1. Urolithiasis. Syndrome of swollen scrotum.
Pavlo Hoschynsky

2. Urolithiasis
Introduction Urolithiasis is increasingly recognized in pediatric patients and is encountered in a variety of clinical settings. The wide geographic variation in the incidence of urolithiasis in childhood is related to climatic, dietary, and socioeconomic factors. Approximately 7% of urinary calculi occur in children younger than 16 years of age. Many children with stone disease have a metabolic abnormality. Revolutionary advances in the minimally invasive and noninvasive management of stone disease over the past 2 decades have greatly facilitated the ease with which stones are removed. Given the frequency with which stones recur, the development of a medical prophylactic program to prevent stone recurrences is desirable. The lifetime prevalence of kidney stone disease is estimated at 1% to 15%, with the probability of having a stone varying according to age, gender, race, and geographic location. Stone disease typically affects boys more co­mmonly as much as two to three times more frequently than females. Upper urinary tract stones occur more commonly in boys than girls by a ratio of 1.4:1 to 2.1:1.

3. Classification of stones
Stone size:
<5 mm,
5-10 mm,
> mm,
> 20 mm.

4. Classification of stones
Stone location:
upper calyx,
middle calyx or lower calyx,
renal pelvis,
upper ureter,
middle ureter or distal ureter,
urinary bladder.

5. Location of Renal stones

6. Classification of stones
X-ray characteristics
Radiopaque
Poor radiopaque
Radiolucent
Calcium oxalate dehydrate
Magnesium ammonium phosphate
Uric acid
Calcium oxalate monohydrate
Apatite
Ammonium urate
Calcium phosphates
Cystine
Xanthine
2,8-dihydroxyadenine
'Drug-stones'

7. Stones classified according to their aetiology
Non-infection stones
Calcium oxalates
Calcium phosphates
Uric acid
Infection stones
Magnesium-ammonium-phosphate
Apatite
Ammonium urate
Genetic causes
Cystine
Xanthine
2,8-dihydroxyadenine
'Drug stones'

8. Calcium oxalate monohydrates
Calcium oxalate dihydrates

9. Uric acid

10. Struvite

11. Cystine

12. High risk stone formers
General factors
Early onset of urolithiasis in life (especially children and teenagers)
Familial stone formation
Brushite containing stones (calcium hydrogen phosphate; CaHP04. 2H20)
Uric acid and urate containing stones
Infection stones
Solitary kidney (The solitary kidney itself does not have a particular increased risk of stone formation, but the prevention of a potential stone recurrence is of more importance)

13. High risk stone formers
Diseases associated with stone formation
Hyperparathyroidism
Nephrocalcinosis
Gastrointestinal diseases or disorders (i.e. jejuno-ileal bypass, intestinal resection, Crohn's disease,malabsorptive conditions)
Sarcoidosis

14. High risk stone formers
Genetically determined stone formation
Cystinuria (type A, B, AB)
Primary hyperoxaluria (PH)
Renal tubular acidosis (RTA) type 1
2,8-dihydroxyadenine
Xanthinuria
Lesh-Nyhan-Syndrome
Cystic fibrosis

15. High risk stone formers
Anatomical and urodynamic abnormalities associated with stone formation
Medullary sponge kidney (tubular ectasia)
Ureteropelvic junction (UPJ) obstruction
Calyceal diverticulum, calyceal cyst
Ureteral stricture
Vesico-uretero-renal reflux
Horseshoe kidney
Ureterocele
Urinary diversion (via enteric hyperoxaluria)
Neurogenic bladder dysfunction

16. Compounds that cause drug stones
Active compounds crystallizing in urine
• Allopurinol / oxypurinol
• Amoxicillin / ampicillin
• Ceftriaxone
• Ciprofloxacin
• Ephedrine
• Indinavir
• Magnesium trisilicate
• Sulfonamide
• Triamterene
Substances impairing urine composition
• Acetazolamide
• Allopurinol
• Aluminium magnesium hydroxide
• Ascorbic acid
• Calcium
• Furosemide
• Laxatives
• Methoxyflurane
• Vitamin D

