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The acute pediatric scrotum
The Journal of Emergency Medicine, Vol 11, pp 565-577,
Prlnted in the USA
1993
Emergency
Medicine
THE ACUTE PEDIATRIC Martin W. Schul,
MD,’
Copyright 0 1993 Pergamon Press Ltd.
in Review
SCROTUM
and Michael A. Keating, rmt
*EmergencyMedicine Resident PGY-1, Methodist Hospitals Inc., Indianapolis, Indiana, and tAssistant Professor Pediatric Urology, Indiana University Medical Center, Indianapolis, Indiana MD, James Whitcomb Riley Hospital for Children, 702 Barnhill Drive, Room 1738, Indiana University Medical Center, Indianapolis, IN 46202
Reprint Address: Michael A. Keating,
0 Abstract -The acute pediatric scrotum is a common clinical condition that can present a diagnostic dilemma for even the most experienced physician. The issue of primary importance in each case is to ensure testicular viability through proper evaluation, prompt diagnosis, and surgical intervention if necessary. A review of the various etiologies of acute scrotal disorders in children aids in the formulation of a logical and systematic approach to their accurate diagnosis and management.
HISTORY AND PHYSICAL EXAMINATION A
thorough history and physical examination are instrumental to making a proper diagnosis. Table 1 summarizes the various lines of questioning that should be followed when initially assessing each case. Examining the child with an acute scrotum can be challenging. Smaller anatomy combined with patient discomfort often make the examination difficult. Ideally, the examination should be performed in a warm, well-lighted room. This decreases the likelihood of the testicles being drawn toward the inguinal region. If the room cannot be suitably heated, a warm towel placed on the groin can be helpful. Inspection should be carried out with the child in the upright position. This allows assessment of the lie of the testes and of any skin changes that might be present, such as erythema or regions of ecchymosis. Palpation should be performed with the child supine and the limbs in the frog-leg position. This serves two purposes: prevention of possible vasovagal episodes and elimination of the cremasteric reflex during bimanual examination. Using warm hands and beginning with the asymptomatic side, one should proceed to palpate each testicle and its adjacent epididymis and spermatic cord. Careful examination of the more proximal inguinal region is also necessary. Irregularities and enlargements of the organs, as well as fullness and twists of the cord, may provide a clue to the diagnosis. In many cases, the scrotal contents
0 Keywords-acute testicular disorders; children; scrotum; testicular torsion
INTRODUCTION
The acute scrotum is any pain or swelling of the scrotum or its contents that has suddenly occurred. This is a common clinical entity, which can represent a true urologic emergency and a diagnostic dilemma for even the most experienced physician. When based on clinical evaluation alone, misdiagnosis has occurred in as many as 50% of patients presenting with an acute scrotum (1,2). Time becomes an important factor when evaluating these patients; a prompt and accurate diagnosis can be essential to the preservation of testicular viability. The focus of this article is to review the common causes of the acute scrotum in children, and to provide a systematic approach to its evaluation, diagnosis, and treatment.
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Martin W. Schul and Michael A. Keating
Table
1. Historicel Scrotum
Clues-The
Acute
Presenting symptoms Onset Duration Severity Diffuse vs. localized pain tenderness Similar episodes Positional change Associated symptoms Fever > 38.0% Nausea or vomiting ;bd;r;nal discomfort Anorexia Genitourinary factors Urinary tract anomalies Previous surgeries Recent manipulations Multiple UTls Sexual habits Urethral discharge Miscellaneous Recent trauma Strenuous exercise Recent viral illness Systemic diseases
are engorged and exquisitely painful, making assessment of anatomic detail difficult or impossible. Transillumination sometimes helps distinguish solid masses from liquid or gas, but adjunct studies often become necessary to further define the problem (3). A working knowledge of inguinal, scrotal, and testicular anatomy is necessary to enable an accurate physical examination. The scrotum is composed of rugous and deeply pigmented skin replete with large sebaceous follicles. Deeper and tightly adherent to its skin lies the dartos tunic, a thin muscular layer continuous with the superficial abdominal and perineal fascias. The dartos layer fuses at the midline to create the median raphe, which separates the scrotal sac into halves. Beneath the dartos are the cremasteric muscle and internal and external spermatic fascia. These 3 layers represent extensions of the abdominal wall musculature and form a trilaminar sac that envelopes the spermatic cord and scrotal contents. The testes are ovoid structures that rest with their long axis in the vertical plane. The left gonad is usually more dependent than the right. Size varies with age but the contralateral asymptomatic gonad usually provides a useful standard during the examination. Posteriorly the testicles are supported by a remnant of the gubernaculum and proximally by the spermatic cord (Figure 1). The anterolateral margins are embedded in the tunica vaginalis, an extension of the peritoneum which is created during testicular
descent. This pouch enables the scrotal contents to slide easily beneath the skin with palpation. Finally, emerging from the superior pole of the testes and passing over its posterolateral aspect is the epididymis. This cone-shaped structure, which is smaller and softer than the gonad, tapers in size before becoming continuous with the vas deferens above. Serving as the root of the testicle, the spermatic cord contains the primary vessels, nerves, and vas deferens, and is surrounded by the previously described fascial layers as it passes through the inguinal canal posteriorly. LABORATORY STUDIES The initial laboratory evaluation should include a complete blood count (CBC) with differential and a urinalysis. The CBC can be helpful in identifying the presence of inflammatory processes, and the urinalysis provides screening of pyuria and proteinuria. Although these studies should be obtained in most children with acute scrotal pain, their results alone are usually insufficient for making a reliable diagnosis. DIAGNOSTIC STUDIES When the diagnosis cannot be made on a clinical basis alone, imaging becomes necessary. The 2 methods most widely used today are testicular scintigra-
Gubernaculum Testis Figure 1. Scrotal contents.
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phy and ultrasonography with real-time color flow Doppler. Testicular scintigraphy is currently the procedure of choice for evaluating the acute scrotum in the pediatric population (4,5). This radionuclide study, which analyzes testicular perfusion, takes little time to perform and provides valid and simple interpretations in most cases. However, full-service nuclear medicine departments are not present in some hospitals and the technology may not be available at all times. Torsion of a testis is indicated by a “cold spot,” reflecting an absence or decrease in blood flow to the testis (Figure 2 a,b). Inflammatory processes, such as orchitis or torsion of a testicular appendage, will demonstrate increased flow and uptake by the affected hemiscrotum. The sensitivity and specificity of scintigraphy was as high as 100% and 97% in one study (6) and 90% and 89% in another (7). False positive scans can be mimicked by large fluid collections within the scrotum, i.e. abscess, hydrocele, hematocele, or bowel herniation (4). False negative scans, though rare, sometimes occur with cases of very early torsion, spontaneous detorsion, or when scanning the anatomy of smaller toddlers or infants
(8). Real-time color Doppler ultrasonography is rapidly gaining popularity as an aid in diagnosing testicular torsion. Recent reports have shown the sensitivity of this study to be 86-100%. Its specificity in diagnosing torsion has been shown to be nearly 100% in adults (9,lO). Color Doppler has the advantage of assessing testicular circulation as well as defining testicular anatomy, although its efficacy in younger age groups is not well defined (11,12). Unnecessary surgical intervention was shown to decrease by 19% in 1 series, when Doppler was used in conjunction with inconclusive nuclear scans (13). Current disadvantages of the study include limited expertise with the technology and limited availability. Defining anatomic detail in smaller children also presents a problem. However, we suspect that Doppler studies will become the diagnostic test of choice for acute scrotal disorders in children, with continued experience and investigation,
DIFFERENTIAL
DIAGNOSIS
The 3 most common causes of the acute pediatric scrotum are testicular torsion, torsion of the appendix testis, and epididymoorchitis (14). Of these, testicular torsion has the most ominous sequelae. Less common causes to be considered include idiopathic scrotal edema, scrotal hernias or hydroceles, trauma,
Henoch-Schonlein Purpura, and testicular tumors. Urologic consultation should be sought immediately in any instance where torsion cannot be ruled out upon the patient’s initial arrival in the emergency department .
