Case Conference

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Case Conference

• Vincent Patrick Tiu Uy
• PGY-1
• January 4, 2011

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General Data

• 17 year old male with scrotal pain

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History of Present Illness
() Testicular pain, bilateral, with no radiation
to the inguinal area, graded 3-4/10, more
pronounced when standing, relieved by sitting ()
Difficulty in walking (-) Dysuria, penile
discharge, hematuria No medications taken Denies
history of trauma to the groin No prior history
of testicular pain
12 hours PTC
Consult to Emergency Department
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History
Review of Systems Unremarkable. Most mentioned in the HPI
Past Medical History Insomnia (?) taking Seroquel, no previous hospitalizations, no previous surgeries, NKDA
Family History Denies any medical/surgical problems among immediate family members
Social History Child lives in an apartment with parents and siblings. No pets at home. No recent travel. Denies any introduction of new foods. Child feels safe at home. Admits to prior sexual activity with 1 female partner. Denies smoking, alcohol and illicit drug use.
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Physical Examination
General Appearance Alert and awake, prefers to sit
Vital Signs T 98 HR 102 RR 20 BP 122/79 SO2 98 RA
Head, Eyes, Ears, Nose Throat, Neck NCAT, pinkish conjunctivae, anicteric sclerae, nasal septum midline, TMs intact, dry oral mucosa, non-hyperemic OP, supple neck, no CLAD
Chest and Cardiovascular CTAB, S1/S2, no murmurs
Abdominal Exam Flat abdomen, hypoactive bowel sounds, no tenderness, no palpable masses, (-) rebound, (-) Rovsings sign, (-) Psoas sign, (-) Obturator sign, (-) Murphys sign
GU/Rectal Tanner V, no penile discharge nor erythema of the tip. Uncircumcised. B/L descended testes. No obvious discoloration of the scrotum. () tenderness to palpation of both testes. No Phrens sign, no blue dot sign and no bag of worms. Transillumination negative for fluid.
Extremities No edema, no cyanosis, brisk capillary refill
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Differentials?
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Management in the ED

• STAT Scrotal Ultrasound
• Urinalysis normal
• Urine sent for culture normal
• Urine GC/Chlamydia sent - negative

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Scrotal Ultrasound
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Scrotal Ultrasound
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Scrotal Ultrasound
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Scrotal Ultrasound
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Impression/Disposition

• Signed off as a case of Epididymitis Small
  Varicocoele
• Pain relief Prophylactic antibiotics

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Evaluation Management of Children with
Testicular Pain or Swelling
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Anatomy of the Testis
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Key Questions in the History

Characteristic of the pain Recurrent pain suggests torsion
History of trauma
History of change in the size of the testicle Changes during Valsalva suggests communicating hydrocoele or varicocele
Sexual history STDs can cause epididymitis
Difficulty voiding urine Suggests intraabdominal mass (hernia), UTI, neurologic problems or spinal cord disease
Flank pain or Hematuria Suggests kidney stone with referred pain to the scrotum
Abdominal pain with diminished appetite, nausea and vomiting Suggests testicular torsion
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Focused Exam

• Inspection
• Palpation
• Cremasteric Reflex
• Phrens sign
• Blue dot sign

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Inspection

• Inspect while the patient is standing check the
  penis, pubic hair and inguinal areas.
• Inspect for ulcers, papules, pubic hair
  infestations or lymphadenopathy
• Does the patient have any tattoo? Piercings?

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Inspection

• The left testicle is slighlty lower than the
  right

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Palpation

• Roll the testicle between thumb and forefingers
  to look for masses
• Palpate for the epididymis and go up towards the
  spermatic cord.
• Transilluminate the scrotum if swelling is
  suspected.

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Predicting Testicular Size
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Cremasteric Reflex

• Stroking the upper thigh results in elevation of
  the ipsilateral testicle.
• Usually present in boys 30 months to 12 years
• Less reliable in teenagers and infants

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Phrens Sign

• Elevation of the scrotal contents relieves pain
  in patients with epididymitis and not with
  testicular torsion.
• POSITIVE SIGN Relief of pain with elevation
  EPIDIDYMITIS
• Not a reliable exam in most situations.

