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Ultrasonography (US) is the primary imaging modality for the evaluation of pediatric scrotal disease. The ability to obtain exceptional anatomical detail and testicular perfusion information without ionizing radiation makes it the essential tool for evaluating scrotal pain and palpable masses. Challenges arise in both the performance and interpretation of scrotal US in the child. Optimizing imaging parameters and recognizing key differentiating US features help minimize misinterpretations that can lead to poor patient outcomes. Key pearls and pitfalls in pediatric scrotal ultrasound methods and diagnoses are reviewed. Knowledge of what is normal for the various ages of childhood from neonate through adolescence is necessary for accurate US analysis. Imaging evaluation of key causes of the acute painful scrotum including testicular appendage torsion, epididymitis, and testicular torsion are discussed. Sonographic features for the diagnosis of benign and malignant scrotal masses, microlithiasis, and cryptorchidism are reviewed.

Objective: Testicular torsion is a common urological emergency, mainly in the younger population. Our aim is to evaluate the efficacy and value of testicular echogenicity in predicting testicular viability. Methods: Patients who were older than 13 years of age and were discharged with the diagnosis of testicular torsion were reviewed. Data obtained included demographic data, history, physical examination results, ultrasound findings including size, color Doppler flow, and echotexture, torsion degrees, and surgical procedure. In addition, the histopathological findings of patients who underwent orchiectomy were reviewed. Results: A total of 71 cases were diagnosed with testicular torsion between January 2016 to December 2018. The mean age at presentation was 20.4±7.0 years. The average time from the onset of pain until the presentation was 36.0±55.1 h. Out of the 71 ultrasound scans reviewed, 45.1% showed homogenous echotexture and 54.9% showed heterogeneous echotexture of the affected testis. On scrotal exploration, the mean degree of torsion was 475.7±301.8 degrees; 66.2% of the patients had a viable testis; and bilateral orchidopexy was done. The remaining 33.8% had a non-viable testis. Homogenous echotexture was after an average of 13.5 h of scrotal pain, while heterogeneous echotexture presented after 53.7 h of scrotal pain. There was a statistically significant difference between the time of presentation and echotexture changes on scrotal ultrasonography (p

The power Doppler is a useful tool in the evaluation of pediatric acute scrotal pain. Nonetheless, it may have some inherent limitations in scrotal vascularization analysis, potentially causing unnecessary surgery. The microvascular imaging ultrasound (MicroV) is an innovative Doppler technique able to improve the detection of very low flow. This retrospective study aims to compare both power Doppler and MicroV in the evaluation of a pediatric population with early-stage scrotal pain onset, first in testis vascularization analysis, and second in their diagnostic performances. 69 patients met the following inclusion criteria, age

Introduction: The prevalence of varicocele is approximately 15% in the general population, and about 2 -10 % of them have chronic scrotal pain. Microsurgical or Laparoscopic testicular vein ligations are preferred surgical options for the patient refractory to conservative therapy. Previous studies have proved the superiority of microscopic surgeries in painful varicocele treatment but the newer HD endo-vision system has improved laparoscopic vision quality signicantly and testicular veins are identied more precisely than ever before. So there is a need to relook the results of laparoscopic varicocele ligation. We have done a prospective observational study to assess patients' perceived changes in scrotal pain scores preand-post HD laparoscopic varicocele ligation. Materials and Methods: This prospective observational study was conducted at a tertiary care referral center. All patients with scrotal pain were evaluated for varicocele between September 2017 and December 2018. Varicocele patients with normal semen count with chronic scrotal pain not responding to conservative therapy were included in the study. The Laparoscopic varicocele ligation surgeries were done by HD endo-vision system under general or spinal anesthesia. Preoperative and post-operative universal pain scores were compared by Student's pair t-test. Result: A total of 34 patients (mean age, 26.2±3.9 years) underwent Laparoscopic varicocele ligation for scrotal pain symptoms. Thirty-two patients (94.11%) reported complete or marked resolution of pain at 3 months follow-up. There was no early or late postoperative complication reported in any study patient. There was a marked improvement in the mean universal pain score, from 5.6 preoperatively to 1.1 postoperatively (p=0.00011). Conclusion: HD Laparoscopic varicocele ligation has a very high success rate with minimal post-operative complications in painful varicocele management.

