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Cryptorchidism and abdominal pain
EMMERGENCY CASE REPORT
Cryptorchidism and Abdominal Pain William D. O'Riordan, MD* Neil J. Sherman, M D t Lynwood, California
In this c a s e r e p o r t , a b d o m i n a l s y m p t o m s s i m u l a t i n g a c u t e a p p e n d i c i t i s were d u e to r e c u r r e n t t o r s i o n o f a n i n t r a - a b d o m i n a l t e s t i c l e . C r y p t o r chidism f r e q u e n t l y g o e s u n n o t e d . M o s t u n d e s c e n d e d t e s t i c l e s are in t h e groin a n d e a s i l y p a l p a b l e . If n o t , t h e y c a n b e a b s e n t , r e t r o p e r i t o n e a l or int r a - a b d o m i n a l . A n i n t r a - a b d o m i n a l t e s t i c l e is m o r e l i k e l y to o c c u r o n t h e right t h a n t h e left.
O'Riordan WD, Sherman NJ: Cryptorchidism and abdominal pain. JACEP 6:196-197, May, 1977. cryptorchidism; abdomen, pain. INTRODUCTION Children a r e c o m m o n l y t a k e n to an emergency d e p a r t m e n t for abdominal pain. A f t e r t h e h i s t o r y is obtained, p h y s i c a l e x a m i n a t i o n is directed t o w a r d s d i s t i n g u i s h i n g between surgical and n o n s u r g i c a l conditions. The e v a l u a t i o n of the external g e n i t a l i a m a y be cursory and an empty h e m i s c r o t u m c a n be e a s i l y overlooked. A l t h o u g h a n y disease in the g e n i t a l r e g i o n c a n p r o d u c e n a u s e a a n d v o m i t i n g , it is r a r e l y considered as an etiology of abdominal pain, There is little information in the literature 1,2 r e l a t i n g c r y p t o r c h i d i s m and a b d o m i n a l pain. In our case, recurrent t o r s i o n of an undescended,
From the Departments of E m e r g e n c y Medicine* and Pediatric Surgery,t St. Francis Hospital of Lynwood, Lynwood, California. Address for reprints: W. D. O'Riordan, MD, Department of Emergency Medicine, St, Francis Hospital of Lynwood, 3630 Iraperial Highway, Lynwood, California 90262.
J~P
6:5 (May) 1977
i n t r a - a b d o m i n a l testicle was responsible for r e c u r r e n t a b d o m i n a l p a i n s i m u l a t i n g an acute appendicitis in a y o u n g boy. CASE REPORT An 11-year-old black male e n t e r e d St. F r a n c i s H o s p i t a l e m e r g e n c y dep a r t m e n t with a 12-hour history of r i g h t lower q u a d r a n t a b d o m i n a l p a i n and a six-hour h i s t o r y of n a u s e a and vomiting. T h o u g h he had complained of s i m i l a r s y m p t o m s in the past, he h a d n e v e r been e x a m i n e d by a physician. T h e r e w a s no family history of sickle cell disease. His vital signs were w i t h i n n o r m a l limits. There was no t e m p e r a t u r e elevation. P e r t i n e n t physical findings were localized tenderness at M c B u r n e y ' s point, moderate r e b o u n d t e n d e r n e s s , a n d hypoactive bowel sounds. His left testicle was n o r m a l a n d his r i g h t testicle was not p a l p a b l e in the scrotum or in the r i g h t i n g u i n a l canal. The r i g h t hemiscrotum w a s underdeveloped. A s m a l l r i g h t i n g u i n a l h e ~ j a was p r e s e n t . The r e s u l t s of e x a m i n a t i o n were normal. The h e m o g l o b i n was 13.3 gms/ 100 ml and t h e h e m a t o c r i t r e a d i n g
w a s 38.6%. The white blood cell count (WBC) w a s 6,800/cu ram, w i t h 70% s e g m e n t a l s , 15% b a n d s , 13% lyrephocytes, and 2% mononuclear cells. Urinalysis and supine abdominal films were normal. Because this episode suggested a c u t e a p p e n d i c i t i s , we o b t a i n e d pediatric surgical consultation. At the t i m e of the consultant's e x a m i n a tion, one hour later, the p a t i e n t was a s y m p t o m a t i c and the results of his abdominal examination were normal. He was sent home only to ret u r n t h r e e h o u r s l a t e r w i t h syruptoms and p h y s i c a l findings s i m i l a r to those described above. The child was a d m i t t e d for observation and a g a i n became a s y m p t o m a t i c by the followi n g morning. Two w e e k s l a t e r he was r e a d m i t t e d to the hospital for surgical explor a t i o n . U n d e r a n e s t h e s i a no r i g h t testicle was palpable. At s u r g e r y an i n t r a - a b d o m i n a l , n o r m a l sized testicle w a s f o u n d . I t w a s p r o l a p s e d t h r o u g h t h e i n t e r n a l r i n g and suspended by a pedicle consisting of the t e s t i c u l a r a r t e r y , vein, and vas deferens. A s m a l l h e r n i a was r e p a i r e d and an orchidopexy was performed. H i s p o s t o p e r a t i v e course w a s uneventful and the abdominal s y m p t o m s h a v e not r e c u r r e d in the e n s u i n g 18 months. DISCUSSION Cryptorchidism, especially when u n i l a t e r a l , is a r e l a t i v e l y s u b t l e