TESTICULAR
TORSION
Testicular torsion represents a true surgical emergency that must be ruled out when evaluating the acute scrotum. This fact is underscored by the realization that testicular viability is directly related to the duration of the insult and is strongly impacted by patient and physician delay. Salvage rates of 8096% have been reported when surgical intervention is performed within 8 hours of the acute event. Salvage drops to 70% between 8 to 12 hours, and to only 20% if surgery is delayed for more than 12 hours (5,lO). Testicular torsion has accounted for nearly half of all acute scrotal disorders in children 17 years of age or younger in one series (14), and has been estimated to occur in 1 of every 4,000 males before the age of 25 (16). The peak incidence of torsion occurs around 13 years of age and coincides with the onset of puberty. It is uncommon after the age of 30 (8917). The predisposition to peripubertal testicular torsion appears to stem largely from abnormal suspension of the testis within its investing layers. These anomalies are nearly always bilateral, the most common of which is known as the “bell clapper” deformity. This defect finds the testis almost completely surrounded by its tunica vaginalis, and minimally fixed at one point by its mesentery (Figure 3 a,b,c). Allowed to lie transversely, the testis is free to rotate upon this stalk leaving it prone to exaggerated twists. The typical presentation is one of sudden onset, severe pain that originates in the scrotum or lower quadrant. It is common to elicit a history of antecedent episodes of similar discomfort that spontaneously resolved. Vigorous exercise or blunt trauma are often implicated in the onset of torsion, but many boys are suddenly awakened from sleep with excruciating pain. Nausea and vomiting occur frequently but attendant fevers are unusual (14). Three common findings that are strongly suggestive but not pathognomonic for torsion are shown in Table 2. The ipsilateral leg is often flexed to guard the affected side. Scrotal erythema and edema are common, and a reactive hydrocele is sometimes seen. The incidence of hydrocele increases with the duration of unresolved torsion and can be as high as 20% (18). Absence of the cremasteric reflex is highly indic-
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Figure 3. (a) Normal anarchnnents of a testis within the tunica vaginalis; (b) “bell-clapper” anomal torsionlatex ploratioln.
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(4 360 degree te
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Martin W. Schul and Michael A. Keating Table 2. Signs Suggestive of Testicular Torsion 1. Elevated testis with palpable cord twist 2. Abnormal epididymalattachment 3. Horizonatalaxis of contralateraltestis
of testicular torsion. In one study, none of 38 patients with torsion of the spermatic cord demonstrated a cremasteric reflex (19). Prehn’s sign, where elevation of the testicle should exacerbate the pain of torsion yet relieve the discomfort caused by epididymitis, has been highly unreliable in our experience. Laboratory values will yield leukocytosis and a left shift in 50% of patients. The urinalysis should be normal (20). When testicular torsion cannot be ruled out, scrotal imaging should be employed. Once the diagnosis has been established, or if testicular torsion cannot be ruled out, the only definitive treatment is surgical exploration. Manual detorsion can be cautiously attempted as the surgical suite is being prepared. The large majority of torsed testes rotate to the midline. ative
Thus, any attempts to detorse the gonad should be made in a medial to lateral direction. Successful detorsion should be accompanied by the immediate cessation of pain. Otherwise, the maneuver should be discontinued for fear of exacerbating the problem. When manual detorsion is effective, the patient should still undergo urgent surgical exploration to assess the viability of the affected testicle and perform an orchiopexy to prevent further torsions. The contralateral testicle, which usually has a similar anatomic predisposition, should also be pexed. If a nonviable testis is discovered, orchiectomy is recommended.
TORSION OF TESTICULAR
APPENDAGES
Torsion of testicular appendages occur nearly as often as actual testicular torsion (14). Any of 5 embryologic remnants found in most males can function as potential sources of this type of torsion. The one most commonly implicated is the appendix testis, a
Figure 4. (a) “Blue dot” sign of a towed testicular appendage; (b) infarcted appendage at exploration.
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The Acute Pediatric Scrotum
mullerian duct remnant, which accounts for 92% of cases (8) (Figure 1). Torsion of an appendage is felt to occur under the influence of human chorionic gonadotropin (HCG) at the onset of puberty. The appendage enlarges, leaving it prone to twist on its mesenteric stalk, and become infarcted (21). Most occur at an average age of 10 (22). Patients typically present with the sudden onset of moderate to severe pain localized solely to the scrotum. Gastrointestinal and urinary symptoms or fevers are uncommon. On physical examination, point tenderness can sometimes be appreciated and is a useful diagnostic sign. In these instances, the child can place a finger on the exact source of his discomfort, which is commonly located at the superior pole of the testicle (5,17). A nodule is sometimes palpable early after the onset of pain, and the cyanotic appendage appreciable beneath the scrotal skin. This pathognomonic finding, known as the “blue dot” sign, can be found in 14 to 22% of cases (14,17), (Figure 4 a,b). Urinalyses should be normal, but onefourth of patients will demonstrate leukocytosis with a left shift in the CBC (14). Testicular torsion may be impossible to rule out because of peritesticular inflammation and scrotal swelling, especially in patients who delay seeking medical attention. In these situations, a nuclear scan is warranted and, if inconclusive, scrotal exploration should be employed. If the diagnosis can be made clinically, conservative therapy is appropriate and analgesia alone should suffice (23). Discomfort generally persists for less than a week as the affected appendage becomes atrophic and is autoamputated.
