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Acute scrotal swelling

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    Beware the facts that everybody knows. Everybody knows, for instance, and paediatric textbooks confirm, that epididymitis is rare in children. Several case series, however, have suggested that this may not be true.

    In Salt Lake City, USA 64 of 90 boys with acute scrotal pain or swelling had epididymitis and 50 of the 64 were under 12 years old (Howard A Kadish and Robert G Bolte. Pediatrics1998;102:73–6). Of the remaining 26, 13 had testicular torsion (TT) and 13 torsion of the appendix testis (TAT). Fewer of those with epididymitis presented within 12 hours of symptom onset and they were more likely than those with torsion to have fever, a history of previous similar pain, or dysuria, although each of these features was present in fewer than 20% of boys with epididymitis. The testicular lie was normal in all boys with epididymitis or TAT but abnormal in almost half of those with TT. The testis as a whole was tender in all those with TT, 69% of those with epididymitis, and 31% of those with TAT, but all boys with TAT had localised tenderness at the superior pole of the testis. The cremasteric reflex was absent in all patients with TT, 14% with epididymitis, and none with TAT. Scrotal erythema or oedema was more common in epididymitis (67%) than in TT (38%) or TAT (8%, one patient). Coloured Doppler ultrasound showed decreased blood flow in all seven patients with TT in whom it was performed, one of 29 with epididymitis, and neither of two with TAT. Ten of the 13 boys with TT had salvageable testes.

    None of this should lead clinicians into delaying surgery for boys who might have testicular torsion. In Salt Lake City they operate right away if the diagnosis is at all likely and do Doppler studies only when there is serious doubt.