Painful Swelling

1. Torsion of epididymal or testicular appendage. Produces gradual discomfort, with periods that are relatively pain free. Progression of inflammation by involvement of epididymis results in steady scrotal pain. Patients often relate having experienced testicular pain a few days earlier, followed by pain-free period; scrotal inflammation and pain may worsen with increased physical activity.

2. Torsion of cord (testis torsion). Most commonly occurs in early puberty (prenatal or neonatal period is second most common time of presentation). Characterized by intense, escalating pain. Patient is unable to find a comfortable position. Nausea and vomiting are common.

3. Incarcerated hernia. More common in infants. May be associated with vomiting as incarceration progresses. These are indirect inguinal hernias due to a persistence of patent processus vaginalis. Usually noted during periods of increased abdominal pressure, during straining or crying.

4. Epididymitis. Rare in childhood; initially produces mild, diffuse tenderness that progresses to involve entire hemiscrotum.

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