What is the best course of action for an 11-year-old male experiencing scrotal pain after a fall into a tub, potentially indicating testicular injury?

Immediate Evaluation and Management of Scrotal Pain After Trauma in an 11-Year-Old

This child requires urgent scrotal ultrasound with Doppler imaging within hours to rule out testicular rupture, as early surgical repair (within hours of injury) is critical to prevent permanent testicular loss and complications. 1, 2

Initial Clinical Assessment

The immediate priority is distinguishing between simple contusion and testicular rupture, as the latter requires emergency surgical exploration. Key clinical features to assess include:

• Severity of scrotal swelling and ecchymosis - Severe swelling that obscures testicular contours suggests possible rupture 2
• Pain characteristics - Persistent severe pain that doesn't resolve within minutes, especially with nausea or vomiting, indicates significant injury 2
• Ability to palpate testicular contours - Difficulty identifying normal testicular anatomy on examination raises concern for rupture 2

In this age group (11 years old), testicular torsion must also be considered in the differential diagnosis, as this represents the peak age for torsion with a bimodal distribution in neonates and postpubertal boys. 1 However, the clear history of trauma makes testicular injury the primary concern.

Diagnostic Imaging Protocol

Scrotal ultrasound with Doppler should be performed urgently (same day, ideally within hours) rather than waiting. 3, 2 The ultrasound examination must include:

• Grayscale imaging to assess for loss of testicular contour and heterogeneous parenchymal echotexture, which are the most specific findings for testicular rupture 2
• Color and Power Doppler to evaluate testicular perfusion and identify areas of hemorrhage or infarction 3, 4
• Comparison to the contralateral testis as an internal control 3

Ultrasound can detect testicular rupture, scrotal hematomas, and areas of hemorrhage or testicular infarction following trauma. 5, 4 Point-of-care ultrasound has been shown to rapidly diagnose testicular rupture by visualizing loss of testicular contour and heterogeneous parenchyma. 6

Management Algorithm Based on Findings

If Testicular Rupture is Confirmed or Highly Suspected:

Immediate urological consultation and emergency surgical exploration are mandatory. 2 The surgical approach includes:

• Scrotal exploration with debridement of non-viable tissue 2
• Primary closure of the tunica albuginea whenever possible 2
• Use of tunica vaginalis grafts if primary closure cannot be achieved 2
• Orchiectomy only when the testis is non-salvageable 2

Early exploration and repair (within hours) significantly reduces complications including ischemic atrophy, infection, chronic pain, and testicular loss. 2 Delayed presentation worsens outcomes substantially. 2

If Simple Contusion Without Rupture:

Conservative management includes:

• Bed rest and scrotal elevation 7
• Oral analgesics for pain control 7
• Close follow-up to monitor for delayed complications 7

Critical Pitfalls to Avoid

Do not delay imaging or surgical consultation based on initial pain improvement - testicular rupture can present with variable pain levels, and delayed diagnosis significantly worsens outcomes. 2

Do not rely solely on physical examination - scrotal swelling and hematoma formation can make accurate clinical assessment impossible, and ultrasound is essential for definitive diagnosis. 7, 6

If ultrasound findings are equivocal, proceed directly to surgical exploration rather than delaying treatment, as the consequences of missed testicular rupture are severe. 2

Additional Differential Considerations

While trauma is the clear mechanism here, in an 11-year-old with acute scrotal pain, testicular torsion remains in the differential and can occasionally be precipitated by minor trauma. 1, 8 The ultrasound will help distinguish between these entities:

• Testicular torsion shows decreased or absent blood flow with the "whirlpool sign" of twisted spermatic cord 3, 1
• Testicular rupture shows loss of testicular contour and heterogeneous parenchyma 2, 6

Both conditions require urgent surgical intervention, so the imaging should not delay urological consultation if clinical suspicion is high. 1, 2