Acute Scrotal Pain in Children

Major Causes

Additional Causes

• Mumps orchitis — viral orchitis, typically presents 4–8 days after parotitis; rare with vaccination
• Epididymitis in infants (<6 months): caused by infected urine tracking up the vas deferens; associated with urinary tract abnormalities
• Post-pubertal epididymo-orchitis: Chlamydia trachomatis, Neisseria gonorrhoeae, E. coli — presents with testicular pain, dysuria, urethral discharge, and fever

• Varicocele — dull aching scrotal pain, "bag of worms" on palpation; left side predominant

• Scrotal haematoma
• Testicular contusion or rupture
• Traumatic testicular dislocation or torsion

• Henoch-Schönlein Purpura (HSP/IgA vasculitis) — scrotal involvement in ~38% of boys; presents with scrotal oedema and pain alongside the classic purpuric rash, arthralgia, and abdominal pain

• Scrotal fat necrosis — uncommon; mild-to-moderate pain in prepubertal overweight boys after cold exposure
• Appendicitis — can rarely present with referred scrotal pain

Critical Priority: Testicular Torsion

• Salvage rate >90% if detorsion occurs within 6 hours
• Salvage rate drops to <10% after 24 hours
• When in doubt, surgical exploration should not be delayed for imaging

Distinguishing Features at a Glance

Button Battery Ingestion — CXR Behind the Heart (Esophageal Location)

Why the Esophagus is Dangerous

• Electrical current generating hydroxide radicals at the negative pole → liquefactive necrosis
• Pressure necrosis from direct mucosal contact
• Heavy metal toxicity (lithium, manganese)

Immediate Management

1. Do NOT wait — Urgent Endoscopic Removal

• Esophageal button battery = surgical/endoscopic emergency
• Target removal within 2 hours of ingestion; do not delay for a full stomach (NPO status)
• Contact on-call pediatric surgery/gastroenterology immediately

2. Pre-Endoscopy Measures (While Arranging Removal)

• Honey (in children >12 months): 2 teaspoons every 10 minutes until endoscopy — coats the battery, reduces tissue injury from alkaline current. Recommended by NASPGHAN guidelines.
• Sucralfate suspension: 10 mL every 10 minutes (if available) — similar mucosal protective role
• Do NOT attempt to induce vomiting
• Do NOT give food or water (except honey/sucralfate as above)
• NPO otherwise

3. Endoscopic Removal

• Performed under general anaesthesia with airway protection
• Use Roth net or alligator forceps — avoid grasping battery directly to prevent leakage of contents
• Remove with the negative pole (flat side) trailing to avoid further injury
• Inspect the entire esophagus for injury after removal

4. Post-Removal Assessment

• Do NOT discharge immediately — inspect mucosa carefully for degree of burn/necrosis
• If esophageal injury found: keep NPO, IV fluids, IV antibiotics, consider imaging (CT chest/neck) to assess for fistula or vascular injury
• Arrange repeat endoscopy at 2–4 weeks if significant mucosal injury

Identifying Battery vs. Coin on CXR

Disposition Summary

Key Contacts

• National Battery Ingestion Hotline (USA): 202-625-3333 (24/7)
• NASPGHAN Guidelines and ASGE Guidelines are the primary references for management protocols

Ferrous Sulphate (Iron) Overdose — Consequences & Treatment

Toxic Doses

Note: Ferrous sulphate is 20% elemental iron by weight. A 325 mg tablet contains ~65 mg elemental iron.

Pathophysiology

• Directly damages GI mucosa (corrosive effect)
• Enters systemic circulation and is taken up by mitochondria
• Disrupts oxidative phosphorylation → metabolic acidosis (lactic acidosis)
• Generates free radicals → lipid peroxidation in liver, heart, kidneys, brain
• Causes vasodilation and increased capillary permeability → distributive shock

Five Clinical Stages of Iron Toxicity

Stage 1 — GI Toxicity (0–6 hours)

• Nausea, vomiting (often haematemesis), diarrhoea (may be bloody), abdominal pain
• Caused by direct mucosal injury
• Mild cases may not progress beyond this stage

Stage 2 — Apparent Recovery / Latent Phase (6–24 hours)

• Temporary clinical improvement
• Do not be deceived — iron continues to be absorbed and redistributed intracellularly
• Severe poisoning skips this phase and deteriorates directly

Stage 3 — Systemic Toxicity (12–24 hours)

• Metabolic acidosis (anion gap), lactic acidosis
• Cardiovascular: hypotension, shock (distributive ± haemorrhagic)
• Hepatotoxicity: elevated LFTs, coagulopathy, jaundice
• CNS: lethargy, coma, seizures
• Renal failure
• Coagulopathy: iron directly inhibits thrombin and other clotting factors

Stage 4 — Hepatic Failure (48–96 hours)

• Fulminant hepatic necrosis
• Coagulopathy, hypoglycaemia, encephalopathy
• Most common cause of death in severe iron poisoning

Stage 5 — GI Scarring (2–8 weeks)

• Gastric outlet obstruction or pyloric stenosis from fibrotic healing of the corrosive mucosal injury
• Presents with persistent vomiting weeks after apparent recovery

Investigations

Serum iron >500 µg/dL (>90 µmol/L) at 4–6 hours post-ingestion is associated with severe systemic toxicity and is an indication for chelation.

