The document discusses the differential diagnosis of acute scrotal pain in children, emphasizing the importance of ruling out testicular torsion, which can lead to testicle loss if not addressed urgently. It compares testicular torsion, epididymitis, and appendicular torsion, detailing symptoms, physical examination findings, lab studies, and imaging techniques for diagnosis. Additionally, it highlights recent studies that propose new biomarkers, like C-reactive protein and erythrocyte sedimentation rate, to differentiate between conditions.

1. Is It torsion or not Main References are from emedicine articles by web MD : Testicular torsion , article by Timothy J Rupp , MD, FACEP, Associate Medical Director, Children's Medical Center of Dallas, Texas Epididymitis , article by Catherine Tubridy , MD, Staff ER Physician, State University of New York Downstate/Kings County Hospital Centers Torsion of the Appendices and Epididymis , article by Jason S Chang , MD, Staff Physician, Section of Emergency Medicine, Yale New Haven Hospital Presented by: Ahmad Kharrouby PGY 3 Urology Conference

2. Introduction A child or adolescent with acute scrotal pain, tenderness, or swelling should be looked on as an emergency situation

3. The list of differential diagnoses for an acute scrotum is extensive In all instances it is imperative to rule out torsion

4. Differential diagnosis of acute scrotum Campbell-Walsh Urology 9 th edition

5. In adolescent males, testicular torsion is the most frequent cause of testicle loss Acute epididymitis is the most common cause of acute scrotum Whereas torsion of testicular appendices is the leading cause of acute scrotum in children

6. Unilateral Bilat. 10% Unilateral Side Moderate to severe moderate severe Severity acute insidious sudden Pain onset Appendicular torsion epidedimitis Torsion

7. History in torsion: Sudden onset pain severe Unilateral Less commonly it is acute 50% of have had episodes of intermittent pain Can occur with activity, or develop during sleep Other symptoms: Scrotal swelling Nausea and vomiting (30%) Abdominal pain (30%) Fever (16%) Urinary frequency (4%)

8. History in epidedimitis Insidious onset pain swelling frequency, urgency, or dysuria Retention in older patients Nausea Abdominal or flank pain Bilateral epididymal involvement (10%) Urethral discharge Previous UTIs and unprotected intercourse Associated with Henoch-Schonlein purpura & amiodarone

9. History in appendicular torsion Acute pain with a more gradual onset than torsion mild to severe Patients may endure pain for several days before seeking medical attention Located to the superior pole, a key distinguishing factor from torsion Systemic symptoms and urinary symptoms are absent

10. Physical Exam in torsion Diffuse tenderness Elevated position Horizontal lie Swelling Ipsilateral loss of cremasteric reflex -ve Prehn sign Fever (uncommon)

11. Physical exam in epidedimitis Edematous tender epididymis Erythematous scrotum Scrotal fixation to epididymis Reactive hydrocele +ve Prehn sign (not reliable) Urethral discharge (10%) Fever with progression

12. Physical exam in appendicular torsion Afebrile Normal scrotum usually Cremasteric reflex present Tenderness localized to upper pole Blue dot sign is pathognomonic (21%) Vertical orientation is preserved The combination of a blue-dot sign with, nontender testes excludes torsion

13. A recent study in 2005 scored 3 key historical elements as predictors for testicular torsion Onset of pain less than 6 hours Absence of cremasteric reflex Diffuse testicular tenderness Out of 141 subjects, in the absence of any of these elements, none of the subjects had testicular torsion With all 3 elements present, 87% were diagnosed with testicular torsion Reference: Karmazyn B, Steinberg R, Kornreich L. Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys. Pediatr Radiol . Mar 2005;35(3):302-10

14. Lab Studies in torsion Urinalysis usually normal In 30% elevated WBCs CBC elevated WBC count in 60%

15. Lab Studies in Epididymitis Urinalysis - Pyuria or bacteriuria (50%) CBC - Leukocytosis

16. Lab Studies in appendicular torsion Usually normal

17. Imaging Studies Testicular torsion is a clinical diagnosis Imaging studies usually are not necessary; ordering them wastes valuable time when the definitive treatment is surgical

18. Imaging Studies Color-coded Doppler ultrasonography This type of ultrasonography assesses perfusion of the testicle and anatomy of the scrotal contents A normal testicle with markedly diminished Doppler wave pulsation represents torsion A thickened enlarged epididymis with increased Doppler wave pulsation represents epididymitis In appendicular torsion Testicular appendage appears as a lesion of low echogenicity with a central hypoechogenic area Normal blood flow to the testis, with an occasional increase on the affected side that possibly is due to inflammation Color Doppler has a sensitivity of 86%, specificity of 100%, and accuracy of 97% in the diagnosis of testicular torsion

19. Imaging Studies In prepubertal patients, this method of imaging is somewhat controversial because the prepubertal testis has low-velocity blood flow, and color Doppler ultrasonography is less accurate in these instances As a result, a negative ultrasonographic result does not necessarily exclude testicular torsion

20. Imaging Studies Radionuclide scintigraphy Radionuclide scintigraphy is used to assess testicle perfusion Decreased perfusion suggests torsion Increased or normal perfusion suggests epididymitis but may occur with torsion The positive pathognomonic sign for testicular appendix torsion is the hot-dot sign, which is an area of increased tracer uptake Radionuclide scans have a sensitivity of 90-100% accuracy in detecting testicular blood flow

21. Important In high clinical suspicion, surgical exploration is essential

22. Under Investigation The use of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to help differentiate epididymitis from testicular torsion A prospective study evaluated 120 patients with the diagnosis of an acute scrotum serum CRP and ESR were drawn at ER arrival Of the 46 patients diagnosed with epididymitis, 44 (95.6%) had elevation of CRP level of the 23 with torsion, 1 (4%) had elevation of CRP level and, of the 51 other patients with other noninflammatory causes of acute scrotum, none had significant elevation of CRP level The authors proposed cutoff values of distinguishing epididymitis from noninflammatory causes of acute scrotum of 24 mg/L for CRP level and 15.5 mm/h for ESR. The use of ESR and CRP is also promising, but again further investigations are necessary

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