Intern Report Case Discussion 2.8

intern-report

Presented by Brian Junnila, MD

CHIEF COMPLAINT:
Abdominal pain, nausea and vomiting

HISTORY OF PRESENT ILLNESS
14 year old male presents with acute onset of abdominal pain 3 hours duration which woke him up from sleep at 0300 this morning.  Pt is accompanied by his mother and father who relate a history of being awakened by their son complaining of abdominal pain and crying inconsolably.  Pain is located to the right lower quadrant radiating to the right inguinal region and scrotum.   Pain is ranked 10/10, constant and stabbing in nature.   Associated symptoms include nausea and vomiting, 2 episodes last 3 hours described as the contents of his dinner, no blood or greenish discoloration reported.  Last oral intake was at 2000 last night and consisted of macaroni and cheese.  Pt acknowledges multiple previous episodes of abdominal and scrotal pain over the last year which always spontaneously resolved in 1-2 hours and had never been this severe.   Pt denies any recent dysuria, hesitancy, urgency or penile discharge.  Pt denies any change in recent change in bowel pattern; last bowel movement was yesterday and normal in consistency.  He denies any recent fever, sore throat, chest pain or shortness of breath.

REVIEW OF SYSTEMS
The following systems were reviewed:  Constitutional, eyes, ears, nose, throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin, neurologic, psychiatric, endocrine, lymphatic and immunologic.  All review and negative except as document in history of present illness.

PAST MEDICAL HISTORY:  Buckle fracture left radius
PAST SURGICAL HISTORY:  Tonsillectomy at age 5
MEDICATIONS:  None
ALLERGIES:  NKDA, peanuts cause swelling
FAMILY HISTORY:  Father with HTN, DM type 2
SOCIAL HISTORY:  Denies tobacco, alcohol, illicit drug use.  In 9th grade, does well in school.

EXAMINATION OF ORGAN SYTEMS AND BODY AREAS

VITALS:  BP 126/56, HR 112, RR 22, T 37.7˚C, Pulse ox 98% RA
CONSITUTIONAL:  A&O x 3, in moderate distress, crying and uncomfortable
HEAD:  NC/AT
EYES:  Injected conjunctiva, PERRLA, EOMI, sclera anicteric
EARS:  TM good light reflex no bulging or erythema bilaterally
NOSE:  Mucous membrane moist, clear rhino rhea
MOUTH:  Mucous membranes moist, no intraoral lesions, no pharyngeal erythema
NECK:  Supple, full ROM, no C-spine tenderness.  No lymphadenopathy, no thyromegaly.
CARDIOVASCULAR:  Tachycardia, regular rhythm.  Normal S1 and S2.  No M, R, G
RESPIRATORY:  Good air movement bilaterally, CTAB, No wheezes, rhonchi, rales
ABDOMIN:  Soft, discomfort to palpation of the right lower quadrant, no rebound, no guarding, ND, no masses.  BS positive throughout.
BACK:  No tenderness to palp of C,T L vertebrae.  No CVA tenderness.
GENTIOURINARY:  Uncircumcised.  No external genital lesions, no urethral discharge, no inguinal lymphadenopathy.  Loss of the cremasteric reflex on right.  Left cremasteric reflex intact.  Scrotal edema.  Right testicle firm and tender to palpation.
MUSCULOSKELETAL:   Full range of motion in all 4 extremities with strength 5/5 both proximally and distally.  No joint effusions.
SKIN:  Warm dry and normal color, no rash, no ecchymosis, no petechiae.

LABORATORY DATA
Electrolytes:  141/3.8/102/26/15/0.5<79
CBC w/diff:  6.7>13.9/4.2<281
Urinalysis:  Clear, yellow, glucose negative, bilirubin negative, ketones negative, specific gravity 1.029, blood negative, pH 5.5, protein negative, urobilinogen negative, nitrite negative, leukocytes esterase negative, RBC < 2, WBC < 5, epithelial cells < 5, casts none, mucous negative, bacteria none, sperm none, trichomonas none

RADIOLOGY
Bilateral transverse color Doppler ultrasound
Right testicle             Left testicle

________________________________________________

QUESTIONS

1. What is the first step in management of patients with this condition?
a.  Color-flow duplex Doppler ultrasound
b.  Manual detorsion
c.  Radionuclide scintigraphy
d.  Systemic intravenous analgesia
e.  Urologic consultation