17. Diagnostic steps in urolithiasis (UTI urinary tract infection, CT computed tomography, MR1 magnetic resonance imaging, PTH parathyroid hormone, pC02 partial pressure of carbon dioxide)

18. Fig. a,b. A 17-year-old girl with cystinuria
Fig.a,b. A 17-year-old girl with cystinuria. a) Abdominal plain radiograph showing urolithiasis on the left, b) IVU showing hydronephrosis on the left due to urolithiasis

19. Fig. a,b. A 4-year-old boy with incomplete RTA and hyperoxaluria, a Sonogram of right kidney showing medullary nephrocalcinosis grade III (Dick et al. 1999). b Sonogram of bladder showing an ureteral stone on the right immediately before the ureterovesical junction

20. An 8-year-old boy with primary hyperparathy­roidism, hypercalciuria, and urinary tract infection. Ab­dominal plain radiograph showing a huge ureteral stone on the left immediately before the ureterovesical junction

21. Bilateral Ureteric Calculus in a patient presenting with Anuria
Helical or Spiral CT provides 3D reconstruction. Helical refers to path the X ray follows on Gantry. These are rapidly performed and do not require contrast agents for reconstruction.

22. Evaluation for a suspected stone.
(RBUS)-renal/bladder ultrasound

23. extracorporeal shockwave lithotripsy (ESWL)
percutaneous nephrolithotomy -(PCNL)

24. Recommendations for pain relief during renal colic:
-1st choice: treatment should be started with an NSAID(Diclophenac sodium, Indomethacin, Ibuprofen)
-2nd choice: Hydromorphine(Pentazocine,Tramadol)
-Diclofenac sodium is recommended to counteract recurrent pain after an episode of
ureteral colic
For septic patients with obstructing stones, the collecting system should be urgently decompressed, using either percutaneous drainage or ureteral stenting.
Definitive treatment of the stone should be delayed until sepsis is resolved.
Medical expulsive therapy
Alpha-blockers (Tamsulosin, 0.4 mg, doxazosin,terazosin, alfuzosin and naftopidil)
Calcium-channel blockers(nifedipine)
Corticosteroids
Chemolytic dissolution of stones:
-Percutaneous irrigation chemolysis
-Oral Chemolysis

25. Methods of percutaneous irrigation chemolysis
Stone composition
Refs.
Irrigation solution
Comments
Struvite Carbon apatite
1-6
10% Hemiacidrin with pH Suby's G
Combination with Shockwave lithotripsy for staghorn stones
Risk of cardiac arrest due to hypermagnesaemia
Brushite 7
Hemiacidrin Suby's G
Can be considered for residual fragments
Cystine
8-13
Trihydroxymethyl- aminomethan (THAM; 0.3 or 0.6 mol/L) with pH range
N-acetylcysteine (200 mg/L)
Takes significantly longer time than for uric acid stones
Used for elimination of residual fragments
Uric acid
10,14-18
Oral chemolysis is the preferred option

27. The figure shows a 12 month-old child treated with the Modulith SLK (Storz Medical AG, Kreuzlingen).

28. Operation: percutaneous nephrolithotomy
■ Rarely used in pediatric surgery
■ Utilize a nephroscope or ureteroscope
■ Extract with visualization
■ Break larger stones using ultrasonography
Operation: open stone removal
■ Rarely necessary, only when urinary calculi are not amenable to ESWL
or PL
■ Make an incision below the 12th rib
■ Expose the kidney and the ureter
■ Open the renal pelvis and extract the stone (or ureter in the case of a
ureteral stone)
■ Wash the entire calyx system
■ Suture the pyelon or the ureter
Postoperative care
■ Ureter drain for 2–5 days with an antegrade contrast X-ray before drain
removal
■ Antibiotic therapy as prophylaxis in cases of vesicoureteral reflux
■ Urine culture once a month
■ Ultrasonography
Prognosis
■ Stone recurrence is rare if urine is sterile and an obstruction does not
occur

