Non-traumatic Scrotal/Testicular Pain Clinical Pathway — Emergency Department

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Goals and Metrics

Patient Education

Transfer from Outside Hospital

Upload Imaging to Ambra — sent to CHOP Radiology
Instructions to Upload Imaging

Child with Non-traumatic
Acute Scrotal/Testicular Pain

Triage Chief Complaint Acute Scrotal Pain

Presence of any of the following:
- Acute onset
- Moderate, severe pain
- Nausea, vomiting
- Reported swelling

PEM Attending Examines Child

For High Probability Testicular Torsion:
- Order US Scrotum Hi Prob with Doppler
- Notify Urology

ED Team Assessment

History and Physical
Review Differential Diagnosis
Consider analgesia, IVF, NPO, POC UA

Non-high Probability Testicular Torsion

Normal lie of testicle
Cremasteric reflex present
Mild pain
No nausea /vomiting
No abdominal pain (Pre-pubertal child)

High Probability Testicular Torsion

Abnormal lie of testicle
- High riding, horizontal
Absent cremasteric reflex
Moderate to severe pain
Nausea, vomiting
Abdominal pain (Peri- or Post-pubertal child)

Testicular, Scrotal exam normal
Pain resolved
Review Differential Diagnosis

Consider US Scrotum w/Doppler,
POC UA, STI Testing

PE Findings consistent with
alternative diagnosis
(low probability testicular torsion)

Urgent US Scrotum w/Doppler

Notify Urology of Child with High
Probability of Testicular Torsion

Order US Scrotum Hi Prob with Doppler
- Notify US Technologist
- Keep child NPO

Ultrasound Results

US Negative
Review Alternative Diagnoses

US consistent with
Alternative Diagnoses

US Positive for
Testicular Torsion

Alternative Diagnoses

Consult Considerations

^*Hydroceles typically cause nontender scrotal swelling

Torsion of Appendix Testis
Orchitis/Epididymitis
Tumor
Incarcerated Inguinal Hernia
Intermittent Testicular Torsion

Varicocele
Vasculitis
Orchalgia
Hydrocele^*

Surgeon notifies OR
IV, NS bolus as indicated
Pain control

Discharge Instructions, Follow-up

Return precautions for possible intermittent torsion

Posted: July 2011
Revised: October 2023

Authors:
- T. Kolon, MD;
- B. Ku, MD;
- MK. Abbadessa, ACCNS-P;
- J. Lavelle, MD;
- S. Kaplan, MD
- K.Fischer, MD
- G. Sharer, MSN

Editors: Clinical Pathways Team

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

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Emergency Department Clinical Pathway for Children with Acute Non-traumatic Scrotal/Testicular Pain

Evidence

Emergency Department Clinical Pathway for Children with
Acute Non-traumatic Scrotal/Testicular Pain