- Email: [email protected]
Evaluation of acute scrotum in the emergency department
Evaluation of Acute Scrotum in the Emergency Department By Alfor G. Lewis, Timothy P. Bukowski, Paul D. Jarvis, Jeffrey Wacksman, and Curtis A. Sheldon Cincinnati, Ohio • A 2-year retrospective review of 238 cases of acute scrotal pain encountered in a children's hospital emergency department is presented. The incidences of testicular torsion, torsion of a testicular appendage, and epididymitis were 16%, 46%, and 35%, respectively. Testicular salvage was critically dependent on the interval between onset of pain and surgical intervention. No testis likely to have been viable at the time of presentation was "lost." The diagnostic error rate on first encounter was 7%, resulting in 10 negative scrotal explorations. With the exception of cases of faradvanced necrotic testes, both color Doppler ultrasound and radioisotope imaging were highly specific diagnostic modalities. Thirty-nine percent of the children with epididymitis who underwent investigation were found to have either structural or functional urinary tract abnormalities. Noninvasive urodynamic studies appear to be useful screening modalities in older children with epididymitis. Copyright © 1995 by W.B. Saunders Company INDEX WORDS: Acute scrotum, testicular torsion, epididymitis.
N C H I L D R E N , acute scrotal pain and swelling is a common source of surgical consultation in the emergency room (ER) setting. The most common diagnoses encountered are testicular torsion, torsion of the appendix testis (or other appendage), and epididymitis. O t h e r scrotal conditions that may present acutely include hernia, hydrocele, acute idiopathic scrotal edema, 1 Henoch-Sch6nlein purpura, 2 trauma, and varicocele. The surgeon caring for children with acute scrotal conditions is faced with several dilemmas. The need for p r o m p t and accurate diagnosis and therapy to prevent gonadal loss is countered by the need to minimize costly, unnecessary negative surgical explorations and scrotal imaging studies. Furthermore, the known association between childhood epididymitis and significant urinary tract pathology 3 has led to the recommendation of u p p e r tract imaging and voiding cystourethrography ( V C U G ) for all such children. A vigorous approach to the diagnostic evaluation of children with epididymitis appears reasonable, given the traditional concept that this condition is a relatively rare cause of acute scrotal pathology. However, the incidence of acute scrotal conditions varies dramatically among reported series (Table 1). It is apparent that, in studies of both surgical and hospital admissions, the incidence and significance of epididymitis are underestimated and the incidence of testicular torsion is overestimated. Accordingly, a policy of routine scrotal exploration for pediatric epididymitis would lead to an excessive n u m b e r of
I
Journa) of Pediatric Surgery, Vol 30, No 2 (February), 1995: pp 277-282
unnecessary operative procedures. Similarly, an unselective imaging evaluation of all children presenting with epididymitis might be excessive. The purposes of this study are (1) to assess the relative incidence of acute scrotat pathology in a primary care setting, (2) to determine the effectiveness of diagnostic and therapeutic modalities from the perspectives of morbidity and cost, and (3) to evaluate the significance of childhood epididymitis and the indications for diagnostic evaluation. MATERIALS AND METHODS We reviewed the medical records of 238 consecutively treated patients who presented to the emergency department, over a 2-year period, for evaluation of acute scrotal pain. Of these, 233 could be evaluated. Patients with a diagnosis of hernia, hydrocele, acute idiopathic scrotal edema, Henoch-SchOnlein purpura, or varicocele were excluded because, in each instance, the initial clinical diagnosis was unequivocal and proven to be accurate through follow-up. The patients were managed according to a strict protocol. If the testis could be documented to be nontender, and normal in size, shape, position, and consistency, the patient was discharged from the ER on therapy appropriate for the clinical diagnosis. The patients whose testicle(s) was not documented to be normal were managed according to the degree of clinical suspicion for testicular torsion. If testicular torsion was suspected, immediate surgical exploration was undertaken. In the event of another diagnosis being suspected, an imaging study (color Doppler ultrasound or radioisotope scan) was performed. The cases were evaluated with respect to accuracyof diagnosis and outcome of treatment. RESULTS Two hundred thirty-eight patients were encountered, accounting for an estimated 0.13% of total E R visits during the period of this study. The final diagnoses, according to imaging studies and clinical follow-up, are shown in Table 2. A significant variation in the incidence of acute scrotal pathologies as a function of age was encountered (Fig 1). The p e a k incidence of acute scrotal presentations was in the 11- to 13-year-old group. During the first year of life, the most common
From the Division of Pediatric Urology, Children's Hospital Medical Center, Cincinnati, OH. Presented at the 25th Annual Meeting of the American Pediatric Surgical Association, Tucson, Arizona, May 14-17, 1994. Address reprint requests to Curtis A. Sheldon, MD, Director, Division of Pediatric Urology, Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229-3039. Copyright © 1995 by W.B. Saunders Company 0022-3468/95/3002-0022503.00/0 277
278
LEWIS ET AL
35
Table 1. Relative Incidence of Childhood Acute Scrotal Pathology Type of Series
No. of Patients TT (%)
TAT (%)
EPI {%)
Reference No.
Surgical
183
64
34
2
4, 5
Admission
529
41
46
13
6-12
Emergency room
145
27
36
37
13, 14
30
25 20
Abbreviations: TT, testicular torsion; TAT, Torsed testicular appendage; EPI, epididymitis.
E
diagnosis (83%) was testicular torsion. For 3 to 13 year olds, the most common diagnosis was torsion of testicular appendage, peaking with the onset of puberty. After age 13, the most common diagnosis was epididymitis, predominating (75%) after the age of 17 years. The initial diagnosis was incorrect for 17 of the 233 patients (7%). For 4 of the 37 patients (11%) with testicular torsion, the diagnosis was missed at the time of initial presentation. Two were sexually active, had significant pyuria, did not undergo imaging studies, and were treated for presumed sexually transmitted disease. Both returned, had a radioisotope scan (RIS), were diagnosed as having testicular torsion, and underwent orchiectomy with contralateral orchiopexy. The other two patients had negative urinalyses and false-negative imaging study results (one from ultrasound [US] alone and the other from both US and RIS). Both were treated for presumed epididymitis, did not respond to therapy, had positive findings during repeat imaging studies (one US, the other both RIS and US), and received orchiectomy with contralateral orchiopexy. A factor common to all four cases was a protracted interval between the onset of pain and presentation. Massively swollen intrascrotal contents, associated with scrotal wall edema and erythema, were encountered, and we doubt that the testes would have been salvageable at the time of presentation. In each instance, true torsion of the spermatic cord was documented, rather than strangulation from epididymitis. Ten patients (9%) with torsion of an appendage were initially diagnosed as having testicular torsion and underwent exploration. Only two had imaging studies (one RIS, one US), which were falsely positive for testicular torsion. All patients underwent excision of the torsed appendage and experienced full recovTable 2. Etiology of Acute Scrotum in Childhood Diagnosis
No. of Patients
Percentage
Torsion of appendage Epididymitis Torsion of testis Other Unable to be evaluated
109 84 37 3 5
46 35 16 1 2
Total
238
100
z
10
0-1
1-3
3-s
s-7
7-9
9-11
11-13
1a-is
ls-17
17-19
Age (years) Fig 1. Relative incidence of testicular torsion, torsion of a testicular appendage, and epididymitis, as a function of age.
