a communicating hydrocele.
 HISTORY
Tumors

Usually present as a hard, painless mass (or vague

heavy feeling) in the testicle detected by the
child, parent, or examining physician

Spermatoceles and epididymal cysts

Painless and round, they usually remain stable in
size but can sometimes enlarge.
 PHYSICAL EXAM
Acute scrotal swelling with pain
Torsion of the testicle
Scrotal erythema
Swelling of the involved hemiscrotum
Higher-than-normal position of the testis within the scrotum
Palpation may show a horizontal rather than normal vertical
orientation of the testicle.
Evaluation of the cremasteric reflex should begin on the
contralateral side; palpate the apparently unaffected testis to
confirm normal size and position.
Unilateral loss of the cremasteric reflex on the side of the
swelling and pain highly correlates with the presence of
torsion.
 PHYSICAL EXAM
The testis should then be palpated.
Despite the pain this maneuver may cause, it
helps differentiate torsion from epididymitis.
Actual point of torsion of the spermatic cord can
sometimes be palpated.
Associated hydrocele may be palpated and
confirmed by transillumination.
 PHYSICAL EXAM
torsion of the appendix testis May demonstrate
hemiscrotal erythema and swelling
A blue-dot sign, if the necrotic appendage visible
through the scrotal skin, can help make the diagnosis.
A normal cremasteric reflex is present bilaterally, and
the testis is normally positioned within the scrotum.
Testicular discomfort, if present, is typically mild, but
point tenderness may be elicited from uppermost pole
of the testis near the head of the epididymis.
PHYSICAL EXAM
Acute epididymitis-orchitis Scrotal erythema
and swelling are present, along with an intact
cremasteric reflex.
Palpation during early phase of the
inflammatory process demonstrates tenderness
limited to the epididymis.
In the later phase, tenderness and inflammation
include both epididymis and testis, and the
distinction between the 2 structures may be
difficult to appreciate.
The Prehn sign (relief of pain with testicular
elevation) may be positive.
 PHYSICAL EXAM
Trauma

Examination must include both hemiscrotums and

surrounding structures (penis, perineum), assessing
for swelling, ecchymosis, and bleeding.
Tenderness may be limited to testis or
epididymis, depending on extent of trauma.
Mumps orchitis

Tender testis
Scrotal skin disease

Redness and edema limited to scrotum, with normal

testicle and spermatic cord
 PHYSICAL EXAM
Scrotal swelling without pain
Inguinalhernias and hydroceles
Feel for the testis first and keep it in mind
during the rest of the examination.
Avoid confusing testis with contents of an
incarcerated hernia.
 PHYSICAL EXAM
Hernia
A bulge in the inguinal region with fluid that can be

gently reduced back into the abdomen is diagnostic

of an inguinal hernia.
In the cooperative child who can increase his

intraabdominal pressure, this procedure may be

repeatedly shown, particularly with the child
standing.
Presence of thickened spermatic cord or silk-

stocking sign (the feel of the layers of the processus

vaginalis being rubbed against each other) suggests
patency of the processus vaginalis or a hernia.
PHYSICAL EXAM
Hydrocele When fluid is limited to the testis
and spermatic cord can be palpated above
the fluid, a hydrocele is present.

Hydrocele of the spermatic cord feels

distinct from the testis and is round or ovoid,
possibly mimicking the presence of an
additional testis.

Hydroceles (communicating, scrotal, or of

the cord) are rarely associated with
tenderness on palpation
 PHYSICAL EXAM
Tumors

On palpation, mass is harder than the substance of

the testis, but this distinction may be difficult to
discern.
Mass may bulge from surface of the testis.

Spermatoceles and epididymal cysts

Separate from the testis and can be transilluminated
Torsion of Sudden onset testicular Discolouration of scrotum;
the testis pain and swelling; exquisitely tender testis,
occasionally nausea, riding high
vomiting. Note: pain may
be in the iliac fossa

Torsion of More gradual onset of Focal tenderness at upper

(hydatid of testicular pain pole of testis; "blue dot" sign
Morgagni) necrotic appendix seen
through scrotal skin

Epididymo Onset may be insidious; Red, tender, swollen

orchitis fever, vomiting, urinary hemiscrotum; tenderness
symptoms; rare in pre- most marked posteriolateral
pubertal boys, unless to testis. Pyuria may be
underlying genitourinary present.
anomaly, when
associated with UTI.
Incarcerat History of intermittent Firm, tender,
ed inguinoscrotal bulge, irreducible,
inguinal with associated inguinoscrotal
hernia irritability swelling

Idiopathic Swelling noted but Bland violaceous

scrotal child not distressed oedema of scrotum,
oedema extending into
perineum + penis;
testes not tender
Hydrocele Swollen hemiscrotum Soft, non-tender
in well, settled baby swelling adjacent to
testis;
transilluminates
 Henoch Painful scrotal oedema, may be difficult to
Schonlein with purpuric rash over distinguish from testicular
purpura scrotum. May have torsion in absence of other
associated vasculitic features
rash of buttocks and
lower limbs, arthritis,
abdominal pain with GI
bleeding, and nephritis

Testicular or Scrotal trauma eg. Tender swollen testis.

epididymis straddle injury, bicycle Bruising, oedema,
rupture handlebars, sports haematoma, or
injury. Delayed onset of haematocele may be
scrotal pain and present.
swelling.
LABORATORY EVALUATION
Urinalysis may help distinguish orchitis from
torsion of the spermatic cord or testicular
appendage when leukocytes or nitrites are
present.
Acute scrotal swelling with pain

Torsion of the testicle

Urinalysis is unremarkable.