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Blue Dot Sign

• Almost always suggestive of torsion of the
  appendix testis.

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Additional Tests
Test Purpose
Complete Blood Count Elevated WBC count in torsion Test usually obtained for pre-operative purposes
Urinalysis and Culture R/o UTI Pyuria may be seen in Epididymitis
Gram stain, culture, rapid molecular amplification testing of urethral discharge -or- Nucleic amplification test of urine R/o sexually transmitted diseases
Color Doppler Ultrasound of the Scrotum Check perfusion R/o torsion if cannot be excluded on clinical grounds
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Differential Diagnosis

• Testicular Torsion
• Torsion of Appendix Testis
• Epididymitis/Orchitis

• Trauma
• Incarcerated Inguinal Hernia
• Henoch-Schoenlein Purpura
• Referred Pain
• Non-specific

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Differential Diagnosis

• Hydrocoele
• Varicocoele
• Spermatocoele
• Testicular Cancer

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Torsion of the Testicle

• Inadequate fixation of the testis to the tunica
  vaginalis through the gubernaculum
• Bell-clapper deformity
• Twisting of the spermatic cord
• Venous compression and edema
• Ischemia

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Torsion of the Testicle

• Peak incidence in the neonatal period and the
  pubertal period
• 65 occur during the 12-18 year old range due to
  increasing weight of the testicles

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Torsion of the Testicle

• Abrupt onset of severe testicular or scrotal pain
  lt12 hours of duration
• 90 have associated nausea and vomiting
• Pain can be constant unless the testicle is
  torsing and detorsing
• Most boys report a previous episode in the past

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Torsion of the Testicle

• Diagnosis is made clinically. Impression is
  stronger if there are previous episodes
• Doppler ultrasound should be done if there are
  uncertainty in diagnosis
• False positive scans (diminished blood flow)
• Large hydrocoeles
• Abscess
• Hematoma
• Scrotal hernia
• False negative scans
• Spontaneous detorsion or Intermittent
  torsion-detorsion

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Torsion of the Testicles

• Timing of operation
• 4-6 hours (100)
• gt12 hours (20)
• gt24 hours (0)
• The contralateral testis should also be explored
  bell-clapper deformity is usually bilateral
• Surgical Detorsion Orchiopexy
• Orchiectomy if non-viable

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Torsion of the Appendix Testis/Epididymis

• Pedunculated shapes of these structures
  predispose them to torsion
• Occurs most commonly in 7-12 year old boys

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Torsion of the Appendix Testis/Epididymis

• Pain is of sudden onset, similar to testicular
  torsion
• The testicle is non-tender, but there is a tender
  localized mass usually at the superior or
  inferior pole
• () Blue dot sign gangrenous appendix
• Doppler ultrasound may be necessary to rule out
  testicular torsion will show a lesion of low
  echogenicity. Blood flow to the affected area
  may be increased
• Radionuclide scan may show the hot dog sign of
  the torsed appendage.

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Torsion of the Appendix Testis/Epididymis

• Management

Bed rest, Analgesia, Scrotal Support
5-10 days out patient
Resolution
Surgery
Removal of the appendage exploration of
contralateral testis not necessary
No follow-up necessary
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Epididymitis

• Inflammation of the epididymis
• Occur more frequently in late adolescent boys and
  even in younger males who deny sexual activity.
• Risk factors
• Sexual activity
• Heavy physical exertion
• Direct trauma
• Bacterial epididymitis think of anatomical
  abnormalities

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Epididymitis

• () Sexual activity

• (-) Sexual Activity

• Chlamydia
• N. gonorrhea
• E. coli
• Viruses
• Ureaplasma
• Mycobacterium
• CMV
• Cryptococcus (HIV)

• Mycoplasma
• Enteroviruses
• Adenovirus

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Epididymitis

• Acute or subacute onset of testicular pain
• History of urinary frequency, dysuria, and fever
• Normal vertical lie on exam, scrotal erythema,
  () scrotal edema, inflammatory nodule
• Normal cremasteric reflex, with negative Prehns
  sign