ery. Two (20%) had a significant reactive epididymitis, and eight (80%) had a reactive hydrocele serving to confound the diagnosis during clinical examination. Six patients (60%) presented after 24 hours of symptoms, accounting for the high incidence of associated pathology. One patient's condition was diagnosed and treated as epididymitis, although he was ultimately proven to have a varicocele. He underwent a high ligation and recovered uneventfully. Another patient was initially diagnosed as having torsion of an appendix testis and was found to have intermittent testicular torsion, which had become relieved by the time of presentation. When his symptoms recurred, he had exploration and underwent bilateral orchiopexy (both testes were salvaged). Another patient had positive RIS findings and underwent surgical exploration. He was found to have torsion of a spermatic cord hemangioma. This structure was excised, his testis was salvaged, and he has recovered completely. Figure 2 shows that testicular salvage was probable only if intervention occurred within 6 hours of pain onset. This was achieved for only 28% of patients, and testicular loss was attributed to a delay in presentation at the ER. No patient in this series whose interval between pain onset and presentation was > 48 hours had a salvageable testis. The success rate was 50% among patients who presented between 6 and 48 hours after pain onset. One hundred five imaging studies were performed. Excellent specificities were observed for both RIS and color Doppler US studies (95.4% and 97.0%, respectively). However, sensitivities were relatively low (85.7% and 80.0%, respectively), especially in light of the potentially devastating outcome of a false-negative result. Both false-negative RIS results and the two false-negative US results were for pa-
EVALUATION OF ACUTE SCROTUM
10
279
invasive urodynamic screening; seven of them (47%) had abnormal findings. This procedure consists of a uroflow study, striated sphincter electromyography, and estimation of residual urine by US. Abnormalities included elevated postvoid residual volume (4), diminished flow rate (3), and straining to void (2).
If,/A Testis Salvaged removed or Atrophied
In 8 t°O ~
6 o en
DISCUSSION 4
E z
2
0-6
7-12
o ml 13-18
19-Z4
25-48
>48
Time from Pain Onset to Surgery (hrs) Fig 2. Testicular salvage for torsion, as a function of the duration between onset of symptoms and surgical intervention.
tients who presented late, with massively swollen intrascrotal contents and intense reactive scrotal wall erythema and edema. For all four studies, the resultant reactive inflammatory hyperemia from a necrotic testis is presumed to be the source of the falsenegative result. None of these testes is believed to have been salvageable at the time of presentation. One false-negative US result was equivocal on the basis of blood flow that was present, although moderately reduced. The patient, a 15 year old, underwent exploration and was found to have an edematous testis, a "bell-clapper" testicular suspension anomaly, and 180° torsion of the testis. It is presumed that intermittent torsion accounted for this equivocal result. A 10-year-old patient had an indeterminate US study, based on the inability to establish conclusively the presence of blood flow in either testis. Subsequently, an RIS scan detected the presence of testicular torsion, following which bilateral orchiopexy was performed and both testes salvaged. No testis was "lost" as a result of false-negative imaging results. Twenty-eight patients with epididymitis (33%) had selective diagnostic studies to identify any associated urinary tract pathology. Structural abnormalities included ectopic ureteral insertion into the seminal vesicle, posterior urethral valves, urethral stricture, meatal stenosis, vesicoureteral reflux, calyceal diverticulum, trabeculated bladder, and duplication (1 instance each). On direct questioning, seven of those with abnormal findings on urinary tract studies (64%) reported subtle voiding problems. These included frequency (4), dribbling (2), urgency (1), sensation of incomplete voiding (1), and dysuria (1). Fifteen patients with epididymitis underwent non-
The ultimate goal of management of the acute scrotum in childhood is avoidance of testicular loss. This requires a high degree of diagnostic accuracy and prompt surgical intervention. Our data suggest that a high chance of testicular salvage is attainable only if intervention is undertaken within 6 hours of the onset of pain. This was achieved for only 28% of our patients, and testicular loss was presumed to be related to a delay in presentation at the ER. All patients who presented after 48 hours of symptoms did not have a salvageable testis. Between these two extremes, however, 50% of testes were salvaged. Presumably, those surgically preserved testes presenting beyond 12 hours had either lower degrees of torsion or intermittent torsion (both are impossible to detect clinically). Our data suggest that a testis should not be presumed necrotic and unsalvageable if fewer than 48 hours have elapsed since the onset of symptoms. Clearly, the greatest impact on testicular preservation lies with the effective education of parents and primary care physicians. Another important means by which gonadal loss can be minimized (when torsion is a probable diagnosis) is through prompt surgical intervention, without the delay incurred by diagnostic imaging studies. Other potentially beneficial maneuvers that we employ are manual detorsion 15 and ice-packing 16 between the time of diagnosis and surgical exploration. Our experience corroborates the observations of Haynes and Haynes, 17 and we would never advocate a delay in surgical intervention based on the presumed efficacy of manual detorsion. In addition to testicular loss, the presence of testicular torsion may indicate a poor prognosis for the contralateral testis; certainly, the risk of torsion in the latter is increased. The contralateral testis should be explored, and if a bell-clapper anomaly is identified, contralateral orchiopexy should be performed. We favor a four-point fixation technique employing nonabsorbable sutures, because we have experienced recurrent torsion with absorbable suture fixation techniques. The risk of ipsilateral testicular atrophy has been shown to increase with the duration of torsion. 18,~9 Whereas some investigators have noted impaired spermatogenesis after torsion, some have suggested a
280
LEWIS ET AL