EPIDIDYMITIS Epididymitis, the most common cause of the acute scrotum in adults, is an overrated etiology in children (14,21). In fact, errors in diagnosis with these types of disorders have often been attributed to infection when torsion of the testicle or its appendage should have been considered instead. Children affected with epididymitis are typically postpubertal or sexually active. When a younger child presents with this condition, it is frequently the herald sign of an underlying urinary tract anomaly. Bacteria are the cause of most epididymitis, with coliforms usually implicated in prepubertal males and venereal organisms such as Neisseria and Chlamydia found after puberty. Children at particular risk include those who have a recent urinary tract infection or urologic instrumentation, including catheterization. Children with genitourinary disor-
ders such as neurogenic bladder, imperforate anus, or hypospadias are also prone to episodes of epididymitis (8,23). Patients usually present with the gradual onset of mild to moderate scrotal pain and swelling that evolved over several days. Symptoms referring to both testes are not uncommon (8). Other complaints include dysuria and urethral discharge. Fevers occur in 14-28% of cases, but other systemic complaints are rare. If the child presents early in the course of his illness, a swollen and indurated epididymis can sometimes be delineated from the testicle. Usually, however, the findings are nonspecific and the examination and differentiation of structures is often impossible due to significant edema of the scrotal sac. The CBC commonly shows an elevated white cell count with a left shift, but the urinalysis, surprisingly enough, demonstrates pyuria in only 15% of cases. If urethral discharge is present, a Gram stain should be obtained and may aid in making the diagnosis. In the face of such nonspecific findings, the diagnosis of epididymitis can be difficult. Six factors suggestive for bacterial epididymitis are shown in Table 3. Knight and Vassy found that children with 3 of these findings had definite epididymitis, and those with 2 were probable cases (14). Where some doubt remains, which is common, nuclear imaging is usually diagnostic and shows increased perfusion to the inflamed hemiscrotum (Figure 2b). Once the diagnosis of epididymitis is made, therapy is directed toward the suspected organism. The urine should be cultured for sensitivities, but in many cases cultures remain negative. Most patients respond rapidly with appropriate antibiotic therapy such as ampicillin or trimethoprim/sulfamethoxazole. Bedrest and scrotal support with elevation and icepacks are also helpful (21). When symptoms persist despite empiric antibiotics, an ultrasound should be obtained to rule out abscess formation. Epididyma1 aspirates for the identification of the offending organism are rarely indicated. After treating the acute event, an appropriate workup for urologic abnormalities including voiding cystourethrography and renal ultrasound are strongly recommended if a cause for the infection is not readily apparent. If Table 3. Findings Suggestive of Epididymltis 1. Gradual onset of symptoms 2. Recent urinary instrumentation or surgery 3. Dysuria, recent urinary infection, or abnormal bladder function 4. Significantly elevated temperature (> 36.3%) 5. Localized tenderness and induration of the epididymis 6. Abnormal urinalysis
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the ultrasound is abnormal, an excretory urogram should be obtained to rule out an ectopic ureter. This anomaly is predisposed to causing bouts of epididymitis in the prepubertal child.
IDIOPATHIC
SCROTAL EDEMA
Idiopathic scrotal edema occurs primarily in prepubertal males, with 77% of cases occurring before the age of 10 (24). Its etiology remains unclear, yet an allergic phenomenon has been implicated on the basis of pathologic changes found in the affected scrotal skin (21). Patients typically present with the sudden onset of unilateral or bilateral scrotal erythema and edema accompanied by little or no discomfort. The characteristic feature in every patient is scrotal erythema and edema that is out of proportion to the minor degrees of tenderness present. Occasionally, the erythema extends to involve the penis, anterior abdominal wall, and the perineum. These children are typically afebrile but a few exhibit associated allergic manifestations of angioneurotic edema. Eosinophilia can be found in as many as 50% of affected children. The nephrotic syndrome can sometimes present with a similar picture of scrotal edema but would be ruled out by the midstream urinalysis, which is universally normal in the idiopathic variety (17). The diagnosis of scrotal edema can usually be made on clinical grounds alone. If torsion is still a consideration, nuclear scanning should be performed. Scrotal edema is a self-limited condition, with resolution occurring in 1 to 4 days (24). Therapy is supportive, yet there has been some evidence that the addition of antihistamines may speed recovery (25). Recurrent episodes occasionally occur, but there appears to be no long-term sequelae associated with the disorder.
the virus continues to present a health hazard. Though the immunization is 97% effective, only an estimated 77% of children in the United States are immunized, leaving a substantial number of boys with their testes unprotected (26). The testicular involvement of mumps rarely affects prepubertal males, yet occurs with a frequency of 30% in boys older than 10 who become infected with the virus (27). Orchitis develops 4 to 6 days after a bout of parotiditis. These patients present typically with the gradual onset of pain and swelling in the scrotum associated with the constitutional symptoms of fever or nausea and vomiting. Testicular pain is usually unilateral, but bilateral involvement occurs in 17-30070 of cases (26). The often unrelenting discomfort is felt to stem from testicular swelling within the unyielding restraints of its encapsulating tunica albuginea. Examination will disclose a diffusely tender, edematous, and swollen testis with or without a reactive hydrocele. Laboratory studies are generally unremarkable. Making the diagnosis of mumps orchitis rests with a history of antecedent parotid swelling. Verification can be made by immunofluorescent antibody testing, in which a titer 1 1 : 256 is considered positive for recent infection (28). Without a history of parotid swelling, the diagnosis becomes difficult, and additional studies are warranted to rule out torsion. Viral orchitis is a self-limited disease process, with symptoms usually resolving within 6 to 10 days. Therapy is directed at swelling and pain using icepacks and analgesics. In rare cases the orchalgia is unremitting and surgical decompression must be considered. Whether surgery is required or not, testicular atrophy is a common sequelae of mumps involvement and occurs in 30-50% of cases (29). Fortunately, however, sterility is rare unless bilateral involvement is present.
HERNIAS AND HYDROCELES ORCHITIS Orchitis can be divided into 1 of 2 categories, bacterial or viral. Bacterial (pyogenic) orchitis is less common in the pediatric age group and generally occurs as a retrograde extension of epididymitis. Diagnosis and treatment are based on the principles discussed above. In contrast, most viral orchitis is caused by the mumps virus, but strains of coxsackie A and lymphocytic choriomeningitis virus have also been implicated (23). The incidence of mumps orchitis has decreased as a consequence of mumps immunization. However,
Scrotal hernias and hydroceles have a common etiology, a patent processus vaginalis (Figure 5). The processus represents an extension of the peritoneum that accompanies gonadal descent into the scrotum. The structure remains patent in the majority of newborns (85%), but gradual obliteration occurs with continued development in most (30). The occasional patent processus vaginalis that becomes clinically apparent can be classified as either a hernia or a hydrocele. A hernia occurs when a viscus or omentum enters the processus. When fluid alone is contained within the structure, a hydrocele results. Hernias and hydro-
The Acute Pediatric Scrotum
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attempted with the patient in the Trendelenburg position. Fortunately, 90-95% of incarcerated hernias are reducible. Should reduction prove difficult, sedation with leg elevation and cold packs are helpful. If attempts at reduction are unsuccessful, emergent surgical exploration is indicated. In patients with rebound tenderness or a cyanotic hue beneath the skin, reduction should not be attempted because a gangrenous loop of bowel is likely present. Immediate surgical intervention is mandatory. Hydroceles most commonly affect the infant age group in keeping with the natural history of the processus vaginalis (32). Like hernias, most occur on the right (30,31). The overwhelming majority of hydroceles are painless and present at birth, but their occasional sudden appearance at a later age, from sudden opening of the processus, is a cause of concern for parents. On physical examination, affected children demonstrate scrotal fullness which allows brilliant transihumination (Figure 6). Scrotal size sometimes changes with position or squeezing, thus demonstrating a continuity of the peritoneum and the tunica
Figure 5. Patent processus vaginalis.
celes are a common cause of scrotal swelling. They comprised 12% of pediatric surgeries in one series, 98% of which were due solely to the presence of a patent processus vaginalis (3 1). The overall incidence of clinically significant hernias in children varies from 0.8-4.4%, depending on the weight and gestational age of the child. Premature infants are at a higher risk, with an incidence of 7-17070 (32). Hernias are right sided in 60% of the cases, and bilateral in 10% (30). The risk of incarceration is highest during the first few months of life, with 69% occurring by the end of the first year (32). An overall 5% incarceration rate from 1 recent report bears testimony to the need for early diagnosis and repair of hernias on a less than emergent basis. Patients with incarcerated hernias may present with a history of inguinal weakness or bulge. Bowel obstruction should be suspected if the patient presents with nausea and vomiting, abdominal pain, fever, and increased irritability. Examination will reveal a distended, tender abdomen, and inguinal and scrotal fullness. The scrotum will transilluminate if gas is present within a viscus, and bowel sounds may also be heard. Gentle manual reduction should be
Figure 6. Tranailluminatlon useful in diagnosis of hydroceles.
