Dr Prashant Jain. Sr. Consultant, Pediatric surgery BLK Superspeciality Hospital

Transcription

1 Dr Prashant Jain Sr. Consultant, Pediatric surgery BLK Superspeciality Hospital

2 Acute Scrotum Presentation 0 Pain in scrotal area 0 Scrotal swelling 0 Scrotal redness

3 take him to nearby emergency...

4 Acute scrotum Epididymitis/ Orchitis Incarcerated Hernia Differential Diagnosis Torsion of Testis Torsion of testicular appendages cellulitis

5 Diagnostic Dilemma 0 History: Similar 0 Examination: Similar 0 Investigations: Inconclusive Prompt diagnosis is mandatory

6 Good history taking is important 0 Timing of onset: acute or insidious onset 0 Prior episodes 0 Age at presentation 0 Vomiting 0 Fever and Dysuria

7 Pathology Age of presentation Torsion of testis (Extravaginal) yrs Torsion of testis (Intravaginal) Perinatal Torsion of testicular appendage Before puberty...peak at 11yrs Epididymitis Mumps Orchitis Incarcerated hernia Idiopathic scrotal edema Infants and at puberty After puberty Any age 0-5 yrs

8 Thorough physical Examination is important 0 Size 0 Location of swelling 0 Look for tenderness 0 High Riding Testes /Tranverses lie 0 Scrotum is Edematous and Erythematous 0 Cremasteric Reflex

9 High riding testis

10 Cremasteric reflux Absence of cremasteric reflux is highly suggestive of torsion Presence of cremasteric reflux doesn't rules out torsion in 10% of cases

11 Torsion of testis 0 Twisting of spermatic cord 0 Number of twists/delay in presentation 0 Types: 0 Intravaginal: Adolescent 0 Extravaginal: Newborn

12 Bell Clapper Deformity

13 Bell Clapper Deformity Bilateral

14 0 Transverse lie 0 High riding left testes 0 Cremasteric reflex absent in nearly all 0 Color doppler: Sensitivity: 69-86% Specificity: 87% to 100% Accuracy: 73% to 97% 0 Lower sensitivity in pre-pubertal testis 0 Nuclear scan: Historical imortance

15 Time is Testes 0 Reported testicular salvage rates are 90% to 100% if surgical exploration is performed within six hours of symptom onset 0 Decreases to 50% if symptoms are present for more than 12 hours 0 Less than 10% if symptom duration is 24 hours or more

16 Time is Testes 0 True Emergency 0 Golden Period 6-8 hrs 0 Colour Doppler sensitivity good in experienced hands in adolescent age 0 Do not waste time in investigations 0 In doubt- Emergent Scrotal exploration

17 Scrotal Exploration Contralateral exploration and fixation

18 Intermittent testicular torsion 0 Intermittent testicular pain 0 Resolves spontaneously 0 One third of patients of testicular torsion have previous history of testicular pain 0 Transverse testicular lie and excess testicular mobility 0 Elective exploration

19 Torsion of testicular appendages 0 Most common cause of acute scrotum in prepubertal age 0 Often mis diagnosed 0 Discrete painful mass...blue dot sign 0 Conservative management: Scrotal support/ analgesia/restricted activities

20 Epididymo-Orchitis 0 Gradual onset 0 Infancy and puberty 0 Associated with fever & voiding symptoms 0 Cremasteric reflux present 0 Doppler US: Increase in size and blood flow 0 Mostly viral...needs only supportive management 0 Bacterial infection : urinary congenital anomaly & sexulally active adolescents

21 Epididymo-Orchitis -orchitis Urine R/M Normal Anti-inflammatory Scrotal support Pyuria Antibiotics Imaging Recurrent

22 Incarcerated Hernia 0 Infant crying excessively 0 Genitalia not examined 0 Presented after 3 days with incarcerated hernia & gangrenous testis Hernia to be repaired as soon as possible

23 Other causes... Idiopathic Scrotal edema Henoch- Schonlein Purpura Scrotal hematoma Varicocoel Testicular tumors

24 Evaluation History and physical examination of the scrotum Consistent with or highly suggestive of testicular torsion Questionable diagnosis Doppler ultrasonography of the scrotum surgical exploration Absent blood flow consistent with torsion Normal or increased blood flow consistent with inflammation or torsion of testicular appendage No further testing needed

25 Good History taking and examination Prompt diagnosis Do not waste time in investigations Early referral Slightest of doubt...surgery

26 Thank you