The appearance of a red, swollen, painful scrotum should always be treated as an emergency situation. This collection of signs and symptoms is known as an "acute scrotum".
What are the causes?
The causes of an "acute scrotum" include trauma, twist of the testicle (torsion), twist of a part of the testicle, infection of the testicle and/or epididymis and swelling of the scrotum for no known cause.
Infection in the testicle or epididymis and 'idiopathic scrotal oedema' (no known cause of swelling) are not common in children and are diagnoses that should only be made by a Paediatric Surgeon.
A twist of the testicle or in other words a testicular torsion, occurs either in newborn babies, or boys who are approaching puberty. The cause of the torsion, in these two age groups, is due to an increase in the mobility of the testicle within different tissue layers surrounding the testicle in the two different age groups.
Unfortunately, in the babies who have a testicular torsion, by the time the diagnosis has been made, it is usually too late to save the testicle.
In older boys with a testicular torsion, they will present with a swollen testicle and associated pain in the scrotum that may extend to the loins. There is usually associated nausea and sometimes vomiting. The scrotum on the affected side will be red and swollen, and the testicle may be sitting higher and more horizontal than the normal testicle on the other side.
When to operate
The diagnosis is usually confirmed by a Paediatric Surgeon, and the operation to fix the testicle should not be delayed by any further investigations. If the testicular torsion is fixed within 6 hours of the twist occurring, there is an excellent chance that the testicle will survive. At the same operation the other testicle is also fixed in place in order to prevent a twist occurring in that testicle.
If the affected testicle is already dead, it will need to be removed.
A twist of a part of the testicle, known as torsion of the testicular appendage, is the most common cause of "acute scrotum" in children. It occurs when a small piece of tissue, situated on the upper part of the testicle, twists on itself. Often this twisted portion appears as a tender black spot, seen through the skin of the scrotum at the upper part of the testicle. If carefully examined, the rest of the testicle is not tender.
Torsion of the appendage, once diagnosed by a Paediatric Surgeon, can be managed with pain relieving medication and usually the pain resolves within 2-3 days. If the pain persists or recurs or if there is any doubt about the diagnosis, a Paediatric Surgeon will need to operate to correct the problem or to resolve the dilemma about the diagnosis.
When is an operation not necessary?
Infection of the testicle or epididymis should resolve with antibiotics that need to be given for 2 weeks. Again, if there is any doubt about the diagnosis, and torsion of the testicle is a possibility, then an operation will be recommended.
In idiopathic scrotal oedema, usually both sides of the scrotum and often the skin above and below the scrotum is thickened and red. The cause of idiopathic scrotal oedema, as mentioned earlier, is unknown, however, it may represent an allergic or immunological reaction.
Once this condition has been diagnosed by a Paediatric Surgeon, antihistamines or antibiotics may be prescribed. However, there is no evidence to suggest that they have a significant effect. In the majority of cases, idiopathic scrotal oedema disappears after 3-4 days.