A 16-year-old boy is brought to the emergency department due to severe scrotal pain. The patient had an abrupt onset of scrotal pain 6 hours ago. He tried to treat it with ibuprofen and ice packs, but it continued to worsen. The pain is now severe, making walking difficult. The patient is nauseated and vomited once but has had no fever or abdominal or flank pain. He has had no chronic medical conditions or previous surgeries. The patient attends high school, where he is the captain of the varsity soccer team and has daily afternoon practice. He is sexually active with 2 current partners and uses condoms only intermittently; he last had intercourse a week ago. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 37.2 C (99 F), blood pressure is 118/72 mm Hg, and pulse is 102/min. The abdomen is soft, nontender, and has no rebound or organomegaly. Bowel sounds are active. Genital examination reveals an exquisitely tender and swollen right testicle approximately 7 cm in its longest axis. Elevation of the testis exacerbates the pain. Which of the following is the most likely additional finding in this patient?

Question

A 16-year-old boy is brought to the emergency department due to severe scrotal pain.  The patient had an abrupt onset of scrotal pain 6 hours ago.  He tried to treat it with ibuprofen and ice packs, but it continued to worsen.  The pain is now severe, making walking difficult.  The patient is nauseated and vomited once but has had no fever or abdominal or flank pain.  He has had no chronic medical conditions or previous surgeries.  The patient attends high school, where he is the captain of the varsity soccer team and has daily afternoon practice.  He is sexually active with 2 current partners and uses condoms only intermittently; he last had intercourse a week ago.  The patient does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.2 C (99 F), blood pressure is 118/72 mm Hg, and pulse is 102/min.  The abdomen is soft, nontender, and has no rebound or organomegaly.  Bowel sounds are active.  Genital examination reveals an exquisitely tender and swollen right testicle approximately 7 cm in its longest axis.  Elevation of the testis exacerbates the pain.  Which of the following is the most likely additional finding in this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c181_0007_8f63_69a7f2c60c8b_MD0005_00 Testicular torsion occurs when a testis with inadequate fixation twists around the spermatic cord, causing venous congestion and ischemia. It presents most commonly in adolescents, and initial symptoms include severe, acute scrotal pain and swelling that often develop hours after vigorous physical activity. Inguinal and lower abdominal pain may also occur, and the majority of patients develop nausea and vomiting. An elevated, transverse testis is typically present on examination. The scrotum is erythematous, edematous, firm, and tender. As seen in this patient, elevating the scrotum does not tend to relieve the pain. A classic finding is an absent cremasteric reflex, in which the testis reflexively elevates on stroking of the upper inner thigh. However, this sign is nonspecific as the reflex may be absent in some children without torsion. twists around the spermatic cord Decreased testicular perfusion on Doppler ultrasound helps confirm the diagnosis in cases of clinical uncertainty. A urologist should treat torsion promptly, typically with emergency surgical detorsion and fixation of both testes (orchiopexy). Detorsion within the first 6 hours typically allows for complete viability. After 24 hours, the testis is rarely salvageable. (Choice A) The transillumination test of the scrotum is positive in hydrocele, a cystic scrotal fluid collection that causes swelling but not usually pain. (Choice B) A cystic mass with calcifications on ultrasound could indicate a testicular tumor, which typically presents as a firm, nontender scrotal mass. (Choice C) Epididymitis, commonly due to chlamydia in sexually active boys, causes scrotal pain and swelling, with increased blood flow to the inflamed epididymis evident on Doppler ultrasound. However, patients with epididymitis often experience pain relief with scrotal elevation (Prehn sign), which is not seen in this patient. (Choice E) Pain in the right lower quadrant with passive ipsilateral hip extension refers to the psoas sign of retrocecal appendicitis. Although this condition may present with referred scrotal pain, it does not cause a swollen, tender testicle, as seen in this patient. Educational objective: Testicular torsion is a surgical emergency that presents with acute-onset scrotal pain and swelling, classically with an absent cremasteric reflex. References: Pediatric testicular torsion. (http://www.ncbi.nlm.nih.gov/pubmed/27894425) Management of acute scrotum in children: a 25-year single center experience on 558 pediatric patients. (http://www.ncbi.nlm.nih.gov/pubmed/27995859)

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