Introduction: Chronic scrotal pain (CSP) can be a debilitating condition for patients and is often difficult to characterize. Methods: A review of literature was performed using Embase, Cochrane and Medline databases in the period 1.January 2010 to 1.January 2021. We found 132 articles, and the authors screened abstract and references. Thirty-seven articles are included after removing duplicates. Results: This review presents a variety of medical and surgical treatment options for CSP such as spermatic cord blocks (36–80% success rate), microsurgical denervation of the spermatic cord (76–100% success rates), Botox (56% success rate), targeted ilioinguinal and iliohypogastric peripheral nerve stimulation, and radical orchiectomy (55–75% success rate). Conclusion: An overview of various treatment options, both non-surgical and surgical are provided, with the aim of establishing what may be the best treatment option for CSP.

Henoch-Schönlein purpura (HSP) is the most common vasculitis of childhood and affects the small blood vessels, leading to arthritis, abdominal pain, and renal involvement. However, scrotal involvement is a rare complication of HSP and scrotal pain. Swelling is the most frequent clinical presentation and can be easily confused with testicular torsion. If not treated in time, the scrotal inflammation will result in irreversible testicular necrosis. We report a 6-year-old male with HSP and scrotal involvement, characterized by swelling and pain on the left side of the scrotum, rashes on both lower extremities, and epididymitis. He was treated with conservative care, corticosteroids, and antibiotic therapy. We were able to avoid surgical intervention. On the 10 days of treatment, he recovered sufficiently well and was discharged. We have reviewed the literature related to HSP with scrotal involvement, identified 21 cases, and revealed that steroid therapy and/or antibiotics are the first-line of therapy in children with scrotal involvement. Vasculitis in the scrotum may predispose to testicular torsion, which is a complication that should not be overlooked. Clinicians should be aware of the atypical types of HSP. Timely diagnosis and appropriate treatment are essential for achieving the best results.

Introduction Botulinum neurotoxin (BoNT) is a recognized therapeutic agent of modern medical care, routinely used to treat medical conditions affecting a variety of organ systems including the musculoskeletal, integumentary, and urological domains. Ongoing research is exploring BoNT's potential role as a therapeutic agent for a variety of male sexual pathologies. Objective To review and analyze the literature regarding BoNT as a treatment option for male sexual dysfunction. Methods A PubMed search was performed for English-language articles in peer-reviewed journals between 1970 and 2019 (with one article from 1897). Relevant articles referenced within these texts were also included. One article did not have an accompanied English full-text available. The following search terms were used: “Botox”, “Botulinum toxin”, “Botulinum toxin A”, “Onabotulinum A”, “Abobutlinum A”, “BoNT”, “BoNT-A”, “Male sexual health”, “Male sexual pathology”, “Peyronie's disease”, “Premature ejaculation”, “Scrotal Pain”, “Penile Retraction”, “Scrotox”, “Erectile Dysfunction”, and “Botox in Urology”. Results There is interest in the potential role of BoNT in the treatment of male sexual pathologies. We identified studies that used BoNT to treat chronic scrotal content pain, premature ejaculation, erectile dysfunction, Peyronie's disease, penile retraction, and more. However, despite preclinical/clinical data indicating some potential efficacy and safety in these settings, a lack of robust clinical trial data has resulted in no current Food and Drug Administration–approved indications for the use of BoNT in the treatment of male sexual pathology. As a result, much of the current use of BoNT by today's providers is “off-label,” and ongoing clinical trials aim to further elucidate the potential role of this therapeutic agent. Conclusion Current data suggest that BoNT could have a potential role as a treatment option for certain types of male sexual pathologies. However, more randomized controlled trial data regarding its long-term safety and efficacy are necessary before a widespread clinical adoption can take place. Reddy AG, Dick BP, Natale C, et al. Application of Botulinum Neurotoxin in Male Sexual Dysfunction: Where Are We Now?. J Sex Med 2021;9:320–330.

Anterior lumbar interbody fusion (ALIF) is performed for the surgical management of lumbar degenerative disc disease with excellent results, particularly for discogenic low back pain. Commonly reported complications associated with this approach include vessel injury, retrograde ejaculation, and ureteral and viscus organ injury. The development of a varicocele after ALIF has not been previously described in the literature. We report a case of varicocele in a 35-year-old patient who underwent ALIF via a left retroperitoneal approach. No intraoperative complications were identified. The postoperative course was uneventful. He was discharged from the hospital on the 5(th) postoperative day. Three months after surgery, he complained of discomfort and scrotal pain. Examination revealed a grade 3 varicocele according to the Dubin and Amelar classification. Scrotal Doppler US demonstrated dilatation of the veins of the pampiniform plexus. A lumbar CT scan revealed a bulky left spermatic vein closed to the ureter. The patient was treated with platelet anti-aggregation. He was seen at control intervals of 1, 3 and 5 months. Progress was seen as we had a regression of clinical signs. Varicocele appears as an uncommon complication of ALIF. After reviewing the literature, we describe the occurrence of a varicocele following ALIF, its pathophysiology, and its treatment options.

