The acute scrotum

The list of differential diagnoses for the acute scrotum is extensive, but it is paramount to rule out torsion of the spermatic cord, most common in boys aged 13–17 years and the most common cause of acute scrotal pain and swelling up to 18 years old. Torsion requires emergency surgical exploration and detorsion if the testis is to be salvaged. The management of perinatal torsion is surrounded by some controversy and best dealt with by dedicated paediatric units. Beyond 18 years epididymitis is a more common finding, usually caused by chlamydial, gonococcal or coliform infection. Investigations, antibiotic treatment and follow up should be based on the 2010 national guidelines. Torsion of the appendix testis and appendix epididymis, remnants of the Mullerian and Wolffian ducts, respectively, can mimic the more common diagnoses but most cases resolve spontaneously with non-operative management. Torsion of the testis is more likely if the onset of pain is sudden, the pain is severe and the patient is younger than 20 years of age. When there is any doubt about the diagnosis, an emergency scrotal exploration should be undertaken.