Acute Scrotal Pain and SwellingCannot Miss Diagnosis No.1Section Editor: Prof. T.K. Partha Sarathy A 14 year old boy, Master Mohan, came home after a game of basketball and shortly after returning home he felt a sharp pain in the right side of his scrotum and inguinal region as well as some pain in the suprapubic area. There was also some swelling of the right side of the scrotum. His father took him to the family physician who examined him and asked the boy whether he has injured the area of the scrotum while playing. Mohan was emphatic that there was no injury that he could remember and he does not recall the basketball hitting the groin at any time. He never had similar problems in the past. Mohan lives in an area where mosquitoes are common. On examination, the boy had a pulse or 130 and the temperature was normal. General examination and systemic examinations were normal. Local examination revealed that the scrotum was somewhat swollen and edematous on the right side. Palpation of the testis was painful. The entire testis and epidermis was involved in the swelling. There was no evidence of any hydrocele or hernia that he could appreciate. The family practitioner considered the possibility of filarial orchitis. While he was in the process of discussing the problem with Mohan’s father, the boy started to retch and vomit and complained of some more pain in the area. The Family Practitioner thought it fit to get a surgical opinion and he referred to his colleague who promptly came down and examined the patient. He was able to appreciate the fact that the right testicle was somewhat drawn up compared to the left and that the scrotum was swollen and edematous.The swelling was not confined to the epididymis alone, but the entire testis was somewhat swollen and tender. Even though he could not rule out epididymo-orchitis, as a surgeon he was more concerned about the possibility of acute torsion of right testis. The surgeon explained to the father that some youngsters develop torsion of the testis, which means that the spermatic cord shows a rotation, and get twisted thereby compromising the vascular supply and venous return in the testicle. If this is not immediately taken care off, the testis may undergo irreversible changes and become gangrenous. Since the whole episode was less than two hours from the onset of symptoms, it may still be possible for him to untwist the spermatic cord and reverse the process. He also mentioned that he could be wrong in his diagnosis and possibly the only way that diagnosis can be established short of exploration is to do a nuclear scanning. Since such a facility was not immediately available and he could not afford to waste time in waiting for the Isotope scanning to be performed in a distant place, he advised that it is worthwhile to explore the right scrotum and if his diagnosis of “torsion of the testis” was correct he will try to reposition the testis and also anchor it properly in the scrotum, so that it will not happen again. He will perform orchidopexy.The surgeon further recommended that it is a good idea to also explore the left side of the scrotum to stabilize the testis to prevent such torsion occurring in the other testis in future. This he will do if he finds the right testis twisted at the spermatic cord, thereby establishing the diagnosis of torsion of right testis. The longer it is delayed the viability of the testis will become compromised. Both the father and the son agreed for immediate surgery and shortly thereafter under general anesthesia, a right scrotal incision was made. The testicular torsion at the spermatic cord level was readily appreciated. The testis appeared somewhat edematous and congested. As soon as the cord was untwisted and warm lap was applied the testis returned to normal. Orchidopexy was performed stabilizing the testis in the scrotum. The left scrotum was explored and again orchidopexy was performed on the left side as well. Post operative course was uneventful and the boy returned to normal and was discharged on the second postoperative day for follow up as an outpatient.