Epidemiology

• Most common in boys aged 7–12 years
• Much less common in infants and after late teens
• Accounts for ~40–60% of acute scrotum cases in prepubertal boys

Presentation

• Localised pain at the superior pole of the testis
• Tender paratesticular nodule at the upper testis/epididymis
• Cremasteric reflex usually preserved (helps differentiate from true torsion)
• Blue-dot sign (small blue/black spot through scrotal skin) – pathognomonic, but seen in ~20% of cases only
• Systemically well; no urinary symptoms

Assessment

• Pain is more localised rather than diffuse
• Testis typically not high-riding or horizontal
• Cremasteric reflex normally intact
• Less severe systemic upset (vomiting less common)
• However – can still be difficult to distinguish clinically from testicular torsion

Diagnosis

• Diagnosis is based on clinical examination (clinical diagnosis)
• Doppler ultrasound may show normal testicular blood flow (if available and does not delay assessment)
• If any doubt – treat as testicular torsion and proceed to surgical exploration

Management

1. Conservative treatment (if diagnosis certain)
   • Bed rest
   • Scrotal support/elevation
   • NSAIDs and simple analgesia
   • Usually resolves within 1 week
2. Surgical Exploration required if:
   • Diagnosis uncertain
   • Examination suggests possible testicular torsion
   • Pain is severe or persistent despite analgesia