A 12-year-old boy is brought to the emergency department due to scrotal pain. Three hours ago, the patient performed a cannonball dive into a swimming pool. He felt immediate, sharp pain in his scrotum after hitting the water. The patient placed a cold compress to the area and took ibuprofen, but the pain persisted. He has no medical conditions and takes no medications. Temperature is 37.2 C (99 F), blood pressure is 120/85 mm Hg, respirations are 26/min, and pulse is 120/min. Physical examination shows an uncomfortable-appearing boy who is bent forward at the waist. Edema, faint ecchymosis, and tenderness are evident along the right hemiscrotum. The remainder of the examination is unremarkable. Which of the following is the best next step in management of this patient?

Question

A 12-year-old boy is brought to the emergency department due to scrotal pain.  Three hours ago, the patient performed a cannonball dive into a swimming pool.  He felt immediate, sharp pain in his scrotum after hitting the water.  The patient placed a cold compress to the area and took ibuprofen, but the pain persisted.  He has no medical conditions and takes no medications.  Temperature is 37.2 C (99 F), blood pressure is 120/85 mm Hg, respirations are 26/min, and pulse is 120/min.  Physical examination shows an uncomfortable-appearing boy who is bent forward at the waist.  Edema, faint ecchymosis, and tenderness are evident along the right hemiscrotum.  The remainder of the examination is unremarkable.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d92d_6344_bc81_6d5927ce687c_MD0003_00 Acute-onset scrotal pain and edema occurring after trauma has a broad differential diagnosis (eg, scrotal contusions, hematoma, testicular rupture). However, testicular torsion is an underrecognized diagnosis that can occur after testicular trauma and should be considered in any patient with significant scrotal pain and swelling. Although the diagnosis of testicular torsion is often made clinically, a Doppler ultrasound of the scrotum is the imaging of choice to evaluate scrotal contents and can confirm torsion in those without a clear diagnosis or evaluate other causes of scrotal pain. Ultrasound findings of reduced or absent blood flow or twisting of the spermatic cord are suggestive of torsion. Testicular torsion occurs due to insufficient attachment of the testicle to the tunica vaginalis, allowing for testicular hypermobility; mild trauma or exercise can induce twisting of the testis on the spermatic cord, leading to testicular ischemia. Spontaneous torsion can also occur. Other classic findings of torsion include absent cremasteric reflex (elevation of the testicle with stroking of the inner thigh) and scrotal pain unrelieved by elevation of the testicle (negative Prehn sign), although this test cannot reliably rule out torsion. Testicular torsion is a surgical emergency; up to 80% of patients with untreated torsion develop a nonviable testicle within 12 hours. twisting of the testis on the spermatic cord (Choice A) Abdominal and pelvic CT scan is indicated to evaluate significant trauma (eg, gunshot wounds) or for Fournier gangrene, which causes severe scrotal pain and edema but is typically associated with fever, erythema, and crepitus on examination. (Choices C and D) Torsion of the appendix testis (an appendage of tissue located on the upper testis) also causes acute-onset testicular pain, but examination often demonstrates a localized, tender mass on the testis, which may have a blue discoloration. It can be distinguished from testicular torsion with Doppler ultrasound demonstrating normal or increased blood flow to the affected testis. Management is supportive and includes pain management and scrotal elevation. (Choice E) Surgical evacuation of a hematoma can be considered in patients with evidence of a rapidly expanding testicular hematoma that may cause compartment syndrome. However, testicular hematomas are visible on ultrasound and typically occur after blunt force trauma. This patient's mild ecchymosis after minimal trauma makes a rapidly expanding hematoma unlikely. Educational objective: Testicular torsion can present with acute testicular pain and swelling after mild trauma. The diagnosis may be made clinically; however, in patients in whom the diagnosis is unclear, a Doppler ultrasound of the scrotum can confirm the diagnosis and exclude other etiologies.

A 12-Year-Old Boy Is Brought to the Emergency Department Due