A case of acute scrotal swelling due to testicular torsion

R.S., 10 year old boy came with severe pain in scrotum/ testis for 1 day and swelling of scrotum for last 5-6 hours. There was no fever, or urinary difficulty.

Clinically, the scrotum was swollen and there was extreme pain to touch. A Doppler scan revealed tot al loss of blood supply to testis and confirmed Testicular torsion.

The boy was taken up for emergency surgery and on exploration- the left testis was black and necrotic, Even after untwisting there was no improvement in the colour of the testis, so it had to removed. Since there are chances of a similar event occurring on the other side, the right testis was fixed at the same time. The boy recovered well and is on follow-up. He will again be called for assessment at 14-15 years to see for a testicular implant.

   
Right testis was also explored and then fixed (Orchiopexy) to
prevent later on torsion on this side.
Completed surgery with anatomical closure of the scrotum
Common causes of pain/ swelling of scrotum/testis
  1. Testicular torsion: The testicle twists on itself and as a result the blood supply is interfered with. This is an absolute emergency as delay in diagnosis and surgery may result in loss of testis due to total stoppage of blood supply. Classically, the child with testicular torsion has sudden onset of pain in scrotum which is severe and there is associated nausea/ vomiting is some cases. There is no fever or urinary symptoms. A doppler ultrasound scan is done in such cases and an emergent surgery may be able to salvage the testis. Within 6 hours of onset of pain, testis can generally be saved. After 6 hours chances of saving the testis decrease and mostly removal of dead testis is required- orchiectomy. It is essential to fix the opposite testis (orchiopexy) at the same time as there is a high chance of torsion occurring on the opposite side.
  2. Epididymo-orchitis: This refers to infection of the testis. There may be associated symptoms of burning micturition, frequency or urgency or fever due to underlying urinary infection. Diagnosis is made clinically and confirmed by Doppler scan. Treatment is with antibiotics and anti-inflammatory agents.
  3. Trauma: injury to testis can result in swelling and pain.
  4. Torsion of testicular appendage: Testicular appendages are small nonfunctional nodules which are located near upper part of testis. They can undergo a twist and present with symptoms quite similar to testicular torsion. In early stages, it is fairly easy to distinguish the two but it may not be so in late stages when swelling sets in. While testicular torsion requires emergency surgery, torsion of the appendage can be managed no-surgically if diagnosed with surety. Sometimes when the diagnosis is in doubt a Doppler scan may help, rarely a surgery may be required if doubts still remain.
 
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