Discussion in 'Spot Diagnosis' started by J.P.C. Peper, Aug 21, 2012.
What’s your diagnosis?
The patient is in a lot of pain.
I’ll post the correct answer in a few days!
scrotal hernia / inguinal hernia
This presents with acute pain in the testis, usually unilateral (and unilateral swelling). It's most commonly caused by a congenital malformation. Ultrasound will reveal a reduced blood flow. It's a medical emergency; detorsion has to be performed immediately.
Related Self Assessment Questions
A 12-year-old boy comes to the emergency department at midnight with a complaint of severe scrotal pain since 7 PM. There is no history of trauma. Which of the following is the most appropriate first step in management?
A. Order a surgical consult immediately.
B. Order a radioisotope scan as an emergency.
C. Order a urinalysis and Gram stain for bacteria.
D. Arrange for an ultrasound examination.
E. Order a Doppler examination.
The majority of all cases of acute scrotal pain and swelling in boys 12 years of age and older are caused by testicular torsion. If surgical exploration occurs within 4 to 6 hours, the testes can be saved 90% of the time. Too often, delay caused by scheduling imaging and laboratory tests, such as those outlined in the question, results in an unsalvageable gonad.
One of the more important diagnoses in the differential is epididymitis. It is often gradual in onset, and the physical examination usually will reveal the testicle to be in its normal vertical position and to be of equal size to its counterpart. Epididymitis usually presents with redness, warmth, and scrotal swelling (but normal cremasteric reflex); the pain is posterior (over the epididymis). Pain relief upon elevation of the testicle (Prehn sign) may be helpful to diagnose epididymitis although it is not specific.
The answer is A.
A 10-year-old boy presents to the emergency room with acute onset of pain in the left testicle. On physical examination, he is noted to have a high-riding, indurated, and markedly tender left testis. Urinalysis is unremarkable. Which of the following statements regarding the patient's diagnosis and treatment is true?
A. There is a strong likelihood that this patient's father or brother has had or will have a similar event.
B. Operation should be delayed until a technetium scan clarifies the diagnosis.
C. The majority of testicles that have undergone torsion can be salvaged if surgery is performed within 24 hours.
D. If torsion is found, both testes should undergo orchiopexy.
E. The differential diagnosis includes spermatocele.
Testicular torsion is a surgical emergency that requires rapid diagnosis and intervention to maintain testicular viability. If left untreated testicular torsion leads to strangulation of the blood supply to the testicle. Testicular torsion usually occurs in adolescent boys 12 to 18 years of age. The underlying pathology is secondary to an abnormally narrowed testicular mesentery with tunica vaginalis surrounding the testis and epididymis in a bell clapper deformity. As the testis twists, it comes to lie in a higher position within the scrotum. Presentation is acute onset of testicular pain and/or swelling. Diagnosis of testicular torsion is mainly made with clinical presentation and examination. A technetium 99m (99mTc) pertechnetate scan or Doppler ultrasound may be helpful in making the diagnosis if clinical suspicion of torsion is low; however, operation should not be delayed in order to maximize testicular salvage. This patient's presentation warrants immediate operation. If treated within the first 4 to 6 hours of onset of symptoms, the chance of saving the testicle is high. During surgery the affected testicle is rotated to its normal position. If it is viable, orchiopexy is performed on both the affected and the unaffected testes. If the affected testicle is nonviable, orchiectomy is performed with orchiopexy of the nonaffected testicle. Both epididymitis and testicular torsion presents with pain and swelling of the testicle, and it is sometimes difficult to differentiate between the two conditions. In the case of epididymitis Doppler ultrasound would demonstrate increased blood flow to the testicle, while there would be no blood flow to the testicle in torsion. A spermatocele presents as a painless fluid-filled sac located above and posterior to the testicle.
The answer is D.
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