Indications for conservative management of acute scrotal pain in children

Forty-three boys who presented with acute scrotal pain were studied retrospectively. Of these, 40 had torsion of scrotal contents. Torsion of testicular appendages, a self limiting condition, tended to present later than testicular torsion (P = 0.002). The testis was saved in all 11 cases of testicular torsion explored within 12h of the onset of pain but orchidectomy was required in four who presented later. In 11 cases, a torted testicular appendage diagnosed as a tender nodule was found on examining the upper pole of the testis. The remaining 14 cases of torted appendage were diagnosed at operation because testicular torsion could not be excluded due to scrotal swelling. Most (12) of this operated group were not seen until 3 days after the onset of pain. This study suggested that urgent operation was unnecessary in those in whom a tender nodule was found (pathognomonic of a torted appendage) and in those presenting after more than 24h of pain with scrotal erythema and oedema. The likely diagnosis in the latter case is a torted appendage and in cases of torsion of the testis there is no prospect of salvage at this stage. These guidelines were applied to a group of 20 boys studied prospectively. In eight, all with less than 24h of pain, immediate exploration was undertaken and testicular torsion was confirmed in six. The remaining 12 fulfilled the criteria for conservative management and were observed. All had normal testes at late review. Careful clinical assessment in boys with scrotal pain indicates which cases may be treated by non-operative management without fear of losing a salvageable testis.