Although the leukocytes count may be mildly

elevated, it is not discriminating.

LABORATORY EVALUATION
Acute epididymitis-orchitis
Urinalysis may prove positive for
leukocytes and nitrite but is often
unremarkable among adolescents.
The leukocyte count is usually elevated
LABORATORY EVALUATION
Scrotal swelling without pain
Inguinalhernias and hydroceles
Laboratory tests are useful only for
incarcerated inguinal hernias, with an
elevated leukocyte count and possible
acidosis.
Tumors

Preoperative tumor markers (-

fetoprotein, -human chorionic
gonadotropin) should be measured and
used for postoperative monitoring.
IMAGING
Acute scrotal swelling with pain
Torsionof the testicle
Imaging by Doppler ultrasonography or
nuclear scintigraphy should be done if the
diagnosis of testicular torsion is in
question.
Perform imaging only when it will not
delay surgical exploration if torsion exists,
adding to the risk of testicular loss.
IMAGING
Torsion of the appendix testis
If an inflammatory process resulting from
torsion of the appendage makes
differentiation from true spermatic cord
torsion impossible, imaging may be
helpful.
Scrotal Doppler ultrasonography or
nuclear scintigraphy will show normal or
increased flow to ipsilateral testis.
IMAGING
Acute epididymitis-orchitis
Ultrasonography and nuclear scintigraphy
show normal symmetric blood flow or
increased blood flow to an enlarged
epididymis or testis.
Voiding cystourethrography has been a
routine part of the evaluation, but its yield is
low with a normal ultrasound and a sterile
urine.
IMAGING

Trauma

Scrotal ultrasonography can document the

integrity of the testis and of the tunica
albuginea and the adequacy of blood flow.
IMAGING
Scrotal swelling without pain
Ultrasonography can determine cystic or
solid nature of a tense scrotal mass (eg,
hydrocele, tumor) or spermaticoInguinal
hernias and hydroceles
Ultrasonography can delineate scrotal
contents, especially when a large or tense
hydrocele limits physical examination of
mass (eg, hydrocele of the cord,
paratesticular tumor).
IMAGING
Tumors

Scrotal ultrasonography is used to

delineate the mass.

Varicoceles

Testicular size, most accurately assessed

by ultrasonography, should be measured;
significant loss of testicular volume is an
indication for surgery.
TREATMENT
Acute scrotal swelling with pain
Torsion of the testicle
Surgical intervention is indicated not only
when testicular torsion is strongly
suspected, but also in equivocal cases
when torsion cannot be convincingly
excluded.
The likelihood of salvaging the testis is
highest when surgery is done shortly after
onset of pain.
TREATMENT
With surgery, first explore the affected testis, and,
when torsion is present, detorse the cord.
Explore the contralateral testis (will have the same
defect in anatomy) and fix it in place to avert a
future torsion.
If the testis can be saved, fix it in the scrotum.
TREATMENT
Torsion of appendix testis Management is
nonsurgical.
The patient should rest and use
nonsteroidal pain relievers and cold
compresses for several days to reduce
inflammation, swelling, and pain.
Surgical intervention is indicated only when
acute testicular torsion cannot be excluded.
In these cases, the infarcted appendage
is removed at surgical exploration.
TREATMENT
Acute epididymitis-orchitis Treat with
antibiotics based on the results of the urine
culture and sensitivities.
Anti inflammatory agents, scrotal elevation,
and rest should be prescribed.
TREATMENT
Trauma

Testicular or spermatic cord contusions:

Manage symptomatically.
Testicular rupture requires surgical
exploration, evacuation of the hematoma,
debridement, and repair (when possible).
Mumps orchitis

Treatment is symptomatic.
TREATMENT
Scrotal swelling without pain
Inguinal hernias and hydroceles
Repair on diagnosis to prevent incarceration ,
Perform surgery inguinally; isolate the sac from
the cord structures and ligate it at the level of the
internal ring.
Inspect the contralateral ring using diagnostic
laparoscopy through the isolated ipsilateral sac.
If the internal ring is open, proceed with
contralateral surgical correction.
If the hydrocele is painful, then surgery should
proceed sooner.
TREATMENT
Tumors Perform radical orchidectomy through an
inguinal approach.
If the mass is not suspicious for cancer, a possible
approach is to enucleate the mass and proceed
with orchidectomy only if the frozen section is
positive.

Spermatoceles and epididymal cysts Management

typically is observation.

Surgerymay be indicated when pain or significant

enlargement is present.
 PROGNOSIS
Acute scrotal swelling with pain
Torsion of the testicle
Spermatogenesis may be compromised after 46
hours of ischemia.
Testicular salvage is time dependent, with universal
loss of the testis after 24 hours of torsion.

Neonatal testicular torsion

Neonatal testicular torsion can exhibit at delivery as a
nontender hard scrotal mass.
Salvage in these cases is rare.

.
 PROGNOSIS

Mumps orchitis
Infertility may occur when the condition results in
atrophy of both testicles.
Scrotal swelling without pain
hydroceles

Most hydroceles resolve spontaneously by 1 year

and should be repaired if they persist beyond this
age.