Pediatric case conference Scrotal pain in children

Personal Data Name: 蔡XX Age: 9 y/o 8 m/o (1998/5/10) Sex: male Chart No.: 9877343

2008-1-11 15:04 Vital signs: BW: 33kg 檢傷3級: BT: 35.6, HR: 99, RR: 20 病患主訴因睪丸腫脹,中度疼痛

Chief complaints Scrotum pain since last night

Present Illness No fever Left scrotum pain No dysuria Activity: decreased Appetite: good Past history: denied Vaccination: as schedule Allergy history:denied Travel history:denied

Physical Examination PAT: E4V5M6 Appearance: ill-looking Breathing: smooth, no retration Circulation: oximeter: 99%, stable E4V5M6 HEENT: throat no injection, ear-drum: ok Chest: bil. Clear, RHB without murmur

Physical Examination (continue) Abdomen: soft, mild distended, general tenderness, no muscle guarding Extremity: free, no skin rash, CRT < 1 sec Left scrotum erythema, swelling and severe tenderness, no relieved by lifting Prehn’s sign: (-)

Impression ??

The most common causes of acute scrotal pain in children torsion of the appendix testis (46%) Epididymitis (35%) Testicular torsion (16%) Lewis, AG, Bukowski, TP, Jarvis, PD, et al. Evaluation of acute scrotum in the emergency department. J Pediatr Surg 1995; 30:277.

Normal testis anatomy

Distinguishing features of conditions associated with scrotal pain Testicular torsion Torsion of appendage Acute epididymitis Historical features Peak incidence Perinatal and puberty Prepubertal <2 years and postpubertal Onset of pain Usually sudden Usually gradual Duration of pain Usually < 12 hours Usually >12 hours Usually >24 hours Previous episodes Typical Unusual If previous episode Nausea and vomiting Common Uncommon Fever History of trauma Occasional Dysuria or discharge Rare

Testicular torsion Torsion of appendage Acute epididymtis Physical findings Suggestive fingings Bell-clapper Palpable nodule "Blue dot" None Cremasteric relfex Usually absent Usually present Tenderness Testicular initially, then diffuse Appendage initially, then testis Epididymis initially, then diffuse Scrotal erythema or edema Common >12 hours

Blue dot sign Infarction and necrosis of the appendix testis can be seen as a "blue dot" sign (arrow) in 21 percent of cases. Reproduced with permission from Charise Johns, MD.

Testicular torsion Torsion of appendage Acute epididymtis Laboratory tests Pyuria Unusual Common Positive smear or culture No Often Leukocytosis Uncommon

Testicular torsion Torsion of appendage Acute epididymtis Perfusion studies Color Doppler Decreased Normal or increased Radionuclide

Urine analysis Color Amber Turbidity Clear SP. gravity 1.028 PH 7.0 Leukocyte Trace Nitrite Negative Protein Glucose Ketone Urobilinogen 1.0 Bilirubin Blood 3+ RBC 141 WBC 1 Epith-Cell

Summary of patient Pre-puberty Acute onset scrotum pain with swelling and tenderness(persistent or intemittent ?) Pain duartion: 12-24 hs Prehn’s sign: (-) U/A no pyuria Q1: Testis torsion/intermittent torsion ? Or appendage torsion ? Favor testis torsion (more information will be better) Q2: what’s next ? Consult Urologist

Urologist Consultation PE: soft abdomen Testis: L’t > R’t Left scrotum swelling with erythema Tenderness Prehn’s sign: negative Testis echo: left testis flow (+) Impression: r/o testis torsion

OP note Scrotal approach left testis torsion about 270 degree was noted, after detorsion testis color recovered, testis appendix congestion, excision of appendix was done. Right orchiopexy was done

Discussion What role is color Doppler playing in diagnosis of acute scrotum? testicular and epididymal size scrotal fluid scrotal wall thickening enlarged appendix testis arterial flow in the testis and epididymis decreased testicular perfusion testicular torsion large hydrocele Abscess Hematoma scrotal hernia Negative scans spontaneous detorsion partial or intermittent torsion How many percentages of diagnosis of testis torsion are done by clinically without color Doppler ?

Thank you for attention