Acute Scrotal Pain and Swelling in Pediatric Emergency Medicine: A Narrative Review of Diagnostic and Management Challenges

Acute scrotal pain in children is a common but diagnostically complex emergency, with testicular torsion being the most time-critical differential diagnosis. Immediate recognition and surgical referral are essential to prevent irreversible ischaemia. However, diagnostic delays remain a leading cause of avoidable orchiectomy and have long-term consequences for fertility, psychosocial well-being, and medico-legal outcomes. A narrative literature search was conducted using PubMed, Ovid, Excerpta Medica Database, and the Cochrane Library, alongside United Kingdom (UK) guideline repositories including National Institute for Health and Care Excellence (NICE), Royal College of Emergency Medicine, Royal College of Paediatrics and Child Health, and National Confidential Enquiry into Patient Outcome and Death. Search terms included combinations of “acute scrotum”, “testicular torsion”, “paediatric”, “child”, "Testicular Workup for Ischemia and Suspected Torsion (TWIST) score”, “ultrasound”, and “point-of-care ultrasound”. Inclusion criteria included pediatric populations (aged <18 years), observational cohorts, systematic reviews, meta-analyses, and national or international clinical guidelines. Case reports (unless landmark), adult-only studies, and non-English publications were excluded. Torsion accounted for approximately 16% of acute scrotal pain cases, with salvage rates declining sharply beyond six hours. The TWIST score demonstrated sensitivities exceeding 90%, and point-of-care ultrasound (POCUS) expedited triage but must not delay exploration. Sports-related trauma, responsible for approximately half of pediatric genital injuries, and vasculitis were frequent diagnostic mimics, complicating timely diagnosis. UK audits revealed that nearly 40% of orchiectomies were attributable to in-hospital or transfer delays, rather than to late presentation. Based on this evidence, a TWIST-based pediatric emergency department-led pathway with structured escalation is proposed to standardise assessment, accelerate referral, and reduce variability in practice. All cases of acute pediatric scrotal pain should be managed as testicular torsion until torsion has been excluded. Adoption of structured pathways integrating TWIST scoring, NICE-based examination, early referral, and POCUS, where available, could reduce orchiectomy rates by 30-40%, although current evidence remains limited by the retrospective nature of most studies and the lack of randomised controlled trials.