the red hot scrotum - california chapter...
TRANSCRIPT
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The Red Hot Scrotum
Andrew L Freedman, M.D. FAAP
Director- Pediatric Urology
Cedars Sinai Medical Center
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Disclosures
• PI on multicenter clinical trial of Botox for neurogenic bladder ¡ Sponsor Allergan
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Acute Scrotum
This is not one of them.
Practical approach to the Evaluation
Treatment
For the child with an acute scrotum
Clinical Experience Pet Peeves
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Why not a cookbook approach
• Literature is a grab bag of numbers ¡ Selection bias
¡ Age bias
¡ Not everyone is explored
§ Diagnosis is assumed
¡ Tremendous overlap in presentation
• High cost for getting it wrong ¡ Loss of an organ
¡ One of the most common torts
§ Urologists and Primary Care
¡ Expensive mistake
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Challenge
• Need to distinguish between multiple competing diagnosis that present very similarly
• Tools are limited
¡ Ultrasound- most accurate but not perfect ¡ History, Physical and Labs are all very non-specific
• High cost to getting it wrong
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Acute Scrotum-Differential Diagnosis
• Testicular Torsion • Torsion of the Appendix Testis • Epididymitis • Henoch-Schonlein Purpura • Trauma • Incarcerated Inguinal Hernia • Varicocele • Hydrocele • Lymphadema • Spermatocele • Testis tumor • Scrotal Cellulitis • Orchitis- mumps, viral • Orchalgia • Referred pain- retrocecal appendicitis, prostatitis • Intermittent Torsion
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Acute Scrotum
• Testicular Torsion • Torsion of the Appendix Testis • Epididymitis • Henoch-Schonlein Purpura • Trauma • Incarcerated Inguinal Hernia • Varicocele • Hydrocele • Lymphadema • Spermatocele • Scrotal Cellulitis • Orchitis- mumps, viral • Orchalgia • Referred pain- retrocecal appendicitis, prostatitis • Intermittent Torsion
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Acute Scrotum
• Testicular Torsion • Torsion of the Appendix Testis • Epididymitis • Henoch-Schonlein Purpura • Trauma • Incarcerated Inguinal Hernia • Varicocele • Hydrocele • Lymphadema • Spermatocele • Scrotal Cellulitis • Orchitis- mumps, viral • Orchalgia • Referred pain- retrocecal appendicitis, prostatitis • Intermittent Torsion
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Acute Scrotum
• Testicular Torsion • Torsion of the Appendix Testis • Epididymitis • Henoch-Schonlein Purpura • Trauma • Incarcerated Inguinal Hernia • Varicocele • Hydrocele • Lymphadema • Spermatocele • Scrotal Cellulitis • Orchitis- mumps, viral • Orchalgia • Referred pain- retrocecal appendicitis, prostatitis • Intermittent Torsion
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Acute Scrotum
• Testicular Torsion • Torsion of the Appendix Testis • Epididymitis • Henoch-Schonlein Purpura • Trauma • Incarcerated Inguinal Hernia • Varicocele • Hydrocele • Lymphadema • Spermatocele • Scrotal Cellulitis • Orchitis- mumps, viral • Orchalgia • Referred pain- retrocecal appendicitis, prostatitis • Intermittent Torsion
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Acute Scrotum
• Testicular Torsion • Torsion of the Appendix Testis • Epididymitis • Henoch-Schonlein Purpura • Trauma • Incarcerated Inguinal Hernia • Varicocele • Hydrocele • Lymphadema • Spermatocele • Scrotal Cellulitis • Orchitis- mumps, viral • Orchalgia • Referred pain- retrocecal appendicitis, prostatitis • Intermittent Torsion
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Acute Scrotum
• Testicular Torsion • Torsion of the Appendix Testis • Epididymitis • Henoch-Schonlein Purpura • Trauma • Incarcerated Inguinal Hernia • Varicocele • Hydrocele • Lymphadema • Spermatocele • Scrotal Cellulitis • Orchitis- mumps, viral • Orchalgia • Referred pain- retrocecal appendicitis, prostatitis • Intermittent Torsion
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Acute Scrotum-Typical Scenario
• Family calls, child is having acute testicular pain • No fever, nausea, vomiting, trauma or dysuria • Otherwise healthy
¡ No prior urologic history
• Send to ED/your office/specialist office • Exam mild pain when touched • Comfortable when lying still
• Obtain Ultrasound ¡ Normal flow in testes ¡ Increased flow in epididymis ¡ Called epididymitis
• What’s your diagnosis?
