The case. I m smiling because it hurts

Transcription

1 Brad Sobolewski, MD

2 The case A 7 year old boy has been referred to the ED because his privates hurt The pain has been present for 2 days It is worse when he jumps up and down There is no history of trauma, fevers, vomiting, or diarrhea He is an otherwise healthy lad I m smiling because it hurts

3 The case GEN HEENT CV PULM ABD DERM GU NAD, comfortable appearing gradeschooler EOMI, PERRL, TM wnl, mmm, normal pharynx normal CTAB +BS, soft NT/ND, no masses, no HSM no rashes or lesions Tanner I, normal penis and urethra, cremaster reflex present, right testicle is tender to palpation, you also see this

4 History What is your differential diagnosis? What tests would you like to order? We ll return to the case later

5 Embryology A 2 months - The testes appear on the urogenital ridge B 3 rd month - The coelomic cavity evaginates into the scrotal swelling and forms the processus vaginalis C 7 th month - Testes descend into the scrotum guided by the gubernaculum D After birth - The processus vaginalis obliterates spontaneously (shortly after birth).

6 Gross anatomy quiz F E Spermatic cord Epididymis Vas deferens A D Testis Gubernaculum B C Tunica vaginalis

7 History Pain? Acute onset suggests torsion, epididymitis, or torsion of the appendix testis/epididymis Trauma? Change in size? Valsalva = hydrocele

8 History Sexually active? Epididymitis in adolescents Difficulty voiding? Think mass, cord lesion, UTI Flank pain or hematuria? Referred pain from a kidney stone Abdominal pain, nausea/vomiting? Torsion

9 Physical exam Setting the stage Get a chaperone if you or patient are uncomfortable Have the patient stand if possible If you suspect a varicocele examine the patient supine as well Respect the patient s privacy!

10 Physical exam Don t forget to examine the; Inguinal folds Penis and urethra Pubic hair Testicular position (left is lower) Testicular lie

11 Physical exam Testes Like a hard boiled egg Epididymis Postero-lateral Spermatic cord Location of varicocele

12 Physical exam Turn your head and cough Feel in the inguinal canal for a hernia Cremasteric reflex Normal in age 30 mos to 12 years May be absent in adolescents Stroke inner thigh Normal = cremaster contraction with testis elevation Absent in torsion, neuromotor disorders, L1-2 lesions Prehn sign Elevation relieves the pain of epidymitis

13 What are the top three causes of scrotal pain? Testicular torsion Torsion of the appendix testis or appendix epididymis Epididymitis

14 Testicular torsion Surgical emergency! The testicle twists on the spermatic cord Venous compression then Edema of testicle and cord then Arterial occlusion then 1/4000 males < age 25 Bimodal - neonatal and puberty 65% between ages years Likely due to increasing testicle volume

15 Bell clapper deformity Testis is not fixed to the tunica vaginalis posteriorly It is free to rotate and is at increased risk of torsion Incidence is approximately 1/125 Usually present bilaterally The testis lies horizontally and the tunica vaginalis extends up over the spermatic cord so that the testis is suspended within the tunica vaginalis by the spermatic cord

16 Testicular torsion Presentation Abrupt onset of pain <12 hours Associated N/V, lower abdominal pain In a retrospective review only 8% had pain prior to this episode (Kadish, 1998) Exam Edema of scrotum Testis tender and slightly elevated, may have a horizontal lie Cremaster reflex is absent

17 Time is of the essence Torsion is ideally a clinical diagnosis If suspected tell your Attending and call Urology ASAP Ultrasound Sensitivity % Specificity % Nuclear medicine scans are very sensitive and specific but not readily available Surgery If viable detorsion of affected testis and fixation (orchiopexy) of both testis

18 Time is of the essence Viability Rates Within 4-6 hours 100% hours 20% >24 hours 0%

19 Testicular torsion Sequelae Males may have increased risk of infertility even when viable de-torsed testis is left in scrotum because of immune-mediated injury to contralateral testis Other studies have failed to show that antisperm antibodies are present