Martin W. Schul and Michael A. Keating
Figure 7. Testicular fracture (arrows) demonstrated by ultrasonography.
vaginalis (30). In most cases, the scrotal swelling does not extend to the inguinal region. When it does, hernia must be ruled out. Therapy is usually conservative. By 18 months of age the majority of hydroceles spontaneously resolve with closure of the processus vaginalis. In patients with persistent hydroceles, elective inguinal repair should be pursued by age 2. The likelihood of hydroceles evolving into clinically significant hernias is unclear but seems uncommon. However, parents should be cautioned about signs of hernia formation. Under no circumstances should a hydrocele or hernia be aspirated. Recurrence would be expected and the risks of introducing an infection or perforating a bowel loop are very real (30,32).
TRAUMA Traumatic lesions to the scrotum and testes include contusions, lacerations, and penetrating injuries. Generally, the history will lead directly to the correct diagnosis. It is important that testicular intactness and perfusion be verified, as tremendous forces are often involved in creating these injuries. A urologist should be involved early, helping guide the direction of care. In cases where damage to the testicle is suspected, ultrasonography is recommended to rule out
surgical conditions. Testicular fractures or paratesticular hematomas may be diagnosed and require immediate surgical attention (Figure 7). Scrotal contusions are detectable by the ecchymotic appearance of the scrotal skin. Superficial lacerations are easily manageable. Scrotal tissue has great healing potential, and when no other gross pathology can be detected, simple primary closure is sufficient. Deeper penetrating wounds are often benign, yet require surgical exploration to assess the status of the gonad. If the tunica of the testicle has been disrupted, debridement and primary closure are recommended. In rare cases where testicular perfusion has been compromised for an extended time, orchiectomy may be warranted. Therapy, other than surgery for traumatic insults, involves rest, analgesia, and scrotal support. Patients must be monitored for further signs of infection, with appropriate antibiotic therapy initiated toward anaerobes and skin flora.
HENOCH SCHONLEIN PURPURA Henoch-Schonlein Purpura (HSP) is a nonthrombocytopenic purpura caused by a systemic necrotizing vasculitis with an unknown etiology. Most commonly seen in children ages 4 to 10, this disease is associ-
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(a)
(W Figure 8. (a) Lesions of the buttocks and extremities commonly seen with Henoch-Schonlein Purpura; (b) scrotal erythema same patient.
Martin W. Schul and Michael A. Keating
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ploration should be considered, although there has been only 1 reported case of true testicular torsion in an HSP patient (34). Testicular symptoms should spontaneously resolve, but analgesics and antiinflammatory agents are helpful in alleviating these manifestations.
History and Physical
TESTICULAR nuclear scan Doppler U/S
*
equivocal
non-torsion
J
Surgery
Conservative Management (EXCEPT FOR HERNIAS)
Figure 9. Algorlthm for management of acute pediatric scrotum.
ated with a variety of symptoms involving the skin, joints, gastrointestinal, and genitourinary systems. Pain and swelling of the spermatic cord and testicle occurs in 2-38070 of HSP patients (33). Although parents are usually previously aware of the condition, there have been 5 cases where an acute scrotum was the initial manifestation of the disease (33). Though this is a rare cause of the acute scrotum, the presenting symptoms often mimic testicular torsion, which must be considered in the differential diagnosis (Figure 8 a,b). The genital pain seen with HSP has a sudden onset and may have associated nausea, vomiting, and fever. Physical examination reveals unilateral swelling and an absent cremasteric reflex. Laboratory values are usually normal. A history of HSP found in combination with a normal nuclear scan should spare these children an exploratory procedure. However, if the nuclear scan is equivocal, prompt surgical ex-
TUMORS
Testicular tumors rarely occur in children but may present as an acute scrotum. When afflicted, boys are generally less than 4 years of age or well into puberty (35). Tumors typically evolve over weeks to several months, and occasionally become painful as a result of spontaneous hemorrhage within the tumor itself. Actual testicular torsion may foreshadow the discovery of a testicular tumor, and has been reported in 5 previous cases (36). On physical examination, the affected testis has an irregular contour and may be swollen and painful. The CBC and urinalysis should be normal. If tumor is suspected, ultrasonography is an invaluable aid to confirming the diagnosis.
SUMMARY Testicular torsion is a true surgical emergency, and boys with acute testicular pain should be presumed to have torsion until proven otherwise. A thorough history and physical examination are instrumental to making a correct diagnosis. When clinical uncertainty persists, nuclear scanning or color Doppler studies are essential to an expeditious and accurate diagnosis. An algorithm for evaluation and management of the acute pediatric scrotum is shown (Figure 9). An orderly approach to diagnosis decreases morbidity by minimizing unnecessary surgical procedures and serves to initiate necessary therapeutic measures at the earliest and most beneficial time in the disease process, regardless of the cause.
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MM, Canning DA. Suspected testicular torsion and ischemia: evaluation with color Doppler sonography. Radiology. 1990; 175:815-21. 10. Lerner RM, Mevorach RA, Hulbert WC, Rabinowitz R. Color Doppler US in the evaluation of acute scrotal disease. Radiology. 1990;176:355-8. 11. DeWire DM, Begun FP, Lawson RK, et al. Color Doppler ultrasonography in the evaluation of the acute scrotum. J Urol. 1992;147:89-91. 12. Middleton WD, Siegel BA, Melson CL, et al. Acute scrotal disorders: prospective comparison of color Doppler US and testicular scintigraphy. Radiology. 1990; 177: 177-81. 13. Mueller DL, Amundson GM, Rubin SZ, Wesenberg RL. Acute scrotal abnormalities in children: diagnosis by combined sonography and scintigraphy. Am J Roentgen. 1988; 150643-6. 14. Knight PJ, Vassy LE. The diagnosis and treatment of the acute scrotum in children and adolescents. AM Surg. 1984;200%64-73. 15. Skoglund RW, McRoberts JW, Ragde H. Torsion of the spermatic cord: a review of the literature and analysis of 70 new cases. J Urol. 1970;104:604-7. 16. Williamson RCN. Torsion of the testis and other allied conditions. Br J Surg. 1976;63:465-76. 17. Melekos MD, Asbach HW, Markou SA. Etiology of acute scrotum in 100 boys with regard to age distribution. J Ural. 1988;139:123-5. 18. Hemaltha V, Rickwood AMK. Diagnosis and management of acute scrotal conditions in boys. Br J Ural. 1981;53:455-9. 19. Caldamone AA, Valvo JR, Altabarmakian VK, Rabinowitz R. Acute scrotal pain in children. J Pediatr Surg. 1984;19: 581-4. 20. Wahher TR, Weigand JV. The acute scrotum. Top Emerg Med. 1991;13:15-24. 21. Son KA, Koff SA. Evaluation and management of the acute scrotum. Primary Care. 1985;12:637-45.