29. Medical treatment of recurrent stones

30. Scrotal Pain and Swelling Outline
Embryology and anatomy
Causes of Pain and Swelling
Torsion, Epididymitis, Orchitis, Trauma
History, Physical, Radiologic Exams, Labs
Causes of Swelling
Hydrocele, Varicocele, Spermatocele, Tumor, Idiopathic

31. Embryology Descent of testes at 32-40 wks gestation
Descends within processes vaginalis
Outpouching of peritoneal cavity
Tunica vaginalis is potential space that remains after closure of process vaginalis

32. Anatomy Spermatic cord –testicular vessels, lymph, vas deferens
Epididymis - sperm formed in testicle and undergo maturation, stored in lower portion
Vas Deferens – muscular action propels sperm up and out during ejaculation
Gubernaculum – fixation point for testicle to tunica vaginalis
Tunica Vaginalis – potential space
Encompasses anterior 2/3’s of testicle
Tunica albuginea is inner layer opposing testis

33. Anatomy – Nuts and Bolts
Posterior
Anterior

34. Causes of Pain and Swelling
Testicular torsion
Torsion of appendix testis
Epididymitis
Trauma
Orchitis and Others
Swelling
Hydrocele
Varicocele
Spermatocele
Tumor

35. Torsion
Inadequate fixation of testes to tunica vagnialis at gubernaculum
Torsion around spermatic cord
Venous compression to edema to ischemia

36. Epidemiology Accounts for 30% of all acute scrotal swelling
Bimodal ages – neonatal (in utero) and pubertal ages
65% occur in ages 12-18yo
Incidence 1 in 4000 in males <25yo
Increased incidence in puberty due to inc weight of testes

37. Predisposing Anatomy Bell-clapper deformity Testicle lacks normal
attachment at vaginalis
Increased mobility
Tranverse lie of testes
Typically bilateral
Prevalence 1/125

38. Torsion: Clinical Presentation
Abrupt onset of pain – usually testicular, can be lower abdominal, inguinal
Often < 12 hrs duration
May follow exercise or minor trauma
May awaken from sleep
Cremasteric contraction with nocturnal stimulation in REM
Up to 8% report testicular pain in past

39. Torsion: Examination Edematous, tender, swollen
Elevated from shortened spermatic cord
Horizontal lie common (PPV 80%)
Reactive hydrocele may be present
Cremasteric reflex absent in nearly all (unreliable in <30mo old) (PPV 95%)
Prehn’s sign elevation relieves pain in epididymitis and not torsion is unreliable

40. Intermittent Torsion
Intermittent pain/swelling with rapid resolution (seconds to minutes)
Long intervals between symptoms
PE: testes with horizontal lie, mobile testes, bulkiness of spermatic cord (resolving edema)
Often evaluation is normal – if suspicious need GU followup

41. Diagnosis – “Time is Testicle”
Ideally -- prompt clinical diagnosis
Imaging
Color doppler – decreased intratesticular flow
False + in large hydrocele, hematoma
Sens % and Spec %
Lower sensitivity in low flow pre-pubertal testes
Nuclear Technetium-99 radioisotope scan
Show testicular perfusion
30 min procedure time
Sens and spec %

42. but dec flow w/in testis
Acute torsion L testis
Dec blood flow on L
Late torsion on R
Inc blood flow around
but dec flow w/in testis

43. Images - Torsion Decreased echogenicity and size of right testicle
Nuclear medicine scan
shows "rim sign“ =no flow
to testicle and swelling

44. Management Detorsion within 6hr = 100% viability
Within hrs = 20% viability
After 24 hrs = 0% viability
Surgical detorsion and orchiopexy if viable
Contralateral exploration and fixation if bell-clapper deformity
Orchiectomy if non-viable testicle
Never delay surgery on assumption of nonviability as prolonged symptoms can represent periods of intermittent torsion

45. Intravaginal torsion with ischemia in a adolescent boy.

46. Manual Detorsion If presents before swelling Appropriate sedation
In 2/3rds of cases testes
torses medially, 1/3rd lateral
Success if pain relief, testes
lowers in scrotum
Still need surgical fixation

