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ACR Appropriateness Criteria® Acute Onset of Scrotal Pain — Without Trauma, Without Antecedent Mass

Remer, Erick M. MD*; Casalino, David D. MD; Arellano, Ronald S. MD; Bishoff, Jay T. MD§; Coursey, Courtney A. MD; Dighe, Manjiri MD; Fulgham, Pat MD#; Israel, Gary M. MD**; Lazarus, Elizabeth MD††; Leyendecker, John R. MD‡‡; Majd, Massoud MD§§; Nikolaidis, Paul MD; Papanicolaou, Nicholas MD∥∥; Prasad, Srinivasa MD¶¶; Ramchandani, Parvati MD##; Sheth, Sheila MD***; Vikram, Raghunandan MD†††; Karmazyn, Boaz MD‡‡‡

doi: 10.1097/RUQ.0b013e3182493c97
ACR Appropriateness Criteria

Men or boys, who present with acute scrotal pain without prior trauma or a known mass, most commonly suffer from torsion of the spermatic cord; epididymitis or epididymoorchitis; or torsion of the testicular appendages. Less common causes of pain include a strangulated hernia, segmental testicular infarction, or a previously undiagnosed testicular tumor. Ultrasound is the study of choice to distinguish these disorders; it has supplanted Tc-99 m scrotal scintigraphy for the diagnosis of spermatic cord torsion. MRI should be used in a problem solving role if the ultrasound examination is inconclusive. The ACR Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that are reviewed every two years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

*Cleveland Clinic, Cleveland, Ohio; †Northwestern University, Chicago, Illinois; ‡Massachusetts General Hospital, Boston, Massachusetts; §Intermountain Urological Institute, Murray, Utah, American Urological Association; ∥Emory University Hospital, Atlanta, Georgia; ¶University of Washington Medical Center, Seattle, Washington; #Presbyterian Hospital of Dallas, Dallas, Texas, American Urological Association; **Yale University School of Medicine, New Haven, Connecticut; ††Alpert Medical School of Brown University, Providence, Rhode Island; ‡‡Wake Forest University School of Medicine, Winston Salem, North Carolina; §§Children’s National Medical Center, Washington, District of Columbia, Society of Nuclear Medicine; ∥∥Hospital of University of Pennsylvania, Philadelphia, Pennsylvania; ¶¶University of Texas Health Science Center, San Antonio, Texas; ##University of Pennsylvania Hospital, Philadelphia, Pennsylvania; ***Johns Hopkins Hospital, Baltimore, Maryland; †††University of Texas MD Anderson Cancer Center, Houston, Texas; and ‡‡‡Riley Hospital for Children, Indiana University, Indianapolis, Indiana.

Received for publication November 29, 2011; accepted December 22, 2011.

The authors declare no conflict of interest.

The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply society endorsement of the final document.

Reprinted with permission of the American College of Radiology.

Corresponding author information: Erick M. Remer, MD, Department of Radiology (A21), Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195-0001 (e-mail:

Reprints: Department of Quality & Safety, American College of Radiology, 1891, Preston White Drive, Reston, VA 20191-4397 (e-mail:

© 2012 Lippincott Williams & Wilkins, Inc.