Acute Scrotum in Children John Mc Carthy 12112020

Acute Scrotum in Children John Mc. Carthy 12/11/2020 RAD 4001 Dr. Tavernier

Clinical History • Patient is an 11 -yo male presenting to the ED with 1 hour of right scrotal pain radiating to RLQ. No trauma, worse when standing. Pain 4/10. • PMH of asthma and testicular torsion in 2017, followed by UT Urology • Denies nausea/vomiting, patient afebrile, VSS • Right testicle TTP, with no visible swelling or erythema, mildly TTP in all four abdominal quadrants, normal bowel sounds, no rebound or guarding • Right testicle with vertical lie in scrotum, no appreciable nodules • Initial workup: • 1. U/A and U C(x) negative • Duplex Doppler U/S of Testes Mc. Govern Medical School

Differential Diagnosis • Acute Scrotum in Children DDX: • Testicular Torsion: major concern due to PMH. Typically acute in onset with severe pain, high riding testicle, and absent cremasteric reflex. • Appendix Torsion: more common than testicular torsion (29% ASP vs 19%). Typically more gradual with less severe pain. • Epididymitis: typically 2/2 to UTI • Orchitis: 2/2 bacterial or viral infection (mumps) • Hematocele: 2/2 trauma • Hernia Mc. Govern Medical School

Relevant Imaging: Anatomy of Testes Epidydimal head Anterior: skin Tunica Albuginea Epidydimal tail R Testicle Cranial Caudal Posterior Mc. Govern Medical School

Relevant Imaging: Rule Out Torsion Mc. Govern Medical School

Relevant Imaging continued Appendix Epididymis • Testicular appendage torsion: appears as an area of low echogenicity adjacent to epididymis with “mesh-like” echotexture • Often not visualized: a diagnosis of exclusion once testicular torsion is ruled out Mc. Govern Medical School

Clinical Picture & Imaging Findings • TWIST Score can be used to assess for testicular torsion in children • • • Testicular swelling: 2 points Hard testicle: 2 points Absent cremasteric reflex: 1 point Nausea/vomiting: 1 point High-riding testicle: 1 point • Score of 2 -5 requires U/S for assessment • Score>5: PPV 100% : requires urgent urologic/surgical consult with possible orchiopexy • Our patient: preserved blood flow in both testes, no masses, hernias, or visible signs of infection. Likely R appendix epididymis torsion: round hypoechoic structure adjacent to epididymis with mesh-like echotexture and no flow Mc. Govern Medical School

Discussion • Torsion of Testicular Appendage: • Most common between ages of 7 – 14 • Has no effect on fertility or surrounding structures • Presents with: • More mild scrotal pain than torsion, often localized to one point of testicle • Physical exam: • Hard, tender, 2 -3 mm nodule at upper pole of teste • Workup: U/A and ultrasound • T(x): scrotal elevation, ice, NSAIDs, resolves between 7 -10 days Mc. Govern Medical School

ACR appropriateness Criteria • US duplex Doppler appropriate per ACR criteria • Cost at MHH: $1184 per Charge Description Master file Mc. Govern Medical School

Take Home Points / Teaching points • Acute scrotal pain in the pediatric population should be worked up emergently • Must assess for blood flow in testes using Duplex Doppler U/S • Absent blood flow in unilateral testicle signifies torsion and requires urgent surgical orchiopexy • Appendix torsion is a diagnosis of exclusion but can sometimes be visualized on U/S Mc. Govern Medical School

References • Urologic Imaging Without X-rays: Ultrasound, MRI, and Nuclear Medicine. Andrew C Peterson, MD, FACS et al in e. Medicine • Scrotal pathology in pediatrics with sonographic imaging (Pub. Med). Munden MM, Trautwein LM. in Curr Probl Diagn Radiol. 2000 Nov-Dec; 29(6): 185 -205. • Clinical and sonographic criteria of acute scrotum in children. Karmazyn B, Steinberg R, Kornreich L, et al. in Pediatr Radiol 2005; 35: 302 -310. • https: //wikem. org/wiki/Torsion_of_testicular_appendage • https: //www. memorialhealthcare. org/patient-information/financial-services/pricing/ • https: //assets. radiopaedia. org/articles/torsion-of-the-appendix-testis Mc. Govern Medical School

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