Introduction: Varicocele is one of the leading causes of male infertility. Anterograde scrotal sclerotherapy (ASS) is one of the most recent techniques. Our objective is to evaluate the results of ASS in the treatment of varicocele in adults. Methods: This is a descriptive and analytical study of 660 patients treated for varicocele causing either a picture of hypofertility and/or symptomatic during the period from January 2008 to December 2018. Preoperative, intraoperative and postoperative data were analysed. Results: The average age was 30. The average duration of the intervention was 16 minutes (13-50 mins) and the average length of hospitalization was 19 hours (9-36 hours). We noticed a statistically significant improvement in all characteristics on the postoperative spermogram. Oligospermia increased from 41% to 29% (p=0.01), asthenospermia increased from 52% to 33% (p=0.02) and teretospermia from 24% to 14% (p=0.006). The paternity rate among hypofertile men was 22%. The disappearance of varicocele in postoperative was objectified in 588 patients (84%), the disappearance of scrotal pain in 322 patients (48%). Complications were identified in 70 patients (10.6%) hydrocele (27 patients, 4%), scrotal hematoma (14 patients), chemical orchitis (20 patients) and testicular atrophy (9 patients). A recurrence was noted in 73 patients (11%) at 9 months. Conclusion: SSA appears to be a reliable and reproducible technique in the treatment of varicocele, with significantly less morbidity in comparison with other techniques. We recommend it as a first-line treatment.

Background Fournier’s gangrene (FG) is a rare but deadly form of necrotizing fasciitis involving the genital, perineal, and anorectal region. Risk factors include diabetes mellitus, immunosuppression, and alcohol misuse. Because multisystem organ failure can rapidly develop, early diagnosis is critical. Treatment includes fluid resuscitation, broad-spectrum antibiotics, and surgical debridement. Uncommonly, extension of perineal infection into adjacent organs can necessitate multivisceral resection, which can make reconstruction a challenge. Even with swift diagnosis and optimal treatment, morbidity and mortality are high. Case Presentation A 66-year-old male with a history of diabetes mellitus presented to the emergency department with progressive scrotal pain, swelling, and perineal skin changes. Examination revealed necrosis of the scrotal soft tissues with involvement of the anal canal and rectum. The patient was initiated on intravenous fluids and broad-spectrum antibiotics, then brought immediately to the operating room where surgical care was provided by a urologist, colorectal surgeon, and general surgeon with expertise in complex mesh repair. Extension of necrotic changes travelling proximally through the full thickness of the rectum was noted. The patient underwent extensive scrotal and perineal debridement, laparotomy, abdominoperineal resection (APR), end colostomy, and polyglactin mesh repair of the resultant pelvic floor defect. The patient had appropriate return of bowel function and satisfactory healing of the perineum postoperatively but ultimately died after a ventricular fibrillation-related cardiac arrest precipitated by a flare of idiopathic pulmonary fibrosis. Conclusion Early diagnosis and referral to the appropriate specialists are essential elements of managing FG. Here we present a case with extension of necrotizing soft tissue infection into the rectum, requiring pelvic dissection and APR as well as absorbable mesh use to aid in perineal closure. Despite expedient treatment, poor outcomes with this condition are unfortunately common.

Zinner syndrome is a rare congenital malformation related to an abnormality in the development of the Wolffian duct, the clinical picture of which consists of a triad of unilateral renal agenesis, ipsilateral seminal vesicle cyst, and obstruction of the ejaculatory duct. Chronic perineoscrotal pain may be an indication of the diagnosis of Zinner syndrome to some extent. We report the observation of a 23-year-old patient, married and father of one child, who presented with chronic perineo-scrotal pain revealing on morphological assessment (ultrasound, uroscanner, prostatic MRI) a cystic formation of the seminal vesicle, left renal agenesis with an empty left renal compartment. Given the patient’s refusal of any surgical procedure, treatment consisted of echo-guided puncture of the seminal vesicle cyst bringing back 30 cc of a seroviscous liquid whose analysis revealed spermatozoa, without atypical cells, compatible with a cyst. The clinical evolution was marked by a progressive remission of the scrotal pain with a delay of several months.

