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CHAPTER 61 ■ PAIN: SCROTAL CATHERINE E PERRON, STEVEN S BIN INTRODUCTION Acute scrotal swelling or pain in a child is a potential surgical emergency requiring prompt evaluation Although some causes of acute scrotal swelling are benign and require only observation and reassurance, other causes may lead to the rapid loss of a testis if diagnosis or treatment is delayed (testicular torsion) Many diagnoses in cases of scrotal pain are most reliably made clinically, differentiating by age, historical features relating to the evolution of pain and associated symptoms, and physical examination findings PATHOPHYSIOLOGY An understanding of scrotal anatomy and development is important for rapid assessment The structures contained in the scrotum include the testis; the epididymis; appendages of the testis; and the nerve, vascular, and lymphatic structures that constitute the spermatic cord and traverse the inguinal canal into the scrotum ( Fig 61.1 ) At 32 to 40 weeks’ gestation, the testis descends through the inguinal canal from the abdomen to the scrotum The testis descends within the process vaginalis, which is an outpouching of the peritoneal cavity The abdominal portion of the process vaginalis then closes and the remaining portion, called the tunica vaginalis, is a potential space that encompasses the anterior two-thirds of the testicle Within this space, fluids of various etiologies can collect The testis, its related structures, and the layers of tissue that surround each testis in the scrotum may each relate to the pathology seen Acute conditions of the scrotum may involve ischemia, inflammation, trauma, and tumor These processes can alter blood flow to structures within the scrotum, making perfusion imaging modalities useful when correlated with clinical examination