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ISSN 0973 - 0958
Acute Swelling and Pain in Scrotal Region
Genital Problems in
Children
Absence of Testis from
Scrotum
Circumcision in Children
Acute Swelling and Pain
in Scrotal Region
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ACUTE SWELLING AND PAIN IN SCROTAL REGION
Testicular torsion - The cause is a congenital anomaly wherein, the testis after
descending into the scrotum is not fixed in place and is mobile.
The testis is free to rotate along its long axis - this in turn leads to a twisting
of the blood vessels of the testis and cutting off of the blood supply to the testis.
As this progresses, the total blood supply of the testis is cut off leading to gangrene or infarction of the testis. This makes the testis atrophy and loose all functions. The twists can be of various degrees i.e. 180 degrees, 360 degrees - thus it may be one full turn or 2 or more turns. Obviously, more the twists the faster the loss of blood supply. Additionally, the time interval from the occurrence of the torsion and its relief is also very important. If corrected within 6 hours - still about 10% of testis can loose their functions; this can increase to 90 % if the time interval goes more than 24 hours. This then is the reason for urgent intervention and untwisting of the torsion. This is also the reason for showing the proper doctor as soon as possible.
Epididymo orchitis (EO) - This is an infective inflammatory condition secondary to urinary infection. Retrograde infection from the urethra via the vas deferens to the epididymis and testis. The infection and subsequent inflammation lead to pain and swelling in the testicular region very similar to that in torsion. The infection could also have come to the epididymis from the normal blood flow. Rarely there may be an abnormal upper urinary tract anomaly and presents as epididymo orchitis.
Differntiating the two is very difficult clinically. However, a detailed history with a proper examination may help if the child allows. Usually, a small child with severe pain will scream just looking at the doctor and examination will not be possible very easily. Some of the things that may help during examination are - check if there is more swelling posteriorly with thickening of the epididymis, suggestive of EO. At times the pain is not very severe and gradually supporting and lifting the epididymis with the palm of the hand may give relief to the child again a sign of inflammation. Another clinical sign that may help is eliciting the Cremasteric reflex by stroking the medial side of the upper thigh. If this results in a positive reflex, the testis gets pulled upwards due to the contraction of the cremaster muscle, it means that the cremaster can function as it is not twisted. Thus, positive cremasteric reflex, usually rules out torsion. On the other hand absence of the reflex does not necessarily mean only torsion as the inflammation and edema due to the infection can temporarily make the cremaster inactive. Thus there is no active and definitive method of clinically differentiating one from the other.
There is one investigation that may help to a certain extent. A Color Doppler study for the blood supply to the testis will show no blood flow in case of Torsion but excess blood flow in EO. However, this is based on many factors like, the person doing the study (experience). The time from onset when the study is done, after 6-9 hours, there is an excess blood flow around the testicular region and could be mistaken for EO and the boy is conserved with poor result and the testis is atrophic and functionless later in life.
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