Objective: To study the value of the filarial dance sign as a diagnostic sign in scrotal ultrasonography in human Bancroftian filariasis. Methods: We studied 3 patients with scrotal pain, with high-resolution ultrasonography (HRUS) of scrotum including power and color Doppler study. All patients underwent peripheral blood smear. Results: Multiple cystic spaces containing motile echogenic twisted tubular structures were observed in the 3 patients. Peripheral blood smears in the 3 patients confirmed the presence of microfilaria. Mild hydrocele in two patients. Conclusions: HRUS is a useful technique for diagnosing scrotal filariasis in symptomatic patients and is very useful in the follow-up treatment.

Purpose This study has been conducted to identify the rate of varicocele recurrence in patients who underwent microscopic subinguinal varicocelectomy at our center. We also aimed to determine the contributing factors to varicocele recurrence. Patients and methods A total of 34 married male patients who underwent microscopic sub-inguinal varicocelectomy were retrospectively included in this study. The medical records of recruited patients were reviewed. The diagnosis of varicocele was based on physical examination, while recurrent varicocele was diagnosed based on both physical examination and colored doppler ultrasound. We investigated contributing factors to varicocele recurrence, including demographic characteristics (such as body mass index), clinical (varicocele grade and size of dilated veins), and laboratory data (semen analysis). Patients were followed up at 3 and 6 months after surgery. Results The mean age of patients was 32.53 years. The majority of patients had left-sided varicocele (70.6%) and underwent surgery due to scrotal pain (82.4%), with a mean operation duration of 92 minutes. Left-sided varicoceles were grade II in 51.7% of patients, while right-sided varicoceles were grade II in 16.1% of patients. Recurrence occurred in 2.9% after 3 and 6 months. Pain recurred in 8.8% and 10.5% of patients at 3 and 6 months, respectively. Pregnancy rates were 44.1% at 3 months and 11.8% at 6 months after surgery. The grade of varicocele (P = 0.24) and the size of the left dilated vein (P = 0.002) was significantly associated with recurrence. Conclusion There was a significant association of advanced grade on the left side and large vein diameter before and after surgery with an increased rate of recurrence; however, due to the small sample size of our study, more and larger studies are still warranted.

BACKGROUND Acute scrotal swellings are common in both children and adults. It is a medical emergency which warrants immediate attention. Though these swellings are frequently encountered, many a times correct diagnosis is not made or delayed, and testis needs to be sacrificed. METHODS In this study 60 cases of acute scrotal swelling were studied from to evaluate the possible aetiological factors and common presentations in patients presenting with acute scrotal swelling. Cases were evaluated based on history, signs, symptoms, and clinical examination. RESULTS The most common cause of scrotal swelling is epididymo-orchitis (41.67 %); the second most common is pyocele (18.33 %). The maximum incidence of scrotal swelling occurred in the age group of 31 - 40 years (45.00 %), followed by 21 - 30 (23.33 %) years age group. All cases had swelling of scrotum, and were associated with pain. Out of 60 cases, 56.67 % cases were given conservative treatment and 43.33 % cases were treated surgically. There was no mortality in our study and all cases showed good recovery in six month follow up. CONCLUSIONS Most common cause of scrotal swelling is epididymo-orchitis. Second most common is pyocele, followed by haematocele. Presence of scrotal swelling with pain is seen in all cases along with fever in some cases, but not in all. Patients with Fournier's gangrene can present with septicaemia with shock. Most common predisposing factor is idiopathic. Earliest presentation was recorded in case of haematoma followed by scrotal trauma, followed by Fournier’s gangrene. Presence of urinary symptoms, with similar complaints in the past, is an important predisposing factor for acute scrotum. Involvement of right side is more common than left side, particularly in epididymo-orchitis.

