A 16-year-old boy is brought to the emergency department with abdominal pain. Two hours ago, the patient was playing in a lacrosse match when he suddenly developed severe, persistent pain in his right lower quadrant with associated nausea. He experienced no trauma to the abdomen and has had no fever, vomiting, or diarrhea. The patient has had similar episodes over the past 3 weeks following lacrosse matches, but these episodes resolved shortly afterward with rest. He has no history of groin or scrotal swelling. The patient has no chronic medical conditions and takes no medications. He is sexually active with 1 partner and uses condoms inconsistently. Temperature is 37.7 C (99.9 F). The abdomen is soft, nontender, and nondistended. There is scrotal erythema and edema; the right hemiscrotum is tender to palpation. The pain is worsened when the scrotum is elevated, and the scrotum does not transilluminate. Which of the following is the most likely cause of this patient's symptoms?

Question

A 16-year-old boy is brought to the emergency department with abdominal pain.  Two hours ago, the patient was playing in a lacrosse match when he suddenly developed severe, persistent pain in his right lower quadrant with associated nausea.  He experienced no trauma to the abdomen and has had no fever, vomiting, or diarrhea.  The patient has had similar episodes over the past 3 weeks following lacrosse matches, but these episodes resolved shortly afterward with rest.  He has no history of groin or scrotal swelling.  The patient has no chronic medical conditions and takes no medications.  He is sexually active with 1 partner and uses condoms inconsistently.  Temperature is 37.7 C (99.9 F).  The abdomen is soft, nontender, and nondistended.  There is scrotal erythema and edema; the right hemiscrotum is tender to palpation.  The pain is worsened when the scrotum is elevated, and the scrotum does not transilluminate.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d84b_414b_bc81_9b0a5966e34b_MD0003_00 This adolescent male has recurrent abdominal pain and nausea after strenuous physical activity; examination reveals a normal abdomen but a tender, erythematous scrotum. This presentation suggests testicular torsion, which occurs due to insufficient fixation of the testis to the tunica vaginalis, allowing testicular hypermobility. Exercise, mild trauma, or movement during sleep can induce twisting of the testis about the spermatic cord, leading to obstruction of blood flow and testicular ischemia. Testicular torsion occurs most commonly in adolescents due to enlargement of the testes during puberty. Classically, patients experience severe, acute-onset scrotal pain that does not resolve with elevation of the testicle (negative Prehn sign); however, some patients report inguinal or lower abdominal pain as their primary symptom. Nausea and vomiting are common. Prior episodes that resolve without intervention (as in this patient) can indicate intermittent torsion. Physical examination classically reveals a tender, high-riding testicle; a horizontal lie of the testis may be visible. The scrotum is typically erythematous and markedly swollen. The cremasteric reflex (stroking the inner thigh causing testicular elevation) is characteristically absent. The diagnosis is often made clinically, but a Doppler ultrasound can be used for confirmation. Testicular torsion is a surgical emergency and should prompt urgent urologic evaluation for detorsion because loss of testicular viability can occur within a matter of hours. (Choice A) Acute epididymitis can cause similar symptoms in a sexually active patient; however, pain (which initially affects the posterior testis, where the epididymis is located) is unlikely to occur intermittently and is typically improved with elevation of the testis (positive Prehn sign). Dysuria and urethral discharge may also be present. (Choice B) Incarcerated inguinal hernia can cause scrotal pain and swelling, but patients typically have a history of a mass that increases with elevated intraabdominal pressure (eg, bearing down). Pain that worsens with testicular elevation makes torsion more likely than inguinal hernia. In addition, an incarcerated hernia would not usually occur intermittently and resolve without intervention. (Choice C) Infected hydrocele is very rare but could present with lower abdominal or scrotal pain; however, infection would more likely cause progressive pain and fevers as opposed to the intermittent, recurrent symptoms this patient has experienced. In addition, hydroceles transilluminate when light is shined behind the scrotum. (Choices D and E) Testicular hematoma and testicular rupture can cause significant pain, scrotal swelling, and erythema. However, these typically occur in the setting of significant trauma (eg, baseball to the scrotum), which was not reported in this case. Educational objective: Testicular torsion presents with abrupt onset of scrotal, inguinal, or abdominal pain, which classically does not resolve with elevation of the testicle. Torsion can occur after exercise, and patients may have recurring, transient symptoms due to intermittent torsion.

A 16-Year-Old Boy Is Brought to the Emergency Department with Abdominal