PER
Hsu Tso Hung 03.20.2008
Scrotal pain or swelling in
children and adolescents
Our case
y Name: Chen x x
y Sex: boy
y Age: 13 y/o, 62 Kg
y Chief complaint: Scrotal pain and swelling since 0229
y Vital signs: BP:130/56 mmHg, TPR: 36/89/19
y Physical examinations: Swelling, tenderness, and erythematous change over scrotum
Lab data
DATE TIME ALB TP BIL,T BIL,D ALKP AST ALT LDH
970303-1135 80
DATE WBC RBC HGB HCT MCV PLT NEUT LYM MON EOS BAS 970303 9400 4.65 13.9 40.7 87.6 280 72.4 18.8 7.8 0.6 0.4
DATE TIME NA K CL CA BUN CREAT CRP LIPASE 970303-1135 141 3.9 0.7 5.1
DATE TIME GLUCOSE PT-P PT-C APTT-P APTT-C TRO-T 970303-1135 93 10.0 10.5 32.6 29.0
DATE SPGR PH PROT GLU KETO BIL UROB OB NIT RBC WBC EPCEL 970303 1.005 7 - - - - 0.1 - - -2 -2 -1
Scrotal image
PER course
y Arrange scrotal image: A photopenic defect in the left scrotum on the dynamic and static image
Torsion of the left testis should be considered
y Arrange sonography: no perform
y Consult PEDS Dr. for suspected torsion of testis
y Emergent surgery (orchiectomy) on 0303
y Surgical pathology: Testis, left, orchiectomy ---
Hemorrhagic infarct, involved testis and epididymis.
The cut end of spermatic cord shows congestion
ACUTE SCROTUM
Discussions
Scrotal anatomy
Anterior portion Posterior portion
Evaluation of scrotal pain or swelling
y A focused history, a complete examination with
particular attention on the abdomen, inguinal region, and genitalia including the testes, epididymis,
spermatic cord, scrotal skin, penis, and cremasteric reflex
y A complete blood count, urinalysis and urine culture, doppler ultrasonongraphy or scintigraphy to assess testicular perfusion, scrotal exploration
History
y Pain: onset and severity, testicular torsion, torsion of testicular or epididymal appendage, and epididymitis
y Trauma history
y Change in testicular or scrotal size: communicating hydrocele or varicocele
y Sexually active: epididymitis
y Difficulty voiding: intraabdominal, pelvic or rectal mass, urinary tract infection, or neurologic problem
y Flank pain or hematuria: renal stone (referred pain)
Examinations
y Inspection: left testicle lower than right testicle
y Palpation: testicle>>epididymis>>spermatic cord, swelling>>transillumination (cystic or solid)
y Cremasteric reflex: stroking the upper thigh while observing the ipsilateral testis>>elevation of the
testis, always absent in patient with testicular torsion
y Prehn sign: elevation of the scrotal contents relieves the pain in patient with epididymitis and aggravates in patient with testicular torsion, not a reliable sign
DDx of scrotal pain
Historical features Testicular torsion
Torsion of appendage
Acute epididymitis Peak incidence Perinatal and
puberty
Prepubertal <2 years and postpubertal
Onset of pain Sudden Sudden Gradual
Duration of pain <12 hours >12 hours >24 hours
Previous episodes Typical Unusual If previous episode
Nausea and vomiting Common Uncommon Umcommon
Fever Unusual Unusual Common
History of trauma Occasional Unusual Unusual
Dysuria or discharge Rare Rare common
From Up to Date 2008
DDx of scrotal pain
PE/Lab Perfusion
Testicular torsion
Torsion of appendage
Acute epididymitis
Suggestive findings Bell-clapper Blue-dot None
Cremasteric reflex Absent Present Persent
Tenderness Testicular initially, then diffuse
Appendage initially, then testis
Epididymis initially, then diffuse Erythema or edema Common>12hours Common>12hours Common>12hours
Pyuria Unusual Unusual Common
Positive culture No No Often
Leukocytosis Common Uncommon Common
Color doppler Decreased Normal or increased
Normal or increased
Radionuclide Decreased Normal or
increased
Normal or increased Treatments Surgical
exploration
Bed rest and scrotal elevation
Antibiotics
Testicular torsion
Left torsion Right torsion
From Up to Date 2008
DDx of painless scrotal mass
Mass Palpation Transilluminates Increases with valsalva maneuver
Tumor Firm No No
Varicocele Fluid-filled No Yes
Noncommunicat ing hydrocele
Fluid-filled Yes No
Spermatocele Fluid-filled Yes(superior to testis) No
From Up to Date 2008
Varicocele
Bag of worms
Transilluminates(-) Valsalva maneuver(+)
From Up to Date 2008
Spermatocele (epididymal cyst)
Transilluminates(+) Valsalva maneuver(-)
Fluid-filled, painless
From Up to Date 2008
Protocol for acute scrotum
From Up to Date 2008