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Epididymitis

• Doppler ultrasound may be necessary to rule out
  testicular torsion
• All patients should get a urinalysis and urine
  culture
• CDC guidelines in sexually active boys
• Gram-stained smear if urethral exudates or
  intrautheral swab specimen or Nucleic
  amplification test
• Urine culture of a first void urine
• RPR and HIV testing

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Epididymitis
ADMSSION CRITERIA CHILDREN SEXUALLY ACTIVE
Doubt diagnosis (?Torsion) () Leukocytes in urine Empiric antibiotics Bactrim/Keflex Ceftriaxone x 1 Doxycycline x 10 days
Severe pain () Leukocytes in urine Empiric antibiotics Bactrim/Keflex Ofloxacin
Immunocompromised (-) Leukocytes in urine Supportive treatment NON-BACTERIAL Levofloxacin
Unreliable patient (-) Leukocytes in urine Supportive treatment NON-BACTERIAL Levofloxacin
Non-compliance (-) Leukocytes in urine Supportive treatment NON-BACTERIAL Levofloxacin

• It is equally important to treat sexual partners
  if an STD is the likely cause.
• Supportive therapy Scrotal support, bed rest and
  NSAIDS

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Other Causes Clues
CAUSES CLUES MANAGEMENT
Trauma Rarely compression of the testis against the pubic bone from straddle injury ? Testicular rupture Hematocoele ? Intratesticular hematoma Color doppler may diagnose the abnormality
Incarcerated Inguinal Hernia Audible bowel sounds in the scrotum
Henoch-Schonlein Purpura Nonthrombocytopenic purpura, arthralgia, renal problems, abdominal pain, GI bleeding Treatment is supportive ? bleeding in the GIT is more priority in management
Orchitis Usually viral (Mumps, Rubella, Coxsackie, Echovirus) Brucellosis Pain and tenderness of the testis with peculiar shininess of the scrotal surface Symptomatic treatment ? rest and ice packs, NSAIDS
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Other Causes Clues
CAUSES CLUES MANAGEMENT
Referred Pain Other signs and symptoms may be apparent Examples include Urolithiasis Nerve root impingement Retrocecal appendicitis Tumor
Nonspecific Scrotal Pain Mild scrotal pain in the light of a normal exam Imaging is not necessary Treatment is not necessary
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Scrotal Swelling
Scrotal Swelling History PE
Hydrocele () Transillumination Increase in size during the day or with Valsalva If non-communicating, no change in size.
Varicocele The spermatic cord has a bag of worms feeling secondary to vessel dilation The varicoceles may be more palpable with standing or with Valsalva (-) Transilluminate
Spermatocele Painless, fluid filled cyst on the head of the epididymis () Transillumination localized to the head of the testis
Testicular CA Firm, painless mass that does not transilluminate () Reactive hydrocele
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Brain Teaser

• An 18 year old male was seen in the ED for
  scrotal pain of 1 day. He denied previous
  episodes before. He recently recovered from a
  febrile infection about a week ago. Patient is
  sexually active with female partners. On exam,
  the testes were not enlarged, () tender to
  palpation B/L, Prehns sign was negative, no blue
  dot sign noted. Urinalysis showed leukocyte
  esterase and nitrites with pyuria. The ED
  attending asks you Whats the plan?

1. No additional test is needed treat empirically
   with Ceftriaxone and Doxycycline
2. Test for STDs like Chlamydia and Gonorrhea
3. Send the urine for culture and sensitivity
4. Scrotal ultrasound to immediately rule out
   torsion.
5. Admit the patient and annoy the floor team

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Brain Cruncher

• A 16 year old male was seen in the ED for acute
  onset of scrotal pain. On further questioning,
  he has had prior episodes of scrotal pain which
  lasted for only 2 minutes on the average. The
  astute ER attending got a urinalysis and scrotal
  ultrasound. The final diagnosis was testicular
  torsion. To alleviate the patients anxiety as
  to benefit of immediate surgery, what should the
  ED attending ask the patient at this point?

1. Where exactly is the pain?
2. What is the quality of the pain?
3. Was there any trauma to the groin?
4. What time did the pain happen?
5. Did you take any pain reliever and did it help
   with the pain somehow?

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Thank you!