Rare Cause of Acute Scrotal Pain in Pediatric Age

The spectrum of conditions that affects the scrotum and its contents ranges from incidental findings to pathological maladies that require immediate diagnosis and treatment [1]. The most common causes of acute scrotal pain in the pediatric age group include testicular torsion, torsion of the testicular appendages, and epididymitis [2]. 

There are five testicular/epididymal appendages described in the literature [3]. Among these, the aberrant duct of Haller or vas aberrans of Haller stands out. It is located in the fissure between the testicle and the epididymis, and being pedunculated predisposes it to torsion, a situation that mimics the symptoms of acute scrotum. 

Although the diagnosis of Haller's vas aberrans torsion can be clinical, it is challenging due to its similar presentation to that of testicular torsion. Despite the clinical differences between these entities, which are important to recognize, ultrasound with Doppler should be performed to confirm the blood flow to the testicle [4,5]. 

As it is a self-limiting condition, the treatment is conservative and consists of rest and treatment with nonsteroidal anti-inflammatory drugs.

A 14-year-old male adolescent, previously healthy, sought urgent medical attention due to sudden onset of left-sided scrotal pain with a 12-hour evolution. He denied experiencing nausea, vomiting, dysuria, urethral discharge, or fever. 

Furthermore, he had not engaged in sexual activity, and there was no history of trauma or recent intense physical exertion. 

On physical examination, he showed signs of pain, with slight to moderate limitation in walking. Perineal inspection did not reveal any changes, including scrotal swelling, redness, or testicular torsion. He had tenderness on palpation in the lower left testicular region, and cremasteric reflex was inconclusive. No other complaints or abnormalities were found on physical examination. 

A testicular ultrasound with Doppler was performed, which showed a rounded formation adjacent to the lower pole of the left testicle, with areas similar in echogenicity to the testicle. Testicular blood flow was symmetrical. Testicular torsion was ruled out, and based on the morphology and location of the findings, a suspicion of Haller's vas aberrans torsion was considered. 

He was discharged with instructions to take anti-inflammatory medication, rest, and undergo clinical and imaging reevaluation in 48 hours. After this follow-up period, he reported significant improvement, residual pain and only mild tenderness on palpation of the left testicle. The ultrasound findings were consistent with those of the previous exam. 

As there was no clinical worsening, he was re-evaluated 8 days after the onset of symptoms, and it was found that the pain complaints and ultrasound abnormalities had completely resolved.

The authors draw attention to Haller's vas aberrans torsion, a rare condition to consider in cases of acute scrotal pain, especially in prepubertal individuals. Although it is a benign condition, it can present similarly to testicular torsion, a true urological emergency. It is emphasized that Haller's vas aberrans torsion is primarily characterized by sudden onset testicular pain, without urinary or systemic complaints. A tender testicular mass can be identified on palpation, the cremasteric reflex is normal, and testicular blood flow is preserved.

Rapid and accurate diagnosis is essential to determine the course of further intervention, including surgery or conservative treatment. The prognosis for these patients is excellent, with a recovery free of complications.

1. Brenner JO, Aderonke (2023) Causes of scrotal pain in children and adolescents. UpToDate.
2. Chang J, Schraga E (2022) Torsion of the Testicular Appendices and Epididymis. Medscape drugs and diseases.
3. Dalati M, Silva T, Entezari K (2015) Review of the Literature: Organ of Giraldes Epididymal Appendage Presenting as a Painless Scrotal Mass in a 19-Year-Old Male-A Rare Urologic Entity. Case Reports in Urology. 2015: 748097.
4. Fujita N, Tambo M, Okegawa T, Higashihara E, Nutahara K (2017) Distinguishing testicular torsion from torsion of the appendix testis by clinical features and signs in patients with acute scrotum. Res Rep Urol. 9: 169-174.
5. Pomajzl A, Leslie S (2022) Appendix Testis Torsion. StatPearls [Internet].