Case Conference

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 12 hours PTC Consult to Emergency Department

4. History

5. Physical Examination

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

15. Key Questions in the History

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

25. Differential Diagnosis • Testicular Torsion • Torsion of Appendix Testis • Epididymitis/Orchitis • Trauma • Incarcerated Inguinal Hernia • Henoch-SchoenleinPurpura • 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 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 • 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

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

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 • 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

41. Other Causes & Clues

42. Causes and Management of Scrotal Swelling