A 10-year-old boy comes to the emergency department with right-sided scrotal pain that began 27 hours earlier.
- What additional questions would you ask to learn more about the pain?
- How do you differentiate the various causes of scrotal pain?
- What features suggest an alarming or urgent problem?
- Can you make a definite diagnosis through an open-ended history followed by focused questions?
Scrotal pain is a relatively common complaint in multiple settings, including primary care and the emergency department (accounting for 0.5% of total emergency department visits each year1). It occurs in all age groups, from childhood to late adulthood. Scrotal pain can result from a variety of causes, including emergencies that can lead to testicular morbidity and benign conditions requiring no intervention.
Although the patient's history may suggest the cause of scrotal pain, a focused physical examination is required to confirm the diagnosis. A careful history can help narrow the diagnosis and identify alarm symptoms that require urgent evaluation and treatment. In addition, it will suggest the appropriate diagnostic testing for more chronic and benign causes of pain.
|Testicular appendage||Remnants of müllerian duct system located on the testicle or epididymis.|
|Orchitis||Inflammation/infection of the testicle.|
|Varicocele||Dilation and engorgement of the pampiniform plexus of spermatic veins.|
|Epididymal cyst||Cyst at the head of the epididymis.|
|Spermatocele||Large epididymal cyst (> 2 cm).|
|Hydrocele||Collection of fluid in the tunica vaginalis that surrounds the testicle and spermatic cord.|
|Epididymitis||Infection and/or inflammation of the epididymis.|
|Testicular torsion||Twisting and strangulation of the testicle on the spermatic cord. Due to a congenital poor fixation of the testicle to the tunica vaginalis.|
|Fournier's gangrene||Severe subcutaneous tissue bacterial infection of the perineum spreading from skin to muscle and underlying structures, causing death of infected tissue.|
|Referred pain||Pain at a site removed from the actual disease.|
The key to understanding the different etiologies of scrotal pain requires an understanding of scrotal anatomy (Figures 45–1 and 45–2). In addition to the testicle, the scrotum contains the epididymis, which sits posteriorly on the testicle connected at its base to the spermatic cord. Within the spermatic cord are the vas deferens, testicular artery, and spermatic veins. A large portion of the testicle and spermatic cord is surrounded by the tunica vaginalis, which has a parietal and a visceral layer. Additionally there are 4 testicular appendages: the appendix testes, appendix epididymis, vas aberrans, and paradidymis. These are embryologic remnants of the müllerian duct system.
Cross section of normal scrotal anatomy.
Scrotal pain should be characterized as either acute or chronic. The age of the patient helps determine the cause. The most ...