Case Presentation by Jonathan Najman, MD
History of Present Illness:
12-yo boy presents to the ED with sudden onset of abdominal pain and vomiting for 1 day. The patient states that he woke up suddenly early in the morning with severe abdominal pain and subsequently had multiple episodes of non-bloody and non-bilious emesis. The pain is intermittent in nature, sharp, radiates to his groin, is the worst pain he has ever felt and seems to be worsening with time. The patient’s mother states that he has been afebrile at home. The patient denied feeling any symptoms the day prior as well as any recent trauma, urinary symptoms, sexual activity or masturbation, or any sick contacts. Denied sexual activity. There is no change in urination, no burning with urination, and reported skin changes. He was well yesterday.
PMH: no known medical problems or hospitalizations
FH: no sick contacts
SH: lives at home with mother and father, denied sexual activity
Vital Signs: BP 108/68, HR 101, RR 20, T 37.9, 98% on RA
General: uncomfortable, with intermittent moments of extreme pain and discomfort
HEENT: NCAT, no pharyngeal erythema, no cervical lymphadenopathy palpated
Cardiovascular: RRR, normal S1 and S2, no murmurs noted
Respiratory: Clear to auscultation bilaterally
GI: Abdomen is mildly tender to palpation over the suprapubic region, otherwise it is soft, nondistended and nontender, with +BS
GU: Mild scrotal tenderness to palpation. There is slight swelling of the left testicle noted with significantly tenderness to palpation. Lifting the testicle does not seem to reduce the pain. The left testicle appears to be higher than the right. Cremasteric reflex is intact bilaterally. Negative blue dot sign bilaterally. There are no rashes or bruises noted over the genitalia. There is no discharge from the penis.
MSK: moving all extremities
Neurological: Alert and conversational, moving all four extremities spontaneously.
Skin: intact, no rashes or bruises noted
The following ultrasound was obtained:
1) What does the patient most likely have?
c) Testicular torsion
2) How would you treat this patient?
a) Manually detorse testicle in a clockwise fashion, if successful, DC home
b) Consult urology for emergent surgical repair
c) Ceftriaxone and Doxycycline
3) What is the most common cause of epididymitis in prepubertal patients?
b) E. coli
c) C. trachomatis
Remember that testicular torsion is a clinical diagnosis that required a high index of suspicion, even with ultrasound findings that show intact vascular flow. While symptoms such as abdominal pain, nausea and vomiting, history of trauma cannot accurately or reliably differentiate torsion from other causative disorders, the most common finding in patients with torsion is loss of the cremasteric reflex. Be careful as the reflex can still be intact in patients with torsion, and asymptomatic children younger than 30 months often have absent cremasteric reflexes. Ultrasound imaging for torsion has a sensitivity of 99-100 and specificity close to 90. False-negative findings occur if the testicle is examined early in the course of the disease or with intermittent torsion such as in this case.
In a patient who you strongly suspect testicular torsion, emergent urology consultation is necessary. About 90% of affected testicles can usually be saved within 6 hours of onset of symptoms, but by 24 hours nearly 100% of testicles are lost., Manual detorsion should be performed, but disposition without urologic consultation would be innappropriate. While standing at the feet of the patient, the testicle is twisted outward and laterally, as in “opening a book.” That is, the patient’s left testicle is twisted in a clockwise fashion and the right testicle is twisted in a counter-clockwise fashion. Analgesia should be given before the procedure such as parenteral or cord block. The testicle sometimes needs to be twisted 2-3x in order for complete pain relief. If it is difficult to detorse, or the pain worsens after rotation, you can attempt to rotate the testicle in the opposite direction and observe the results. Even with successful detorsion, patients still need to be evaluated by urology as the torsion can recur or there may have been irreparable damage to the testicle requiring further intervention, as well subsequent ultrasound after detorsion is necessary.
While epididymitis is uncommon in prepubertal children, the most likely cause is idiopathic unless the child has a congenital genitourinary anomaly that predisposes them to recurrent infections. Infants, on the other hand, more commonly have bacterial causes. As such, antibiotics should only be given after urine cultures are obtained and reveal causative bacteria, unlike other age groups where empiric treatment with antibiotics are usually given. Have a high suspicion for unreported sexual activity in adolescents and preadolescents.
“Hippo EM.” Emergency Medicine Board Review, LLSA, & More. Web. <http://www.hippoem.com>
Marx, JA, Hockerberger R, Walls RM. Rosen’s Emergency Medicine: Concepts and Clinical Practice (8th edition), Mosby 2013.
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