Introduction

Learning objectives

Recognize the typical presentation of testicular torsion in children and adolescents.
Differentiate testicular torsion from other causes of acute scrotum.
Understand why high clinical suspicion should not wait for an additional test.

Video lesson

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Video pending upload (embedded YouTube)

Summary

What is it?

Acute scrotum is a condition characterized by:

acute-onset scrotal pain;
swelling;
local inflammatory changes.

There are several causes, but there is one that the physician must recognize quickly.

Testicular torsion

Testicular torsion occurs when the spermatic cord twists on its axis and compromises blood flow to the testicle.

It is a time-dependent surgical emergency.

Typical presentation

severe pain of sudden onset;
nausea or vomiting;
high-riding testicle or abnormal position;
scrotal edema;
cremasteric reflex frequently absent.

No single finding completely excludes torsion.

Differential diagnoses

These include:

torsion of the testicular appendix;
epididymitis/epididymo-orchitis;
trauma;
incarcerated inguinal hernia;
scrotal edema;
other less common causes.

Doppler ultrasound

It can help assess testicular blood flow when there is diagnostic doubt.

But there is a fundamental rule: if clinical suspicion of torsion is high, an additional test must not delay surgical evaluation.

Why such urgency?

Because the chance of saving the testicle decreases as ischemia time increases.

⚠️ Alert

Child or adolescent + acute testicular pain = testicular torsion until quickly ruled out.

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Practical algorithm

Non-retractile foreskin in a young child, without scarring or complications → probably physiological → do not force.
Retracted foreskin that cannot be returned + edema → paraphimosis → emergency.
Testicle outside the scrotum after the first months of life → refer → do not wait years.
Painless, fluctuant scrotal swelling → consider communicating hydrocele.
Adolescent with varicocele → assess testicular development and volume.
Infant with fever without a source → consider urinary tract infection.
Recurrent febrile UTI → assess the need to investigate urinary anomalies/VUR.
Sudden testicular pain → urgently rule out testicular torsion.

In Pediatric Urology, the primary care physician does not need to resolve every condition: they need to distinguish the physiological from the pathological, and recognize when to observe, when to investigate, when to refer and, above all, when to act urgently.

Clinical case

Content pending upload Progressive clinical case focused on decision-making.

Self-assessment

Questions pending upload 5–10 multiple-choice questions on this lesson.

References

Links pending upload References to PubMed, DOI, scientific society guidelines and journals.

Pediatric acute scrotum