What are the treatment options for scrotal swelling?

Treatment of Scrotal Swelling

The treatment of scrotal swelling depends entirely on the underlying cause, with testicular torsion requiring immediate surgical exploration within 6-8 hours, while most other causes can be managed conservatively with supportive care or medical therapy. 1, 2

Emergency Surgical Conditions Requiring Immediate Intervention

Testicular Torsion

• Immediate urological consultation and surgical exploration is the definitive treatment and must occur within 6-8 hours of symptom onset to prevent permanent ischemic damage and testicular loss. 1, 2
• Surgical outcomes are significantly better when surgery occurs within 12 hours of symptom onset, with testicular viability compromised beyond this window. 1
• The surgical procedure involves detorsion of the affected testis, assessment of testicular viability, and bilateral orchiopexy to prevent recurrence (the contralateral testis requires fixation due to the high risk of bilateral bell-clapper deformity). 1
• Any delay in surgical intervention increases the risk of testicular loss and compromises salvage rates. 1

Testicular Rupture (Trauma)

• Immediate surgical exploration with debridement and tunical closure is recommended for testicular rupture, with orchiectomy reserved only for non-salvageable tissue. 2
• Early surgical intervention in cases of rupture and hematocele achieves the best long-term results. 3

Fournier's Gangrene

• If Fournier's gangrene is suspected clinically (look for crepitus, skin necrosis, or systemic toxicity), proceed directly to surgical debridement without delay for imaging. 4
• CT scan may help determine disease extent in stable patients, but should never delay surgical intervention. 5, 4

Medical Management for Infectious/Inflammatory Causes

Epididymitis/Epididymo-orchitis

• Bed rest, scrotal elevation, and analgesics are the cornerstone of conservative management until inflammation subsides. 1, 4
• Age-appropriate antibiotic therapy should be initiated based on risk factors (empiric therapy with ceftriaxone plus doxycycline is recommended after obtaining cultures). 2
• This represents the most common cause of scrotal swelling in adults (approximately 600,000 cases annually in the United States). 1

Torsion of Testicular Appendage

• Conservative management with analgesics and scrotal support is appropriate, as this condition is self-limiting. 1
• This is the most common cause of testicular pain in prepubertal boys. 1

Conservative Management for Benign Conditions

Hydrocele

• Hydrocele is the most common extratesticular cause of scrotal swelling (75% of all scrotal swellings are extratesticular). 6
• Conservative observation is appropriate for most cases, with surgical intervention reserved for symptomatic or large hydroceles.

Acute Idiopathic Scrotal Edema

• This rare, self-limiting condition requires only supportive care with observation. 1, 4
• It is characterized by marked scrotal wall thickening with minimal or no pain, and is a diagnosis of exclusion. 1

Scrotal Swelling Secondary to Systemic Conditions

• When scrotal swelling occurs as a complication of acute pancreatitis, it usually resolves spontaneously with conservative medical management including diuretics and leg elevation. 7
• For scrotal swelling related to Crohn's disease (metastatic Crohn's disease), treatment of the underlying gastrointestinal condition with systemic medications is most effective. 8

Critical Diagnostic Algorithm Before Treatment

Initial Assessment

• Duplex Doppler ultrasound is the first-line imaging study for all cases of scrotal swelling with acute pain, with sensitivity of 96-100% for detecting testicular perfusion abnormalities. 2, 1
• The ultrasound should include grayscale examination (looking for the "whirlpool sign" with 96% sensitivity for torsion), color Doppler assessment of testicular perfusion, and power Doppler for slow flow states. 1, 2

Risk Stratification

• Use the TWIST scoring system for pediatric patients (3 months-18 years) to determine need for urgent surgical exploration versus imaging. 2
• A negative Prehn sign (pain not relieved with testicular elevation) strongly suggests torsion over epididymitis. 1, 2

Common Pitfalls to Avoid

• Never assume isolated scrotal edema is simply "fluid overload" requiring only diuretics—always investigate for surgical emergencies and localized causes first. 4
• Do not delay surgical consultation if Fournier's gangrene is suspected, even to obtain imaging, due to high mortality risk. 4
• When clinical suspicion for testicular torsion remains high despite normal Doppler ultrasound, proceed to surgical exploration anyway—false-negative rates can reach 30%, particularly with partial torsion. 1, 2
• Color Doppler ultrasound has variable sensitivity (69-96.8%) and can miss partial torsion or early presentation, so clinical judgment must override imaging when suspicion is high. 1
• In prepubertal boys, normally reduced intratesticular blood flow can mimic torsion on Doppler, leading to false-positive evaluations—always use the contralateral testis as an internal control. 1