47. Torsion: Special Considerations
Adolescents may be embarrassed and not seek care until late in course
Torsion 10x more likely in undescended testicle
Suspicious if empty scrotum, inguinal pain/swelling
Adult Emergency Physicians accurate in bedside US diagnoses with sens of 95% and specificity of 94% (missed 1 epididymitis, no torsion)
Blavis M., Emergency Evaluation of Patients Presenting with A Cute Scrotum, Academy of Emergency Medicine. Jan 2001

48. Neonatal Torsion 70% prenatal, 30% post-natal
Post-natal typically 7-10 days after birth
Unrelated to gestation age, birth weight
Post-natal presents in typical fashion
Doppler U/S and radionucleotide scans less accurate with low blood flow in neonates
Surgical intervention if post-natal
Prenatal torsion presents with painless testicular swelling, rare testicular viability
Rare intervention in prenatal torsion

49. Perinatal torsion

50. Torsion of Appendix Testis
Small vestigial structure,
remnant of Mullerium duct
Pedunculated, 0.3cm long
Other appendix structures
Prepubertal estrogen may
enlarge appendix and cause
torsion

51. Torsion of Appendix Testis
Peak age 3-13 yo (prepubertal)
Sudden onset, pain less severe
Classically, pain more often in abd or groin
Non-tender testicle
Tender mass at superior or inferior pole
May be gangrenous, “blue-dot” (21% of cases)
Normal cremasteric reflex, may have hydrocele
Inc or normal flow by doppler U/S

52. Torsion of Appendix Testis
Blue dot of gangrenous
appendix testis

53. Testicular Appendages
Appendix testis
Appendix epididymis

55. Torsion of Appendix Testis
Management supportive
analgesics, scrotal support to relieve swelling
Surgery for persistent pain
no need for contralateral exploration

56. Epididymitis Inflammation of epididymis
Subacute onset pain, swelling localized to epididymis, duration of days
With time swelling and pain less localized
Testis has normal vertical lie
Systemic signs of infection
inc WBC and CRP, fever + in 95%
Cremasteric reflex preserved
Urinary complaints: discharge/dysuria PPV 80%

57. Epididymitis Scrotum has overlying erythema, edema in 60%
Normal vertical
lie

58. Epididymitis Sexually active males
Chlamydia > N. gonorrhea > E. coli
Less commonly pseudomonas (elderly) and tuberculosis (renal TB)
Young boys, adolescents often post-infectious (adenovirus) or anatomic
Reflux of sterile urine through vas into epididymis
50-75% of prepubertal boys have anatomic cause by imaging

59. Etiologies of Epididymitis

60. Epididymitis Diagnosis
Leukocytosis on UA in ~40% of patients
PCR Chlamydia + in 50%, GC + in 20% of sexually active
95% febrile at presentation
Doppler and Nuclear imaging show increased flow
If hx consistent with STD, CDC recommends:
Cx of urethral discharge, PCR for C and G
Urine culture and UA
Syphilis and HIV testing

61. Laboratory Adjuncts Studies of acute phase reactants: CRP, IL-1, IL-6
Documented epididymitis have 4 fold increase in CRP compared to testicular torsion
PPV 94% and NPV 94% (inc 2 fold)
Testicular tumor showed no increase in CRP
Doehn C., Value of Acute Phase Proteins in the Differential Diagnosis of A Cute Scrotum, Journal of Urology. Feb 2001.

