case conference vincent patrick tiu uy pgy-1 january 4, 2011

Case ConferenceCase ConferenceVincent Patrick Tiu UyVincent Patrick Tiu Uy

PGY-1PGY-1January 4, 2011January 4, 2011

General DataGeneral Data

17 year old male with scrotal pain17 year old male with scrotal pain

History of Present IllnessHistory 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, hematuriaNo medications takenDenies history of trauma to the groinNo prior history of testicular pain

(+) 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, hematuriaNo medications takenDenies history of trauma to the groinNo prior history of testicular pain

Consult to Emergency DepartmentConsult to Emergency Department

HistoryHistoryReview 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. Denies sexual activity. Denies smoking, alcohol and illicit drug use.

Physical ExaminationPhysical ExaminationGeneral 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

Differentials?Differentials?

Management in the EDManagement in the ED

STAT Scrotal UltrasoundSTAT Scrotal Ultrasound

Urinalysis – normalUrinalysis – normal

Scrotal UltrasoundScrotal Ultrasound

DispositionDisposition

Signed off as a case of Epididymitis + Small Signed off as a case of Epididymitis + Small VaricocoeleVaricocoele

Pain relief + Prophylactic antibioticsPain relief + Prophylactic antibiotics

Evaluation & Management of Evaluation & Management of Children with Testicular Pain or Children with Testicular Pain or

SwellingSwelling

Anatomy of the TestisAnatomy of the Testis

Key Questions in the Key Questions in the HistoryHistory

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 ExamFocused Exam

InspectionInspection

PalpationPalpation

Cremasteric ReflexCremasteric Reflex

Phren’s signPhren’s sign

Blue dot signBlue dot sign


Inspect while the patient is standing – check the Inspect while the patient is standing – check the penis, pubic hair and inguinal areas.penis, pubic hair and inguinal areas.

Inspect for ulcers, papules, pubic hair infestations Inspect for ulcers, papules, pubic hair infestations or lymphadenopathy or lymphadenopathy

Does the patient have any tattoo? Piercings?Does the patient have any tattoo? Piercings?


The left testicle is The left testicle is slighlty lower than slighlty lower than the rightthe right

PalpationPalpation

Roll the testicle between thumb and forefingers to Roll the testicle between thumb and forefingers to look for masseslook for masses

Palpate for the epididymis and go up towards the Palpate for the epididymis and go up towards the spermatic cord. spermatic cord.

Transilluminate the scrotum if swelling is Transilluminate the scrotum if swelling is suspected.suspected.

Predicting Testicular Predicting Testicular SizeSize

Cremasteric ReflexCremasteric Reflex

Stroking the upper Stroking the upper thigh results in thigh results in elevation of the elevation of the ipsilateral testicle. ipsilateral testicle.

Usually present in Usually present in boys 30 months to 12 boys 30 months to 12 yearsyears

Less reliable in Less reliable in teenagers and infantsteenagers and infants

Phren’s SignPhren’s Sign

Elevation of the scrotal contents relieves pain in Elevation of the scrotal contents relieves pain in patients with epididymitis and not with testicular patients with epididymitis and not with testicular torsion.torsion.

Not a reliable exam in most situations. Not a reliable exam in most situations.

Blue Dot SignBlue Dot Sign

Almost always Almost always suggestive of torsion suggestive of torsion of the appendix of the appendix testis. testis.

Additional TestsAdditional Tests

Test Purpose

Complete Blood Count Elevated WBC count in torsion Test usually obtained for pre-operative purposes

Urinalysis and Culture R/o UTIPyuria 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 perfusionR/o torsion if cannot be excluded on clinical grounds

Differential DiagnosisDifferential Diagnosis

Testicular TorsionTesticular Torsion

Torsion of Appendix Torsion of Appendix TestisTestis

Epididymitis/OrchitisEpididymitis/Orchitis

TraumaTrauma

Incarcerated Inguinal Incarcerated Inguinal HerniaHernia

Henoch-Schoenlein Henoch-Schoenlein PurpuraPurpura

Referred PainReferred Pain

Non-specificNon-specific

Differential DiagnosisDifferential Diagnosis

HydrocoeleHydrocoele

VaricocoeleVaricocoele

SpermatocoeleSpermatocoele

Testicular CancerTesticular Cancer

Torsion of the TesticleTorsion of the Testicle

Inadequate fixation of Inadequate fixation of the testis to the tunica the testis to the tunica vaginalis through the vaginalis through the gubernaculumgubernaculum

““Bell-clapper” Bell-clapper” deformitydeformity

Twisting of the Twisting of the spermatic cordspermatic cord

Venous compression Venous compression and edemaand edema

IschemiaIschemia


Peak incidence in the neonatal period and the Peak incidence in the neonatal period and the pubertal periodpubertal period

~65% occur during the 12-18 year old range due ~65% occur during the 12-18 year old range due to increasing weight of the testiclesto increasing weight of the testicles


Abrupt onset of Abrupt onset of severe testicular or severe testicular or scrotal pain <12 scrotal pain <12 hours of durationhours of duration