Background: Fournier's gangrene (FG) is a debilitating type of infective necrotizing fascitis of the perineal, genital, or perianal regions. Despite the rarity of this disease, unfavorable ­prognosis related to this disease depends much on the timing of medical care. Hence; the present study was undertaken for assessing and summarizing data of surgical management of 30 patients of Fournier gangrene. Materials & methods: Thirty patients who presented with clinical signs and symptoms suggestive of FG were enrolled. Emergency debridement of all the patients was carried out under the cover of broad spectrum antibiotics. Tissue samples were subjected to analysis for culture and antibiotic sensitivity testing. At the time of first debridement, hydrogen peroxide was used, followed by Eusol dressings until slough had separated. This was followed by Povidone Iodine dressings until the wound was healthy and ready for graft. Fournier’s Gangrene Severity Index (FGSI) was assessed. Surgical management procedures employed were recorded separately and follow-up was done. Results: Mean age of the patients was 58.4 years. Diabetes was found to be present in 66.67 percent of the patients. Mean FGSI score was found to be 3.96. Mean number of debridements was found to b 4.69. Fever, scrotal pain and headache were the most common symptoms encountered in the present study. Mean duration of hospital stay was 30.1 days. Partial thickness skin grafting was done in 36.67 percent of the cases while thigh pouch reconstruction was done in 20 percent of the cases. Secondary suturing was done in 53.33 percent of the cases. Multiple additional incisions on inguinal region and psoas for draining abscess were done in 12 patients. Mortality was nil in the present study. Conclusion: Adequate debridement along with surgical therapy results in significant favorable outcome in FG patients. Also, mortality can be significantly reduced by achieving with rapid diagnosis and carrying out urgent surgical debridement of all necrotic tissues under cover of adequate antimicrobial therapy.

Background: Testicular pain encompasses a vast medical diagnostic field, with numerous organ and system convergence. Acute testicular pain is a medical emergency that requires accurate evaluation and immediate resolution, whereas chronic testicular pain is enigmatic and requires sound knowledge of the mechanisms of testicular pain and the differential diagnosis. Objective: To review the causes of testicular pain and propose a new etiologic classification consisting of 10 subgroups. Methods: A bibliographic search was carried out utilizing Google and the National Library of Medicine’s PubMed databases to identify original articles and review articles (hard copy or electronic) published on testicular pain, up to March 2020. The search included: MeSH terms: testicular disease (classification, complications, etiology, trauma, microbiology, pathology, pathophysiology, secondary, surgery, treatment) and vasectomy; Non-MeSH terms: acute and chronic orchialgia, scrotalgia, orchidynia, groin pain, epididymalgia, testalgia, chronic testicular pain, chronic scrotal pain syndrome, testicular pain syndrome, epididymal pain syndrome, and post-vasectomy pain syndrome. The initial search produced 625 articles, of which 143 were included in the present review. Results: To better understand testicular pain etiology, 100 possible diagnoses were divided into ten subgroups: infectious, neoplastic, traumatic, torsional, vascular, immunologic, neurologic, pharmacologic, obstructive, and miscellaneous causes. Likewise, treatment can be divided into two main groups, according to therapeutic options: pharmacologic and non-pharmacologic, with the latter subdivided into: noninvasive and the increasingly performed invasive (surgical) alternatives. Conclusions: Testicular pain should be understood as a complex pain syndrome of enigmatic origin. Treatment success depends on the correct identification, from hundreds of possibilities, of the cause of pain. Logical grouping of those possibilities could aid in making the accurate etiologic identification.

Traditionally, inguinal hernias have been treated with open Lichtenstein hernioplasty. But in the last 2 decades, the trends have changed with the introduction of laparoscopic inguinal hernia repair techniques mainly by totally extraperitoneal herniorrhaphy. This was a case series analysis of 160 consecutive patients who underwent totally extraperitoneal repair and were included accrual between January 2015 and August 2018 in our single tertiary center. Patient demographics, details of the surgery, postoperative Visual Analogue Scale, return time to work, early and late postoperative complications, recurrence, and chronic pain were evaluated. A hundred seventy-eight repairs were performed in the study cohort (median age, 46.3 years; range, 22–84 years; men, 93%). The mean follow-up was 15 months (range = 12–30). Mean hospital stay time was 22.6 h (range 15–27). The mean surgery time was 55 min (range 35–110). Second day postoperative mean Visual Analogue Scale was 2.3 (range 1–5). The mean return time to their routine work was 8.3 days (range 5–17). Seroma (10%), scrotal pain (9%), scrotal paresthesia (6%), and hydrocele (6%) were the most commonly noted complications. Recurrence was detected in 4 (2.5%) patients. Recurrences were noted at 1st week and 6th month following surgery. Chronic groin pain was reported by 4 (2.5%) patients. Totally extraperitoneal hernia repair has become increasingly applicable among surgeons due to less postoperative pain, short return time to routine work, acceptably few complications, and recurrence rates compared with the other inguinal herniorrhaphy techniques.