196/29
p h y s i c a l a b n o r m a l i t y in the prepub e r t a l child. 1,2 It is not u n u s u a l for n e i t h e r the p a r e n t s nor the child to be a w a r e of an e m p t y hemiscrotum. E v e n if t h e y have been informed of it previously, the p a r e n t and child m a y forget to tell t h e physician a b o u t it d u r i n g the a n x i e t y of the e m e r g e n c y and because t h e y cannot see a n y rel a t i o n s h i p b e t w e e n an u n d e s c e n d e d testicle a n d a b d o m i n a l pain. Most undescended testicles are located in the groin and are easily p a l p a b l e . 2 I n a cold r o o m w i t h a f r i g h t e n e d child, the cremasteric ref l e x m a y r e t r a c t a n o r m a l l y des c e n d e d t e s t i c l e up to, or t h r o u g h , t h e e x t e r n a l ring. R a r e r locations for undescended testicles are the p e r i n e u m and the thigh. 2 If c a u s i n g symptoms, t h e y are easily recognizable as a t e n d e r lump. W h e n no testicle can be felt, it is a s s u m e d t h a t it is a b s e n t , ret r o p e r i t o n e a l , or i n t r a - a b d o m i n a l . The c r y p t o r c h i d testicle t h a t is retr o p e r i t o n e a l is a d h e r e n t to the post e r i o r p e r i t o n e u m . I , 2 Because of this,
30/197
it is fixed a n d immobile and would be u n l i k e l y to produce symptoms. Tors i o n of a t e s t i c l e in t h e i n g u i n a l c a n a l is well recognized, 2 b u t it is e a s i l y detected by direct p a l p a t i o n of a n e x q u i s i t e l y t e n d e r l u m p in the ing u i n a l canal. Of course, the complete absence of a testicle can only be proven by surgical exploration. A n i n t r a - a b d o m i n a l t e s t i c l e is more l i k e l y to occur on the r i g h t side t h a n on the left. 1 The testicle m a y ~hang" like a p e n d u l u m w i t h i n the p e r i t o n e a l c a v i t y w h e n t h e testicle a n d a t t a c h e d a r t e r y , vein, a n d vas deferens have attained sufficient length by previous migration t h r o u g h t h e i n t e r n a l r i n g into t h e inguinal canal. For unknown reasons, the testicle t h e n m a y prolapse i n t e r n a l l y back t h r o u g h the i n t e r n a l i n g u i n a l r i n g and r e m a i n t h e r e suspended in the peritoneal cavity. Torsion of a n i n t r a - a b d o m i n a l testicle on the r i g h t side m a y present s y m p t o m s s i m i l a r to an acute appendicitis. 1 If the torsion is on the left side, t h e r e m a y be n a u s e a and vomiting, p a i n and point t e n d e r n e s s in the left lower
q u a d r a n t w i t h rectal tenderness i~ t h e s a m e area. 1 In addition, the pc. t i e n t u s u a l l y has a low grade feve~ and an e l e v a t e d pulse rate. The WI~ is u s u a l l y elevated with a left shits. R e c u r r e n t s y m p t o m s m a y result fr0~ i n t e r m i t t e n t t o r s i o n t h a t untwists s p o n t a n e o u s l y as in t h e case Pre. s e n t e d a b o v e . T r e a t m e n t of the i n t r a - a b d o m i n a l testicle is orchi~lo F exy,1, 2 d e p e n d i n g on the viability of the testicle at the time of surgical es. p l o r a t i o n . The testicle and attach. m e n t s are a l m o s t always long enough due to t h e i r e a r l i e r presence in the i n g u i n a l canal. The authors wish to t h a n k Mrs. Eva Kratz for editing, Mrs. Kathleen Roepke for typing, and St. Francis Hospital of Lynwood for permission to publish this case. REFERENCES
1. Richie JL: Torsion of an intra-abd°m" inal testicle. A m J Surgery 94"672-675, 1957. . 2. Campbell MF, Harrison JH: Urol. ogy, Philadelphia, W.B. Saunders, 1970, vol. 2, ed 3, pp 1628-1644.
