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

2. 17 year old male with scrotal pain
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
12 hours PTC
Consult to Emergency Department

4. History Review of Systems Past Medical History Family History
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. Denies sexual activity. Denies smoking, alcohol and illicit drug use.

5. 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, TM’s 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, (-) Rovsing’s sign, (-) Psoas sign, (-) Obturator sign, (-) Murphy’s 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 Phren’s sign, no blue dot sign and no “bag of worms”. Transillumination negative for fluid.
Extremities
No edema, no cyanosis, brisk capillary refill

6. Differentials?

7. Management in the ED
STAT Scrotal Ultrasound
Urinalysis – normal

8. Scrotal Ultrasound

9. Scrotal Ultrasound

10. Scrotal Ultrasound

11. Scrotal Ultrasound

12. 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
Apart from the obvious, the tunica vaginalis and the epididymis are two structures often missed in the examination of the testicles. Understanding the normal anatomy can guide the clinician. The tunica vaginalis occupies the anterior 2/3 of the testicle, where it becomes a potential space for fluid collection. The epididymis, if palpable, can be located posterolaterally to 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 Inspection Palpation 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.
Not a reliable exam in most situations.

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

24. 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

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

26. Differential Diagnosis
Hydrocoele
Varicocoele
Spermatocoele
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 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
Abscess
Hematoma
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
The appendix testis is a small vestigial structure on the anterosuperior aspect of the testis (which is an embryologic remnant of the Mullerian duct). The appendix epididymis is a small remnant of the Wolffian duct located at the head of the epididymis.

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
Removal of the appendage; exploration of contralateral testis not necessary
No follow-up 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 (-) Sexual Activity Mycoplasma
Chlamydia
N. gonorrhea
E. coli
Viruses
Ureaplasma
Mycobacterium
CMV
Cryptococcus (HIV)
Mycoplasma
Enteroviruses
Adenovirus

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 transmitted 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 CHILDREN SEXUALLY ACTIVE
Doubt diagnosis
(?Torsion)
(+) Leukocytes in urine
Empiric antibiotics – Bactrim*/Keflex*
Ceftriaxone x 1 + Doxycycline x 10 days
Severe pain
Ofloxacin
Immunocompromised
(-) Leukocytes in urine
Supportive treatment [NON-BACTERIAL]
Levofloxacin
Unreliable patient
Non-compliance
Doxycycline is not approved for patients less than 8 years old
Quinolones should not be used in patients <18 years old if an alternative is available. However, homosexual males practicing anal intercourse should be treated with antibiotics that cover for enteric coliforms – Ofloxacin/Levofloxacin is sufficient
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 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

41. 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

42. Causes and Management of Scrotal Swelling