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22. Anderson PAM, Giacomantonio JM, Schwarz RD. Acute scrotal pain in children: prospective study of diagnosis and management. Can J Surg. 1989;32:29-32. 23. Hermann D. The pediatric acute scrotum. Pediatr Ann. 1989; 18:198-204. 24. Najmaldin A, Burge DM. Acute idiopathic scrotal oedema: incidence, manifestations and aetiology. Br J Surg. 1987;74: 634-5. 25. Harrison RH. Monograph on torsion at the spermatic cord, testis, and vestigial appendages. Norwich, NY: Eaton; 1982. 26. Sullivan KM, Halpin TJ, Kim-Farley R, Marks JS. Mumps disease and its health impact: an outbreak based report. Pediatrics. 1985;76:533. 27. Manson AL. Mumps orchitis. Urology. 1990;36:355-8. 28. Brown CC, Baublis JV, O’Leary TP. Development and duration of mumps antibodies in various immunoglobulin fractions of human serum. J Immunol. 1970;104:86. 29. Nickel WR, Plumb RT. Mumps orchitis. In: Harrison JH, et al., eds. Campbell’s urology, 5th ed., Vol. 1, Sect. VII, Chap. 20. W.B. Saunders Co.; 1986:977-8. 30. Campbell JR. Inguinal and scrotal problems in infants and children. Pediatr Ann. 1989;18:189-91. 3 1. Wilson-Storey D. Scrotal swellings in the under 5s. Arch Dis Child. 1987;62:50-2. 32. Nakayama DK, Rowe MI. Inguinal hernia and the acute scrotum in infants and children. Pediatr Rev. 1989;11:87-93. 33. Clark WR, Kramer SA. Henoch-Schonlein purpura and the acute scrotum. J Pediatr Surg. 1986;21:991-2. 34. Loh HS, Jalan OM. Testicular torsion of Henoch-Schonlein syndrome. Br Med J. 1974;2:96-7. 35. Lin JN, Wang KL, Cuang JH. Primary testicular tumors in children. Int Surg. 1988;73:190-2. 36. Perez JM. Testicular tumor presenting with torsion of the testicle. J Urol. 1990:144:995-6.
Prlnted in the USA
1993
Emergency
Medicine
THE ACUTE PEDIATRIC Martin W. Schul,
MD,’
Copyright 0 1993 Pergamon Press Ltd.
in Review
SCROTUM
and Michael A. Keating, rmt
*EmergencyMedicine Resident PGY-1, Methodist Hospitals Inc., Indianapolis, Indiana, and tAssistant Professor Pediatric Urology, Indiana University Medical Center, Indianapolis, Indiana MD, James Whitcomb Riley Hospital for Children, 702 Barnhill Drive, Room 1738, Indiana University Medical Center, Indianapolis, IN 46202
Reprint Address: Michael A. Keating,
0 Abstract -The acute pediatric scrotum is a common clinical condition that can present a diagnostic dilemma for even the most experienced physician. The issue of primary importance in each case is to ensure testicular viability through proper evaluation, prompt diagnosis, and surgical intervention if necessary. A review of the various etiologies of acute scrotal disorders in children aids in the formulation of a logical and systematic approach to their accurate diagnosis and management.
HISTORY AND PHYSICAL EXAMINATION A
thorough history and physical examination are instrumental to making a proper diagnosis. Table 1 summarizes the various lines of questioning that should be followed when initially assessing each case. Examining the child with an acute scrotum can be challenging. Smaller anatomy combined with patient discomfort often make the examination difficult. Ideally, the examination should be performed in a warm, well-lighted room. This decreases the likelihood of the testicles being drawn toward the inguinal region. If the room cannot be suitably heated, a warm towel placed on the groin can be helpful. Inspection should be carried out with the child in the upright position. This allows assessment of the lie of the testes and of any skin changes that might be present, such as erythema or regions of ecchymosis. Palpation should be performed with the child supine and the limbs in the frog-leg position. This serves two purposes: prevention of possible vasovagal episodes and elimination of the cremasteric reflex during bimanual examination. Using warm hands and beginning with the asymptomatic side, one should proceed to palpate each testicle and its adjacent epididymis and spermatic cord. Careful examination of the more proximal inguinal region is also necessary. Irregularities and enlargements of the organs, as well as fullness and twists of the cord, may provide a clue to the diagnosis. In many cases, the scrotal contents
0 Keywords-acute testicular disorders; children; scrotum; testicular torsion
INTRODUCTION
The acute scrotum is any pain or swelling of the scrotum or its contents that has suddenly occurred. This is a common clinical entity, which can represent a true urologic emergency and a diagnostic dilemma for even the most experienced physician. When based on clinical evaluation alone, misdiagnosis has occurred in as many as 50% of patients presenting with an acute scrotum (1,2). Time becomes an important factor when evaluating these patients; a prompt and accurate diagnosis can be essential to the preservation of testicular viability. The focus of this article is to review the common causes of the acute scrotum in children, and to provide a systematic approach to its evaluation, diagnosis, and treatment.
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Martin W. Schul and Michael A. Keating
Table
1. Historicel Scrotum
Clues-The
Acute
Presenting symptoms Onset Duration Severity Diffuse vs. localized pain tenderness Similar episodes Positional change Associated symptoms Fever > 38.0% Nausea or vomiting ;bd;r;nal discomfort Anorexia Genitourinary factors Urinary tract anomalies Previous surgeries Recent manipulations Multiple UTls Sexual habits Urethral discharge Miscellaneous Recent trauma Strenuous exercise Recent viral illness Systemic diseases
are engorged and exquisitely painful, making assessment of anatomic detail difficult or impossible. Transillumination sometimes helps distinguish solid masses from liquid or gas, but adjunct studies often become necessary to further define the problem (3). A working knowledge of inguinal, scrotal, and testicular anatomy is necessary to enable an accurate physical examination. The scrotum is composed of rugous and deeply pigmented skin replete with large sebaceous follicles. Deeper and tightly adherent to its skin lies the dartos tunic, a thin muscular layer continuous with the superficial abdominal and perineal fascias. The dartos layer fuses at the midline to create the median raphe, which separates the scrotal sac into halves. Beneath the dartos are the cremasteric muscle and internal and external spermatic fascia. These 3 layers represent extensions of the abdominal wall musculature and form a trilaminar sac that envelopes the spermatic cord and scrotal contents. The testes are ovoid structures that rest with their long axis in the vertical plane. The left gonad is usually more dependent than the right. Size varies with age but the contralateral asymptomatic gonad usually provides a useful standard during the examination. Posteriorly the testicles are supported by a remnant of the gubernaculum and proximally by the spermatic cord (Figure 1). The anterolateral margins are embedded in the tunica vaginalis, an extension of the peritoneum which is created during testicular
descent. This pouch enables the scrotal contents to slide easily beneath the skin with palpation. Finally, emerging from the superior pole of the testes and passing over its posterolateral aspect is the epididymis. This cone-shaped structure, which is smaller and softer than the gonad, tapers in size before becoming continuous with the vas deferens above. Serving as the root of the testicle, the spermatic cord contains the primary vessels, nerves, and vas deferens, and is surrounded by the previously described fascial layers as it passes through the inguinal canal posteriorly. LABORATORY STUDIES The initial laboratory evaluation should include a complete blood count (CBC) with differential and a urinalysis. The CBC can be helpful in identifying the presence of inflammatory processes, and the urinalysis provides screening of pyuria and proteinuria. Although these studies should be obtained in most children with acute scrotal pain, their results alone are usually insufficient for making a reliable diagnosis. DIAGNOSTIC STUDIES When the diagnosis cannot be made on a clinical basis alone, imaging becomes necessary. The 2 methods most widely used today are testicular scintigra-
Gubernaculum Testis Figure 1. Scrotal contents.
