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
for Torsion
Triage RN Notifies PEM Attending
to examine Patient
to examine Patient
Notify Urology if High Probability
Order US Scrotum Hi Prob with Doppler
Order US Scrotum Hi Prob with Doppler
FLOC/RN 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 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
Pain resolved
Review Differential Diagnosis
Consider POC UA, STI Testing
PE Findings consistent with
alternative diagnosis
(low probability testicular torsion)
alternative diagnosis
(low probability testicular torsion)
Urgent US Scrotum with Doppler
Notify Urology of Patient with High
Probability of Testicular Torsion
Probability of Testicular Torsion
- Order US Scrotum Hi Prob with Doppler
- Notify US Technologist
- Keep patient NPO
Ultrasound Results
US Negative
Review Alternative Diagnoses
Review Alternative Diagnoses
US consistent with
Alternative Diagnoses
Alternative Diagnoses
US Positive for
Testicular Torsion
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
Posted: July 2011
Revised: June 2021
Authors: T. Kolon, MD; B. Ku, MD; MK. Abbadessa, ACCNS-P; J. Lavelle, MD; S. Kaplan, MD
Revised: June 2021
Authors: T. Kolon, MD; B. Ku, MD; MK. Abbadessa, ACCNS-P; J. Lavelle, MD; S. Kaplan, MD
Evidence