A.B. is a 10 year old male with no significant PMHx c/o testicular pain x 2 hours

 

History Elements: 

Onset: 2 hours ago

Location: left scrotum

Duration: began 2 hrs ago, abruptly

Characteristics: sharp, localized to left scrotum 

Aggregation/Alleviation: progressively worsening 

Radiation: does not radiate

Timing: constant 

Severity: 10/10

No systemic symptoms (fever, chills)

No urinary symptoms (dysuria, hematuria, frequency/urgency) 

No abnormal penile discharge 

No abdominal pain

No vomiting, slightly nauseous 

Medications taken for pain: OTC Ibuprofen 200 mg, did not relieve the pain (last dose: 1 hour ago) 

No previous episodes of similar symptoms

No past medical history

Not on any current medications

No allergies

No sexual history (has never been sexually active), no hx of STIs

No previous surgeries

No significant family history 

 

Physical Exam:

Vitals: P-90, BP-110/70, R-18, T-98.6 F, SpO2-100%

General: alert, in acute distress, guarding scrotum  

Heart: RRR, S1 & S2 distinct, no murmurs or gallops

Lung: Clear to auscultation bilaterally. No adventitious breath sounds. 

Abdominal: +BS, soft, no rebound, tenderness, or guarding.

Male GU: circumcised male, exquisitely tender, swollen left scrotum with left testicle positioned higher than normal and in a horizontal lie. No erythema or discharge. No cremasteric reflex elicited on the left side. No relief of pain with elevation of testicle (Phren’s sign). 

 

Differential Diagnosis:

1. Testicular Torsion:
   1. Presents as an abrupt onset of severe scrotal pain localized to the one side which is usually unrelieved by OTC pain medication. PE reveals an exquisitely tender and swollen left scrotum with the left testicle positioned abnormally high and horizontally oriented. The absence of a cremasteric reflex on the left side is also indicative of testicular torsion. 
2. Epididymitis
   1. Epididymitis presents with unilateral scrotal pain that worsens with palpation of the epididymis and may show signs of inflammation such as scrotal erythema and warmth. Additionally, there was no pain relief with elevation of the testicle (Phren’s sign). There is also an absence of urinary symptoms such as dysuria, frequency, and urgency. 
3. Torsion of the appendix testis
   1. Presents similarly to testicular torsion with sudden onset of localized scrotal pain, but tends to be less severe and less urgent. Physical examination may reveal tenderness and swelling at the upper pole of the testicle, with a palpable nodule known as the “blue dot sign” in appendix testis torsion.

 

Tests:

Urinalysis: no WBC, hematuria, bacteria

Ultrasound w/ Doppler: demonstrates decreased blood flow to left testicle

 

Treatment:

Immediate surgical/urology consult for detorsion and bilateral orchiopexy

Pain management: Morphine 4 mg 

For nausea: Ondansetron 4 mg

 

Patient Counseling:

Explain the diagnosis and treatment: 

– Testicular torsion is a condition where the spermatic cord, which provides blood flow to the testicle, becomes twisted, leading to reduced blood flow and severe pain. It is a medical emergency that requires immediate surgical intervention to prevent damage to the testicle. The surgery involves untwisting the spermatic cord and securing the testicle to prevent future torsion (orchiopexy). 

Explain post-op management:

– Monitored for pain management and any possible complications, use pain medications + ice packs to relieve pain and swelling. 

Social/Emotional: 

– Empathize with the patient and demonstrate understanding that it is a difficult time. Reassure the patient that he has a team who will be taking care of him and will be happy to answer any questions he may have. 

Discharge Instructions: 

– Once discharged, explain that the patient can gradually return to activities after avoiding strenuous activities for 1-2 weeks. Explain that the patient should follow up regularly with his primary care provider to ensure healing is progressing well.