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The Acute Pediatric Scrotum
phy and ultrasonography with real-time color flow Doppler. Testicular scintigraphy is currently the procedure of choice for evaluating the acute scrotum in the pediatric population (4,5). This radionuclide study, which analyzes testicular perfusion, takes little time to perform and provides valid and simple interpretations in most cases. However, full-service nuclear medicine departments are not present in some hospitals and the technology may not be available at all times. Torsion of a testis is indicated by a “cold spot,” reflecting an absence or decrease in blood flow to the testis (Figure 2 a,b). Inflammatory processes, such as orchitis or torsion of a testicular appendage, will demonstrate increased flow and uptake by the affected hemiscrotum. The sensitivity and specificity of scintigraphy was as high as 100% and 97% in one study (6) and 90% and 89% in another (7). False positive scans can be mimicked by large fluid collections within the scrotum, i.e. abscess, hydrocele, hematocele, or bowel herniation (4). False negative scans, though rare, sometimes occur with cases of very early torsion, spontaneous detorsion, or when scanning the anatomy of smaller toddlers or infants
(8). Real-time color Doppler ultrasonography is rapidly gaining popularity as an aid in diagnosing testicular torsion. Recent reports have shown the sensitivity of this study to be 86-100%. Its specificity in diagnosing torsion has been shown to be nearly 100% in adults (9,lO). Color Doppler has the advantage of assessing testicular circulation as well as defining testicular anatomy, although its efficacy in younger age groups is not well defined (11,12). Unnecessary surgical intervention was shown to decrease by 19% in 1 series, when Doppler was used in conjunction with inconclusive nuclear scans (13). Current disadvantages of the study include limited expertise with the technology and limited availability. Defining anatomic detail in smaller children also presents a problem. However, we suspect that Doppler studies will become the diagnostic test of choice for acute scrotal disorders in children, with continued experience and investigation,
DIFFERENTIAL
DIAGNOSIS
The 3 most common causes of the acute pediatric scrotum are testicular torsion, torsion of the appendix testis, and epididymoorchitis (14). Of these, testicular torsion has the most ominous sequelae. Less common causes to be considered include idiopathic scrotal edema, scrotal hernias or hydroceles, trauma,
Henoch-Schonlein Purpura, and testicular tumors. Urologic consultation should be sought immediately in any instance where torsion cannot be ruled out upon the patient’s initial arrival in the emergency department .
TESTICULAR
TORSION
Testicular torsion represents a true surgical emergency that must be ruled out when evaluating the acute scrotum. This fact is underscored by the realization that testicular viability is directly related to the duration of the insult and is strongly impacted by patient and physician delay. Salvage rates of 8096% have been reported when surgical intervention is performed within 8 hours of the acute event. Salvage drops to 70% between 8 to 12 hours, and to only 20% if surgery is delayed for more than 12 hours (5,lO). Testicular torsion has accounted for nearly half of all acute scrotal disorders in children 17 years of age or younger in one series (14), and has been estimated to occur in 1 of every 4,000 males before the age of 25 (16). The peak incidence of torsion occurs around 13 years of age and coincides with the onset of puberty. It is uncommon after the age of 30 (8917). The predisposition to peripubertal testicular torsion appears to stem largely from abnormal suspension of the testis within its investing layers. These anomalies are nearly always bilateral, the most common of which is known as the “bell clapper” deformity. This defect finds the testis almost completely surrounded by its tunica vaginalis, and minimally fixed at one point by its mesentery (Figure 3 a,b,c). Allowed to lie transversely, the testis is free to rotate upon this stalk leaving it prone to exaggerated twists. The typical presentation is one of sudden onset, severe pain that originates in the scrotum or lower quadrant. It is common to elicit a history of antecedent episodes of similar discomfort that spontaneously resolved. Vigorous exercise or blunt trauma are often implicated in the onset of torsion, but many boys are suddenly awakened from sleep with excruciating pain. Nausea and vomiting occur frequently but attendant fevers are unusual (14). Three common findings that are strongly suggestive but not pathognomonic for torsion are shown in Table 2. The ipsilateral leg is often flexed to guard the affected side. Scrotal erythema and edema are common, and a reactive hydrocele is sometimes seen. The incidence of hydrocele increases with the duration of unresolved torsion and can be as high as 20% (18). Absence of the cremasteric reflex is highly indic-
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Figure 3. (a) Normal anarchnnents of a testis within the tunica vaginalis; (b) “bell-clapper” anomal torsionlatex ploratioln.
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(4 360 degree te
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Martin W. Schul and Michael A. Keating Table 2. Signs Suggestive of Testicular Torsion 1. Elevated testis with palpable cord twist 2. Abnormal epididymalattachment 3. Horizonatalaxis of contralateraltestis
of testicular torsion. In one study, none of 38 patients with torsion of the spermatic cord demonstrated a cremasteric reflex (19). Prehn’s sign, where elevation of the testicle should exacerbate the pain of torsion yet relieve the discomfort caused by epididymitis, has been highly unreliable in our experience. Laboratory values will yield leukocytosis and a left shift in 50% of patients. The urinalysis should be normal (20). When testicular torsion cannot be ruled out, scrotal imaging should be employed. Once the diagnosis has been established, or if testicular torsion cannot be ruled out, the only definitive treatment is surgical exploration. Manual detorsion can be cautiously attempted as the surgical suite is being prepared. The large majority of torsed testes rotate to the midline. ative
Thus, any attempts to detorse the gonad should be made in a medial to lateral direction. Successful detorsion should be accompanied by the immediate cessation of pain. Otherwise, the maneuver should be discontinued for fear of exacerbating the problem. When manual detorsion is effective, the patient should still undergo urgent surgical exploration to assess the viability of the affected testicle and perform an orchiopexy to prevent further torsions. The contralateral testicle, which usually has a similar anatomic predisposition, should also be pexed. If a nonviable testis is discovered, orchiectomy is recommended.
TORSION OF TESTICULAR
APPENDAGES
Torsion of testicular appendages occur nearly as often as actual testicular torsion (14). Any of 5 embryologic remnants found in most males can function as potential sources of this type of torsion. The one most commonly implicated is the appendix testis, a
Figure 4. (a) “Blue dot” sign of a towed testicular appendage; (b) infarcted appendage at exploration.