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• Do you think an otherwise healthy pre-pubertal child with a normal urine has epididymo-orchitis?
¡ What organism?
¡ Do you treat with antibiotics?
§ Which antibiotic?
• What else can it be?
• How to differentiate
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Acute Scrotum
• Torsion of the Appendix Testis- 60-70%
• Testicular Torsion 10-15% of acute scrotum ¡ 1/4000 age <25
• Epididymitis 5-10%
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Rule out Epididymitis
• Epididymitis is very common post-pubertal patients ¡ Most epididymitis is due to an STI ¡ Most common cause of pain in adolescent and adults ¡ But very rare in pre-pubertal patients
• So for me to believe its epididymitis I need a good story ¡ A reason this child is at risk
• Fever • UTI symptoms
¡ At least a positive UA • Congenital anomaly
¡ Neurogenic bladder ¡ Hypospadias ¡ Ectopic ureter
• Recent instrumentation • Urologic history
¡ Urethral stricture
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Rule out Epididymitis
• Non STI causes ¡ UTI bugs- E coli, Klebsiella
¡ Specific infections- Mumps (very rare)
¡ Reactions to infections- mycoplasm, viruses
§ Resolve spontaneously
• Only small percent culture proven 4-9%
¡ Most studies do not explore everyone so if the ultrasound shows epididymal inflammation and they get better they assume is was epididymitis
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Rule out Epididymitis
• Physical findings ¡ Enlarged very tender and indurated epididymis
¡ Testis enlarged and tender
¡ Normal position and orientation
¡ Scrotal erythema and edema
¡ (+/-) Cremasteric reflex intact
• Positive urine
• Often febrile
• History and ultrasound usually not able to distinguish from torsion of appendix testis
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Epididymitis vs Torsion of Appendix testis
• Torsion of Appendix testis
• History ¡ Frequently history of mild trauma
• Physical exam ¡ No fever ¡ Normal urine ¡ Epididymis soft without induration ¡ Testis usually not very tender ¡ Exquisite tenderness at a single spot in the area of the head of testis and epididymis
¡ Blue dot sign- rarely seen but pathognomonic ¡ Ultrasound with normal flow in testis and increased flow in epididymis
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Torsion of appendix testis
• Often physical exam so clear that ultrasound is not necessary ¡ Pain only when touched
¡ Mild external changes
¡ Discrete tenderness at palpable nubbin
¡ Blue dot sign
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Appendix testis can be multiple
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Blue dot sign
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Torsion of Appendix Testis vs. Epididymitis
• If exam equivocal
¡ Fever, positive urine, or good reason -> epididymitis
¡ No story, localized pain and not torsion -> appendix testis
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Treatment
• Epididymitis ¡ Antibiotics- 3 weeks
§ Children- Bactrim
§ Adolescents/Adults- STI treatment- Ceftiaxone and Doxycycline – Chlamydia and Gonorrhea
• Torsion of Appendix testis
¡ Rest
¡ Anti-inflammatories
¡ Until 100% better
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What about Torsion
• Testicular torsion ¡ Diagnosis- you do not need to make a diagnosis you just need to decide if you want to explore
§ OK to have occasional negative explorations
¡ Ultrasound with no flow or diminished flow
¡ Cannot be sure it is one of the other two
¡ Clinical suspicion
• The diagnosis is torsion until proven otherwise
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Clinical suspicion
• Factors that increase suspicion
• Nausea and vomiting- most important
• Severe discomfort
¡ These boys cannot get comfortable
• Pain radiating to groin or abdomen
• Elevated testis
• Loss of cremasteric reflex
• Testis itself is hard and enlarged • Testis is very tender thoughout
• Reactive hydrocele
• Scrotal discoloration
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Testicular Torsion
• But there can be great overlap between conditions • A dead testis does not hurt as much as a dying testis
• Some boys will be comfortable until you touch it
• So must always start with the idea it is torsion until you are convinced it is not.
