Acute Scrotal/Testicular Pain (6 mo - 18 years)

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Acute Scrotal/Testicular Pain (6 mo - 18 years)

Morphine 0.1 mg/kg IV

Consider urology consult

Severe pain?

Signs of incarceration?

Urology referral

Follow up with PMD, NSAIDs

Urology consult

Follow up with PMD, NSAIDs

Ceftriaxone injection
Azithromycin tabs

Note: Testicular torsion may be intermittent and a negative US, but with worrisome clinical findings should prompt further evaluation.


Follow up with PMD, NSAIDs, Evaluation of urine culture

  1. Epididymis
  2. Head of epididymis
  3. Lobules of epididymis
  4. Body of epididymis
  5. Tail of epididymis
  6. Duct of epididymis
  7. Deferent duct (vas deferens)

High risk of testicular torsion?

Hours to Surgical Detorsion

Testicular Salvage







> 24

< 1%

Off pathway, treat appropriately

Ongoing pain > 1 week?

Goal: Testicular torsion to OR in ≤ 4 hours from onset pain

NPO Diet
  • Emergent urology consultation and operative reduction
  • Consider manual detorsion if emergent surgical intervention is not rapidly available

Urinalysis With Microscopic & Reflex To Culture
Urine Culture
  • Follow up with PMD
  • Rest
  • Scrotal support

High Risk Testicular Torsion

  • Abnormal testicle location (horizontal, high riding)
  • Cremasteric reflex absent
  • Moderate to severe pain
  • Post-pubertal patient
  • Nausea/vomiting

US Testicular W Color Flow Complete - Indication: R/O Torsion

Manual Detorsion

  • Rotate the testicle outward towards the thigh 1-2 rotations
  • Assess for pain relief (should be immediate)
  • If no relief, rotate the testicle 1-2 rotations in the opposite direction ('Non-classical' lateral rotation can occur in up to 1/3rd of patients)

Cremasteric reflex

  • Stroking the upper thigh while observing the testis (ipsilateral) - in normal patients there is elevation of the testis
  • Consistant in boys 30 mo - 12 years, less so in infants and teenagers
  • Usually absent in patients with testicular torsion

Prehn sign

  • Elevation of the scrotal contents relieves pain
  • Associated with epididymitis with little to no effect in testicular torsion
  • Poorly reliable

Inclusion Criteria
  • Acute constant or intermittent scrotal/testicular pain
Exclusion Criteria
  • Traumatic injury
  • History of complex urology surgery/abnormalities
  • Painless scrotal swelling

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