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The Acute Pediatric Scrotum
mullerian duct remnant, which accounts for 92% of cases (8) (Figure 1). Torsion of an appendage is felt to occur under the influence of human chorionic gonadotropin (HCG) at the onset of puberty. The appendage enlarges, leaving it prone to twist on its mesenteric stalk, and become infarcted (21). Most occur at an average age of 10 (22). Patients typically present with the sudden onset of moderate to severe pain localized solely to the scrotum. Gastrointestinal and urinary symptoms or fevers are uncommon. On physical examination, point tenderness can sometimes be appreciated and is a useful diagnostic sign. In these instances, the child can place a finger on the exact source of his discomfort, which is commonly located at the superior pole of the testicle (5,17). A nodule is sometimes palpable early after the onset of pain, and the cyanotic appendage appreciable beneath the scrotal skin. This pathognomonic finding, known as the “blue dot” sign, can be found in 14 to 22% of cases (14,17), (Figure 4 a,b). Urinalyses should be normal, but onefourth of patients will demonstrate leukocytosis with a left shift in the CBC (14). Testicular torsion may be impossible to rule out because of peritesticular inflammation and scrotal swelling, especially in patients who delay seeking medical attention. In these situations, a nuclear scan is warranted and, if inconclusive, scrotal exploration should be employed. If the diagnosis can be made clinically, conservative therapy is appropriate and analgesia alone should suffice (23). Discomfort generally persists for less than a week as the affected appendage becomes atrophic and is autoamputated.
EPIDIDYMITIS Epididymitis, the most common cause of the acute scrotum in adults, is an overrated etiology in children (14,21). In fact, errors in diagnosis with these types of disorders have often been attributed to infection when torsion of the testicle or its appendage should have been considered instead. Children affected with epididymitis are typically postpubertal or sexually active. When a younger child presents with this condition, it is frequently the herald sign of an underlying urinary tract anomaly. Bacteria are the cause of most epididymitis, with coliforms usually implicated in prepubertal males and venereal organisms such as Neisseria and Chlamydia found after puberty. Children at particular risk include those who have a recent urinary tract infection or urologic instrumentation, including catheterization. Children with genitourinary disor-
ders such as neurogenic bladder, imperforate anus, or hypospadias are also prone to episodes of epididymitis (8,23). Patients usually present with the gradual onset of mild to moderate scrotal pain and swelling that evolved over several days. Symptoms referring to both testes are not uncommon (8). Other complaints include dysuria and urethral discharge. Fevers occur in 14-28% of cases, but other systemic complaints are rare. If the child presents early in the course of his illness, a swollen and indurated epididymis can sometimes be delineated from the testicle. Usually, however, the findings are nonspecific and the examination and differentiation of structures is often impossible due to significant edema of the scrotal sac. The CBC commonly shows an elevated white cell count with a left shift, but the urinalysis, surprisingly enough, demonstrates pyuria in only 15% of cases. If urethral discharge is present, a Gram stain should be obtained and may aid in making the diagnosis. In the face of such nonspecific findings, the diagnosis of epididymitis can be difficult. Six factors suggestive for bacterial epididymitis are shown in Table 3. Knight and Vassy found that children with 3 of these findings had definite epididymitis, and those with 2 were probable cases (14). Where some doubt remains, which is common, nuclear imaging is usually diagnostic and shows increased perfusion to the inflamed hemiscrotum (Figure 2b). Once the diagnosis of epididymitis is made, therapy is directed toward the suspected organism. The urine should be cultured for sensitivities, but in many cases cultures remain negative. Most patients respond rapidly with appropriate antibiotic therapy such as ampicillin or trimethoprim/sulfamethoxazole. Bedrest and scrotal support with elevation and icepacks are also helpful (21). When symptoms persist despite empiric antibiotics, an ultrasound should be obtained to rule out abscess formation. Epididyma1 aspirates for the identification of the offending organism are rarely indicated. After treating the acute event, an appropriate workup for urologic abnormalities including voiding cystourethrography and renal ultrasound are strongly recommended if a cause for the infection is not readily apparent. If Table 3. Findings Suggestive of Epididymltis 1. Gradual onset of symptoms 2. Recent urinary instrumentation or surgery 3. Dysuria, recent urinary infection, or abnormal bladder function 4. Significantly elevated temperature (> 36.3%) 5. Localized tenderness and induration of the epididymis 6. Abnormal urinalysis
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the ultrasound is abnormal, an excretory urogram should be obtained to rule out an ectopic ureter. This anomaly is predisposed to causing bouts of epididymitis in the prepubertal child.
IDIOPATHIC
SCROTAL EDEMA
Idiopathic scrotal edema occurs primarily in prepubertal males, with 77% of cases occurring before the age of 10 (24). Its etiology remains unclear, yet an allergic phenomenon has been implicated on the basis of pathologic changes found in the affected scrotal skin (21). Patients typically present with the sudden onset of unilateral or bilateral scrotal erythema and edema accompanied by little or no discomfort. The characteristic feature in every patient is scrotal erythema and edema that is out of proportion to the minor degrees of tenderness present. Occasionally, the erythema extends to involve the penis, anterior abdominal wall, and the perineum. These children are typically afebrile but a few exhibit associated allergic manifestations of angioneurotic edema. Eosinophilia can be found in as many as 50% of affected children. The nephrotic syndrome can sometimes present with a similar picture of scrotal edema but would be ruled out by the midstream urinalysis, which is universally normal in the idiopathic variety (17). The diagnosis of scrotal edema can usually be made on clinical grounds alone. If torsion is still a consideration, nuclear scanning should be performed. Scrotal edema is a self-limited condition, with resolution occurring in 1 to 4 days (24). Therapy is supportive, yet there has been some evidence that the addition of antihistamines may speed recovery (25). Recurrent episodes occasionally occur, but there appears to be no long-term sequelae associated with the disorder.
the virus continues to present a health hazard. Though the immunization is 97% effective, only an estimated 77% of children in the United States are immunized, leaving a substantial number of boys with their testes unprotected (26). The testicular involvement of mumps rarely affects prepubertal males, yet occurs with a frequency of 30% in boys older than 10 who become infected with the virus (27). Orchitis develops 4 to 6 days after a bout of parotiditis. These patients present typically with the gradual onset of pain and swelling in the scrotum associated with the constitutional symptoms of fever or nausea and vomiting. Testicular pain is usually unilateral, but bilateral involvement occurs in 17-30070 of cases (26). The often unrelenting discomfort is felt to stem from testicular swelling within the unyielding restraints of its encapsulating tunica albuginea. Examination will disclose a diffusely tender, edematous, and swollen testis with or without a reactive hydrocele. Laboratory studies are generally unremarkable. Making the diagnosis of mumps orchitis rests with a history of antecedent parotid swelling. Verification can be made by immunofluorescent antibody testing, in which a titer 1 1 : 256 is considered positive for recent infection (28). Without a history of parotid swelling, the diagnosis becomes difficult, and additional studies are warranted to rule out torsion. Viral orchitis is a self-limited disease process, with symptoms usually resolving within 6 to 10 days. Therapy is directed at swelling and pain using icepacks and analgesics. In rare cases the orchalgia is unremitting and surgical decompression must be considered. Whether surgery is required or not, testicular atrophy is a common sequelae of mumps involvement and occurs in 30-50% of cases (29). Fortunately, however, sterility is rare unless bilateral involvement is present.
