A PCP’s guide to benign pathology in the scrotum

Scrotum-testicular-abnormalities

As a urologist at Boston Children’s Hospital, I’m often found treating common abnormalities of the scrotum and testicles. These benign conditions can typically be fixed when kids are very young, so most patients go on to live their lives never having to see us again.

The right diagnosis is important to a child’s swift recovery. Learn about the diagnosis and treatment of the four most common testicular abnormalities seen in practice today.

Undescended testicles or cryptorchidism

  • What to look for: A baby boy should have two testicles down in the scrotum. At the newborn child exam, if you are unable to feel both testicles or have any reason to believe one is not in the right place in the scrotum, refer your patient to a pediatric urologist.
  • Treatment: As long as there are no other associated abnormalities, we’ll wait to perform surgery until the child is six months of age. If at that point, the testicle hasn’t descended on its own, we’ll perform a day surgery called an orchiopexy where we release the testicle from the attachments hindering its descent and tack it down in the scrotum so it can develop appropriately.
  • Important to know: Children with an undescended testicle have a slightly increased chance of developing testicular cancer if it is not brought down to the scrotum in a timely fashion, especially for those with a testicle in the abdomen. There’s also theoretically a risk to fertility if the testicle — because of its location — wasn’t developing at the right temperature.

Testicular torsion

  • What to look for: Common in prepuberal boys (ages 12-16), testicular torsion is caused when a testicle is not attached well to the scrotum. If a child complains of a swollen scrotum and an acute onset of pain that may or may not be accompanied by nausea and vomiting, refer him to the emergency department of a local hospital immediately.
  • Treatment: We perform a physical exam and an ultrasound to make sure the blood supply to the testicle is intact. If testicular torsion is determined to be the cause of the pain, we immediately perform a surgical exploration to untwist the testicle and sew both testicles in place so they can’t turn in the future. Infrequently we have to remove the testicle if the blood supply is completely cut off for a long period of time.

Epididymitis

  • What to look for: A child who complains of testicular pain and does not present with torsion will most likely have inflammation of the epididymis, this is called epididymitis.
  • Treatment: We recommend Advil or Tylenol, elevation, icing and a decrease in activity. Swelling and pain will typically improve within a few days. In sexually active teens, epididymitis is more likely infectious and therefore treated with antibiotics.
  • Important to know: Both torsion and epididymitis can present with some of the same symptoms, so all testicular pain cases should be referred to a hospital with a pediatric urologist.

Hernias and hydroceles

  • What to look for: Parents are typically the first to notice the swelling of a child’s scrotum associated with an inguinal hernia or hydrocele. If you push gently on the bulge when the child is calm and lying down, it will usually get smaller or go back into the abdomen.
  • Treatment: Hernias usually require surgery. We wait to repair a hydrocele until the child is a year old, in case the patient’s processus closes on its own. But for hernias, the risk of reoccurrence is high enough that we perform the surgery within a few weeks of diagnosis.
  • Important to know: Incarcerated or strangulated hernias require urgent correction. A hernia that is bulging, red or very hard should be referred immediately to the emergency department of a local hospital.

For all of these conditions, it’s important to reassure anxious parents that benign abnormalities of the testicles and scrotum are common and treatable. But even the most routine surgery can feel worrisome, so we encourage parents to use our secure nursing line to ask questions and send photos if anything changes between appointments.

McNamara-Erin

 

Erin McNamara, MD, MPH, is a urologist at Boston Children’s Hospital and an instructor in surgery at Harvard Medical School.

 

 

 

Learn more about Boston Children’s Department of Urology.