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A Tale of Two Testes
• Patient A • 13 yo boy • Woke up with pain the day before • Seen in Mexico, received a shot (unclear if Abx or pain med) • Still in pain when seen almost 30 hours later
¡ Comfortable standing ¡ Pain when you touch it ¡ No nausea, vomiting, fever ¡ Normal UA
• Ultrasound: ¡ Enlarged hyperemic epididymis on the right. ¡ Moderate right-sided hydrocele ¡ The right testicle appears enlarged with diminished blood flow compared to the left.
• Differential possibilities include epididymitis or intermittent torsion.
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A Tale of Two Testes
• Patient B ¡ 17 yo boy with acute pain that morning
¡ Seen at 6 hours, still in pain but primarily when touched, comfortable at rest
¡ No nausea, vomiting, fever or dysuria ¡ Testis very enlarged, hard and tender
¡ Scrotum very erythematous
• Ultrasound: The findings are strongly suspect for testicular torsion. The etiology of the swollen and heterogeneous epididymis on the left may also represent partial torsion with an element of inflammation
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Diagnosis
• Patient A
• Patient B
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Appearance
A B
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Ultrasound A
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Ultrasound B
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Operative findings: A
540orota)on
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Operative Findings: B
720orota)on
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This is why it is hard
• Patient A ¡ 30 hour history of pain, questionable exam and flow on US
¡ Could easily talk yourself into epididymitis
¡ Significant torsion but salvageable
• Patient B
¡ 6 hours of pain
¡ Pain only when touched
¡ Significant torsion- unsalvageable testis
• It torsion until proven otherwise
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Manual Detorsion
• Manual detorsion is often attempted in the ED ¡ This impulse should be strongly repressed
• The only role for manual detorsion is after diagnosis made if there is going to be a significant delay in getting to the OR
• Not a substitute for surgical repair
• Is very difficult to know if completely detorsed
• May create torsion
• May so muddy the diagnosis that we feel the need to explore when it may not have been necessary
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Prosthesis
• Classical teaching is to delay placement ¡ Risk of infection
¡ Age of patient
§ Size of scrotum
§ Size of prosthesis
¡ Unknown if desired
• Some groups are now advocating for immediate placement with good results in adolescents with a mature contralateral testes
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Intermittent torsion
• Uncommon condition where the testis can experience torsion and spontaneous detorsion.
• Untreated has a significant risk for developing a more definitive torsion. • Unfortunately a diagnosis of exclusion
¡ Unless witnessed there is no effective test for risk of torsion
• Treatment with bilateral orchiopexy
• But only 50% ‘success’ in preventing further painful episodes
¡ But does take torsion off the table.
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Recurrent torsion
• Can a testicle that has been fixed have a recurrent episode of torsion?
• Unfortunately yes
¡ Because operation not done properly ¡ Usually these testes are lost because of delay in diagnosis
• Even if prior repair in the clinical setting of significant pain still need to rule out torsion
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Intermittent pain
• Frequent brief episodes of discomfort is not torsion • Usually referred pain or other not emergent process
¡ Dysfunctional voiding
¡ Prostatitis
¡ Orchalgia
¡ Do not need to go to ED
¡ Voiding history/voiding diary
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A Practical Approach
• Sustained testicular pain warrant investigation ¡ Whether that is ED, Your Office, My office or radiology will depend on resources available to you, time of day, level of suspicion.
¡ But should be seen emergently
§ You will be held responsible for any delay ¡ Hard part is convincing the family this is an emergency
• Evaluation
¡ History/Physical
§ N/V, radiation of pain, reason for infection, trauma
§ Absent cremasteric reflex, location of pain, position of testis
¡ UA
¡ Ultrasound
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Practical approach
• Starting point is it is torsion until proven otherwise ¡ Rule out epididymitis
§ Give me a reason
¡ Remember torsion of appendix testis
§ Ultrasound with normal flow to testis and increased flow to epididymis
§ Localized pain
¡ If the blood flow to testis is abnormal
§ Absent or diminished then needs exploration
• If at all uncertain than should explore
• The ultrasound is only there to support your clinical suspicion not make a diagnosis
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Thankyou