Acute Scrotum in Paediatric: Clinical Profile and Management
Acute Scrotum in Paediatric: Clinical Profile and Management
Authors and Affiliations
Wael Mohammed Taha Mohammed Saad: Senior registrar, Khartoum Teaching Hospital, Khartoum, Sudan.
Amir Abdalla Mohamadain: Associate professor of Paediatric Surgery, Al Neelain University, Khartoum, Sudan.
Aamir Abdullahi Hamza: Professor of General Surgery, University of Bahri, Khartoum, Sudan.
Corresponding Author Contact: waelmtaha@yahoo.com
Abstract
Definition of Acute Scrotum: Acute scrotum is characterized as acute scrotal pain accompanied by swelling and other local or general symptoms. It necessitates immediate evaluation and intervention as a surgical emergency due to the critical risk of testicular torsion, which can lead to irreversible ischemic damage and testicular loss if not addressed promptly.
Objective of Study: The primary objective of this study was to comprehensively assess the clinical presentation patterns and management strategies employed for cases of acute scrotum in paediatric surgery settings in Khartoum, Sudan, aiming to improve diagnostic pathways and outcomes.
Study Design: This research employed a prospective descriptive analytical study design. It was conducted over a period of 21 months, from March 2013 to November 2014, spanning three distinct hospitals within Khartoum to gather a broad and representative sample.
Patients Studied: The study meticulously included all paediatric male patients aged under 13 years who presented with symptoms indicative of acute scrotum at the participating institutions during the study period.
Final Diagnosis Methods: Diagnoses were definitively established through a combination of imaging, specifically Doppler ultrasound, and, crucially, surgical exploration. These methods revealed a diverse etiology:
Epididymoorchitis: The most frequent diagnosis, accounting for 39.5\% of cases.
Testicular torsion: A significant and critically urgent cause, found in 34.2\% of patients.
Torsion of testicular appendage: Identified in 10.5\% of presentations.
Scrotal abscess: Accounted for 6.6\% of cases.
Haematocele: Present in 5.3\% of patients.
Obstructed inguinal hernia: Represented a smaller proportion, at 3.9\%.
Common Symptoms: The most universally reported symptom was pain, observed in 100\% of patients. This was closely followed by scrotal swelling, reported by 90.8\% , and a significant incidence of fever in 46.1\% of the cases, indicating systemic involvement.
Common Signs: Clinical examination revealed consistent signs, with tenderness being almost ubiquitous at 96.1\%. Erythema (redness) was prominent in 82.9\% of patients, and oedema (swelling) was noted in 80.3\%, forming a common diagnostic triad.
Surgical Findings: Surgical exploration was deemed necessary and performed in 49 patients, constituting 64.5\% of the total study cohort. These explorations yielded various pathological findings directly related to the acute scrotal conditions.
Salvage Rates: For cases of testicular torsion, the overall testicular salvage rate was relatively low at 38.5\%. A critical observation was that the majority of successful testicular salvages (preservation) occurred when surgical intervention took place within the crucial first 24 hours of symptom onset, underscoring the time-sensitive nature of this condition.
Introduction
Definition of Acute Scrotum: Acute scrotum is a comprehensive term used to describe any acute painful swelling affecting the scrotum or its contents. This condition is frequently accompanied by distinct local signs such as tenderness, erythema, and oedema, alongside potential general symptoms like fever or nausea, presenting a diagnostic and therapeutic challenge in paediatric patients.
Diagnostic Challenge: The primary diagnostic difficulty in acute scrotum stems from its diverse array of underlying etiologies, ranging from benign conditions to surgical emergencies, coupled with significantly overlapping clinical presentations. This overlap makes differentiating between conditions like testicular torsion and epididymoorchitis particularly challenging based solely on clinical examination, potentially delaying critical interventions.
Common Causes: While many conditions can cause acute scrotum, three are most frequently encountered and clinically significant in the paediatric population:
Testicular torsion: This is considered the most critical cause due to the rapid onset of testicular ischemia. It involves the twisting of the spermatic cord, which compromises the blood supply to the testis. Without urgent surgical detorsion, it can lead to irreversible damage and loss of the affected testicle.
Epididymoorchitis: An inflammatory condition involving the epididymis and often the testis, typically caused by bacterial infection. It is a common cause of scrotal pain but generally less urgent than torsion.
Torsion of testicular appendage: Involves the twisting of small vestigial structures (like the appendix testis or appendix epididymis). While painful, it is a self-limiting condition that rarely leads to testicular loss.
Time Sensitivity: The viability of the testis in cases of torsion is critically dependent on the duration of ischemia. Irreversible cellular damage to the testicular parenchyma begins to initiate beyond six hours from the onset of symptoms. The probability of testicular loss dramatically increases, with nearly complete loss expected if surgical intervention is delayed beyond 24 hours. This emphasizes the need for rapid diagnostic pathways and immediate surgical consultation.
