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Scrotal pain and testicular torsion

Why do doctors say that scrotal pain, particularly in a child, is an emergency? What is testicular torsion? Read on to find out more.

What is testicular torsion?

Most boys are born with two balls, or two testes, in one scrotal sac.

Each testis is supplied by its own nerves and blood vessels.

In testicular torsion, the attachments and blood vessels one or both of the testes can twist on themselves.

Because the testis has an impaired blood supply, a boy with torsion can feel a lot of pain. Sometimes this pain also comes with nausea, vomiting, and difficulty walking due to pain of the scrotum and groin.

Eventually, if the testis supply continues to be twisted, unfortunately, the testis can become “nonviable.”

In short, if the problem is not corrected, a child may lose a testis.

How soon should a child with torsion be seen by a doctor?

The short answer: as soon as possible.

The long answer: many studies suggest that the longer a testis supply is twisted, the more damage the testis can have.

Most doctors agree that after six hours from the time the symptoms started, a twisted or “torted” testis becomes less and less likely to recover from this damage.

This is why parents and caregivers should bring a child with scrotal pain to the emergency room at once, where they can be quickly assessed.

What happens as part of the assessment?

The doctors in the emergency room will make sure first the child is stable.

They will also ask the child to stop eating or drinking, just in case they need to prepare for a possible surgery.

They will examine the child’s testis and scrotum.

Many times, the physical examination is convincing enough for a torsion. Then, a pediatric urologist or pediatric surgeon is called in and may or may not decide to bring the patient to the operating room, even without further testing, because time is of the essence.

Sometimes, if there is uncertainty about the problem, the physician may order an emergency ultrasound of the scrotum and testis. This checks whether there is any remaining blood supply in the torted testis.

This ultrasound also allows the doctors to check other potential causes of scrotal pain.

What other causes can there be?

Physical examination, ultrasound, or both can help doctors to identify different causes of pain in the testis or scrotum.

These include:

Infection of inflammation the testis (orchitis)
Infection or inflammation of the tubes of the testis, or epididymis (epididymitis). Orchitis and epididymitis can occur together.
Torsion of the appendix testis (see below).
A hernia or hydrocele, where fluid, fat, or bowel loops from inside the abdomen can abnormally come into the groin.
Intermittent torsion, where a torted testis has untwisted by itself, but may twist again.
Tumors of the groin or testis.

If there is a testicular torsion, what surgery needs to be done?

The pediatric urologist or pediatric surgeon will bring the patient to the operating room.

While the child is asleep, the doctors may already attempt to untwist the testis.

Whether or not the testis is untwisted this way, it is still recommended that an “exploration” of the scrotum is done. This means that a cut is made into the scrotum or the groin, and the testis is brought out to be examined, and untwisted further if needed.

At this point, the surgeon will have to decide if the testis is “salvageable” or can be saved, or if the testis is no longer viable, and should be removed.

If the testis can be saved, a procedure called an “orchidopexy” or “orchiopexy” is done. This means that a stitch is placed to “fix” the testis in place so that it will no longer twist in the future.

In many cases, the doctor will also consider doing an “orchidopexy” of the other testis, which also helps to avoid future testicular torsion on the other side.

Typically, the procedure is relatively short. The patient is awoken after the procedure, and if all is well, may even be discharged on the same day.

What if the testis can’t be saved?

If the testis cannot be saved, an “orchiectomy” happens.

This means that the testis is surgically removed.

While an attempt to save the testis is made as much as possible, sometimes, if the testis is clearly not viable or “alive”, it is better to remove it so as to avoid infection or the formation of an “abscess” or pus.

Is it okay for my child to have only one testis?

Most of the time, if the remaining testis is healthy, a child can still do very well with just one testis.

This means that the functions of the testis, including fertility and producing hormones, can be well undertaken by just one testis.

In the long term your child’s primary provider or pediatrician will continue to observe their progress through puberty. If puberty proceeds as planned and the child is otherwise normal, no further urology consultation is needed.

A child with only one testis will need to be extra careful to wear protective gear if they undertake activities with more risk of injuring the testis, like contact sports.

What is a torsion of the appendix testis?

This condition sounds very similar to a testicular torsion, and even mimics it.

However, breathe easy: a torsion of the appendix testis, while it may cause pain, does not require surgery.

The appendix testis is a vestigial part of male reproductive organs. It is also located in the scrotum. Sometimes, this tiny structure also twists it on itself and can lose its blood supply.

However, because it does not serve a known purpose, it does not have to be emergently saved.

However, because a testicular torsion and torsion of the appendix testis can be hard to differentiate at home, any episode of scrotal pain should still be checked as soon as possible in the emergency room.

If the diagnosis of torsion of the appendix testis is made, most children will be sent home with pain killers and other soothing measures like compresses and scrotal supports. The pain will self-resolve.

Image source here.

The information in this infographic is for general information purposes only.

We encourage you to seek an individualized consult for the most appropriate management. You may book an appointment with us or with your preferred pediatric urologist or pediatric surgeon.

Please feel free to send us a message for questions on pediatric urologic health!