6:5 (May)1977 ,,,,,~P
Cryptorchidism and Abdominal Pain William D. O'Riordan, MD* Neil J. Sherman, M D t Lynwood, California
In this c a s e r e p o r t , a b d o m i n a l s y m p t o m s s i m u l a t i n g a c u t e a p p e n d i c i t i s were d u e to r e c u r r e n t t o r s i o n o f a n i n t r a - a b d o m i n a l t e s t i c l e . C r y p t o r chidism f r e q u e n t l y g o e s u n n o t e d . M o s t u n d e s c e n d e d t e s t i c l e s are in t h e groin a n d e a s i l y p a l p a b l e . If n o t , t h e y c a n b e a b s e n t , r e t r o p e r i t o n e a l or int r a - a b d o m i n a l . A n i n t r a - a b d o m i n a l t e s t i c l e is m o r e l i k e l y to o c c u r o n t h e right t h a n t h e left.
O'Riordan WD, Sherman NJ: Cryptorchidism and abdominal pain. JACEP 6:196-197, May, 1977. cryptorchidism; abdomen, pain. INTRODUCTION Children a r e c o m m o n l y t a k e n to an emergency d e p a r t m e n t for abdominal pain. A f t e r t h e h i s t o r y is obtained, p h y s i c a l e x a m i n a t i o n is directed t o w a r d s d i s t i n g u i s h i n g between surgical and n o n s u r g i c a l conditions. The e v a l u a t i o n of the external g e n i t a l i a m a y be cursory and an empty h e m i s c r o t u m c a n be e a s i l y overlooked. A l t h o u g h a n y disease in the g e n i t a l r e g i o n c a n p r o d u c e n a u s e a a n d v o m i t i n g , it is r a r e l y considered as an etiology of abdominal pain, There is little information in the literature 1,2 r e l a t i n g c r y p t o r c h i d i s m and a b d o m i n a l pain. In our case, recurrent t o r s i o n of an undescended,
From the Departments of E m e r g e n c y Medicine* and Pediatric Surgery,t St. Francis Hospital of Lynwood, Lynwood, California. Address for reprints: W. D. O'Riordan, MD, Department of Emergency Medicine, St, Francis Hospital of Lynwood, 3630 Iraperial Highway, Lynwood, California 90262.
J~P
6:5 (May) 1977
i n t r a - a b d o m i n a l testicle was responsible for r e c u r r e n t a b d o m i n a l p a i n s i m u l a t i n g an acute appendicitis in a y o u n g boy. CASE REPORT An 11-year-old black male e n t e r e d St. F r a n c i s H o s p i t a l e m e r g e n c y dep a r t m e n t with a 12-hour history of r i g h t lower q u a d r a n t a b d o m i n a l p a i n and a six-hour h i s t o r y of n a u s e a and vomiting. T h o u g h he had complained of s i m i l a r s y m p t o m s in the past, he h a d n e v e r been e x a m i n e d by a physician. T h e r e w a s no family history of sickle cell disease. His vital signs were w i t h i n n o r m a l limits. There was no t e m p e r a t u r e elevation. P e r t i n e n t physical findings were localized tenderness at M c B u r n e y ' s point, moderate r e b o u n d t e n d e r n e s s , a n d hypoactive bowel sounds. His left testicle was n o r m a l a n d his r i g h t testicle was not p a l p a b l e in the scrotum or in the r i g h t i n g u i n a l canal. The r i g h t hemiscrotum w a s underdeveloped. A s m a l l r i g h t i n g u i n a l h e ~ j a was p r e s e n t . The r e s u l t s of e x a m i n a t i o n were normal. The h e m o g l o b i n was 13.3 gms/ 100 ml and t h e h e m a t o c r i t r e a d i n g
w a s 38.6%. The white blood cell count (WBC) w a s 6,800/cu ram, w i t h 70% s e g m e n t a l s , 15% b a n d s , 13% lyrephocytes, and 2% mononuclear cells. Urinalysis and supine abdominal films were normal. Because this episode suggested a c u t e a p p e n d i c i t i s , we o b t a i n e d pediatric surgical consultation. At the t i m e of the consultant's e x a m i n a tion, one hour later, the p a t i e n t was a s y m p t o m a t i c and the results of his abdominal examination were normal. He was sent home only to ret u r n t h r e e h o u r s l a t e r w i t h syruptoms and p h y s i c a l findings s i m i l a r to those described above. The child was a d m i t t e d for observation and a g a i n became a s y m p t o m a t i c by the followi n g morning. Two w e e k s l a t e r he was r e a d m i t t e d to the hospital for surgical explor a t i o n . U n d e r a n e s t h e s i a no r i g h t testicle was palpable. At s u r g e r y an i n t r a - a b d o m i n a l , n o r m a l sized testicle w a s f o u n d . I t w a s p r o l a p s e d t h r o u g h t h e i n t e r n a l r i n g and suspended by a pedicle consisting of the t e s t i c u l a r a r t e r y , vein, and vas deferens. A s m a l l h e r n i a was r e p a i r e d and an orchidopexy was performed. H i s p o s t o p e r a t i v e course w a s uneventful and the abdominal s y m p t o m s h a v e not r e c u r r e d in the e n s u i n g 18 months. DISCUSSION Cryptorchidism, especially when u n i l a t e r a l , is a r e l a t i v e l y s u b t l e
