1. Pediatric case conference
Scrotal pain in children

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

3. 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

4. Chief complaints
Scrotum pain since last night

5. 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

6. 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

7. 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: (-)

8. Impression ??

9. 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.

10. Normal testis anatomy

12. 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

13. 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

14. 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.

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

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

17. 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

18. Summary of patient Pre-puberty
Acute onset scrotum pain with swelling and tenderness(persistent or intemittent ?)
Pain duartion: 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

19. 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

20. 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

21. 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 ?

22. Thank you for attention