Methodology
Study Design: This study utilized a prospective descriptive design, meaning data was collected forward in time from patients presenting with acute scrotum. The study was conducted across three major hospitals in Khartoum, Sudan, providing a multi-center approach to gathering clinical data.
Inclusion Criteria: Participants were strictly defined as male paediatric patients aged under 13 years who presented to the emergency department or surgical clinics with an acute onset of scrotal pain and/or swelling.
Exclusion Criteria: Patients who were older than 13 years at the time of presentation were systematically excluded from the study cohort to maintain a consistent paediatric focus.
Data Collection: A standardized questionnaire was employed for data collection, gathering information directly from patients (where age-appropriate), their parents or guardians, and retrospective review of medical records. Key data points meticulously analyzed included:
Age: Recorded to establish demographic distribution and its correlation with specific diagnoses.
Symptoms and duration of complaints: Detailed recording of pain characteristics, swelling, fever, and the exact timetable from symptom onset to presentation.
Clinical presentation: Comprehensive documentation of physical examination findings, including specific signs like tenderness, erythema, oedema, cremasteric reflex status, and testicular position/axis.
Urinalysis and other diagnostics: Results from laboratory tests, particularly urinalysis (to detect infection), and the findings from imaging studies like Doppler ultrasound.
Surgical treatment and intraoperative findings: If surgery was performed, detailed notes on the surgical approach, observed pathology (e.g., degree of torsion, viability of testis), and any procedures undertaken (e.g., detorsion, orchiectomy).
Results
Patients Studied: The study included a total of 76 paediatric patients with acute scrotum. Their ages ranged significantly from 1 month to 13 years, with a calculated mean age of 7.8 \pm 4.8 years, indicating a broad age distribution within the paediatric bracket.
A significant majority of the patients (64.5\%) fell within the age group of 6 to 13 years, suggesting a higher incidence of acute scrotal conditions in older children.
Involvement of the right and left sides was found to be almost equally distributed, with 42.1\% for each side. Bilateral involvement was less common, observed in 15.8\% of cases, primarily attributable to epididymoorchitis rather than torsion.
Common Symptoms: Consistent with the abstract, pain was the universal symptom, reported by 100\% of all patients, highlighting its cardinal role in acute scrotal presentations. Scrotal swelling was nearly as prevalent, affecting 90.8\%, while fever was noted in 46.1\%.
Sudden Onset of Symptoms: A sudden and abrupt onset of symptoms, often characteristic of testicular torsion, was observed in a substantial 76.3\% of the patients, emphasizing the need to consider torsion in a majority of cases.
Table 1: Relation between Age Groups and Final Diagnosis
Notable Diagnoses: The study meticulously categorized final diagnoses, with a clear distribution across the patient cohort:
Testicular torsion was confirmed in 26 patients, underscoring its significant prevalence.
Torsion of testicular appendage affected 8 patients.
Epididymoorchitis was the most common diagnosis, impacting 30 patients. This finding is critical as it is often a differential diagnosis for torsion.
Scrotal abscess was diagnosed in 5 patients.
Haematocele was found in 4 patients.
Obstructed inguinal hernia, while less common, was identified in 3 patients, representing a distinct surgical emergency.
These distributions highlight the importance of a thorough diagnostic workup to differentiate these conditions, especially given their varied management pathways.
Common Signs Observed
Triad of Signs: Clinical examination frequently revealed a triad of signs indicating inflammation and acute pathology:
Tenderness: Present in an overwhelming 96.1\% of patients, indicating localized pain upon palpation.
Erythema: Observed in 82.9\% of cases, signifying localized redness of the scrotal skin.
Oedema: Noted in 80.3\% of patients, reflecting swelling of the scrotal wall.
Involvement Manifestations: Specific signs were also assessed for their diagnostic utility, particularly in identifying testicular torsion:
Changed testicular axis: Identified in 26.9\% of patients specifically within the torsion group, where the long axis of the testis may be horizontal rather than vertical.
Absent cremasteric reflex: A significant finding in 65.3\% of patients with torsion. This reflex, normally elicited by stroking the inner thigh, is often absent in testicular torsion due to nerve compromise.
High riding testicle: Observed in 61.5\% of torsion cases, where the affected testicle appears positioned higher in the scrotum due to the shortening of the spermatic cord by twisting. These specific signs, while not 100\% sensitive or specific, are crucial indicators for suspicion of torsion.
Urinalysis and Doppler Ultrasound Findings
Urinalysis Results: Urinalysis was performed as part of the diagnostic workup. Significant findings such as pyuria (pus in urine) or bacteriuria (bacteria in urine) were detected in 27.2\% of patients among those diagnosed with epididymoorchitis, testicular torsion, and scrotal abscess. While indicative of infection in some cases, its absence does not rule out infectious processes and its presence in non-infectious conditions (like torsion) can be misleading.
