The age of the child should be considered in evaluating scrotal pain and/or swelling, but overlaps in age at presentation exist Testicular torsion occurs in the newborn or early pubertal age range Torsion of an appendage of the testis, HSP, idiopathic scrotal edema, and Kawasaki disease commonly occur in the prepubertal age group Epididymitis is more common in adolescents but may occur in prepubertal boys Historical features regarding swelling, pain, and associated symptoms should be considered A history of change in testicular or scrotal size should be determined If there is pain associated with scrotal swelling, the examiner should determine its onset and severity Pain is abrupt in onset and severe in testicular torsion, whereas the pain of appendage torsion and epididymitis may be less severe and more gradual Questions about recent activity and behavior may indicate milder pain or a more insidious course The onset of pain and even the exact location of pain in children can be difficult to pinpoint because they may not initially localize sensation to the scrotum, but rather complain of lower abdominal pain An embarrassed adolescent may not report scrotal pain early Inquire about prior episodes of pain which may indicate intermittent torsion Nausea and vomiting often accompany testicular torsion, and fever and symptoms of urinary tract infection may suggest epididymitis or other inflammatory diseases (vasculitides) A history of trauma should always be addressed, recognizing the difference between significant trauma associated with severe acute pain and minor trauma to which the pain of torsion may mistakenly be attributed Sexual activity history should be sought A history of prior genitourinary surgeries may indicate a predisposition to urinary tract infections and epididymitis related to genitourinary abnormalities or prior instrumentation Prior surgery for hernias, hydroceles, and undescended testis, unless associated with other genitourinary or anorectal abnormalities, does not suggest a predisposition to infection In addition, torsion can occur despite prior scrotal surgeries believed to secure the testis Physical Examination Initial observation of the patient’s gait, resting position, and facial expression are helpful Writhing or an especially quiet supine posture may indicate the degree of pain Associated skin changes, presence and location of swelling, and the natural position (lie) of the testicle in the scrotum while standing should then be appreciated Next note presence/absence of cremasteric reflexes and palpate the lower abdomen, inguinal canal, cord, and scrotal contents Ask the patient to localize pain with one finger if possible The unaffected hemiscrotum should be palpated first Knowledge of the location and specific attempt at palpation of the