2. After what time from symptom onset will the salvage rate for the affected testes drop below 90%?
a.  3 hours
b.  6 hours
c.  9 hours
d.  12 hours
e.  24 hours

3.  What is the correct procedure for manual detorsion of the right testis?
a.  180˚ clockwise rotation
b.  180˚ counterclockwise rotation
c.  360˚ clockwise rotation
d.  360˚ counterclockwise rotation
e.  540˚ clockwise rotation
f.  540˚ counterclockwise rotation

4.  Which physical exam finding is present in nearly 100% of all adolescent patients with our patient’s condition?
a.  Tender firm testicle
b.  High position of affected testicle
c.  Loss of the ipsilateral cremasteric reflex
d.  Prehn sign
e.  Transverse orientation of affected testicle

Answers

E.  Immediate urologic consultation
B.  6 hours
F.  540˚ counterclockwise rotation
C.  Loss of the ipsilateral cremasteric reflex

DISCUSSION

Testicular torsion is a urologic emergency which requires prompt recognition and treatment for preservation of testicular viability.  Twisting of the spermatic cord produces venous outflow obstruction and arterial occlusion.  Undiagnosed torsion leads to testicular infarction and impaired fertility.

Torsion is the most common cause of acute scrotal pain in prepubertal boys.  It has a peak incidence in the first year of life and a second peak incidence at puberty.  There are two types, extra and intravaginal.

Extravaginal torsion is a diagnosis of newborns.  An anatomic abnormality of the attachment of the tunica vaginalis to the dartos layer of the scrotum leaves testicle and tunica vaginalis unanchored.  Testicle and the tunica vaginalis are unanchored in the scrotum and are free to rotate as a unit. This can happen in-utero and by the time the condition is noted at birth the testicle is not salvageable.

Intravaginal torsion is spermatic cord rotation within the tunica vaginalis.  Predisposing factors include increased cord length and an abnormally high insertion of the tunica vaginalis onto the testicle, the so called “bell clapper deformity.”  The testicle lacks normal fixation to the fascial and muscular coverings that surround the spermatic cord within the scrotum.  It freely moves within the tunica vaginalis.  Contraction of the cremasteric muscle causes a rotational force and can lead to torsion.  Testicular trauma has also been associated with torsion.  Consider torsion in the setting of persistent scrotal pain after trauma.

The classical presentation of testicular torsion is the acute onset of unilateral scrotal pain.  The pain may radiated to the inguinal canal and the lower abdomen.  Associated symptoms of nausea and vomiting are common.  Patients by relate a history of prior episodes of scrotal pain which resolved spontaneously representing the spontaneous torsion and detorsion of the spermatic cord.

Physical exam findings include

  • Ipsilateral loss of the cremasteric reflex (most common finding, nearly 100%)
  • Erythema and swelling of the scrotum
  • Testicular enlargement
  • High-riding testicle in the scrotum due to twisting and shortening of the spermatic cord
  • Transverse/horizontal lie of the testicle
  • Firm and painful testicle
  • Displacement of the epididymis from the usual posterior aspect of the scrotum.

The initial management in cases of strong clinical evidence of torsion high suspicion is immediate urologic consultation.  Surgical exploration should not be delayed for imaging studies.  The definitive treatment for testicular torsion is surgical exploration, detorsion and bilateral orchiopexy.

After consultation, IV access and analgesia manual detorsion may be attempted.  Normally torsion occurs from lateral to medial.  Detorsion should be attempted by rotating the affected testicle away from the midline, 540˚ from medial to lateral.  This is a counterclockwise rotation for the right testicle and clockwise rotation for the left.  The rotation can be thought of as opening a book.
For cases in which the history and physical findings are equivocal or after manual detorsion, obtain laboratory and radiographic studies.

Color Doppler ultrasound imaging is inexpensive, rapid and be performed in the emergency department.  It has a sensitivity of 88-100% and specificity of 90%.  Testicular torsion is demonstrated suggested by an absence of blood flow to one testicle.  False positive tests can occur early in the course of the injury and in very young boys.   Radionucleotide scintography has improved sensitivity 100% compared with ultrasonography however it takes more time and is more expensive.

The duration of vascular obstruction is directly related to the ability to salvage the testicle.  Prompt recognition and treatment is essential.  Salvage rate is 90% if treatment is rendered within 6 hours of symptom onset.  After 24 hours of symptoms testicular necrosis is certain.

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