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testis after neonatal torsion is rare and therefore management remains
controversial. A recent survey of pediatric urologists indicates that most advocate
for exploration of neonatal torsion through a scrotal incision with orchiopexy of
the contralateral testicle, as most view neonatal torsion as a surgical emergency.

EVALUATION AND DECISION
Although this chapter is entitled scrotal pain, the most efficient approach to the
differential diagnosis is through consideration of the important entities causing
painful versus painless scrotal swelling. This approach is outlined in Figure 61.9
. The specific causes of painful and painless scrotal swelling are discussed
previously in this chapter ( Table 61.1 ). As noted, some etiologies may cause
either painful or painless scrotal swelling. No one aspect of the history or physical
examination may be diagnostic, but collectively the clinical findings often
suggest a diagnosis. Color Doppler ultrasonography is a helpful adjunct when the
clinician is fully aware of the capabilities and limitations, and it is readily
available so as not to delay necessary surgical intervention.

Initial Approach
As a first step in the evaluation of the child with a complaint of scrotal swelling
or pain, the physician should determine whether the child is suffering from a
generalized edematous state, such as the nephrotic syndrome. When the problem
is localized to the scrotum, patients can be divided into those who have a painless
swelling and those who are experiencing pain.