correlation with the duration of t o r s i o n , 19-21 and others have not. 22,23The latter data lead us to question whether torsion itself causes contralateral injury, or whether a preexisting contralateral abnormality is present. Contralateral testicular biopsy specimens taken at the time of orchiopexy for torsion have shown a significant amount of seminiferous tubule degeneration, suggesting that, in many instances, bilateral testicular disease actually predates the acute event of t o r s i o n . 24'25 In this series, our approach to the management of the acute scrotum in childhood resulted in no lost testes that were likely to have been viable at the time of presentation. There were 10 false-negative scrotal explorations, three false-positive imaging results, and 77 true-negative imaging results, which, arguably, did not benefit the patients. This translates to an expense of $206.87 per patient encountered, which, given the high morbidity of a delayed diagnosis, is, in our opinion, justified. Forty-two percent of this expense resulted from negative surgical exploration. Epididymitis is a nonspecific term describing inflammation of the epididymis, which is generally associated with acute pain, swelling, and tenderness. It may be classified, according to etiology, as infectious, traumatic, or reactive. Additionally, it may be associated with systemic diseases such as sarcoidosis, Kawasaki's disease, and Henoch-Sch6nlein purpura. 26 Reactive etiologies include instances associated with torsion of an appendage, and chemical irritation from reflux of sterile urine into the seminal tract. Coliform bacteria are a common source of epididymitis in both men and boys who have congenitally abnormal urinary tracts. C trachomatis and N gonorrhaeae must be strongly considered in patients who are sexually active. 27,2sLikitnukul et al reported on 22 children who had epididymal cultures. 26 Isolated organisms included coagulase-negative Staphylococcus, S aureus, Escherichia coli, and Haemophilus influenzae, proteus, and salmonella. Viral agents, including mumps, coxsackie, echovirus, and adenovirus, also have been implicated. 29,3° Noteworthy is the occurrence of type B H influenzae epididymoorchitis, which may present in the prepubertal boy. 31,32 Here, the urinary tract is not considered to be the primary source of the infection, and such children are characteristically toxic at the time of presentation. Epididymitis has traditionally been believed to be
an uncommon cause of acute scrotal pathology in children. 3,6,33-36 Our data refute this concept, which appears to have arisen from surgical and admission series rather than a study of the primary care setting. Although it is known that infants and children have a significant incidence of urinary tract anomalies, 3 older children are generally described as having "idiopathic" epididymitis. However, an underlying overt neurogenic bladder or maintenance on intermittent catheterization is well recognized as a causative factor in this age group. 37,38 Amar and Chabra 33 found epididymitis in a patient with unrecognized vesicoureteral reflux, which can be associated with an underlying unstable bladder. The highly significant incidence of elevated postvoid residual volumes, abdominal straining, and diminished flow rates encountered in our series strongly suggests that previously unrecognized dysfunctional voiding may account for the idiopathic epididymitis in many children. Presumably, however, many such children also will have epididymitis that is reactive to an associated torsed appendage that is impalpable and unrecognized. Dysfunctional voiding may, in analogy to urethral obstruction (eg, posterior urethral valves and urethral strictures), cause epididymitis by elevating proximal urethral voiding pressure. Both primary and secondary (volitional) detrusor-sphincter dyssynergia are likely mechanisms. We encountered one patient who presented with epididymitis who subsequently was confirmed to have primary detrusor-sphincter dyssynergia. The proposed mechanism is similar to that known to be present in children who have vesicoureteral reflux associated with dyssynergia or bladder instability. We recommend that urinalysis and urine culture be performed for all children with epididymitis, and that urethral swabs sampled from those who are sexually active include cultures for chlamydia. Renal ultrasonography and VCUG are recommended for all infants and young children with epididymitis. Furthermore, careful questioning regarding voiding symptoms and screening via noninvasive urodynamic studies should be performed in all older children. Those with symptoms, abnormal screening study results, or positive urinalyses and cultures should undergo renal ultrasonography.
REFERENCES 1. Najmaldin A, Burge DM: Acute idiopathic scrotal oedema: Incidence, manifestations, and aetiology. Br J Surg 74:634-635,
boys: Underlying urogenital anomalies and efficacy of imaging modalities. J Urol 138:1100-1103, 1987
1987 2. Clark WR, Kramer SA: Henoch-Sch6nlein purpura and the acute scrotum. J Pediatr Surg 21:991-992, 1986 3. Siegel A, Snyder H, Duckett JW: Epididymitis in infants and
4. Flanigan RC, Dekernien JB, Persky L: Acute scrotal pain and swelling in children: A surgical emergency. Urology 17:51-53, 1981 5. Ben-Chaim J, Leibovitch I, Ramon J, et al: Etiology of acute
EVALUATION OF ACUTE SCROTUM
281
scrotum at surgical exploration in children, adolescents and adults. Eur Urol 21:45-47, 1992 6. Qvist O: Swelling of the scrotum in infants and children and nonspecific epididymitis: Study of 158 cases. Acta Chit Seand 110:417-421, 1955 7. Anderson PAM, Giacomantonio JM: The acutely painful scrotum in children: Review of 113 consecutive cases. Can Med Assoc J 132:1153-1155, 1985 8. Nour S, MacKinnon AE: Acute scrotal swellingin children. J R Coll Surg Edinb 36:393-394, 1991 9. Moharib NH, Krahn HP: Acute scrotum in children with emphasis on torsion of spermatic cord. J Urol 104:601-603, 1970 10. Hemalatha V, Rickwood AMK: The diagnosis and management of acute scrotal condition in boys. Br J Uro153:455-459, 1981 11. Kaplan GW, King LR: Acute scrotal swelling in children. J Urol 104:219-223, 1990 12. Melekos MD, Asbach HW, Markou SA: Etiology of acute scrotum in 100 boys with regard to age distribution. J Urol 139:1023-1025, 1988 13. Caldamone AA, Valvo JR, Altebarmakian VK, et al: Acute scrotal swellingin children. J Pediatr Surg 19:581-584, 1984 14. Anderson PAM, Giacomantonio JM, Schwartz RD: Acute scrotal pain in children: Prospective study of diagnosis and management. Can J Surg 32:29-32, 1989 15. Betts JM, Norris M, Cromie WJ, et ah Testicular detorsion using Doppler ultrasound monitoring. J Pediatr Surg 18:607-610, 1983 16. Miller DC, Per0n SE, Keck RW, et al: Effects of hypothermia on testicular ischemia. J Urol 143:1046-1048, 1990 17. Haynes BE, Haynes VE: Manipulative detorsion: Beware the twist that does not turn. J Urol 137:118-119, 1987 18. Krarup I: The testis after torsion. Br J Uro150:43-46, 1978 19. Bartsch G, Marberger FH, Mikuz G: Testicnlar torsion: Late effects with special regard to fertility and endocrine function. J Urol 124:375-378, 1980 20. Chakraborty J, Hikim APS, Jhunjhunwala JSJ: Quantitative evaluation of testicular biopsies from men with unilateral torsion. Urology 25:145-150, 1985 21. Danner C, Frick J, Royan E: Testicular function after torsion. Int J Androl 5:276-281, 1982 22. Anderson JB, Williamson RCN: The fate of the human testes followingunilateral torsion of the spermatic cord. Br J Urol 58:698-704, 1986
