1. Case Conference Vincent Patrick Tiu Uy PGY-1 January 4, 2011

2. General Data 17 year old male with scrotal pain

3. 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 Consult to Emergency Department

4. 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.

5. Physical Examination General AppearanceAlert and awake, prefers to sit Vital SignsT 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, TM’s intact, dry oral mucosa, non- hyperemic OP, supple neck, no CLAD Chest and CardiovascularCTAB, +S1/S2, no murmurs Abdominal ExamFlat abdomen, hypoactive bowel sounds, no tenderness, no palpable masses, (-) rebound, (-) Rovsing’s sign, (-) Psoas sign, (-) Obturator sign, (-) Murphy’s sign GU/RectalTanner 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 Phren’s sign, no blue dot sign and no “bag of worms”. Transillumination negative for fluid. ExtremitiesNo edema, no cyanosis, brisk capillary refill

6. Differentials?

7. Management in the ED STAT Scrotal Ultrasound Urinalysis – normal Urine sent for culture – normal Urine GC/Chlamydia sent - negative

8. Scrotal Ultrasound

12. Impression/Disposition Signed off as a case of Epididymitis + Small Varicocoele Pain relief + Prophylactic antibiotics

13. Evaluation & Management of Children with Testicular Pain or Swelling

14. Anatomy of the Testis

15. 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 STD’s 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

16. Focused Exam InspectionPalpation Cremasteric Reflex Phren’s sign Blue dot sign

17. 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?

18. Inspection The left testicle is slighlty lower than the right

19. 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.

20. Predicting Testicular Size

21. 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

22. Phren’s 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.

23. Blue Dot Sign Almost always suggestive of torsion of the appendix testis.

24. Additional Tests TestPurpose Complete Blood CountElevated WBC count in torsion Test usually obtained for pre-operative purposes Urinalysis and CultureR/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

25. Differential Diagnosis Testicular Torsion Torsion of Appendix Testis Epididymitis/OrchitisTrauma Incarcerated Inguinal Hernia Henoch-Schoenlein Purpura Referred Pain Non-specific

26. Differential Diagnosis HydrocoeleVaricocoeleSpermatocoele Testicular Cancer

27. 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

28. 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

29. Torsion of the Testicle Abrupt onset of severe testicular or scrotal pain <12 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

30. 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 AbscessHematoma Scrotal hernia False negative scans Spontaneous detorsion or Intermittent torsion-detorsion

31. Torsion of the Testicles Timing of operation 4-6 hours (100%) >12 hours (20%) >24 hours (0%) The contralateral testis should also be explored; “bell-clapper deformity” is usually bilateral Surgical Detorsion + Orchiopexy Orchiectomy if non-viable

32. Torsion of the Appendix Testis/Epididymis Pedunculated shapes of these structures predispose them to torsion Occurs most commonly in 7-12 year old boys

33. 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.

34. Torsion of the Appendix Testis/Epididymis Management Bed rest, Analgesia, Scrotal Support 5-10 days out patient Resolution Surgery No follow-up necessary Removal of the appendage; exploration of contralateral testis not necessary

35. 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

36. Epididymitis (+) Sexual activity Chlamydia N. gonorrhea E. coli VirusesUreaplasmaMycobacteriumCMV Cryptococcus (HIV) (-) Sexual Activity MycoplasmaEnterovirusesAdenovirus

37. 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 Prehn’s sign

38. 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

39. Epididymitis ADMSSION CRITERIA CHILDRENSEXUALLY ACTIVE Doubt diagnosis (?Torsion) (+) Leukocytes in urine Empiric antibiotics – Bactrim*/Keflex* Ceftriaxone x 1 + Doxycycline x 10 days Severe painOfloxacin Immunocompromised(-) Leukocytes in urine Supportive treatment [NON-BACTERIAL] Levofloxacin Unreliable patient Non-compliance It is equally important to treat sexual partners if an STD is the likely cause. Supportive therapy: Scrotal support, bed rest and NSAIDS

40. Other Causes & Clues CAUSESCLUES & 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

41. Other Causes & Clues CAUSESCLUES & 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

42. 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

44. 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, Prehn’s sign was negative, no blue dot sign noted. Urinalysis showed leukocyte esterase and nitrites with pyuria. The ED attending asks you : “What’s the plan?” A.No additional test is needed – treat empirically with Ceftriaxone and Doxycycline B.Test for STD’s like Chlamydia and Gonorrhea C.Send the urine for culture and sensitivity D.Scrotal ultrasound to immediately rule out torsion. E.Admit the patient and annoy the floor team

45. 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 patient’s anxiety as to benefit of immediate surgery, what should the ED attending ask the patient at this point? A.“Where exactly is the pain?” B.“What is the quality of the pain?” C.“Was there any trauma to the groin?” D.“What time did the pain happen?” E.“Did you take any pain reliever and did it help with the pain somehow?”

46. Thank you!