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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