23. Laor E, Fisch H, Tennenbaum S, et al: Unilateral testicular torsion: Abnormal histologicalfindings in the contralateral testis-Cause or effect? Br J Urol 65:520-523, 1990 24. Horica CA, Hadziselimovic F, Kreutz, et al: Ultrastructural studies of the contorted and contralateral testicle in unilateral testicular torsion. Eur Urol 8:358-362, 1982 25. Hadziselmovic F, Snyder H, Duckett JW, et al: Testicular histology in children with unilateral testicular torsion. J Urol 136:208-210, 1986 26. Likitnukul S, McCracken GH, Nelson JD, et al: Epididymitis in children and adolescents. A 20-year retrospective study. Am J Dis Child 141:41-44, 1987 27. Pearson RC, Baumer CD, McGhie D, et al: The relevance of Chlamydia trachomatis in acute epididymitis in young men. Br J Urol 62:72-75, 1988. 28. Berger RE, Kessler D, Holmes KK: Etiology and manifestations Of epididymitis in young men: Correlations with sexual orientation. J Infect Dis 155:1341-1343, 1987 29. Hermansen MC, Shusid MJ, Sty JR: Bacterial epididymoorchitis in Children and adolescents. Clin Pediatr 19:812-815, 1980 30. Coran AG, Perlmutter AD: Mumps epididymitis without orchitis. N Engl J Med 272:735, 1965 31. Greenfield SP: Type B hemophilus influenzae epididymoorchitis in the prepubertal boy. J Urol 136:1311-1313,1986 321 Lin YC, King DR, Birken GA, et al: Acute scrotum due to haemophilus influenzae type B. J Pediatr Surg 23:183-184, 1988 33. Amar AD, Chabra K: Epididymitis in prepubertal boys. JAMA 207:2397-2400, 1969 34. Doolittle KH, Smith JP, Saylor ML: Epididymitis in the prepubertal boy. J Uro196:364-366, 1966 35. Megalli M, Gursel E, Lattimer JK: Reflux of urine into ejaculatory ducts as a cause of recurring epididymitis in children. J Urol 108:978-979, 1972 36. Umeyama T, Kawamura T, Hasegawa A, et al: Ectopic ureter presenting with epididymitisin childhood: Report of 5 cases. J Urol 134:131-133, 1985 37. Gislason T, Noronha RF, Gregory JG: Acute epididymitisin boys: A 5-year retrospective study. J Urol 124:533-534,1980 38. Thirumavalavan VS, Ransley PG: Epididymitis in children and adolescents on clean intermittent catheterisation. Eur Urol 22:53-56, 1992
Discussion J. Noseworthy (Wilmington, DE)." A l t h o u g h this study is retrospective, t h e r e are o p p o r t u n i t i e s in the s u b g r o u p of c h i l d r e n with acute epididymitis ( A E ) to p e r f o r m f u r t h e r retrospective analyses. T h e m a n u s c r i p t p r e s e n t s a n d discusses d a t a regarding testicular t o r s i o n (TT), a p p e n d i c e a l t o r s i o n (AT), a n d imaging errors, b u t t h e r e is really n o t h i n g n e w in these data. N o r is the discussion r e l a t i n g to subseq u e n t infertility following T T a n y t h i n g that h a s n o t b e e n b r o u g h t forward before. I n fact, the d a t a in this p a p e r do n o t really address t h a t issue at all. A t e r m u s e d in the m a n u s c r i p t , " d e g r e e of clinical suspicion," l e a d i n g to i m m e d i a t e surgical i n t e r v e n tion, should b e precisely defined. W h a t were the
e l e m e n t s in the degree of clinical suspicion that led to i m m e d i a t e o p e r a t i o n ; f u r t h e r m o r e , how do those e l e m e n t s c o m p a r e a m o n g the t h r e e groups (TT, A T , and A E ) ? T h i r t y - s e v e n p a t i e n t s with T T were i n c l u d e d in the series. F o u r T T cases were missed at the time of initial p r e s e n t a t i o n . Two of the p a t i e n t s were sent from the e m e r g e n c y r o o m o n the basis of pyuria, with n o initial imaging. I w o u l d c a u t i o n all of us to n o t let pyuria a l o n e override o t h e r clinical findings in this group of patients, w i t h o u t some a d d i t i o n a l supporting data such as flow scintigraphy. T h e p o i n t I would like to e m p h a s i z e is the large n u m b e r of c h i l d r e n with A E in this s e r i e s - - 3 5 % of
282
the total in a series collected over a relatively short period in comparison to other series that have been reported. In 1987, the exPerience at another large children's hospital (over 9 years) found only 47 patients with AE. In that report, there was clear emphasis on the underlying urogenital anomalies associated with AE. These data from the Cincinnati group show that the incidence of AE and the subsequent potential etiologic pathologies are important, occur with significant frequency, and should not be overlooke& Unfortunately only one third of the total group was fully evaluated beyond making the diagnosis of AE, and it is in that regard that I would urge that the 56 patients with AE who were not evaluated as to etiology be studiedl even retrospectively. The frequent findings of both structural and urodynamic abnormalities in this group (AE) warrant their being subjected to close and well-organized evaluation. The combination of ultrasonography, contrast voiding cystourethrography, excretory urography, and particularly, urodynamic evaluations (well described in the manuscript) should be used. This latter technique is particularly important because it emphasizes one important final common pathway in pediatric AE, that of elevated proximal urethral voiding pressure, a concept appropriately emphasized by D r Sheldon and his colleagues. Last, I ask the authors for some comments regarding subsequent therapies for these children, both those with structural anomalies and those with urodynamic anomalies. How many of them needed further surgical correction of their anatomic anomaly or required pharmacological manipulation of their voiding dysfunction? T.P. Bukowski (response): First of all, the study was
LEWIS ET AL
initiated to study the overall incidence of the different scrotal pathologies, and was therefore limited to a 2-year period. We felt it necessary to review the torsion data thoroughly to show that our data were similar to those from published series, which would then validate the epididymitis,data. CIinical suspicion for torsion included traditional indices such as very tender, high-riding testicle, with a negative cremasteric reflex. The indices for epididymitis were localized tenderness posteriorly, with or without a history significant for sexually transmitted diseases, intermittent catheterization, et cetera. The clinica! suspicion for a torsed appendix testis would involve a tender nodule at the superior pole of the testis. We agree that most patients with pyuria should have a complete workup. The two patients in the study who had some pyuria also had a recenthistory of sexual activity and were strongly believed to have had a sexually transmitted disease. Patients who have epididymitis with functional voiding disorders are put on a bladder training regimen with antibiotic prophylaxis until their voiding is normalized. The patients with anatomic abnormalities (mostly in the 0- to 4-year-old group) underwent surgery. We feel that functional voiding problems in the older child with epididymitis are significant. All 28 patients evaluated with urodynamics for epididymitis were from one surgeon's clinic, who would evaluate the children if they did not have any immediately identifiable cause for epididymitis. We expect to have a complete review of these children in the near future.