The use of onabotulinum toxin A to chemically denervate the testis has been studied as a minimally invasive therapy to treat chronic scrotal pain. To our knowledge no randomized, controlled trials of onabotulinum toxin A for chronic scrotal pain management have been reported to date.In this double-blind, randomized, controlled trial men with chronic scrotal pain who achieved at least temporary pain relief following a cord block with local anesthesia were randomly assigned to a block using local anesthesia alone vs local anesthesia plus 200 IU onabotulinum toxin A. Standardized assessments of pain levels using a visual analogue score, disease impact, quality of life and mood were performed 1, 2, 3, 4, 12 and 18 weeks after injection. The study primary outcome was the change in the visual analogue score at 1 month. After study completion the men in the control group were given the option to receive onabotulinum toxin A as part of an open label trial.Of 64 men with a mean ± SD age of 45.9 ± 11 years and a mean 5.7 ± 5.7-year history of pain 32 received local anesthesia plus onabotulinum toxin A and 32 received local anesthesia alone. There was no statistically significant difference in any measured outcome when comparing those who received onabotulinum toxin A to controls. Nine of the 13 men (69.2%) in the open label trial achieved an improvement in the visual analogue score (mean group score 6.1 ± 1.66 to 4.5 ± 2.36, Student t-test p=0.022) with a reduction in persistent pain at 3 months in 6 of the 9 (66.7%).This randomized, double-blind, controlled trial showed no superiority of onabotulinum toxin A plus local anesthesia over local anesthesia alone for pain control in men with chronic scrotal pain. Interestingly, significant pain improvement was noted in our open label onabotulinum toxin A trial, suggesting a potential placebo effect.

Purpose Many experts recommend ordering an ultrasound and a urinalysis on all patients with scrotal pain. While the ultrasound may help diagnose a number of potential causes of scrotal pain, the urinalysis primarily has value in assessing for epididymo-orchitis. This study sought to evaluate the utility of these diagnostic tests for patients who presented to the emergency department (ED) with acute scrotal pain and possible epididymo-orchitis. Patients and methods This was a single-center chart review of patients presenting to the ED with scrotal pain. Trained research assistants reviewed charts to obtain urinalysis and ultrasound results as well as diagnoses and treatments provided. Using the final diagnosis as a gold standard, the sensitivity and specificity of ultrasound and urinalysis were calculated for the diagnosis of epididymo-orchitis. Also, through a prespecified definition of "changed management," we estimated the percentage of cases in which a urinalysis changed management of patients with acute scrotal pain. Results We identified 663 adult and pediatric patients who presented with scrotal pain during 2016. All patients had an ultrasound performed, and 458 (69.1%) had a urinalysis done. The sensitivity of urinalysis for epididymo-orchitis was 58.2% (95% CI 48.9% to 67.1%), and the specificity was 85.1% (95% CI 80.8% to 88.7%). For ultrasound, the sensitivity was 78.8% (95% CI 71.4% to 85.0%) and the specificity was 98.1% (95% CI 96.4% to 99.1%). In 24 of 458 cases (5.2% [95% CI 3.4% to 7.7%]) where a urinalysis was obtained, its results may have changed management of the patient. Conclusion The diagnosis of patients who present to the ED with scrotal pain is primarily driven by the ultrasound results. While the urinalysis may occasionally provide some benefit in the evaluation of patients with suspected epididymo-orchitis, the reflexive ordering of a urinalysis in patients with scrotal pain may be unnecessary.

Objectives Acute scrotal pain in children is a common presenting complaint in hospital, and it is imperative that cases of testicular torsion are identified and managed promptly. We aim to identify the most influential points in the pathway in determining whether patients are managed in the appropriate time frame, so these areas can be targeted to improve salvage rates. Methods Using quality improvement principles, the pediatric scrotal pain pathway was mapped out, commencing with initial symptom onset and ending with definitive surgical management. We retrospectively reviewed data on all patients between 0 and 18 years of age attending the emergency department at Whipps Cross University Hospital with acute scrotal pain between October 2010 and October 2013. Results Over the 3-year period, 238 patients 18 years or younger presented to casualty with scrotal pain. Of the patients assessed initially by an emergency department physician, 52.8% (n = 67) were discharged without referral. To our knowledge, none of these patients presented later with a missed torsion. Torsion was diagnosed in 23.2% of the patients operated on (n = 22), of which 5 required orchidectomy, comprising 2.1% of all patients presenting with scrotal pain. In this group, 4 were due to late presentation by the patient. Conclusions We demonstrate the value of different stages of the pathway, as more than half of patients seen in A&E were correctly discharged without referral. In the context of our study, late presentation to hospital appears to be the most significant factor leading to orchidectomy. To target this issue, awareness among both children and parents must be improved.