90% have associated 90% have associated nausea and vomitingnausea and vomiting

Pain can be constant Pain can be constant unless the testicle is unless the testicle is torsing and detorsingtorsing and detorsing

Most boys report a Most boys report a previous episode in previous episode in the pastthe past


Diagnosis is made clinically. Impression is stronger if Diagnosis is made clinically. Impression is stronger if there are previous episodesthere are previous episodes

Doppler ultrasound should be done if there are Doppler ultrasound should be done if there are uncertainty in diagnosisuncertainty in diagnosis

False positive scans (diminished blood flow)False positive scans (diminished blood flow)Large hydrocoelesLarge hydrocoelesAbscessAbscessHematomaHematomaScrotal herniaScrotal hernia

False negative scansFalse negative scansSpontaneous detorsion or Intermittent torsion-detorsionSpontaneous detorsion or Intermittent torsion-detorsion

Torsion of the TesticlesTorsion of the Testicles

Timing of operationTiming of operation4-6 hours (100%)4-6 hours (100%)>12 hours (20%)>12 hours (20%)>24 hours (0%)>24 hours (0%)

The contralateral testis The contralateral testis should also be explored; should also be explored; “bell-clapper deformity” “bell-clapper deformity” is usually bilateralis usually bilateral

Surgical Detorsion + Surgical Detorsion + OrchiopexyOrchiopexy

Orchiectomy if non-Orchiectomy if non-viableviable

Torsion of the Appendix Torsion of the Appendix Testis/EpididymisTestis/Epididymis

Pedunculated shapes Pedunculated shapes of these structures of these structures predispose them to predispose them to torsiontorsion

Occurs most Occurs most commonly in 7-12 commonly in 7-12 year old boysyear old boys


Pain is of sudden onset, similar to testicular torsionPain is of sudden onset, similar to testicular torsion

The testicle is non-tender, but there is a tender The testicle is non-tender, but there is a tender localized mass usually at the superior or inferior polelocalized mass usually at the superior or inferior pole

(+) Blue dot sign – gangrenous appendix(+) Blue dot sign – gangrenous appendix

Doppler ultrasound may be necessary to rule out Doppler ultrasound may be necessary to rule out testicular torsion – will show a lesion of low testicular torsion – will show a lesion of low echogenicity. Blood flow to the affected area may be echogenicity. Blood flow to the affected area may be increasedincreased

Radionuclide scan may show the “hot dog” sign of Radionuclide scan may show the “hot dog” sign of the torsed appendage. the torsed appendage.


ManagementManagement

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

EpididymitisEpididymitis

Inflammation of the epididymisInflammation of the epididymis

Occur more frequently in late adolescent boys and Occur more frequently in late adolescent boys and even in younger males who deny sexual activity. even in younger males who deny sexual activity.

Risk factorsRisk factorsSexual activitySexual activity

Heavy physical exertionHeavy physical exertion

Direct traumaDirect trauma

Bacterial epididymitis – think of anatomical Bacterial epididymitis – think of anatomical abnormalitiesabnormalities


(+) Sexual activity(+) Sexual activity

ChlamydiaChlamydia

N. gonorrheaN. gonorrhea

E. coliE. coli

VirusesViruses

UreaplasmaUreaplasma

MycobacteriumMycobacterium

CMVCMV

Cryptococcus (HIV)Cryptococcus (HIV)

(-) Sexual Activity(-) Sexual Activity

MycoplasmaMycoplasma

EnterovirusesEnteroviruses

AdenovirusAdenovirus


Acute or subacute onset Acute or subacute onset of testicular painof testicular pain

History of urinary History of urinary frequency, dysuria, and frequency, dysuria, and feverfever

Normal vertical lie on Normal vertical lie on exam, scrotal erythema, exam, scrotal erythema, (+) scrotal edema, (+) scrotal edema, inflammatory noduleinflammatory nodule

Normal cremasteric Normal cremasteric reflex, with negative reflex, with negative Prehn’s signPrehn’s sign


Doppler ultrasound may be necessary to rule out Doppler ultrasound may be necessary to rule out testicular torsiontesticular torsion

All patients should get a urinalysis and urine All patients should get a urinalysis and urine cultureculture

CDC guidelines in sexually transmitted boysCDC guidelines in sexually transmitted boysGram-stained smear if urethral exudates or Gram-stained smear if urethral exudates or intrautheral swab specimen or Nucleic amplification intrautheral swab specimen or Nucleic amplification testtest

Urine culture of a first void urineUrine culture of a first void urine

RPR and HIV testingRPR and HIV testing


ADMSSION CRITERIA

CHILDREN SEXUALLY ACTIVE

Doubt diagnosis (?Torsion)

(+) Leukocytes in urineEmpiric antibiotics – Bactrim*/Keflex*

Ceftriaxone x 1 + Doxycycline x 10 days

Severe pain Ofloxacin

Immunocompromised

(-) Leukocytes in urineSupportive 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

Other Causes & CluesOther Causes & CluesCAUSES 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 & CluesOther Causes & CluesCAUSES 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

Causes and Management Causes and Management of Scrotal Swellingof Scrotal Swelling

case conference vincent patrick tiu uy pgy-1 january 4, 2011

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