case conference vincent patrick tiu uy pgy-1 january 4, 2011
TRANSCRIPT
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Case ConferenceCase ConferenceVincent Patrick Tiu UyVincent Patrick Tiu Uy
PGY-1PGY-1January 4, 2011January 4, 2011
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General DataGeneral Data
17 year old male with scrotal pain17 year old male with scrotal pain
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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
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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.
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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
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Differentials?Differentials?
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Management in the EDManagement in the ED
STAT Scrotal UltrasoundSTAT Scrotal Ultrasound
Urinalysis – normalUrinalysis – normal
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Scrotal UltrasoundScrotal Ultrasound
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Scrotal UltrasoundScrotal Ultrasound
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Scrotal UltrasoundScrotal Ultrasound
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Scrotal UltrasoundScrotal Ultrasound
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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
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Evaluation & Management of Evaluation & Management of Children with Testicular Pain or Children with Testicular Pain or
SwellingSwelling
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Anatomy of the TestisAnatomy of the Testis
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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
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Focused ExamFocused Exam
InspectionInspection
PalpationPalpation
Cremasteric ReflexCremasteric Reflex
Phren’s signPhren’s sign
Blue dot signBlue dot sign
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InspectionInspection
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?
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InspectionInspection
The left testicle is The left testicle is slighlty lower than slighlty lower than the rightthe right
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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.
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Predicting Testicular Predicting Testicular SizeSize
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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
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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.
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Blue Dot SignBlue Dot Sign
Almost always Almost always suggestive of torsion suggestive of torsion of the appendix of the appendix testis. testis.
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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
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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
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Differential DiagnosisDifferential Diagnosis
HydrocoeleHydrocoele
VaricocoeleVaricocoele
SpermatocoeleSpermatocoele
Testicular CancerTesticular Cancer
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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
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Torsion of the TesticleTorsion of the Testicle
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
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Torsion of the TesticleTorsion of the Testicle
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
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Torsion of the TesticleTorsion of the Testicle
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
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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
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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
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Torsion of the Appendix Torsion of the Appendix Testis/EpididymisTestis/Epididymis
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.
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Torsion of the Appendix Torsion of the Appendix Testis/EpididymisTestis/Epididymis
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
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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
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EpididymitisEpididymitis
(+) 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
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EpididymitisEpididymitis
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
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EpididymitisEpididymitis
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
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EpididymitisEpididymitis
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
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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
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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
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Causes and Management Causes and Management of Scrotal Swellingof Scrotal Swelling
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