Unilateral acute scrotal pain and inflammation in the child

Specialty: Pediatrics.

• Acute infantile scrotum
• suspected testicular torsion
• acute testicular pain in the boy

Why it occurs

• Torsion of the spermatic cord or testicular torsion (absolute urological surgical emergency due to the rotation of the testicle on its axis with strangulation of its blood vascular flow, more common in puberty and the neonatal period)
• Torsion of the hydatid of Morgagni or the testicular appendix (most common cause of acute scrotum in children from 2 to 10 years old, due to the torsion of an embryological remnant, with a benign and self-limiting course)
• Acute orchiepididymitis (infection or inflammation of the testicle and epididymis, secondary to bacterial pathogens, viruses such as mumps/paramyxovirus, or reflux of sterile urine, more common in sexually active adolescents or children with urinary tract anomalies)
• Henoch-Schönlein purpura or IgA vasculitis (can present with inflammation, erythema and bilateral or unilateral scrotal pain due to vasculitis of the testicular vessels)
• Incarcerated inguinal hernia or complicated tension hydrocele.

Initial workup

Meticulous clinical diagnosis is a priority. If the suspicion of testicular torsion is high, the patient should be immediately referred to the operating room for surgical exploration without delaying the intervention to perform imaging tests, since the testicular viability time is less than 6 hours. Urgent scrotal Doppler ultrasound (the highly sensitive study of choice to evaluate testicular anatomy, detect the presence or complete absence of intratesticular blood flow, visualize the "swirl sign" in the spermatic cord, or identify the painful and hyperemic point of the tortured hydatid with the "blue dot" sign). Systematic urine analysis and urine culture if associated epididymitis is suspected.

Standard management

• The definitive treatment of testicular torsion is surgical detorsion and urgent bilateral orchidopexy. Preoperative systemic analgesic management with Fentanyl — dose of 1 to 2 mcg/kg IV) or Metamizole sodium (dose of 20 mg/kg slow IV
• Ibuprofen — Anti-inflammatory indicated in the conservative treatment of Morgagni hydatid torsion once unequivocally confirmed by Doppler; dose of 10 mg/kg orally every 6-8 hours
• Ceftriaxone plus Doxycycline (antibiotherapy indicated if epididymitis of bacterial origin/sexually transmitted infection is confirmed in adolescents; ceftriaxone at a single dose of 250-500 mg IM; doxycycline at a dose of 100 mg orally twice a day for 10-14 days).