Diagnosis. Features on examination:

Features on examination:

· observation of the patients gait and resting position

· natural position of the testis in the scrotum while standing

· presence or absence of cremasteric reflex (this is absent in torsion)

· palpation of lower abdomen, inguinal canal and cord

· palpation of scrotum and contents, compare with unaffected hemiscrotum

· transillumination

· Is the swelling reducible?

Features on investigations:

· Check urinalysis.

· Blood tests are not useful in the acute setting.

· Doppler ultrasound is useful to evaluate an acute scrotum

Table 8.4

Diagnosis	Suggestive features on history	Suggestive features on examination
Torsion of the testis	Sudden onset testicular pain and swelling; occasionally nausea, vomiting. Note: pain may be in the iliac fossa	Discolouration of scrotum; exquisitely tender testis, riding high
Torsion of the appendix testis (hydatid of Morgagni)	More gradual onset of testicular pain	Focal tenderness at upper pole of testis; "blue dot" sign – necrotic appendix seen through scrotal skin Note: Difficult to distinguish from testicular torsion
Epididymoorchitis	Onset may be insidious; fever, vomiting, urinary symptoms; rare in pre-pubertal boys, unless underlying genitourinary anomaly, when associated with UTI.	Red, tender, swollen hemiscrotum; tenderness most marked posteriolateral to testis. Pyuria may be present.
Incarcerated inguinal hernia	History of intermittent inguinoscrotal bulge, with associated irritability	Firm, tender, irreducible, inguinoscrotal swelling
Idiopathic scrotal oedema	Swelling noted but child not distressed	Bland violaceous oedema of scrotum, extending into perineum + penis; testes not tender
Hydrocele	Swollen hemiscrotum in well, settled baby	Soft, non-tender swelling adjacent to testis; transilluminates brightly.
Varicocele	Collection of abnormally enlarged spermatic cord veins, found in teenage boys, mostly on the left.	Mass of varicose veins ("bag of worms") above testicle, non-tender, more prominent when standing.
Henoch Schonlein purpura	Painful scrotal oedema, with purpuric rash over scrotum. May have associated vasculitic rash of buttocks and lower limbs, arthritis, abdominal pain with GI bleeding, and nephritis	may be difficult to distinguish from testicular torsion in absence of other features
Testicular or epididymis rupture	Scrotal trauma eg. straddle injury, bicycle handlebars, sports injury. Delayed onset of scrotal pain and swelling.	Tender swollen testis. Bruising, oedema, haematoma, or haematocele may be present.
Testis tumor	Can be painful in rapid growing tumors associated with haemorrhage or infarction	Painless, unilateral, firm to hard scrotal swelling. Leukaemic infiltration may present bilaterally.
Antenatal torsion testis	Newborn may present with painless, smooth, testicular enlargement.	Does not transilluminate, dark in colour.

In the early phase, location of the pain can lead to the diagnosis. Patients with acute epididymitis experience a tender epididymitis, while patients with testicular torsion are more likely to have a tender testicle and patients with torsion of the appendix testis feel isolated tenderness of the superior pole of the testis.

An abnormal position of the testis was more frequent in testicular torsion than in patients with epididymitis.

Looking for the absence of the cremasteric reflex is a simple method with a sensitivity of 100% and specificity of 66% for the presence of testicular torsion.

Fever occurs often in epididymitis (11-19%). The classical sign of a 'blue dot' (this is the appendix of the testis which has become discolored and is noticeably blue through the skin) was found only in 10-23% patients with torsion of the appendix testis.

A positive urine culture is only found in a few patients with epididymitis. It should be remembered that a normal urinalysis does not exclude epididymitis. Similarly, an abnormal urinalysis does not exclude testicular torsion.

Doppler ultrasound is useful to evaluate an acute scrotum, with a sensitivity of 63,6-100% and a specificity of 97-100%, and a positive predictive value of 100% and negative predictive value 97,5%.

The use of Doppler ultrasound may reduce the number of patients with acute scrotum undergoing scrotal exploration. It may also show a misleading arterial flow in the early phases of torsion and in partial or intermittent torsion: persistent arterial flow does not exclude testicular torsion.

Scintigraphy and, more recently, dynamic contrast-enhanced subtraction MRI of the scrotum also provide a comparable sensitivity and specificity to ultrasound. These investigations may be used when diagnosis is less likely and if torsion of the testis still cannot be excluded from history and physical examination. This should be done without inordinate delays for emergent intervention.

Ultrasonography with color Doppler now has become a more popular study in most institutions because it allows determination of blood flow, is less time-consuming, is more readily available, and does not expose the patient to ionizing radiation. It also is highly reliable in experienced hands.

The diagnosis of acute epididymitis in boys is mainly based on clinical judgement and adjunctive investigation. However, it should be remembered that findings of secondary inflammatory changes in the absence of evidence of an extra-testicular nodule by Doppler ultrasound might suggest an erroneous diagnosis of epididymitis in children with torsion of appendix testes.

Prepubertal boys with acute epididymitis have an incidence of underlying urogenital anomalies of 25-27.6%. Complete urological evaluation in all children with acute epididymitis is still debatable.

A discussion of the most important and common conditions that cause acute scrotal pain or swelling follows:

Дата добавления: 2014-10-15