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Comparison of common conditions associated with testicular pain in children and adolescents

Comparison of common conditions associated with testicular pain in children and adolescents
  Testicular torsion Torsion of appendage Acute epididymitis
Historical features
Peak incidence Perinatal and puberty Prepubertal <2 years and postpubertal
Onset of pain Usually sudden Usually sudden Usually gradual
Duration of pain Usually <12 hours Usually >12 hours Usually >24 hours
Previous painful episodes Typical Unusual Uncommon unless prior history of epididymitis
Nausea and vomiting Common Uncommon Uncommon
Fever Unusual Unusual Common
History of trauma Occasional Unusual Unusual
Dysuria or discharge Rare Rare Common
Physical findings
Suggestive findings Horizontal lie, high-riding testicle Palpable nodule "blue dot" None
Cremasteric reflex Usually absent Usually present Usually present
Tenderness Testicular initially, then diffuse Appendage initially, then testis Epididymis initially, then diffuse
Scrotal erythema or edema Common >12 hours Common >12 hours Common >12 hours
Laboratory tests
Pyuria Unusual Unusual Common
Positive smear, culture, rapid molecular testing, or NAAT for STD No No Often
Leukocytosis Common Uncommon Common
Imaging
Color Doppler ultrasound* Decreased blood flow, spermatic cord knot Normal or increased Normal or increased
This table provides important clinical findings that help distinguish between testicular torsion, torsion of the epididymis or appendix testes, and epididymitis. In some boys with scrotal pain, significant overlap in history, physical examination, and diagnostic studies exist. When testicular torsion cannot be excluded, consult a pediatric urologist or surgeon with similar expertise.

NAAT: nucleic acid amplification testing; STD: sexually transmitted disease.

* When clinical findings are strongly suggestive for testicular torsion, promptly consult a surgeon with pediatric urologic expertise to evaluate the patient before ordering imaging. If clinical findings are equivocal for testicular torsion, then obtain color Doppler ultrasound to assess blood flow to the testicles.
Adapted from:
  1. Burgher SW. Acute scrotal pain. Emerg Med Clin North Am 1998; 16:781.
  2. Haynes BE, Bessen HA, Haynes VE. The diagnosis of testicular torsion. JAMA 1983; 249:2522.
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