N C H I L D R E N , acute scrotal pain and swelling is a common source of surgical consultation in the emergency room (ER) setting. The most common diagnoses encountered are testicular torsion, torsion of the appendix testis (or other appendage), and epididymitis. O t h e r scrotal conditions that may present acutely include hernia, hydrocele, acute idiopathic scrotal edema, 1 Henoch-Sch6nlein purpura, 2 trauma, and varicocele. The surgeon caring for children with acute scrotal conditions is faced with several dilemmas. The need for p r o m p t and accurate diagnosis and therapy to prevent gonadal loss is countered by the need to minimize costly, unnecessary negative surgical explorations and scrotal imaging studies. Furthermore, the known association between childhood epididymitis and significant urinary tract pathology 3 has led to the recommendation of u p p e r tract imaging and voiding cystourethrography ( V C U G ) for all such children. A vigorous approach to the diagnostic evaluation of children with epididymitis appears reasonable, given the traditional concept that this condition is a relatively rare cause of acute scrotal pathology. However, the incidence of acute scrotal conditions varies dramatically among reported series (Table 1). It is apparent that, in studies of both surgical and hospital admissions, the incidence and significance of epididymitis are underestimated and the incidence of testicular torsion is overestimated. Accordingly, a policy of routine scrotal exploration for pediatric epididymitis would lead to an excessive n u m b e r of
I
Journa) of Pediatric Surgery, Vol 30, No 2 (February), 1995: pp 277-282
unnecessary operative procedures. Similarly, an unselective imaging evaluation of all children presenting with epididymitis might be excessive. The purposes of this study are (1) to assess the relative incidence of acute scrotat pathology in a primary care setting, (2) to determine the effectiveness of diagnostic and therapeutic modalities from the perspectives of morbidity and cost, and (3) to evaluate the significance of childhood epididymitis and the indications for diagnostic evaluation. MATERIALS AND METHODS We reviewed the medical records of 238 consecutively treated patients who presented to the emergency department, over a 2-year period, for evaluation of acute scrotal pain. Of these, 233 could be evaluated. Patients with a diagnosis of hernia, hydrocele, acute idiopathic scrotal edema, Henoch-SchOnlein purpura, or varicocele were excluded because, in each instance, the initial clinical diagnosis was unequivocal and proven to be accurate through follow-up. The patients were managed according to a strict protocol. If the testis could be documented to be nontender, and normal in size, shape, position, and consistency, the patient was discharged from the ER on therapy appropriate for the clinical diagnosis. The patients whose testicle(s) was not documented to be normal were managed according to the degree of clinical suspicion for testicular torsion. If testicular torsion was suspected, immediate surgical exploration was undertaken. In the event of another diagnosis being suspected, an imaging study (color Doppler ultrasound or radioisotope scan) was performed. The cases were evaluated with respect to accuracyof diagnosis and outcome of treatment. RESULTS Two hundred thirty-eight patients were encountered, accounting for an estimated 0.13% of total E R visits during the period of this study. The final diagnoses, according to imaging studies and clinical follow-up, are shown in Table 2. A significant variation in the incidence of acute scrotal pathologies as a function of age was encountered (Fig 1). The p e a k incidence of acute scrotal presentations was in the 11- to 13-year-old group. During the first year of life, the most common
From the Division of Pediatric Urology, Children's Hospital Medical Center, Cincinnati, OH. Presented at the 25th Annual Meeting of the American Pediatric Surgical Association, Tucson, Arizona, May 14-17, 1994. Address reprint requests to Curtis A. Sheldon, MD, Director, Division of Pediatric Urology, Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229-3039. Copyright © 1995 by W.B. Saunders Company 0022-3468/95/3002-0022503.00/0 277
278
LEWIS ET AL
35
Table 1. Relative Incidence of Childhood Acute Scrotal Pathology Type of Series
No. of Patients TT (%)
TAT (%)
EPI {%)
Reference No.
Surgical
183
64
34
2
4, 5
Admission
529
41
46
13
6-12
Emergency room
145
27
36
37
13, 14
30
25 20
Abbreviations: TT, testicular torsion; TAT, Torsed testicular appendage; EPI, epididymitis.
E
diagnosis (83%) was testicular torsion. For 3 to 13 year olds, the most common diagnosis was torsion of testicular appendage, peaking with the onset of puberty. After age 13, the most common diagnosis was epididymitis, predominating (75%) after the age of 17 years. The initial diagnosis was incorrect for 17 of the 233 patients (7%). For 4 of the 37 patients (11%) with testicular torsion, the diagnosis was missed at the time of initial presentation. Two were sexually active, had significant pyuria, did not undergo imaging studies, and were treated for presumed sexually transmitted disease. Both returned, had a radioisotope scan (RIS), were diagnosed as having testicular torsion, and underwent orchiectomy with contralateral orchiopexy. The other two patients had negative urinalyses and false-negative imaging study results (one from ultrasound [US] alone and the other from both US and RIS). Both were treated for presumed epididymitis, did not respond to therapy, had positive findings during repeat imaging studies (one US, the other both RIS and US), and received orchiectomy with contralateral orchiopexy. A factor common to all four cases was a protracted interval between the onset of pain and presentation. Massively swollen intrascrotal contents, associated with scrotal wall edema and erythema, were encountered, and we doubt that the testes would have been salvageable at the time of presentation. In each instance, true torsion of the spermatic cord was documented, rather than strangulation from epididymitis. Ten patients (9%) with torsion of an appendage were initially diagnosed as having testicular torsion and underwent exploration. Only two had imaging studies (one RIS, one US), which were falsely positive for testicular torsion. All patients underwent excision of the torsed appendage and experienced full recovTable 2. Etiology of Acute Scrotum in Childhood Diagnosis
No. of Patients
Percentage
Torsion of appendage Epididymitis Torsion of testis Other Unable to be evaluated
109 84 37 3 5
46 35 16 1 2
Total
238
100
z
10
0-1
1-3
3-s
s-7
7-9
9-11
11-13
1a-is
ls-17
17-19
Age (years) Fig 1. Relative incidence of testicular torsion, torsion of a testicular appendage, and epididymitis, as a function of age.
