Acute Scrotal Inflammation in a 23-Month-Old Child
In a 23-month-old with inflamed testicular sac outer skin and tenderness to palpation, perform immediate scrotal ultrasound with Doppler to rule out testicular torsion, which is a surgical emergency requiring intervention within 6-8 hours, and if torsion is excluded, treat for epididymitis or torsion of testicular appendage based on imaging findings. 1
Immediate Diagnostic Approach
Obtain urgent duplex Doppler ultrasound of the scrotum as the first-line imaging modality to differentiate between surgical emergencies and inflammatory conditions. 2, 1 This is the established standard for evaluating acute scrotal conditions in children. 2
Key Ultrasound Findings to Identify:
For testicular torsion (surgical emergency):
- Decreased or absent blood flow to the affected testicle compared to the contralateral side 1, 3
- The "whirlpool sign" showing twisted spermatic cord with 96% sensitivity 1, 3
- Enlarged heterogeneous testis with hypoechoic areas 1, 3
- Associated hydrocele and scrotal wall thickening 3
For torsion of testicular appendage (most common in this age group):
- Enlarged appendix testis >5 mm in the groove between testis and epididymis 3, 4
- Lack of perfusion in the enlarged appendage with increased vascularity of surrounding testis and epididymis 3
- Variable echogenicity (hypoechoic if acute, hyperechoic if prior torsion) 3
- Associated hydrocele 3
For epididymitis/epididymo-orchitis:
- Enlarged epididymis with increased blood flow on color Doppler 2, 3
- Inhomogeneous echogenicity of epididymis or testis 3
- Increased diastolic flow velocities and decreased resistance index on spectral Doppler 3
Age-Specific Considerations
At 23 months, torsion of testicular appendage is the most common cause of acute scrotal pain in prepubertal boys, followed by testicular torsion and epididymitis. 1 However, testicular torsion has a bimodal distribution with one peak in neonates and another in postpubertal boys, making it still a critical consideration even in toddlers. 1, 5
Management Algorithm Based on Diagnosis
If Testicular Torsion is Diagnosed or Cannot Be Excluded:
Immediate urological consultation and surgical exploration within 6-8 hours of symptom onset is mandatory to prevent testicular loss. 1, 6 Do not delay surgery to obtain additional imaging if clinical suspicion is high. 6 Surgical outcomes are significantly better when intervention occurs within 12 hours of symptom onset. 1
If Torsion of Testicular Appendage is Confirmed:
Consider early surgical treatment if the child presents with signs of severe inflammation such as hard scrotum or scrotal erythema, as surgery shortens hospital stay (median 2.0 days vs 3.5 days for conservative treatment) and prevents recurrence. 4 Conservative management with analgesics and observation is acceptable for mild cases, but surgical excision is safe, uncomplicated, and definitively prevents recurrence. 4
If Epididymitis/Epididymo-orchitis is Diagnosed:
Initiate antibiotic therapy targeting common pathogens. 7 In this age group, epididymitis is less common than in adults but can occur. 1 Treatment includes bed rest, scrotal elevation, and analgesics until inflammation subsides. 1
Critical Clinical Pitfalls to Avoid
Do not rely solely on physical examination findings, as there is significant overlap in clinical presentation between different causes of acute scrotal pain. 1 The cremasteric reflex may be absent in testicular torsion but this is not 100% sensitive. 7
Do not assume normal urinalysis excludes testicular torsion, as urinalysis can be normal in torsion cases. 1
Always use the contralateral asymptomatic testicle as an internal control during ultrasound evaluation to accurately assess blood flow differences. 1, 3
Be aware that false-negative Doppler evaluations can occur with partial torsion or spontaneous detorsion, so maintain high clinical suspicion even with equivocal imaging. 1
Technical Ultrasound Requirements
The ultrasound must use a high-resolution linear transducer (>10 MHz) with specific Doppler settings: low pulse repetition frequency (<4 cm/s), low wall filter (<100 Hz), and adequate gain. 3 Power Doppler is particularly useful for prepubertal testes with slow flow. 1