Intended for healthcare professionals

Clinical Review

The management of acute testicular pain in children and adolescents

BMJ 2015; 350 doi: (Published 02 April 2015) Cite this as: BMJ 2015;350:h1563
  1. Matthew T Jefferies, specialist registrar in urology12,
  2. Adam C Cox, specialist registrar in urology1,
  3. Ameet Gupta, specialist registrar in urology1,
  4. Andrew Proctor, general practitioner3
  1. 1Department of Urology, University Hospital of Wales, Cardiff, UK
  2. 2Institute of Cancer and Genetics, Cardiff University School of Medicine, Cardiff, UK
  3. 3Roath House Surgery, Cardiff, UK
  1. Correspondence to: M T Jefferies Jefferiesmt1{at}

The bottom line

  • The acute scrotum is a medical emergency because any unnecessary delay can result in irreversible damage to the testis

  • Key elements in the history are the age of the patient and the duration and onset of symptoms

  • Testicular torsion is most common in neonates and post-pubertal boys

  • If testicular torsion is suspected urgent exploration and detorsion are key to maximise testicular salvage rates

  • Although ultrasonography is useful, it should not delay surgical exploration if testicular torsion is suspected. A small but real, negative exploration rate is acceptable to minimise the risk of missing a critical surgical diagnosis

Sudden onset testicular pain with or without swelling, often referred to as the “acute scrotum,” is a common presentation in children and adolescents, and such patients are seen by urologists, paediatricians, general practitioners, emergency doctors, and general surgeons. Of the many causes of acute scrotum, testicular torsion is a medical emergency; it is the one diagnosis that must be made accurately and rapidly to prevent loss of testicular function.

Sources and selection criteria

We searched PubMed and Clinical Evidence online using the search terms “acute scrotum”, “testicular torsion”, “epididymo-orchitis”, and “torted testicular appendage”. Historically, the management of the acute scrotum has changed little, and much of the data reviewed were case series and best expert opinion from book chapters. In addition we consulted up to date national and international guidelines published by the European Association of Urology and the Royal College of General Practitioners.

This review aims to cover the salient points in the history and clinical examination of acute scrotum to facilitate accurate diagnosis and prompt treatment of the most common presentations. In particular, it will guide clinicians in distinguishing testicular torsion from the other conditions that commonly mimic this surgical emergency in children and adolescents—epididymo-orchitis and torsion of the testicular appendage (cyst of Morgagni).

What are the common causes of the acute scrotum?

The …

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