ery. Two (20%) had a significant reactive epididymitis, and eight (80%) had a reactive hydrocele serving to confound the diagnosis during clinical examination. Six patients (60%) presented after 24 hours of symptoms, accounting for the high incidence of associated pathology. One patient's condition was diagnosed and treated as epididymitis, although he was ultimately proven to have a varicocele. He underwent a high ligation and recovered uneventfully. Another patient was initially diagnosed as having torsion of an appendix testis and was found to have intermittent testicular torsion, which had become relieved by the time of presentation. When his symptoms recurred, he had exploration and underwent bilateral orchiopexy (both testes were salvaged). Another patient had positive RIS findings and underwent surgical exploration. He was found to have torsion of a spermatic cord hemangioma. This structure was excised, his testis was salvaged, and he has recovered completely. Figure 2 shows that testicular salvage was probable only if intervention occurred within 6 hours of pain onset. This was achieved for only 28% of patients, and testicular loss was attributed to a delay in presentation at the ER. No patient in this series whose interval between pain onset and presentation was > 48 hours had a salvageable testis. The success rate was 50% among patients who presented between 6 and 48 hours after pain onset. One hundred five imaging studies were performed. Excellent specificities were observed for both RIS and color Doppler US studies (95.4% and 97.0%, respectively). However, sensitivities were relatively low (85.7% and 80.0%, respectively), especially in light of the potentially devastating outcome of a false-negative result. Both false-negative RIS results and the two false-negative US results were for pa-
EVALUATION OF ACUTE SCROTUM
10
279
invasive urodynamic screening; seven of them (47%) had abnormal findings. This procedure consists of a uroflow study, striated sphincter electromyography, and estimation of residual urine by US. Abnormalities included elevated postvoid residual volume (4), diminished flow rate (3), and straining to void (2).
If,/A Testis Salvaged removed or Atrophied
In 8 t°O ~
6 o en
DISCUSSION 4
E z
2
0-6
7-12
o ml 13-18
19-Z4
25-48
>48
Time from Pain Onset to Surgery (hrs) Fig 2. Testicular salvage for torsion, as a function of the duration between onset of symptoms and surgical intervention.
tients who presented late, with massively swollen intrascrotal contents and intense reactive scrotal wall erythema and edema. For all four studies, the resultant reactive inflammatory hyperemia from a necrotic testis is presumed to be the source of the falsenegative result. None of these testes is believed to have been salvageable at the time of presentation. One false-negative US result was equivocal on the basis of blood flow that was present, although moderately reduced. The patient, a 15 year old, underwent exploration and was found to have an edematous testis, a "bell-clapper" testicular suspension anomaly, and 180° torsion of the testis. It is presumed that intermittent torsion accounted for this equivocal result. A 10-year-old patient had an indeterminate US study, based on the inability to establish conclusively the presence of blood flow in either testis. Subsequently, an RIS scan detected the presence of testicular torsion, following which bilateral orchiopexy was performed and both testes salvaged. No testis was "lost" as a result of false-negative imaging results. Twenty-eight patients with epididymitis (33%) had selective diagnostic studies to identify any associated urinary tract pathology. Structural abnormalities included ectopic ureteral insertion into the seminal vesicle, posterior urethral valves, urethral stricture, meatal stenosis, vesicoureteral reflux, calyceal diverticulum, trabeculated bladder, and duplication (1 instance each). On direct questioning, seven of those with abnormal findings on urinary tract studies (64%) reported subtle voiding problems. These included frequency (4), dribbling (2), urgency (1), sensation of incomplete voiding (1), and dysuria (1). Fifteen patients with epididymitis underwent non-
The ultimate goal of management of the acute scrotum in childhood is avoidance of testicular loss. This requires a high degree of diagnostic accuracy and prompt surgical intervention. Our data suggest that a high chance of testicular salvage is attainable only if intervention is undertaken within 6 hours of the onset of pain. This was achieved for only 28% of our patients, and testicular loss was presumed to be related to a delay in presentation at the ER. All patients who presented after 48 hours of symptoms did not have a salvageable testis. Between these two extremes, however, 50% of testes were salvaged. Presumably, those surgically preserved testes presenting beyond 12 hours had either lower degrees of torsion or intermittent torsion (both are impossible to detect clinically). Our data suggest that a testis should not be presumed necrotic and unsalvageable if fewer than 48 hours have elapsed since the onset of symptoms. Clearly, the greatest impact on testicular preservation lies with the effective education of parents and primary care physicians. Another important means by which gonadal loss can be minimized (when torsion is a probable diagnosis) is through prompt surgical intervention, without the delay incurred by diagnostic imaging studies. Other potentially beneficial maneuvers that we employ are manual detorsion 15 and ice-packing 16 between the time of diagnosis and surgical exploration. Our experience corroborates the observations of Haynes and Haynes, 17 and we would never advocate a delay in surgical intervention based on the presumed efficacy of manual detorsion. In addition to testicular loss, the presence of testicular torsion may indicate a poor prognosis for the contralateral testis; certainly, the risk of torsion in the latter is increased. The contralateral testis should be explored, and if a bell-clapper anomaly is identified, contralateral orchiopexy should be performed. We favor a four-point fixation technique employing nonabsorbable sutures, because we have experienced recurrent torsion with absorbable suture fixation techniques. The risk of ipsilateral testicular atrophy has been shown to increase with the duration of torsion. 18,~9 Whereas some investigators have noted impaired spermatogenesis after torsion, some have suggested a
280
LEWIS ET AL