20 Testicular torsion Intermittent torsion 80% have bell clapper deformity Pain is brief and resolves quickly (minutes) Eaton et al, 26% had nausea and vomiting, 21% pain awakened patient from sleep Neonatal torsion A topic that could have its own talk Many cases occur in utero

21 Vestigial structures Appendix testis Müllerian system Appendix epididymis Wolfian system They torse easily Torsion of the appendix testis and appendix epididymis Boys 7-12 years of age Pain is usually less severe

22 Torsion of the appendix testis and appendix epididymis The blue dot sign is the pathognomonic physical finding Due to infarction/necrosis of the appendix A reactive hydrocele may also be seen

23 Diagnosis Torsion of the appendix testis and appendix epididymis Usually clinical if you see a blue dot sign Get an Ultrasound in cases where you can t r/o torsion Management Analgesics Rest Scrotal support The pain typically resolves in 5-10 days

24 Epididymitis Etiology Sexually active? Chlamydia, gonorrhea, E.coli, viruses Prepubertal? Viruses, E. coli, mycoplasma Presentation Pain and swelling localized to the epididymis Testis has a normal lie 50% have scrotal edema The scrotum is sometimes red Cremaster reflex is present Positive Prehn sign (not reliable) Patient may have dysuria

25 Epididymitis The work-up Clinical exam Ultrasound Urinalysis Obtain in ALL patients with suspected epididymitis STD testing Get gc/chlamydia DNA of urine if sexually active Syphilis and HIV testing

26 Treatment of epididymitis Prepubertal boys Antibiotics are NOT always indicated Treat if.. Pyuria >3-5 wbc, positive U/C, or underlying UTI risk factors - TMP/SMX or Cephalexin for 10 days Teenagers (Pro-Tip: think about STDs) Ceftriaxone 250mg IM x1 then doxycyline 100mg bid x10 days For enterics AND negative STD 10 days of ofloxacin 300mg bid or levofloxacin 500mg qday Tx also includes rest, NSAIDs, and scrotal elevation

27 Other causes of scrotal pain Trauma (Duh) Incarcerated and/or strangulated hernia Henoch Schönlein purpura Orchitis (mumps) Referred pain Kidney stone Retrocecal appy Tumor

28 Though they are relatively uncommon causes of acute scrotal pain, inguinal hernias deserve mention They are generally NOT painful unless Incarceration - cannot be reduced Strangulation - vascular compromise of an incarcerated hernia In children most are indirect in that they pass through the inguinal canal More about hernias

29 More about hernias Incidence and Epidemiology 1-5% newborns and 9-11% of preemies Boys 3x Girls Right > Left, bilateral 10% full term, 50% preemies Incarceration 14-31% usually <1 year of age More common in girls, and it involves the ovary Clinical features Irritability, vomiting, and abdominal distention Firm tender discrete mass Management Manually reduce unless the child has peritonitis, obstruction, or is toxic

30 Recall that this is a 7 year old male with right sided scrotal pain and the exam finding seen at right His urinalysis is normal The ultrasound shows the following Back to the case

31 Back to the case What is the diagnosis? Torsion of the appendix testis What are your discharge instructions? Rest no running or contact sports until pain resolves NSAIDs - as needed for pain Scrotal elevation tighty whities

32 The big 5 Take home points about scrotal pain Testicular torsion is a clinical diagnosis and a surgical emergency In general urinalysis/culture and ultrasound are the most useful diagnostic tests for the workup of scrotal pain Treat epididymitis in prepubertal boys only if pyuria, postive urine culture, or UTI risk factors exist Rest, NSAIDs, and scrotal elevation are treatment mainstays In males with abdominal pain DO NOT forget to examine the testicles

33 Any questions?

34 Brad Sobolewski, MD Fellow in Pediatric Emergency Medicine