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

Non-Traumatic Acute Scrotal/Testicular Pain
Transport/Referred Patients
  • Notify Urology at the time of initiation
  • Assures images routed to CHOP
  • Presence of any of the following:
    • Acute onset
    • Moderate, severe pain
    • Nausea, vomiting
    • Reported swelling
Significant Suspicion
for Torsion
Triage RN Notifies PEM Attending
to examine Patient
Notify Urology if High Probability
Order US Scrotum Hi Prob with Doppler
FLOC/RN Team Assessment
Non-high Probability Testicular Torsion
  • Normal lie of testicle
  • Cremasteric reflex present
  • Mild pain
  • No nausea /vomiting
  • No abdominal pain (Pre-pubertal patient)
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 patient)
Testicular, Scrotal exam normal
Pain resolved
Review Differential Diagnosis
Consider POC UA, STI Testing
PE Findings consistent with
alternative diagnosis
(low probability testicular torsion)
Urgent US Scrotum with Doppler
Notify Urology of Patient with High
Probability of Testicular Torsion
  • Order US Scrotum Hi Prob with Doppler
    • Notify US Technologist
    • Keep patient NPO
Ultrasound Results
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
  • 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: June 2021
Authors: T. Kolon, MD; B. Ku, MD; MK. Abbadessa, ACCNS-P; J. Lavelle, MD; S. Kaplan, MD