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

Transfer from Outside Hospital
Child with Non-traumatic
Acute Scrotal/Testicular 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
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 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
Editors: Clinical Pathways Team