Treatment Approach

1. Resuscitation (Immediate)

• Airway, Breathing, Circulation
• IV access, continuous cardiac monitoring
• Aggressive IV fluid resuscitation for shock (normal saline boluses)
• Correct hypoglycaemia with IV dextrose
• Correct coagulopathy with FFP/vitamin K if needed
• ICU admission for severe toxicity

2. GI Decontamination

• Activated charcoal: NOT effective — iron does not bind to activated charcoal
• Gastric lavage: Limited role; may be considered if massive ingestion within 1–2 hours and patient is not vomiting
• Whole-bowel irrigation (WBI): The preferred decontamination method
  • Polyethylene glycol-electrolyte solution (e.g., GoLYTELY)
  • Rate: 2 L/hour in adults, 0.5 L/hour in children, via NG tube
  • Patient must be seated upright
  • Continue until rectal effluent is clear
  • Especially useful if radiopaque tablets visible on AXR
  • Contraindicated in ileus, haemodynamic instability, or bowel perforation (Harrison's, p. 13027)

3. Chelation Therapy — Deferoxamine

• Serum iron >500 µg/dL (>90 µmol/L)
• Symptomatic toxicity: shock, metabolic acidosis, altered consciousness, or significant GI haemorrhage
• Serum iron > TIBC

• IV infusion: 15 mg/kg/hour (preferred route in severe toxicity)
• Maximum: 6 g in 24 hours (though higher doses have been used in extremis)
• Continue until:
  • Urine colour returns to normal (no more ferrioxamine excretion)
  • Patient clinically improves
  • Serum iron normalises
  • Acidosis resolves

• Hypotension (with rapid infusion — keep rate ≤15 mg/kg/hr)
• Pulmonary toxicity (ARDS) with prolonged use >24–48 hours
• Yersinia enterocolitica sepsis (iron is a growth factor for this organism)

4. Supportive Care

• Liver failure: N-acetylcysteine has been used as hepatoprotective adjunct
• Renal failure: Consider dialysis (ferrioxamine is dialysable)
• GI injury: Proton pump inhibitors, consider surgical consultation if perforation suspected
• Late pyloric obstruction: May require endoscopic dilatation or surgical correction

Summary Algorithm

Iron ingestion
     ↓
Estimate elemental iron dose
     ↓
<20 mg/kg → Observe, supportive care
>20 mg/kg → AXR + serum iron at 4–6 hrs + ABG + LFTs
     ↓
Radiopaque tablets on AXR? → Whole-bowel irrigation
     ↓
Serum iron >500 µg/dL or symptomatic?
     → YES → IV Deferoxamine 15 mg/kg/hr + ICU
     → NO → Observe, repeat iron level at 8 hrs

Prognosis

• Mild-to-moderate toxicity (<60 mg/kg): generally good prognosis with supportive care
• Severe toxicity (>60 mg/kg) with shock or coma carries significant mortality, especially if hepatic failure develops
• Late complication of pyloric/gastric scarring may occur even after seemingly mild initial presentations

Clinical Classification of Scrotal Swelling

The Three Examination Questions

1. Can you get above the swelling?
   • Yes → swelling originates within the scrotum
   • No → swelling extends into the inguinal canal → suggests inguinoscrotal hernia
2. Is the testis palpable separately from the swelling?
   • Yes → swelling is extratesticular (epididymal or paratesticular)
   • No → swelling is either intratesticular or encloses the testis (e.g., hydrocele)
3. Does the swelling transilluminate?
   • Yes → fluid-filled (e.g., hydrocele, epididymal cyst)
   • No → solid or blood-filled (e.g., tumour, haematocele, hernia)

Classification Framework

Class 1 — Cannot Get Above the Swelling

Class 2 — Can Get Above, Testis NOT Separately Palpable

Class 3 — Can Get Above, Testis Palpable Separately

Summary Decision Tree

Scrotal swelling
       ↓
Can you get above it?
   NO → Inguinoscrotal hernia
   YES ↓
Is testis palpable separately?
   NO → Does it transilluminate?
         YES → Hydrocele
         NO  → Haematocele / Pyocele
   YES ↓
Where is the swelling?
   Epididymis/cord → Epididymal cyst / Epididymitis / Varicocele
   Testis itself   → Tumour / Orchitis / Torsion
       ↓
Does it transilluminate?
   YES → Cystic (benign likely)
   NO  → Solid — USS mandatory, exclude malignancy

Investigations to Support Clinical Classification

Classification of Scrotal Swelling by Pain

Painful Scrotal Swellings

Painless Scrotal Swellings

Important Caveats

• Testicular tumours can occasionally present with pain (~10%) due to haemorrhage within the tumour or a secondary reactive hydrocele — a painful testis does not exclude malignancy
• Epididymo-orchitis can mimic torsion in early stages; Doppler USS is essential when the distinction is unclear
• Chronic epididymitis may cause a dull, intermittent ache rather than acute pain
• Any painless solid intratesticular lump must be treated as a tumour until proven otherwise — urgent USS and tumour markers are mandatory

Quick Bedside Rule