Indications for conservative management of acute scrotal pain in children

Hastie, K. J.; Charlton, Clive

doi:10.1002/bjs.1800770324

Cited by 23 publications

(16 citation statements)

References 9 publications

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“…Scrotal tenderness, the position or lie of the testis, the presence of a blue dot, hydrocoeles, the cremasteric reflex and erythema are reported as useful signs [6]. Different centres place varying emphasis on each of these factors [7][8][9]. However, we found that clinical signs were not absolute.…”

Section: Discussionmentioning

confidence: 74%

Early scrotal exploration in all cases is the investigation and intervention of choice in the acute paediatric scrotum

2006

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The acute scrotum in the paediatric population is a clinical dilemma where a definitive diagnosis can only truly be made at surgical exploration. We postulate that surgical exploration in all cases allows truly accurate diagnoses, treats the torted appendage testes and enables the validity of clinical signs associated with scrotal pathology to be assessed. We retrospectively reviewed all boys less than 15 years old who presented to our institution with scrotal pain over a 2 year period. A total of 121 patients attended of whom 113 had exploratory surgery, 31 (27%) had testicular torsion, 64 (57%) had a torted appendage testis, 12 (11%) had epididymitis, 1 (1%) had fat necrosis and 5 (4%) had no abnormality detected. On exploration 9 (29%) of the torted testis were unsalvageable and thus required excision. The initial clinical impression was frequently demonstrated to be flawed. Two patients with testicular torsion presented with a painless swelling and two further patients had necrotic testes despite a history of pain for less than 4 h. A normal cremasteric reflex and a visible blue dot were detected in boys with testicular torsion. Doppler ultrasound scans were not reliable with 50% sensitivity to clearly differentiate between torsion of the testis and that of the appendage testis. Absolute dependence on clinical features can lead to a misdiagnosis of testicular torsion. The surgical treatment of torted appendage testis is safe, allowing accurate diagnosis and pain relief with minimal morbidity. Early scrotal exploration of all cases with testicular pain ensures maximal testicular salvage.

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Section: Discussionmentioning

confidence: 74%

Early scrotal exploration in all cases is the investigation and intervention of choice in the acute paediatric scrotum

2006

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“…The transverse elevated lie of the testis described in testicular torsion [5] was observed in only 4 (36.4%) patients in our study, and in 46% by Kadish and Bolte [11] . Early cases of torsion of testicular appendage may be distinguished by the localized polar tenderness and by the blue dot sign which have been reported in around 40% of patients [2,5,6] ; this sign contributed to the diagnosis in 1 of our patients. However when the presentation is beyond 24 h, there is often generalized swelling and tenderness making the condition diffi cult to diagnose clinically [6] .…”

Section: Discussionmentioning

confidence: 97%

“…Early cases of torsion of testicular appendage may be distinguished by the localized polar tenderness and by the blue dot sign which have been reported in around 40% of patients [2,5,6] ; this sign contributed to the diagnosis in 1 of our patients. However when the presentation is beyond 24 h, there is often generalized swelling and tenderness making the condition diffi cult to diagnose clinically [6] . Leukocytosis and pyuria have been reported to occur in around two thirds of patients with epididymitis [9], but is occasionally observed in some patients with testicular torsion [2,11] .…”

Section: Discussionmentioning

confidence: 97%

“…In epididymitis the pain is usually insidious in onset with a longer duration of pain at presentation, in comparison to testicular torsion where the pain is of sudden onset with a short duration of pain at presentation [2,5] . Torsion of testicular appendage may be distinguished from testicular torsion by its more insidious onset and slightly longer duration of pain at presentation, presumably because this condition is less painful [2,6] . History of scrotal trauma (reported in 4-22% of patients with torsion) may be misleading [1,7,8] .…”

Section: Discussionmentioning

confidence: 99%

“…When found on exploration, excision of the twisted vestige is all that is necessary. When established clinically, conservative management may be carried out [6,23] , though some believe that surgical excision is preferable as it rapidly relieves the symptoms [2] . In the differential diagnosis, idiopathic scrotal edema must be considered.…”

Section: Discussionmentioning

confidence: 99%

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The Acute Scrotum: A Review of 40 Cases

2005

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Objective: To determine the relative importance of clinical presentation, laboratory studies, and ultrasonography in the diagnosis of acute scrotum, and to suggest an effective method of management. Subjects and Methods: Forty patients who were hospitalized between January 2002 and December 2002 for acute scrotum were studied with respect to history, physical examination, blood tests, urine analysis including culture, and scrotal ultrasonography with color Doppler study. Results: Epididymitis (n = 24) was the commonest cause of acute scrotum followed by testicular torsion (n = 11), torsion of testicular appendages (n = 4), and idiopathic scrotal edema (n = 1). Both mean age (40.7 vs. 13.8 years), and average duration of pain at presentation (4.5 days vs. 19.1 h) were higher in patients with epididymitis than in torsion. Onset was usually insidious in epididymitis, sudden in testicular torsion, and variable in torsion of testicular appendages. The majority (87.5%) of patients with epididymitis were managed conservatively. The testis was salvaged in 81.8% of patients with testicular torsion. The accuracy of ultrasonography was only 72.7% in testicular torsion, but was good in epididymitis. Conclusion: Our results show that a careful clinical evaluation, by an experienced examiner, provides the correct diagnosis in acute scrotum rather than ultrasonography. It is of utmost importance to exclude testicular torsion in those who are younger than 16 years and whose pain duration is less than 24 h.

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Acute scrotal pain complicating familial Mediterranean fever in children

Eshel

Vinograd

Barr

et al. 1994

British Journal of Surgery

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Twenty-nine children with familial Mediterranean fever presented with 39 attacks of acute scrotal pain. Of these, 25 patients had an acute scrotum complicating familial Mediterranean fever and only four had testicular torsion. Scrotal pain was the only manifestation of a familial Mediterranean fever crisis in 36 episodes and in 15 boys scrotal involvement was the first manifestation of the condition. Fourteen patients were treated medically. Of 15 patients who underwent scrotal exploration there were no definite diagnostic findings in 11 and four had testicular torsion. Three cardinal features strongly suggest the diagnosis of acute scrotum in familial Mediterranean fever in a boy of Mediterranean origin with a relevant family history: recurrent scrotal pain or swelling; body temperature above 37.5 degrees C; and gradual onset of pain, usually of more than 12 h duration. Conservative management can safely be undertaken in these boys without fear of losing a salvageable testis.

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Indications for conservative management of acute scrotal pain in children

Cited by 23 publications

References 9 publications

Early scrotal exploration in all cases is the investigation and intervention of choice in the acute paediatric scrotum

Early scrotal exploration in all cases is the investigation and intervention of choice in the acute paediatric scrotum

The Acute Scrotum: A Review of 40 Cases

Acute scrotal pain complicating familial Mediterranean fever in children

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