Scrotal Pain & Swelling
There are a number of things which can cause pain and/or swelling in the area of the testicles. In general PAIN IS FAR MORE CONCERNING than swelling, and both appearing together SUDDENLY in a child over 2y with no prior history of a scrotal problem can be a very serious matter. What we worry about in that circumstance is TESTICULAR TORSION, which is when the testicle (and usually it is only one) literally twists on the cord that holds it, cutting off it’s own blood supply. This can sometimes result from trauma, but more often happens spontaneously. Testicular Torsion is a true medical emergency. If surgery is not done within a matter of 6-12 hours the testicle can be lost! Therefore, you should always call and page us immediately if there is the sudden onset of one-sided scrotal pain & swelling in a previously well child.
Luckily, Testicular Torsion is fairly rare. Although every child who has sudden onset of pain and swelling needs to be evaluated for it (because the consequences of missing it are so serious), most of these children will turn out to have something else. Most often that something else is Torsion of the “Appendix Testes”, a little flap of tissue which hangs off the normal testicle and serves no known function (very much like the appendix hangs off the intestines – which is how it got its name). Torsion of the Appendix Testes is not serious, lasts several days, and is treated only with pain relievers once Testicular Torsion has been ruled out.
Another cause of acute pain and/or swelling in the scrotum is Epididymitis. This is an infection of the tubes around the testicle. This happens in kids, but is far more common in adults. It’s treated with antibiotics.
Finally, while not usually painful or of acute onset, by far the most common cause of scrotal swelling are HERNIA’s and HYDROCELES (see below).
Hernias & Hydroceles
These are the most common causes of swelling in the scrotum of boys. They are usually noticed immediately after birth or in the first few months of life because they are congenital. “Acquired” hernias which develop later in life from a rupture in the abdominal wall can occasionally happen in older children, but are much more common in adulthood. Indeed, if an older boy develops new onset pain/swelling in the scrotum it is more likely to be another sort of problem – a twisted or infected testicle – which can be an urgent & serious matter itself. This requires prompt medical attention. While it is possible for girls also to have both congenital and acquired hernias (but not hydroceles), it is much more common in boys.
A hydrocele is a sac of fluid around the testicle, while a hernia is an outpouching of abdominal contents. When congenital, both are remnants of abdominal lining pulled down into the scrotum in mid pregnancy by the testicle as it was making it’s trip from where it formed higher up near the kidney. The tube of abdominal lining so pulled down is supposed to disintegrate once the testicle reaches it’s destination, but this doesn’t always happen completely. If the result is a sac that is still connected to the abdominal cavity, it’s hernia. If it’s not connected, it’s a hydrocele. Most hydroceles go away (finish disintegrating) on their own by the time a baby is one year old with no intervention. Hernia’s never go away by themselves, and will always need to be repaired surgically, although unless they incarcerate there is no urgency to doing this.
It can be hard to tell the difference between a hydrocele and a hernia on examination, even for an experienced pediatrician – it we think it’s a hernia on exam we are almost always right, but when we think it’s just a hydrocele it may turn out to be a hernia anyway.
In any case, correct management is to WAIT until EITHER:
1.) It becomes obvious that it’s really a hernia on exam, or
2.) The child is approaching his first birthday and it isn’t going away.
If you get to one of these points, a surgical consultation (either with a urologist or a pediatric surgeon) is indicated. If there is any chance that it’s a hernia they will operate. A fairly high percentage of hydroceles that aren’t going away by one year actually do turn out to be hernias at surgery. It’s a simple and safe operation at any age – even just a few weeks of life – at a good Children’s Hospital.
On the other hand, if the surgeon is very sure it’s really just a hydrocele, they may try draining it with a needle – this sometimes needs to be done several times but often works and avoids surgery.
Finally, while observing or waiting for surgery, the one and only danger is “incarceration”. This is when, with a hernia (which all suspected hydroceles MIGHT be), the abdominal contents get “stuck” in the hernia sac, can’t get back into the abdomen, and start to suffer an impaired blood supply. While a “normal”, non-incarcerated hernia is soft and varies in size – bigger when crying or having a BM, smaller when calm and relaxed – an incarcerated hernia is firm, bigger, and fixed in size. Likewise, a “normal” hernia is not painful or tender, while an incarcerated hernia is very tender to touch. A “normal” hernia may have be normal skin color or have a faint blue tinge – but an incerated hernia may be red or deep purple like a bruise. While few hernias actually incarcerate, when they do it is a MEDICAL EMERGENCY and requires surgery within a matter of hours.