Testicular pain known as acute scrotum can occur with or with our scrotal swelling or in the absence of redness. The common causes in children are as follows:

• Torsion of epididymis or appendix of testis (60%)
• Torsion of testis (30%)
• Idiopathic scrotal oedema (< 5%)
• Epididymitis or orchitis (< 5%)
• Tumour
• Trauma

Image Source: Sutter Health

In all cases of acute scrotum, it is IMPORTANT to bring the child to see a paediatric surgeon as soon as possible as the testicle may die of ischemia (lack of oxygen) is the case of a testicle torsion if left untreated for more than 6-8 hours.

Torsion of the epididymis or appendix of testis
The epididymis or appendix of testis are embryonic remnants of the fallopian tube during the development of the child. These can cause torsion and the pain is felt at the upper pole of the testicle.

Torsion of the testis
Torsion of the testis affects 1 in 4,000 men. It is more common in boys who have a testicle which lies horizontally (as opposed to vertically in normal cases) known as a Bell clapper deformity. This position allows the testis room to twist around its spermatic cord causing severe pain and nausea or vomiting. It can occur at any age but more commonly between 12-18 years. Sometimes it can occur after a sports injury to the groin. This a medical emergency and requires prompt treatment.

Torsion of the testis can also occur in undescended testicle which will be felt as a tender lump in the groin.

Idiopathic Scrotal Oedema
There is swelling and redness on both scrotum with oedema but no pain.  The cause is not known but thought to be due to allergic reaction to insect bites.  Clinical examination and ultrasound test is required to make a diagnosis.  No surgery is required as the condition subsides within 2-4 days with medication such as anti-histamine.

Epididymitis
Epididymitis is due to infection from retrograde flow of bacteria from the urine (reflux) from the urethra. The epididymis is the coiled duct behind the testicle which carries the sperm. The child usually has fever or pain when passing urine with positive bacteria culture in the urine test. Antibiotics may be required to treat this condition.

Tumour
The most common tumour in the testicle is a teratoma which is hard and painless. There may be a family history of teratoma or a history of undescended testis. Clinical examination, ultrasound and MRI can differentiate a tumour from a torsion of the testis. Treatment is a combination of surgery and chemotherapy. Prognosis is good if the tumour is discovered early.

Reference: Cancer Research UK

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