Diagnosis and treatment in acute scrotal problems in children

Objective To summarize the clinic characteristics and surgical strategy in children's acute scrotum disease. Methods The clinical data in 314 cases with acute scrotum disease were retrospectively study between October 2010 and March 2014. All boys were found one sided scrotal pain or with local redness. The physical examination showed unilateral scrotal swelling or with a haphalgesia. Among them, 63 cases were diagnosed as testicular torsion (TT), including 58 cases at left side, and 5 cases at right side. The age of onset covered newborn 9 cases, 1 m-1 y in 11 cases, 1 y1m-4 y in 12 cases, 4 y1m-7 y 11 cases, 7 y1m-10 y in 10 cases, and 10 y1m-13 y in 10 cases. Five cases of testicular torsion outside sheath that were all newborn, 4 cases of cryptorchidism torsion, 54 cases of testicular torsion inside sheath, which occured all on the left side. The onset time ranged from 2 hours to 15 days. The physical examination showed scrotal haphalgesia and testicular position moved up obviously in the boys whose onset time were less than 10 hours, and scrotal skin redness and swelling beginning to appear, testicular position slightly upward were shown between 10 hours and 10 days, the scrotal skin redness and swelling were disappeared in more than 10 days. The pre-operative ultrasound showed testicular blood flow decreased or disappeared and displayed testis fissure shaped changing when the onset time exceeded 24 hours. 130 cases were diagnosed as testicular appendage torsion (TAT), including 1 m-1 y in 1 case, 1 y1m-4 y in 5 cases, 4 y1m-7 y in 24 cases, 7 y1m-10 y in 32 cases, 10 y1m-13 y in 68 cases. The onset time ranged from 12 hours to 8 days. The color Doppler ultrasound examination showed a heterogeneous mass between the upper pole of testis and the head of epididymis in 70 cases, and the rest of 60 cases hadn′t been found the similar mass. but the heads of epididymis were all swelling and the testicular blood flow were normal. Ninety-nine cases were diagnosed as epididymitis, including 45 cases at left side, and 54 cases at right side, whose age of onset covered 6 cases of newborn, 1 m-1 y in 45 cases, 1y1m-4 y in 40 cases, 4 y1m-7y in 5 cases, 7 y1m-10 y in 3 cases. The onset time ranged from 6 hours to 5 days. The color doppler ultrasound examination showed testicular blood flow were normal and whole body of epididymis was enlargement with rich blood flow in 50 cases, the rest of 49 cases showed testicular blood flow reduced or unclear. The orchitis was found in 2 cases, including one 7 years old case mergered with mumps, whose color doppler ultrasound showed testicular blood flow was rich, and one 12 years old case, whose ultrasound showed 4cm×3cm×2cm heterogeneity echo of mass and testicular like tissue instead of the normal testis. The sheath membrane inflammation was found in 17 cases, including newborn in 4 cases, 1 m-1 y in 6 cases, 1y1m-4 y in 7 cases. Thirteen cases existed diarrhea before onset and the onset time were more than 24 hours. The ultrasound in 14 cases showed that testicular blood flow were unclear. Testicular sheath membrane hemorrhage was diagnosed in 3 cases, which were all the newborn. Unilateral scrotum showed blue color. Ultrasound showed densely dotted echo and heterogeneity mass. Results In 63 cases of TT, 54 cases were received unilateral testis resection and opposite side proceeded fixation due to the esticular necrosis. Six cases were received the testis reversion and bilateral fixation whose onset time were from 4 hours to 11 hours. One case appeared testicular atrophy. In 130 cases with TAT, 82 cases were underwent testicular appendage resection, 48 cases adopted conservative treatment of oral antibiotics. Forty-nine cases of epididymitis which proceeded testicular exploration and testicular membrane decompression, the rest of 50 cases received oral or intravenous antibiotics therapy and topical analgesic anti-inflammatory ointment treatment. 1 case with orchitis was given conservative treatment and the other underwent necrotic tissue removed. In 17 cases with sheath membrane inflammation, 14 cases, whose ultrasound showed vague blood flow, were underwent testicular membrane decompression and other 3 cases received anti-infection conservative treatment. 1 case with sheath within membrane hemorrhage was given hemostatic conservative treatment and other 2 cases accepted evacuation of hematoma. Conclusion TAT was the commonest cause of acute scrotum disease in children, whose onset peak ranged from 7 to 13 years old. TT was the most urgent type, in which left side occupied absolute morbidity, TT outside sheath happened at the newborn frequently. The incidence of orchitis was extremely low. epididymitis and sheath membrane inflammation often occurred in less than 3 years old which is related to the diarrhea. We advocated a positive exploration for the acute scrotum that can′t be ruled out from TT. Key words: Acute scrotum; Children; Surgical treatment