What should be done to manage scrotal swelling?

Management of Scrotal Swelling

Immediate Priority: Rule Out Surgical Emergencies

The first and most critical step in managing scrotal swelling is to immediately exclude testicular torsion, which requires surgical exploration within 6-8 hours to prevent permanent testicular loss. 1, 2

Emergency Conditions Requiring Immediate Surgical Consultation

• Testicular torsion: Presents with sudden onset of severe scrotal pain and swelling, negative Prehn sign (pain not relieved with testicular elevation), and requires immediate urological consultation 1, 2
• Testicular rupture: Occurs after trauma with loss of testicular contour on examination, requires surgical exploration with debridement 2, 3
• Fournier's gangrene: Proceed directly to surgical debridement without delay for imaging if suspected clinically 2

Diagnostic Algorithm

Step 1: Clinical Assessment

Determine the timing and onset of symptoms to differentiate between emergent and non-emergent causes 1:

• Abrupt, severe pain: Strongly suggests testicular torsion (surgical emergency) 1
• Gradual onset: More consistent with epididymitis or other inflammatory causes 1, 3

Age-specific considerations 1:

• Adolescents and neonates: Higher risk for testicular torsion (bimodal distribution) 1
• Adults >25 years: Epididymitis most common (600,000 cases annually in US) 2
• Prepubertal boys: Torsion of testicular appendage most common 2

Step 2: Immediate Imaging

Duplex Doppler ultrasound is the mandatory first-line imaging study for all acute scrotal swelling with pain 2, 3:

The ultrasound protocol must include 2, 3:

• Grayscale examination: Assess for "whirlpool sign" (twisted spermatic cord), testicular heterogeneity, hydrocele 1, 2
• Color Doppler: Compare testicular perfusion to contralateral side 2, 3
• Power Doppler: More sensitive for slow-flow states, especially in prepubertal boys 1, 2

Critical pitfall: Color Doppler has variable sensitivity (69-96.8%) and false-negative rates up to 30% for testicular torsion 1, 2. When clinical suspicion remains high despite normal Doppler, proceed to surgical exploration anyway 2, 3.

Step 3: Use TWIST Score for Pediatric Patients

For children 3 months to 18 years, use the TWIST scoring system to determine need for urgent surgical exploration versus imaging 1, 2.

Treatment Based on Diagnosis

Testicular Torsion (Surgical Emergency)

Immediate urological consultation and surgical exploration within 6-8 hours of symptom onset 1, 2:

• Surgical procedure involves detorsion, assessment of viability, and bilateral orchiopexy 2
• Testicular viability is compromised beyond 6-8 hours, with significantly worse outcomes after 12 hours 1, 2
• Any delay increases risk of testicular loss 2

Epididymitis/Epididymo-orchitis (Most Common in Adults)

Empiric antibiotic therapy should be initiated immediately before culture results 4:

For patients <35 years or sexually active (likely gonococcal/chlamydial infection) 4:

• Ceftriaxone 250 mg IM single dose 4, 5
• PLUS Doxycycline 100 mg orally twice daily for 10 days 4, 6

For patients >35 years or with urinary tract instrumentation (likely enteric organisms) 4:

• Ofloxacin 300 mg orally twice daily for 10 days 4
• OR Levofloxacin 500 mg orally once daily for 10 days 4

Adjunctive therapy 4, 2:

• Bed rest, scrotal elevation, and analgesics until fever and inflammation subside 4, 2
• Failure to improve within 3 days requires reevaluation of diagnosis and therapy 4

Ultrasound findings: Enlarged hypoechoic epididymis with increased blood flow on color Doppler, scrotal wall thickening 1, 3

Torsion of Testicular Appendage

Conservative management with analgesics and scrotal support 2:

• Self-limiting condition, most common in prepubertal boys 2
• "Blue dot sign" is pathognomonic but only seen in 21% of cases 1

Acute Idiopathic Scrotal Edema

Supportive care with observation only 2, 3:

• Characterized by marked scrotal wall thickening with minimal or no pain 2
• Diagnosis of exclusion, self-limiting 1, 2

Hydrocele (Most Common Extratesticular Cause)

Ultrasound shows fluid collection around testis with normal testicular perfusion 7:

• 75% of scrotal swellings are extratesticular and almost always benign 7
• Conservative management unless symptomatic or concerning features present 7

Critical Pitfalls to Avoid

1. Never assume isolated scrotal edema is simply "fluid overload" requiring only diuretics—always investigate for surgical emergencies first 2. While diuretics may help with secondary edema from conditions like pancreatitis 8, this is only after excluding emergent causes.

2. In prepubertal boys, normally reduced intratesticular blood flow can mimic torsion on Doppler—always use the contralateral testis as internal control 1, 2

3. Do not delay surgical consultation for Fournier's gangrene to obtain imaging due to high mortality risk 2

4. Clinical judgment must override imaging when suspicion for torsion is high, as false-negative Doppler evaluations occur in partial torsion, spontaneous detorsion, or early presentation 1, 2, 3

5. Persistent swelling after completing antimicrobial therapy for epididymitis requires comprehensive evaluation for tumor, abscess, infarction, tuberculosis, or fungal infection 4

Follow-Up for Epididymitis

• Sex partners should be evaluated and treated if contact occurred within 60 days of symptom onset for confirmed or suspected gonococcal/chlamydial epididymitis 4
• Patients should avoid sexual intercourse until they and partners complete therapy and are asymptomatic 4