HERNIAS AND HYDROCELES ORCHITIS Orchitis can be divided into 1 of 2 categories, bacterial or viral. Bacterial (pyogenic) orchitis is less common in the pediatric age group and generally occurs as a retrograde extension of epididymitis. Diagnosis and treatment are based on the principles discussed above. In contrast, most viral orchitis is caused by the mumps virus, but strains of coxsackie A and lymphocytic choriomeningitis virus have also been implicated (23). The incidence of mumps orchitis has decreased as a consequence of mumps immunization. However,
Scrotal hernias and hydroceles have a common etiology, a patent processus vaginalis (Figure 5). The processus represents an extension of the peritoneum that accompanies gonadal descent into the scrotum. The structure remains patent in the majority of newborns (85%), but gradual obliteration occurs with continued development in most (30). The occasional patent processus vaginalis that becomes clinically apparent can be classified as either a hernia or a hydrocele. A hernia occurs when a viscus or omentum enters the processus. When fluid alone is contained within the structure, a hydrocele results. Hernias and hydro-
The Acute Pediatric Scrotum
573
attempted with the patient in the Trendelenburg position. Fortunately, 90-95% of incarcerated hernias are reducible. Should reduction prove difficult, sedation with leg elevation and cold packs are helpful. If attempts at reduction are unsuccessful, emergent surgical exploration is indicated. In patients with rebound tenderness or a cyanotic hue beneath the skin, reduction should not be attempted because a gangrenous loop of bowel is likely present. Immediate surgical intervention is mandatory. Hydroceles most commonly affect the infant age group in keeping with the natural history of the processus vaginalis (32). Like hernias, most occur on the right (30,31). The overwhelming majority of hydroceles are painless and present at birth, but their occasional sudden appearance at a later age, from sudden opening of the processus, is a cause of concern for parents. On physical examination, affected children demonstrate scrotal fullness which allows brilliant transihumination (Figure 6). Scrotal size sometimes changes with position or squeezing, thus demonstrating a continuity of the peritoneum and the tunica
Figure 5. Patent processus vaginalis.
celes are a common cause of scrotal swelling. They comprised 12% of pediatric surgeries in one series, 98% of which were due solely to the presence of a patent processus vaginalis (3 1). The overall incidence of clinically significant hernias in children varies from 0.8-4.4%, depending on the weight and gestational age of the child. Premature infants are at a higher risk, with an incidence of 7-17070 (32). Hernias are right sided in 60% of the cases, and bilateral in 10% (30). The risk of incarceration is highest during the first few months of life, with 69% occurring by the end of the first year (32). An overall 5% incarceration rate from 1 recent report bears testimony to the need for early diagnosis and repair of hernias on a less than emergent basis. Patients with incarcerated hernias may present with a history of inguinal weakness or bulge. Bowel obstruction should be suspected if the patient presents with nausea and vomiting, abdominal pain, fever, and increased irritability. Examination will reveal a distended, tender abdomen, and inguinal and scrotal fullness. The scrotum will transilluminate if gas is present within a viscus, and bowel sounds may also be heard. Gentle manual reduction should be
Figure 6. Tranailluminatlon useful in diagnosis of hydroceles.
Martin W. Schul and Michael A. Keating
Figure 7. Testicular fracture (arrows) demonstrated by ultrasonography.
vaginalis (30). In most cases, the scrotal swelling does not extend to the inguinal region. When it does, hernia must be ruled out. Therapy is usually conservative. By 18 months of age the majority of hydroceles spontaneously resolve with closure of the processus vaginalis. In patients with persistent hydroceles, elective inguinal repair should be pursued by age 2. The likelihood of hydroceles evolving into clinically significant hernias is unclear but seems uncommon. However, parents should be cautioned about signs of hernia formation. Under no circumstances should a hydrocele or hernia be aspirated. Recurrence would be expected and the risks of introducing an infection or perforating a bowel loop are very real (30,32).
TRAUMA Traumatic lesions to the scrotum and testes include contusions, lacerations, and penetrating injuries. Generally, the history will lead directly to the correct diagnosis. It is important that testicular intactness and perfusion be verified, as tremendous forces are often involved in creating these injuries. A urologist should be involved early, helping guide the direction of care. In cases where damage to the testicle is suspected, ultrasonography is recommended to rule out
surgical conditions. Testicular fractures or paratesticular hematomas may be diagnosed and require immediate surgical attention (Figure 7). Scrotal contusions are detectable by the ecchymotic appearance of the scrotal skin. Superficial lacerations are easily manageable. Scrotal tissue has great healing potential, and when no other gross pathology can be detected, simple primary closure is sufficient. Deeper penetrating wounds are often benign, yet require surgical exploration to assess the status of the gonad. If the tunica of the testicle has been disrupted, debridement and primary closure are recommended. In rare cases where testicular perfusion has been compromised for an extended time, orchiectomy may be warranted. Therapy, other than surgery for traumatic insults, involves rest, analgesia, and scrotal support. Patients must be monitored for further signs of infection, with appropriate antibiotic therapy initiated toward anaerobes and skin flora.
HENOCH SCHONLEIN PURPURA Henoch-Schonlein Purpura (HSP) is a nonthrombocytopenic purpura caused by a systemic necrotizing vasculitis with an unknown etiology. Most commonly seen in children ages 4 to 10, this disease is associ-
The Acute Pediatric Scrotum
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(a)
(W Figure 8. (a) Lesions of the buttocks and extremities commonly seen with Henoch-Schonlein Purpura; (b) scrotal erythema same patient.
Martin W. Schul and Michael A. Keating
576
ploration should be considered, although there has been only 1 reported case of true testicular torsion in an HSP patient (34). Testicular symptoms should spontaneously resolve, but analgesics and antiinflammatory agents are helpful in alleviating these manifestations.
History and Physical
TESTICULAR nuclear scan Doppler U/S
*
equivocal
non-torsion
J
Surgery
Conservative Management (EXCEPT FOR HERNIAS)
Figure 9. Algorlthm for management of acute pediatric scrotum.
ated with a variety of symptoms involving the skin, joints, gastrointestinal, and genitourinary systems. Pain and swelling of the spermatic cord and testicle occurs in 2-38070 of HSP patients (33). Although parents are usually previously aware of the condition, there have been 5 cases where an acute scrotum was the initial manifestation of the disease (33). Though this is a rare cause of the acute scrotum, the presenting symptoms often mimic testicular torsion, which must be considered in the differential diagnosis (Figure 8 a,b). The genital pain seen with HSP has a sudden onset and may have associated nausea, vomiting, and fever. Physical examination reveals unilateral swelling and an absent cremasteric reflex. Laboratory values are usually normal. A history of HSP found in combination with a normal nuclear scan should spare these children an exploratory procedure. However, if the nuclear scan is equivocal, prompt surgical ex-
TUMORS
Testicular tumors rarely occur in children but may present as an acute scrotum. When afflicted, boys are generally less than 4 years of age or well into puberty (35). Tumors typically evolve over weeks to several months, and occasionally become painful as a result of spontaneous hemorrhage within the tumor itself. Actual testicular torsion may foreshadow the discovery of a testicular tumor, and has been reported in 5 previous cases (36). On physical examination, the affected testis has an irregular contour and may be swollen and painful. The CBC and urinalysis should be normal. If tumor is suspected, ultrasonography is an invaluable aid to confirming the diagnosis.
SUMMARY Testicular torsion is a true surgical emergency, and boys with acute testicular pain should be presumed to have torsion until proven otherwise. A thorough history and physical examination are instrumental to making a correct diagnosis. When clinical uncertainty persists, nuclear scanning or color Doppler studies are essential to an expeditious and accurate diagnosis. An algorithm for evaluation and management of the acute pediatric scrotum is shown (Figure 9). An orderly approach to diagnosis decreases morbidity by minimizing unnecessary surgical procedures and serves to initiate necessary therapeutic measures at the earliest and most beneficial time in the disease process, regardless of the cause.
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