Doppler Ultrasound Use: Doppler ultrasound, a non-invasive imaging modality, was employed in 56.6\% of the cases. This technique proved particularly effective in identifying variations in blood flow, thereby significantly aiding in the diagnosis of epididymoorchitis (characterized by increased flow) and providing valuable information for other etiologies, though its accuracy is operator-dependent.
Surgical Exploration
Patients Explored Surgically: Surgical exploration was carried out in 49 patients, representing 64.5\% of the total cohort. This high percentage underscores the clinical imperative to rule out testicular torsion definitively when suspicion remains high, even after non-invasive diagnostics.
Torsion Group Outcomes: Within the group diagnosed with testicular torsion, a salvage rate of only 38.5\% was achieved, indicating that more than half of the testicles could not be saved. Crucially, statistical analysis showed that 90\% of successful salvages (when the testicle remained viable) were associated with surgical execution occurring within 24 hours from the onset of symptoms. This reinforces the "golden hours" concept.
Orchiectomy: Testicular removal (orchiectomy) was primarily performed in cases where viability could not be established. The majority of these procedures occurred in patients who presented and underwent surgery more than 24 hours after symptom onset, with a mean time to operation of 94.1 \pm 43.9 hours, starkly contrasting with salvage times.
Table 3: Time from Onset to Operation and Testicular Viability
Duration and Results: The data clearly demonstrates a stark correlation between the time elapsed from symptom onset to surgical intervention and the viability of the affected testicle in cases of torsion.
6 - 12 hours: Of the 4 testicles operated on within this window, all 4 were found to be viable (100\% salvage).
13 - 24 hours: Among 6 testicles operated on, 5 were viable, but 1 was non-viable, showing a drop in salvage rate to approximately 83\% (5/6).
24 - 48 hours: For cases operated within this timeframe, 1 testicle was viable while 2 were non-viable, indicating a significant decline in viability.
> 48 hours: Alarmingly, for the 13 testicles operated on after 48 hours, none were found to be viable, with all 13 being non-viable. This data graphically illustrates the rapid and irreversible damage to testicular tissue with prolonged ischemia, emphasizing that early surgical intervention is the single most critical factor for testicular preservation in torsion.
Discussion
Comparative Studies: This study's findings, particularly regarding the prevalence of etiologies, provide valuable context when compared to previous research. While past studies have shown variations in the leading causes of acute scrotum globally, epididymoorchitis emerged as the most common cause in this specific Khartoum-based series (39.5\%), aligning with some literature but diverging from others that frequently cite testicular torsion as primary.
Overlap of Clinical Profiles: A significant challenge highlighted in this study, and endorsed by numerous other research publications (e.g., Lyronis ID et al., Cavusoglu YH et al.), is the substantial overlap of clinical symptoms and signs among different acute scrotal conditions. This inherent ambiguity complicates accurate presumptive diagnosis based solely on history and physical examination, necessitating reliance on ancillary diagnostics and, often, surgical exploration.
Salvage Rates: The testicular salvage rate observed in this study for torsion (38.5\%) was notably lower than rates cited in many international studies, which often report higher preservation rates. This discrepancy could be attributed to several factors including delayed presentation to healthcare facilities, diagnostic delays, or challenges in accessing immediate surgical care within the critical time window in the study's setting.
Urinalysis Findings: While urinalysis is a routinely performed test, the study's discussion points out its limitations as a definitive diagnostic tool for epididymoorchitis. Despite the presence of pyuria or bacteriuria in a subset of patients with this inflammation, its absence does not rule out the condition, and its presence can sometimes be observed in non-infectious conditions like torsion, making it a poor indicator for differentiating emergent conditions.
Doppler Ultrasound: Doppler ultrasound was identified as a viable and valuable non-invasive imaging tool for aiding diagnosis by assessing testicular blood flow. However, its effectiveness is critically dependent on the operator's skill and experience. Furthermore, relying solely on ultrasound can introduce delays in treatment, especially in settings where immediate access to skilled sonographers or urgent interpretation is limited, potentially pushing patients beyond the critical window for testicular salvage in torsion cases.
Conclusion
Clinical Implication: The study emphatically concludes that while epididymoorchitis presents as the numerically most prevalent cause of acute scrotum in this paediatric cohort, testicular torsion uniquely poses the most profound and immediate risk for irreversible testicular loss. This critical distinction is often obscured by the significant diagnostic challenges arising from the overlapping clinical features of various acute scrotal conditions.
Importance of Evaluation: Therefore, a particularly careful and high index of suspicion is paramount in evaluating every paediatric patient presenting with acute scrotum. Relying solely on history and clinical examination, despite their importance, frequently falls short in conclusively confirming or ruling out testicular torsion, underscoring the necessity for rapid diagnostic protocols and, when in doubt, immediate surgical exploration to prevent catastrophic outcomes.
References
Lyronis ID et al., Indian Journal of Pediatrics (2009)
Cavusoglu YH et al., Indian Journal of Pediatrics (2005)
Nason GJ et al., Scandinavian Journal of Urology (2013)
Various other studies indicated in the references.