Cryptorchidism Acute Scrotum Case Study When a

Cryptorchidism Acute Scrotum Case Study When a male presents with acute scrotum pain and swelling a number of different diagnoses are possible; however, if the diagnosis is testicular torsion then the patient needs to be evaluated by a competent surgeon immediately (reviewed by Kass and Lundack, 1997). Of the many possible diagnoses that can produce similar symptoms, including epididymitis, hernia/hydrocele, varicocele, epididymo-orchitis, torsion of a testicular or epididymal appendage (appendiceal torsion), or Henoch-Schonlein purpura, only testicular torsion represents a bona fide medical emergency.

For this reason, a detailed patient history and physical examination should be undertaken at once in order to preserve testicular function. Every effort should be made to gather a complete urologic and surgical history for the patient to exclude other conditions, including a urinary tract infection and epididymitis. A recent study examined the diagnosis distribution for 388 boys under the age of 17 who were treated at the Hospital for Children and Adolescents in Helsinki between 1977 and 1995 for acute scrotum (Makela, Lahdes-Vasama, Rajakorpi, and Wikstrom, 2007).

Testicular torsion occurred in 26% of cases, while appendiceal torsion, epididymitis, and hernia occurred in 45%, 10%, and 8% of cases, respectively. The peak ages for testicular torsion occurred during the first year of life and adolescence (13 to 16 years). By comparison, the peak age for appendiceal torsion was between 9 and 12 years of age. Epididymitis preferentially occurred in infants under one year of age and was only rarely found on older boys and adolescents. The case study considered here describes a 15-year-old boy presenting with a painful and red hemiscrotum containing a swollen descended testicle.

Based on the findings of the Helsinki study (Makela, Lahdes-Vasama, Rajakorpi, and Wikstrom, 2007) the most likely diagnosis is testicular torsion given the boy's age, although he could still be suffering from several other conditions. The age of 15 is well within the adolescent peak range of 13 to 16 years for males diagnosed with testicular torsion. Scrotal pain, testicular oedema, and scrotal erythema were found in patients with testicular torsion (68%, 44%, 16%), appendiceal torsion (94%, 39%, 32%), and epididymitis (58%, 50%, 37%). The patient is also nauseated and running a temperature of 101° F.

Based on the Helsinki study (Makela, Lahdes-Vasama, Rajakorpi, and Wikstrom, 2007) 5%, 2%, and 3% of patients with testicular torsion, appendiceal torsion, or epididymitis experience nausea or vomiting, respectively, so this was a rare symptom. Febrile patients were also rare in the first two conditions, but slightly more common in epididymitis (16%). Urine cultures were found to be positive in 26% of patients with epididymitis, but all of these patients were under one year of age.

Statistically, the most likely diagnosis for the patient considered here is testicular torsion; however, the other possibilities cannot be ruled out. Sudden onset of pain is more characteristic of testicular torsion than appendiceal torsion or epididymitis, whereas the onset of pain for the latter two conditions tends to occur more gradually (Kass and Lundack, 1997). If the patient is rushed to the hospital immediately or within a few hours of pain onset, this would be consistent with a diagnosis of testicular torsion.

The severity of the pain can also be assessed by observing whether the patient is preoccupied by the pain or easily engaged in conversation with family and friends. The cremasteric reflex should be examined by stroking or gently pinching the medial thigh, but this should be done with the unaffected side first to establish a baseline. An absent cremasteric reflex for the affected testicle is a strong, but not absolute indication of testicular torsion (Nelson, Williams, and Bloom, 2003).

In cases of testicular torsion the testicle is already retracted to an upper position and therefore no movement of the testicle occurs. The patient being considered here does not have a cremasteric reflex and the most likely diagnosis is testicular torsion; however, as boys grow older (> 12 years of age) the cremasteric reflex is less prevalent. The length of time that the symptoms have been present can help with the evaluation (Kass and Lundack, 1997).

By 24 hours there is little difference between testicular torsion, appendiceal torsion, and epididymitis, but cases with recent symptom onset can reveal subtle differences. A testicle positioned high in the scrotum and to one side (transverse) is more consistent with testicular torsion. Upon palpation of testicles with recent acute onset, palpation will reveal a swollen testicle if the patient is suffering from testicular torsion. Tenderness will be more diffuse for testicular torsion, but limited to the upper pole in cases of appendiceal torsion.

If the epididymis is tender in the absence of testicular tenderness then epididymitis is probable. Given that the patient in this case study has a swollen descended testicle the most consistent diagnosis is testicular torsion. The only laboratory test that should be run is a urinalysis to check for a urinary tract infection (Kass and Lundack, 1997). A positive result showing pus and/or the presence of bacteria would be consistent with epididymitis.

The preferred method of imaging is pulsed color Doppler ultrasonography, which can reveal differences in intratesticular anatomy and testicular blood velocity. Reduced or absent blood flow compared to the unaffected testis is diagnostic of testicular torsion, while increase blood flow would be consistent with epididymitis. If adequate imaging resources are not immediately available, exploratory surgery should be undertaken immediately. Time is of the essence, since the testicle should be detorsed within 6 hours of symptom onset to increase the chance of rescuing the testicle (Makela, Lahdes-Vasama, Rajakorpi, and Wikstrom, 2007).

The Helsinki study revealed a 100% rescue rate if surgery was performed within 6 hours of onset. The rescue rate decreased to 50% between 6 and 12 hours and to 4% between 12 and 24 hours. Given the age of onset for the patient under consideration here, the scrotal pain and redness, the testicular swelling, and an absent cremasteric reflex, the most likely diagnosis is testicular torsion. Surgery should be performed immediately to detorse the affected testicle or to exclude this diagnosis (Kass and Lundack, 1997).

The goals of the surgery should be to detorse the testicle if it can be rescued and to correct the anatomic deformity (orchiopexy).