Transcript Evaluation of Scrotal Pain 1.4.11 Case Conference

Case Conference
Vincent Patrick Tiu Uy
PGY-1
January 4, 2011
General Data
17 year old male with scrotal pain
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
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.
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, nonhyperemic 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
Differentials?
Management in the ED
STAT Scrotal Ultrasound
Urinalysis – normal
Urine sent for culture – normal
Urine GC/Chlamydia sent - negative
Scrotal Ultrasound
Scrotal Ultrasound
Scrotal Ultrasound
Scrotal Ultrasound
Impression/Disposition
Signed off as a case of Epididymitis + Small Varicocoele
Pain relief + Prophylactic antibiotics
Evaluation & Management of Children
with Testicular Pain or Swelling
Anatomy of the Testis
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
Focused Exam
Inspection
Palpation
Cremasteric Reflex
Phren’s sign
Blue dot sign
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?
Inspection
The left testicle is slighlty
lower than the right
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.
Predicting Testicular Size
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
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.
Blue Dot Sign
Almost always suggestive
of torsion of the
appendix testis.
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
-orNucleic 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
Differential Diagnosis
Testicular Torsion
Trauma
Torsion of Appendix
Testis
Incarcerated Inguinal
Hernia
Epididymitis/Orchitis
Henoch-Schoenlein
Purpura
Referred Pain
Non-specific
Differential Diagnosis
Hydrocoele
Varicocoele
Spermatocoele
Testicular Cancer
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
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
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
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
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
Torsion of the Appendix
Testis/Epididymis
Pedunculated shapes of
these structures
predispose them to
torsion
Occurs most commonly
in 7-12 year old boys
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.
Torsion of the Appendix
Testis/Epididymis
Management
Bed rest, Analgesia, Scrotal Support
5-10 days out patient
Resolution
No follow-up necessary
Surgery
Removal of the appendage;
exploration of contralateral testis not
necessary
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
Epididymitis
(+) Sexual activity
(-) Sexual Activity
Chlamydia
Mycoplasma
N. gonorrhea
E. coli
Viruses
Ureaplasma
Mycobacterium
CMV
Cryptococcus (HIV)
Enteroviruses
Adenovirus
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
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
Epididymitis
ADMSSION
CRITERIA
Doubt diagnosis
(?Torsion)
Severe pain
Immunocompromised
Unreliable patient
Non-compliance
CHILDREN
SEXUALLY ACTIVE
(+) Leukocytes in urine
Empiric antibiotics –
Bactrim*/Keflex*
Ceftriaxone x 1 +
Doxycycline x 10 days
(-) Leukocytes in urine
Supportive treatment
[NON-BACTERIAL]
Levofloxacin
Ofloxacin
• It is equally important to treat sexual partners if an STD is the likely cause.
• Supportive therapy: Scrotal support, bed rest and NSAIDS
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
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
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
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
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?”
Thank you!