62. Doppler Epididymitis Left Epididymitis Inc blood flow in
and around left testis

63. Epididymitis Treatment
Sexually active treat with Ceftriaxone/Doxycycline or Ofloxacin
Pre-pubertal boys
Treat for co-existing UTI if present
Symptomatic tx with NASIDs, rest
Referral all to GU for studies to rule out VUR, post urethral valves, duplications
Negative culture has 100% NPV for anomaly

64. Orchitis Inflammation/infection of testicle Spread from epididymitis,
Swelling pain tenderness, erythema and shininess to overlying skin
Spread from epididymitis,
hematogenous, post-viral
Viral: Mumps, coxsackie,
echovirus, parvovirus
Bacterial: Brucellosis

65. Mumps Orchitis Extremely rare if vaccinated
20-30% of pts with mumps, 70% unilateral, rare before puberty
Presents 4-6 days after mumps parotitis
Impaired fertility in 15%, inc risk if bilateral

66. Trauma
Result of testicular compression against the pubis bone, from direct blow, or straddle injuries
Extent depends on location of rupture
Tunica albuginea ruptures (inner layer of tuncia vaginalis) allows intratesticular hematoma to rupture into hematocele
Rupture of tunica vaginalis allow blood to collect under scrotal wall causing scrotal hematoma
Doppler often sufficient to assess extent
Surgery for uncertain dx, tunica albuginea rupture, compromised doppler flow

67. Testicular Hematoma
Blood as a filling
defect in testis

68. Other Causes of Pain Incarcerated inguinal hernia
Henoch-Schonlein Purpura
Vasculitis of testicular vessels
Rarely presents with only scrotal pain
Referred pain
Retrocecal appendix, urolithiasis, lumbar/sacral nerve injury
Non specific scrotal pain
Minimal pain, nl exam – return immediately for inc symptoms

69. Scrotal Swelling
Hydrocele
Varicocele
Spermatocele
Testicular Cancer

70. Hydrocele Fluid accumulation in potential space of tunica vaginalis
May be primary from
patent PV or secondary
to torsion/epididymitis

71. Hydrocele
Transilluminating
anterior cystic
mass

72. Hydrocele
Mass increases in size during day or with crying and decreases at night if communicating
If non-communicating and <1 yo follow
If communicating (enlarging), scrotum tense (may impair blood flow) requires repair
Unlikely to close spontaneously and predisposes to hernia

73. Varicocele Collection dilated veins in pampiniform plexus
surrounding spermatic cord
More common on left side
R vein direct to IVC
L vein acute angle to renal vein
~20% of all adolescent males

74. Varicocele Often asymptomatic or c/o dull ache/fullness upon standing
Spermatic cord has ‘bag of worms’ appearance that increased with standing/valsalva
If prepubertal, rapidly enlarging, or persists in supine position rule out IVC obstruction
Most management conservatively
Surgery if affected testis < unaffected testis volume

75. Spermatocele Painless sperm containing cyst of testis, epipdidymis
Distinct mass from testis
on exam
Transilluminates
Do not affect fertility
Surgery for pain relief only

76. Testicular Cancer Painless mass
Most common solid tumor in yo males
20% of all cancers in this group
Painless mass
Rapidly growing germ cell tumors may cause hemorrhage and infarction
Present as firm mass
Typically do not transilluminate
Diagnostic imaging with U/S initially

77. Acute Idiopathic Scrotal Edema
Scrotal skin red and tender
underlying testis normal
no hydrocele
Erythema extends off
scrotum onto perineum
Empiric tx, cause unknown
Antihistamine, steroids
Resolves w/in 48-72hrs

78. Conclusions
Clinical history and careful exam are key factors in formulating accurate differential
Imaging and labs useful adjuncts in unclear cases
U/S superior to nuclear imaging if time essential
TIME IS TESTICLE
Early surgical intervention and GU involvement
Swelling without pain, usually less time sensitive diagnostically

79. Thank you for listening

80. References
Ciftci, AO. Clinical Predictors for Diff. Diagnosis of Acute Scrotum, European J. of Ped. Surgery. Oct 2004.
Blavis M., Emergency Evaluation of Patients Presenting with Acute Scrotum, Academy of Emergency Medicine. Jan 2001
Doehn C., Value of Acute Phase Proteins in the Differential Diagnosis of Acute Scrotum, Journal of Urology. Feb 2001.
Kaplan G., Scrotal Swelling in Children. Pediatrics in Review. Sep 2000.
Luzzi GA. Acute Epididymitis. BJU International. May 2001.
Fleisher G, Ludwig S, Henretig F. Textbook of Pediatric Emergency Medicine