Examqo › Examqo library › Pediatrics › Paediatric nephrology and gastroenterology · IMLE
Undescended testis and the acute scrotum in children
In the acute scrotum, testicular torsion is a surgical emergency where time is testis — operate without waiting for ultrasound when suspicion is high; and a testis that has not descended by 6 months is referred for orchiopexy, ideally done by 18 months.
Why it matters in the exam
The classic question is a 14-year-old boy with sudden severe testicular pain, nausea and vomiting, a high-riding horizontal testis and an absent cremasteric reflex — testicular torsion. The next step is urgent surgical exploration; Doppler ultrasound is done only when the diagnosis is unclear and only if it causes no delay. The chance of saving the testis is highest within the first six hours. At surgery the other testis is fixed as well.
The differential diagnosis matters: torsion of the appendix testis is common at age 7–12, with upper-pole tenderness, sometimes a "blue dot", and a preserved cremasteric reflex — and it is treated conservatively. Epididymitis develops gradually with dysuria; in a sexually active adolescent think of Chlamydia and gonorrhoea (ceftriaxone and doxycycline), and in a young child of a urinary tract anomaly. An incarcerated inguinal hernia is another cause of painful swelling.
An undescended testis (cryptorchidism) is found in about 3% of term boys and about 30% of preterm boys; most testes descend by 3 months (corrected). If not descended by 6 months — refer to a urologist, and surgery is ideally done by 18 months. Hormonal treatment is not recommended, and ultrasound before referral is not needed; a non-palpable testis is located by laparoscopy. Bilateral non-palpable testes with hypospadias need work-up for a disorder of sex development (including CAH). A "retractile" testis, which can be pulled into the scrotum and remains there, needs yearly follow-up. Early surgery reduces the risk of infertility and makes malignancy easier to detect.
Key points
- Testicular torsion — immediate surgery; salvage is best within 6 hours.
- Torsion of the appendix testis — age 7–12, blue dot, conservative treatment.
- Epididymitis in a sexually active adolescent — ceftriaxone and doxycycline.
- Undescended testis — refer at 6 months, surgery by 18 months.
- Bilateral non-palpable testes with hypospadias — DSD work-up.
Summary table
| Situation | Age and picture | Test | Treatment |
|---|---|---|---|
| Testicular torsion | Newborn and adolescent; sudden pain, vomiting, high horizontal testis, no cremasteric reflex | Surgical exploration; Doppler only if no delay | Immediate surgery and bilateral fixation |
| Torsion of the appendix testis | 7–12; upper-pole pain, blue dot, reflex preserved | Clinical, Doppler with normal flow | NSAIDs and rest |
| Epididymitis | Gradual, dysuria | Urinalysis, STI tests in adolescents | Ceftriaxone and doxycycline if sexually active; look for anomalies in the young |
| Undescended testis | 3% of term, 30% of preterm boys | Physical examination; no ultrasound before referral | Refer by 6 months; surgery by 18 months |
| Retractile testis | Can be brought into the scrotum and stays | Examination sitting or squatting | Annual follow-up |
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: Pediatrics, Medical licensing exam (IMLE), Urology, Pediatric surgery, Emergency medicine.
Subscriber? Read the full topic Plans and prices 25 free questions
Sources
- AUA Guideline: Evaluation and Treatment of Cryptorchidism, 2014 (amended 2018) — Referral timing and orchiopexy
- EAU/ESPU Guidelines on Paediatric Urology, 2024 — Acute scrotum and undescended testes
- Nelson Textbook of Pediatrics, 22nd edition (2024) — Disorders of the Scrotum and its Contents
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.