196/29
p h y s i c a l a b n o r m a l i t y in the prepub e r t a l child. 1,2 It is not u n u s u a l for n e i t h e r the p a r e n t s nor the child to be a w a r e of an e m p t y hemiscrotum. E v e n if t h e y have been informed of it previously, the p a r e n t and child m a y forget to tell t h e physician a b o u t it d u r i n g the a n x i e t y of the e m e r g e n c y and because t h e y cannot see a n y rel a t i o n s h i p b e t w e e n an u n d e s c e n d e d testicle a n d a b d o m i n a l pain. Most undescended testicles are located in the groin and are easily p a l p a b l e . 2 I n a cold r o o m w i t h a f r i g h t e n e d child, the cremasteric ref l e x m a y r e t r a c t a n o r m a l l y des c e n d e d t e s t i c l e up to, or t h r o u g h , t h e e x t e r n a l ring. R a r e r locations for undescended testicles are the p e r i n e u m and the thigh. 2 If c a u s i n g symptoms, t h e y are easily recognizable as a t e n d e r lump. W h e n no testicle can be felt, it is a s s u m e d t h a t it is a b s e n t , ret r o p e r i t o n e a l , or i n t r a - a b d o m i n a l . The c r y p t o r c h i d testicle t h a t is retr o p e r i t o n e a l is a d h e r e n t to the post e r i o r p e r i t o n e u m . I , 2 Because of this,
30/197
it is fixed a n d immobile and would be u n l i k e l y to produce symptoms. Tors i o n of a t e s t i c l e in t h e i n g u i n a l c a n a l is well recognized, 2 b u t it is e a s i l y detected by direct p a l p a t i o n of a n e x q u i s i t e l y t e n d e r l u m p in the ing u i n a l canal. Of course, the complete absence of a testicle can only be proven by surgical exploration. A n i n t r a - a b d o m i n a l t e s t i c l e is more l i k e l y to occur on the r i g h t side t h a n on the left. 1 The testicle m a y ~hang" like a p e n d u l u m w i t h i n the p e r i t o n e a l c a v i t y w h e n t h e testicle a n d a t t a c h e d a r t e r y , vein, a n d vas deferens have attained sufficient length by previous migration t h r o u g h t h e i n t e r n a l r i n g into t h e inguinal canal. For unknown reasons, the testicle t h e n m a y prolapse i n t e r n a l l y back t h r o u g h the i n t e r n a l i n g u i n a l r i n g and r e m a i n t h e r e suspended in the peritoneal cavity. Torsion of a n i n t r a - a b d o m i n a l testicle on the r i g h t side m a y present s y m p t o m s s i m i l a r to an acute appendicitis. 1 If the torsion is on the left side, t h e r e m a y be n a u s e a and vomiting, p a i n and point t e n d e r n e s s in the left lower
q u a d r a n t w i t h rectal tenderness i~ t h e s a m e area. 1 In addition, the pc. t i e n t u s u a l l y has a low grade feve~ and an e l e v a t e d pulse rate. The WI~ is u s u a l l y elevated with a left shits. R e c u r r e n t s y m p t o m s m a y result fr0~ i n t e r m i t t e n t t o r s i o n t h a t untwists s p o n t a n e o u s l y as in t h e case Pre. s e n t e d a b o v e . T r e a t m e n t of the i n t r a - a b d o m i n a l testicle is orchi~lo F exy,1, 2 d e p e n d i n g on the viability of the testicle at the time of surgical es. p l o r a t i o n . The testicle and attach. m e n t s are a l m o s t always long enough due to t h e i r e a r l i e r presence in the i n g u i n a l canal. The authors wish to t h a n k Mrs. Eva Kratz for editing, Mrs. Kathleen Roepke for typing, and St. Francis Hospital of Lynwood for permission to publish this case. REFERENCES
1. Richie JL: Torsion of an intra-abd°m" inal testicle. A m J Surgery 94"672-675, 1957. . 2. Campbell MF, Harrison JH: Urol. ogy, Philadelphia, W.B. Saunders, 1970, vol. 2, ed 3, pp 1628-1644.
6:5 (May)1977 ,,,,,~P