correlation with the duration of t o r s i o n , 19-21 and others have not. 22,23The latter data lead us to question whether torsion itself causes contralateral injury, or whether a preexisting contralateral abnormality is present. Contralateral testicular biopsy specimens taken at the time of orchiopexy for torsion have shown a significant amount of seminiferous tubule degeneration, suggesting that, in many instances, bilateral testicular disease actually predates the acute event of t o r s i o n . 24'25 In this series, our approach to the management of the acute scrotum in childhood resulted in no lost testes that were likely to have been viable at the time of presentation. There were 10 false-negative scrotal explorations, three false-positive imaging results, and 77 true-negative imaging results, which, arguably, did not benefit the patients. This translates to an expense of $206.87 per patient encountered, which, given the high morbidity of a delayed diagnosis, is, in our opinion, justified. Forty-two percent of this expense resulted from negative surgical exploration. Epididymitis is a nonspecific term describing inflammation of the epididymis, which is generally associated with acute pain, swelling, and tenderness. It may be classified, according to etiology, as infectious, traumatic, or reactive. Additionally, it may be associated with systemic diseases such as sarcoidosis, Kawasaki's disease, and Henoch-Sch6nlein purpura. 26 Reactive etiologies include instances associated with torsion of an appendage, and chemical irritation from reflux of sterile urine into the seminal tract. Coliform bacteria are a common source of epididymitis in both men and boys who have congenitally abnormal urinary tracts. C trachomatis and N gonorrhaeae must be strongly considered in patients who are sexually active. 27,2sLikitnukul et al reported on 22 children who had epididymal cultures. 26 Isolated organisms included coagulase-negative Staphylococcus, S aureus, Escherichia coli, and Haemophilus influenzae, proteus, and salmonella. Viral agents, including mumps, coxsackie, echovirus, and adenovirus, also have been implicated. 29,3° Noteworthy is the occurrence of type B H influenzae epididymoorchitis, which may present in the prepubertal boy. 31,32 Here, the urinary tract is not considered to be the primary source of the infection, and such children are characteristically toxic at the time of presentation. Epididymitis has traditionally been believed to be
an uncommon cause of acute scrotal pathology in children. 3,6,33-36 Our data refute this concept, which appears to have arisen from surgical and admission series rather than a study of the primary care setting. Although it is known that infants and children have a significant incidence of urinary tract anomalies, 3 older children are generally described as having "idiopathic" epididymitis. However, an underlying overt neurogenic bladder or maintenance on intermittent catheterization is well recognized as a causative factor in this age group. 37,38 Amar and Chabra 33 found epididymitis in a patient with unrecognized vesicoureteral reflux, which can be associated with an underlying unstable bladder. The highly significant incidence of elevated postvoid residual volumes, abdominal straining, and diminished flow rates encountered in our series strongly suggests that previously unrecognized dysfunctional voiding may account for the idiopathic epididymitis in many children. Presumably, however, many such children also will have epididymitis that is reactive to an associated torsed appendage that is impalpable and unrecognized. Dysfunctional voiding may, in analogy to urethral obstruction (eg, posterior urethral valves and urethral strictures), cause epididymitis by elevating proximal urethral voiding pressure. Both primary and secondary (volitional) detrusor-sphincter dyssynergia are likely mechanisms. We encountered one patient who presented with epididymitis who subsequently was confirmed to have primary detrusor-sphincter dyssynergia. The proposed mechanism is similar to that known to be present in children who have vesicoureteral reflux associated with dyssynergia or bladder instability. We recommend that urinalysis and urine culture be performed for all children with epididymitis, and that urethral swabs sampled from those who are sexually active include cultures for chlamydia. Renal ultrasonography and VCUG are recommended for all infants and young children with epididymitis. Furthermore, careful questioning regarding voiding symptoms and screening via noninvasive urodynamic studies should be performed in all older children. Those with symptoms, abnormal screening study results, or positive urinalyses and cultures should undergo renal ultrasonography.
REFERENCES 1. Najmaldin A, Burge DM: Acute idiopathic scrotal oedema: Incidence, manifestations, and aetiology. Br J Surg 74:634-635,
boys: Underlying urogenital anomalies and efficacy of imaging modalities. J Urol 138:1100-1103, 1987
1987 2. Clark WR, Kramer SA: Henoch-Sch6nlein purpura and the acute scrotum. J Pediatr Surg 21:991-992, 1986 3. Siegel A, Snyder H, Duckett JW: Epididymitis in infants and
4. Flanigan RC, Dekernien JB, Persky L: Acute scrotal pain and swelling in children: A surgical emergency. Urology 17:51-53, 1981 5. Ben-Chaim J, Leibovitch I, Ramon J, et al: Etiology of acute
EVALUATION OF ACUTE SCROTUM
281
scrotum at surgical exploration in children, adolescents and adults. Eur Urol 21:45-47, 1992 6. Qvist O: Swelling of the scrotum in infants and children and nonspecific epididymitis: Study of 158 cases. Acta Chit Seand 110:417-421, 1955 7. Anderson PAM, Giacomantonio JM: The acutely painful scrotum in children: Review of 113 consecutive cases. Can Med Assoc J 132:1153-1155, 1985 8. Nour S, MacKinnon AE: Acute scrotal swellingin children. J R Coll Surg Edinb 36:393-394, 1991 9. Moharib NH, Krahn HP: Acute scrotum in children with emphasis on torsion of spermatic cord. J Urol 104:601-603, 1970 10. Hemalatha V, Rickwood AMK: The diagnosis and management of acute scrotal condition in boys. Br J Uro153:455-459, 1981 11. Kaplan GW, King LR: Acute scrotal swelling in children. J Urol 104:219-223, 1990 12. Melekos MD, Asbach HW, Markou SA: Etiology of acute scrotum in 100 boys with regard to age distribution. J Urol 139:1023-1025, 1988 13. Caldamone AA, Valvo JR, Altebarmakian VK, et al: Acute scrotal swellingin children. J Pediatr Surg 19:581-584, 1984 14. Anderson PAM, Giacomantonio JM, Schwartz RD: Acute scrotal pain in children: Prospective study of diagnosis and management. Can J Surg 32:29-32, 1989 15. Betts JM, Norris M, Cromie WJ, et ah Testicular detorsion using Doppler ultrasound monitoring. J Pediatr Surg 18:607-610, 1983 16. Miller DC, Per0n SE, Keck RW, et al: Effects of hypothermia on testicular ischemia. J Urol 143:1046-1048, 1990 17. Haynes BE, Haynes VE: Manipulative detorsion: Beware the twist that does not turn. J Urol 137:118-119, 1987 18. Krarup I: The testis after torsion. Br J Uro150:43-46, 1978 19. Bartsch G, Marberger FH, Mikuz G: Testicnlar torsion: Late effects with special regard to fertility and endocrine function. J Urol 124:375-378, 1980 20. Chakraborty J, Hikim APS, Jhunjhunwala JSJ: Quantitative evaluation of testicular biopsies from men with unilateral torsion. Urology 25:145-150, 1985 21. Danner C, Frick J, Royan E: Testicular function after torsion. Int J Androl 5:276-281, 1982 22. Anderson JB, Williamson RCN: The fate of the human testes followingunilateral torsion of the spermatic cord. Br J Urol 58:698-704, 1986
