The acute scrotum.

Every boy with acute onset scrotal pain and swelling requires an immediate evaluation. Our protocol (Fig. 6) for the evaluation of these children is based on the history and physical examination combined with the selective use of imaging studies. When used appropriately, this protocol facilitates the rapid identification of children with torsion and minimizes the number of unnecessary scrotal explorations. When the duration of the pain is brief, and history and physical examination suggest that torsion is the most likely diagnosis, urgent surgical exploration without additional imaging studies is recommended. When it is not possible to definitely diagnose or exclude the diagnosis of testicular torsion, or when the duration of pain is greater than 12 hours, then diagnostic imaging can provide significant information. Color Doppler sonography is, in the authors' opinion, preferable to nuclear imaging for the evaluation of children with acute scrotums. When normal or increased blood flow is present, scrotal exploration is not required. When the study demonstrates decreased blood flow or does not provide a definite diagnosis, scrotal exploration is recommended. The authors recommend this approach because less than one third of these children have testicular torsion, and if routine scrotal exploration is performed for all boys with acute scrotums, a significant number of unnecessary surgical procedures will result.