A 14-year-old boy is brought to the emergency department for evaluation of severe scrotal pain. Half an hour ago, the patient was accidentally hit in the scrotum during wrestling practice. He applied ice and took acetaminophen, neither of which relieved the pain. He has not tried urinating due to fear of the pain. The patient underwent a right orchiopexy as an infant due to unilateral cryptorchidism but has no chronic medical conditions. Temperature is 36.7 C (98.1 F), blood pressure is 114/76 mm Hg, and pulse is 108/min. Abdominal examination is unremarkable. There is moderate bruising on the right hemiscrotum but not on the medial thigh or perineum. The right testis is exquisitely tender to palpation but has normal contours. Bilateral testes retract with stroking of the medial thigh. The penis has no blood at the meatus or open wounds. Intravenous morphine provides significant pain relief, and the patient is able to urinate spontaneously. Urinalysis results are as follows: Which of the following is the best next step in management of this patient?

Question

A 14-year-old boy is brought to the emergency department for evaluation of severe scrotal pain.  Half an hour ago, the patient was accidentally hit in the scrotum during wrestling practice.  He applied ice and took acetaminophen, neither of which relieved the pain.  He has not tried urinating due to fear of the pain.  The patient underwent a right orchiopexy as an infant due to unilateral cryptorchidism but has no chronic medical conditions.  Temperature is 36.7 C (98.1 F), blood pressure is 114/76 mm Hg, and pulse is 108/min.  Abdominal examination is unremarkable.  There is moderate bruising on the right hemiscrotum but not on the medial thigh or perineum.  The right testis is exquisitely tender to palpation but has normal contours.  Bilateral testes retract with stroking of the medial thigh.  The penis has no blood at the meatus or open wounds.  Intravenous morphine provides significant pain relief, and the patient is able to urinate spontaneously.  Urinalysis results are as follows:  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfd7_47dd_8f63_83860cfeea88_MD0005_00 Scrotal trauma is usually due to sports, bicycle, or motor vehicle injuries and can result in significant testicular injury. Because the right spermatic cord is slightly shorter, the right testis is higher and more vulnerable to injury from compression against the pubis. Patients typically have scrotal pain, swelling, and bruising. An absent cremasteric reflex on examination is a nonspecific finding that can occur with significant testicular injury or testicular torsion or as a normal variant. However, the presence of a cremasteric reflex, as in this patient, does not exclude testicular injury. In a patient with mild, self-resolving symptoms and a normal physical examination, minor injury can be managed with oral analgesics, ice packs, and outpatient follow-up (Choice B). If significant swelling (eg, moderate bruising) or marked pain (eg, requiring intravenous morphine) are present, as in this patient, further workup is indicated. A urinalysis evaluates for hematuria, which may indicate a potential injury of the urinary tract. Scrotal ultrasound assesses the extent of injury and guides therapy. If ultrasound reveals testicular rupture, fracture, avulsion, or compression by scrotal hematoma, urgent surgical exploration and repair are required. Surgery should be performed within 72 hours of the injury to optimize testicular salvage. To prevent scrotal trauma, clinicians should counsel patients to wear a protective cup while participating in contact sports (eg, wrestling, hockey, football). (Choice A) Emergent surgical detorsion and orchiopexy are used to treat testicular torsion, which causes scrotal pain and swelling despite the lack of preceding trauma. The cremasteric reflex is typically absent. Torsion is unlikely in this case, as it rarely occurs in patients with a previous orchiopexy. (Choice C) Retrograde urethrography is indicated when urethral injury is suspected (eg, blood at the tip of the meatus, hematuria). This patient has a normal penile examination with no blood on urinalysis. (Choice E) Testicular fine-needle aspiration may be used for sperm retrieval in the evaluation of male infertility but is not used to assess scrotal trauma. Educational objective: Mild scrotal trauma is managed conservatively with analgesics. Significant scrotal pain and swelling require scrotal ultrasound to assess for testicular injury. References: Sonography of pediatric blunt scrotal trauma: what the pediatric urologist wants to know. (http://www.ncbi.nlm.nih.gov/pubmed/27112160) Role of ultrasonography for testicular injuries in penetrating scrotal trauma. (http://www.ncbi.nlm.nih.gov/pubmed/27132505) Can ultrasound help to manage patients with scrotal trauma? (http://www.ncbi.nlm.nih.gov/pubmed/27433221)

A 14-Year-Old Boy Is Brought to the Emergency Department for Evaluation