23. Laor E, Fisch H, Tennenbaum S, et al: Unilateral testicular torsion: Abnormal histologicalfindings in the contralateral testis-Cause or effect? Br J Urol 65:520-523, 1990 24. Horica CA, Hadziselimovic F, Kreutz, et al: Ultrastructural studies of the contorted and contralateral testicle in unilateral testicular torsion. Eur Urol 8:358-362, 1982 25. Hadziselmovic F, Snyder H, Duckett JW, et al: Testicular histology in children with unilateral testicular torsion. J Urol 136:208-210, 1986 26. Likitnukul S, McCracken GH, Nelson JD, et al: Epididymitis in children and adolescents. A 20-year retrospective study. Am J Dis Child 141:41-44, 1987 27. Pearson RC, Baumer CD, McGhie D, et al: The relevance of Chlamydia trachomatis in acute epididymitis in young men. Br J Urol 62:72-75, 1988. 28. Berger RE, Kessler D, Holmes KK: Etiology and manifestations Of epididymitis in young men: Correlations with sexual orientation. J Infect Dis 155:1341-1343, 1987 29. Hermansen MC, Shusid MJ, Sty JR: Bacterial epididymoorchitis in Children and adolescents. Clin Pediatr 19:812-815, 1980 30. Coran AG, Perlmutter AD: Mumps epididymitis without orchitis. N Engl J Med 272:735, 1965 31. Greenfield SP: Type B hemophilus influenzae epididymoorchitis in the prepubertal boy. J Urol 136:1311-1313,1986 321 Lin YC, King DR, Birken GA, et al: Acute scrotum due to haemophilus influenzae type B. J Pediatr Surg 23:183-184, 1988 33. Amar AD, Chabra K: Epididymitis in prepubertal boys. JAMA 207:2397-2400, 1969 34. Doolittle KH, Smith JP, Saylor ML: Epididymitis in the prepubertal boy. J Uro196:364-366, 1966 35. Megalli M, Gursel E, Lattimer JK: Reflux of urine into ejaculatory ducts as a cause of recurring epididymitis in children. J Urol 108:978-979, 1972 36. Umeyama T, Kawamura T, Hasegawa A, et al: Ectopic ureter presenting with epididymitisin childhood: Report of 5 cases. J Urol 134:131-133, 1985 37. Gislason T, Noronha RF, Gregory JG: Acute epididymitisin boys: A 5-year retrospective study. J Urol 124:533-534,1980 38. Thirumavalavan VS, Ransley PG: Epididymitis in children and adolescents on clean intermittent catheterisation. Eur Urol 22:53-56, 1992
Discussion J. Noseworthy (Wilmington, DE)." A l t h o u g h this study is retrospective, t h e r e are o p p o r t u n i t i e s in the s u b g r o u p of c h i l d r e n with acute epididymitis ( A E ) to p e r f o r m f u r t h e r retrospective analyses. T h e m a n u s c r i p t p r e s e n t s a n d discusses d a t a regarding testicular t o r s i o n (TT), a p p e n d i c e a l t o r s i o n (AT), a n d imaging errors, b u t t h e r e is really n o t h i n g n e w in these data. N o r is the discussion r e l a t i n g to subseq u e n t infertility following T T a n y t h i n g that h a s n o t b e e n b r o u g h t forward before. I n fact, the d a t a in this p a p e r do n o t really address t h a t issue at all. A t e r m u s e d in the m a n u s c r i p t , " d e g r e e of clinical suspicion," l e a d i n g to i m m e d i a t e surgical i n t e r v e n tion, should b e precisely defined. W h a t were the
e l e m e n t s in the degree of clinical suspicion that led to i m m e d i a t e o p e r a t i o n ; f u r t h e r m o r e , how do those e l e m e n t s c o m p a r e a m o n g the t h r e e groups (TT, A T , and A E ) ? T h i r t y - s e v e n p a t i e n t s with T T were i n c l u d e d in the series. F o u r T T cases were missed at the time of initial p r e s e n t a t i o n . Two of the p a t i e n t s were sent from the e m e r g e n c y r o o m o n the basis of pyuria, with n o initial imaging. I w o u l d c a u t i o n all of us to n o t let pyuria a l o n e override o t h e r clinical findings in this group of patients, w i t h o u t some a d d i t i o n a l supporting data such as flow scintigraphy. T h e p o i n t I would like to e m p h a s i z e is the large n u m b e r of c h i l d r e n with A E in this s e r i e s - - 3 5 % of
282
the total in a series collected over a relatively short period in comparison to other series that have been reported. In 1987, the exPerience at another large children's hospital (over 9 years) found only 47 patients with AE. In that report, there was clear emphasis on the underlying urogenital anomalies associated with AE. These data from the Cincinnati group show that the incidence of AE and the subsequent potential etiologic pathologies are important, occur with significant frequency, and should not be overlooke& Unfortunately only one third of the total group was fully evaluated beyond making the diagnosis of AE, and it is in that regard that I would urge that the 56 patients with AE who were not evaluated as to etiology be studiedl even retrospectively. The frequent findings of both structural and urodynamic abnormalities in this group (AE) warrant their being subjected to close and well-organized evaluation. The combination of ultrasonography, contrast voiding cystourethrography, excretory urography, and particularly, urodynamic evaluations (well described in the manuscript) should be used. This latter technique is particularly important because it emphasizes one important final common pathway in pediatric AE, that of elevated proximal urethral voiding pressure, a concept appropriately emphasized by D r Sheldon and his colleagues. Last, I ask the authors for some comments regarding subsequent therapies for these children, both those with structural anomalies and those with urodynamic anomalies. How many of them needed further surgical correction of their anatomic anomaly or required pharmacological manipulation of their voiding dysfunction? T.P. Bukowski (response): First of all, the study was
LEWIS ET AL
initiated to study the overall incidence of the different scrotal pathologies, and was therefore limited to a 2-year period. We felt it necessary to review the torsion data thoroughly to show that our data were similar to those from published series, which would then validate the epididymitis,data. CIinical suspicion for torsion included traditional indices such as very tender, high-riding testicle, with a negative cremasteric reflex. The indices for epididymitis were localized tenderness posteriorly, with or without a history significant for sexually transmitted diseases, intermittent catheterization, et cetera. The clinica! suspicion for a torsed appendix testis would involve a tender nodule at the superior pole of the testis. We agree that most patients with pyuria should have a complete workup. The two patients in the study who had some pyuria also had a recenthistory of sexual activity and were strongly believed to have had a sexually transmitted disease. Patients who have epididymitis with functional voiding disorders are put on a bladder training regimen with antibiotic prophylaxis until their voiding is normalized. The patients with anatomic abnormalities (mostly in the 0- to 4-year-old group) underwent surgery. We feel that functional voiding problems in the older child with epididymitis are significant. All 28 patients evaluated with urodynamics for epididymitis were from one surgeon's clinic, who would evaluate the children if they did not have any immediately identifiable cause for epididymitis. We expect to have a complete review of these children in the near future.