Dr. Douglass Clayton, MD is Assistant Professor of Pediatric Urologic Surgery at Vanderbilt. He presented at AAP 2017 on the importance of identifying acute scrotum in the pediatric setting. Doximity interviewed him after the session.

When we’re thinking about the differential for a young male with testicular pain, what things get you most concerned about torsion?

shutThe most concerning findings of torsion are patient age, sudden onset of intense unilateral testicular pain, and nausea. An adolescent male with these findings is very worrisome for acute torsion.

If the torsion is intermittent when do you get concerned?

Intermittent torsion is sometimes very difficult to diagnose. I am concerned when a child has an episode that is very similar to acute torsion that resolves with sudden relief of pain.

What physical exam maneuvers are essential? Should pediatricians attempt to ‘open the book?’

Physical examination is key to assessing scrotal pain. Evaluating the child in both the supine and standing positions is very helpful but one should never examine the scrotum in the standing position only. Assessment of the cremasteric reflex is helpful but not crucial to making the diagnosis. I think it is quite reasonable to attempt manual detorsion with an open the book technique but if successful, this would not prevent the need for emergent operation to address the torsion.

How does appendix torsion differ from testicular torsion on exam and on ultrasound?

Appendix testis torsion can look quite similar to testicular torsion, and it is the most common cause of acute scrotal pain in prepubertal boys. However, the size and tenderness of the testicle is usually less in appendix testis torsion. Tenderness is more often noted near the upper pole of the testicle where the appendix testis typically resides and in about 50% of cases a “blue dot” sign will be seen at the upper pole of the testicle. Ultrasound is very helpful for evaluating this issue. The ultrasound will typically show good intratesticular blood flow, increased blood flow around the the testicle and a lack of blood flow in the area of the appendix testis. In contrast, the testicle will show no blood flow if true testicular torsion is present.