Testicular Issues (Acute Scrotal Pain/Swelling + Undescended Testis) Flashcards
What are the 6 main questions you need to ask if a patient presents with acute scrotal pain or swelling?
Age of child: neonatal, prepubertal, adolescent
Onset and severity
Trauma
Fever
Sexual Activity
Prior genitourinary surgeries/urological abnormalities
What are the 6 features to be covered in the examination of this child?
Observation of the patients gait and resting position
Natural position of the testis in the scrotum while standing
Presence or absence of cremasteric reflex (think torsion)
Palpation of lower abdomen, inguinal canal and cord and then palpation of scrotum and contents while making sure to compare affected hemiscrotum with unaffected hemiscrotum
Transillumination (think hydrocele)
Is the swelling reducible? (think hernia)
What are the investigations which need to be conducted (and which don’t)?
Check urinalysis and send sample for M&C
No need for blood tests or for Doppler U/S as it is not useful in the acute setting. While Doppler U/S can be useful in the visualisation of anatomy and blood flow. This investigation can be carried out if torsion and incarcerated hernia are ruled out by a surgical consult.
Scenario 1: Acute Scrotal Swelling + Pain + Trauma =? (5 DDx)
Haematocoele Haematoma Testicular Rupture Epidydimitis Torsion
Scenario 2: Acute Scrotal Swelling + Pain + No Trauma + Tender Testis =? (5 DDx)
Testicular Torsion Epididymitis Orchitis Torsion of Appendix testis Tumour
Scenario 3: Acute Scrotal Swelling + Pain + No Trauma + NOT Tender Testis =? (4)
Torsion of Appendix testis
Incarcerated Hernia
HSP
Kawasaki’s Disease
Scenario 4: Acute Scrotal Swelling + NO Pain + Enlarged Testis =? (3)
Tumour
Leukaemia
Antenatal Torsion (newborn)
Scenario 5: Acute Scrotal Swelling + NO Pain + NO enlarged testis + Reducible Swelling =? (1)
Hernia
Scenario 6: Acute Scrotal Swelling + NO Pain + NO enlarged testis + NOT reducible swelling + Scrotal wall swelling =? (3)
Idiopathic Oedema
HSP
Kawasaki’s Disease
Scenario 7: Acute Scrotal Swelling + NO Pain + NO enlarged testis + NOT reducible swelling + NO scrotal swelling + Transillumination =? (3)
Hydrocoele
Speramatocoele
Hernia with hydrocele
Scenario 8: Acute Scrotal Swelling + NO Pain + NO enlarged testis + NOT reducible swelling + NO scrotal swelling + NO Transillumination =? (2)
Varicocoele
Hernia
What are 3 conditions which usually present with predominant pain?
What are 4 conditions which usually present with predominant swelling?
Pain: Testicular torsion, appendage torsion, epididymitis.
Swelling: hydrocoele, varicoele, tumour, spermatocoele (epididymal cyst)
What predisposes an individual to getting testicular torsion and describe the anatomy of this?
Bell-clapper deformity.
High attachment of posterior part tunica vaginalis so both attachments are superior to the testis. (Instead of one superior and one posterior - covering anterior 2/3)
What are the suggestive factors on Hx of testicular torsion?
Peaks in neonatal and adolescent age groups.
Less than 12 hour history, sudden onset, can occur during sleep (50-60%) or following minor trauma or spontaneous. May have previous episodes (intermittent torsion).
No fever, yes nausea/vomiting, no discharge/dysuria.
What are the suggestive features O/E of testicular torsion?
Discolouration of the scrotum, exquisitely tender and swollen testis, riding high
Cremasteric reflex is absent
What is the acute management of testicular torsion?
Early surgical consultation is vital, as delay in scrotal exploration and detorsion of a torted testis will result in testicular infarction within 8-12 hours.
What features on Hx and O/E are seen in the torsion of the testicular appendix (hyatid of Morgani)?
On Hx: Peaks at 11 years old, there is a more gradual onset of testicular pain.
On O/E: Focal tenderness on the upper pole of the testis, blue dot sign is when the necrotic appendage is seen through scrotal skin.
Note: it is difficult to distinguish torsion of the testis and torsion of the appendage clinically.
What is the acute management of torsion of the hyatid of Morgani/testicular appendage?
Analgesia and rest. The pain usually resolves in 2 to 12 days, pain should have lessened within 48 hours.
What are the features on Hx and O/E suggestive of epididymoorchitis?
Hx: Usually in a young child, over days (acute is possible), usually gradual buildup, no trauma history, previous pain if previous episodes. Fever yes, rarely N/V, discharge/dysuria common.
O/E: Red, tender, swollen hemiscrotum; tenderness most marked posteriolateral to testis. Pyuria may be present.
What is the management of epididymoorchitis?
Should be managed with antibiotics once a suitable urine sample has been sent.
Young infants or systemically unwell children should be admitted for i.v. antibiotics (eg. amoxycillin and gentamicin). Most patients can be successfully managed as out-patients, with co-trimoxazole.
Adolescents should have a first-pass urine sample for chlamydia and gonococcus PCR. The process is slow to resolve and the patient may have several weeks of gradually subsiding discomfort and scrotal swelling.
How does an inguinal hernia form?
The processus vaginalis is the hole through which the testes descend into the scrotum during pregnancy. If this hole does not close behind the testes descent then an inguinal hernia may result (or a hydrocele or an encysted hydrocele of the cord). This means that bowel to enter the inguinal canal.
What is the usual presentation of an inguinal hernia that is not strangulated or incarcerated? Who is more likely to get an inguinal hernia?
The younger you are the more likely to twist and as a result, the more urgent the treatment needs to take place.
Pre-term babies are more likely to have larger hernias because their tissue is more distensible.
The presentation of a simple inguinal hernia is intermittent swelling, overlying the external inguinal ring, that has been noticed by a parent. At times it may appear to cause discomfort. It is most likely to be obvious during an episode of crying or straining, and in infants may be seen during nappy changes.
What is the presentation of a strangulated/incarcerated hernia?
Hx of intermittent inguinoscrotal bulge with associated irritability.
O/E: Firm, tender, irreducible, inguinoscrotal swelling
What is the management of a strangulated/incarcerated inguinial hernia?
Important to reduce the hernia as soon as possible so that it doesn’t become incarcerated. If it is already incarcerated, then important to reduce to prevent the contents becoming gangrenous.
