Acute Scrotal Swelling

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Gain understanding of presentation and management of acute scrotal swelling in pediatric patients. Learn about testicular torsion, differentials, examination findings, and diagnostic investigations.

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  1. Acute Scrotal Swelling Anum Salam, Gillian Winter Created: February 2023 Tag year: Year 4 Tag speciality: Paediatric surgery Tag condition: Testicular torsion

  2. Learning Aim To develop a greater understanding of the presentation and management of an acute scrotal swelling in the paediatric population

  3. Presentation A 15-year-old boy is admitted to the emergency department with scrotal pain at 2:30pm. Mum reports he was well when he woke up this morning, but when he was outside playing football he suddenly started complaining about this pain.

  4. 1 2 3 List 8 differentials 4 5 6 7 8

  5. What do you want to know about the pain? Site right side of scrotum Onset started suddenly and reached maximal intensity within a few minutes Character throbbing Radiation no Associated symptoms- felt nauseous and vomited twice, no urinary symptoms T- has been present since it started 2 hours ago E- nothing makes it better, moving makes it worse Severity- 9/10 This Photo by Unknown author is licensed under CC BY-SA-NC.

  6. 1 2 Narrow down to 5 differentials 3 4 5

  7. Any other questions PMH- usually fit and well, normal pregnancy and birth, reached all his developmental milestones and up to date with immunizations Not on any regular medication, no previous admissions, no past surgeries, no allergies FH- nil noted SH- lives with his one brother and parent in a house, not sexually active

  8. What would you like to do next? Testicular exam video: Testicular Examination - OSCE Guide - YouTube

  9. What would you expect to find for each differential? testicular torsion (1,8,7) torted hydatid of Morgagni, (2,4,7,5,8,9) Epididymitis (3,6,7,5,9) 1 sudden pain 2 gradual pain 3 pain develops over a few days 4 blue spot 5 normal cremasteric reflex 6 Frequent and painful micturition 7 swelling of scrotum 8 Prehn's sign negative 9 normal testicular lie

  10. Back to our child On examination you see a swollen, erythematous testicle that is high riding with a horizontal lie. Very tender to palpation. The cremasteric reflex is absent.

  11. What is your top differential

  12. Investigations Which investigation is routinely used to diagnose testicular torsion? Doppler ultrasound Urinalysis X-ray MRI

  13. What should the next step be? Urgent senior evaluation for scrotal exploration

  14. Management Management will depend on the level of damage to the testicle seen intraoperatively and would include either anorchidectomy or orchidopexy. Additionally, the contralateral testis is also fixed to prevent torsion of that side

  15. Can you think of any risk factors? Boys aged 12-15 Bell clapper deformity Undescended testes

  16. Summary Testicular torsion is a urological emergency which usually affects young males but can occur at any age It is caused by the twisting of the testicle on the spermatic cord which compromises the vascular supply to the testes If the history and examination suggests testicular torsion, an immediate surgical exploration is required Diagnostic investigations are not usually used in diagnosing testicular torsion Testicular torsion can lead to sub-fertility or infertility

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