Hodentorsion: Diagnose, Differenzialdiagnose und Therapie im Kindesalter

[Acute genital diseases]

Acute genital diseases can occur at any age and are characterized by complaints of various kinds of the external genitalia. Pain, swelling, and redness of the scrotum, adjacent groin region, and immediate surroundings are the leading symptoms, the severity of which may vary. In addition, peritonitic symptoms such as nausea, vomiting, and circulatory sensations may be present and are comparable to symptoms of an acute abdomen. The term "acute scrotum" encompasses various clinical entities, where scrotal symptoms are predominant and represent a urological emergency situation. Immediate and comprehensive diagnostics are necessary to ensure timely management in case of necessary surgical intervention.

[Ultrasound imaging of the testes in children and adolescents]

BACKGROUND

Ultrasound, the imaging method of choice to evaluate abnormalities of the testes and the scrotum, provides accurate anatomic details and allows the assessment of perfusion using color Doppler and power Doppler. Ultrasound represents a rapid and reliable procedure which in most cases leads to a conclusive diagnosis.

DIFFERENTIAL DIAGNOSIS

The three most common conditions in the clinical picture of acute scrotum are testicular torsion, torsion of the testicular appendages and inflammatory changes of the testis and the epididymis (epididymo-orchitis). Especially in the case of testicular torsion, rapid diagnosis is essential since time is an important factor to initiate organ-preserving therapy.

EQUIPMENT TECHNOLOGY

High-frequency linear array transducer (at least 10 MHz), which allows detection of slow flow rates, is recommended.

Testicular Torsion in the Absence of Severe Pain: Considerations for the Pediatric Surgeon

Testicular torsion is a surgical emergency. Early diagnosis and surgical treatment are vital in order to preserve the affected gonad. Current surgical teaching emphasizes sudden, severe, persistent, unilateral scrotal pain as a cardinal symptom of testicular torsion. We present the case of unilateral testicular torsion in a 14-year-old patient who presented with the absence of severe pain. Despite a delayed presentation to the emergency department, the gonad could be salvaged successfully. Literature on the topic of testicular torsion presenting with minimal pain is limited. Nevertheless, pediatric surgeons might be faced with cases similar to the one we describe. Underestimating this phenomenon might lead to a delay of treatment. In such cases, ultrasound can be a beneficial addition in the diagnosis and accelerate definitive operative treatment. The presented case clearly demonstrates that, although we do not include testicular torsion without severe pain in our surgical teaching algorithms, we might encounter it in our clinical practice.

[Scrotal ultrasound examinations in infants and toddlers]

BACKGROUND

Besides physical examination, ultrasonography is the most valuable diagnostic tool to assess the scrotum and testes in the case of an acute scrotum or scrotal pathology.

PROBLEMS

In infants and toddlers the examination can be challenging. Due to the limited patient compliance, the small testicular size (< 0.5 ml), and low blood flow velocity (< 3 cm/s), it can be difficult to achieve a proper flow curve when assessing blood flow.

CONCLUSION

The examiner's skills are as important as adequate equipment (i. e., linear ultrasound probe, 12-14 MHz) and optimal program settings (Doppler scale < 3 cm/s, gate 1 mm). However, if there is doubt, surgical exploration is unavoidable.

Dirofilariasis Mimicking an Acute Scrotum

Human infections caused by Dirofilaria repens have been reported in many areas of the world. We describe a case of a 3-year-old child with an intrascrotal mass caused by D repens mimicking an acute scrotum. This represents the first case of scrotal dirofilariasis described in pediatric age with such an unusual presentation.

The acute scrotum in childhood and adolescence

BACKGROUND

The acute scrotum in childhood or adolescence is a medical emergency. Inadequate evaluation and delays in diagnosis and treatment can result in irreversible harm, up to and including loss of a testis. Various diseases can produce this clinical picture. The testis is ischemic in only about 20% of cases.

METHODS

This review is based on a selective literature search, the existing clinical guideline, and the authors' experience.

RESULTS

The clinical approach to the acute scrotum must begin with a standardized, rapidly performed diagnostic evaluation. Dopper ultrasonography currently plays a central role. Its main use is to demonstrate the central arterial blood supply and venous drainage of the testis. The resistance index of the testicular vessels should also be determined.

CONCLUSION

Physical examination and properly performed Doppler ultrasonography enable adequate evaluation of the acute scrotum in childhood and adolescence. In the rare cases of diagnostic uncertainty, immediate surgical exposure of the testis remains the treatment of choice.

Clinical predictors of testicular torsion in children

OBJECTIVE

To distinguish the prognostic factors that decrease the probability of a negative exploration for "acute scrotum." In some institutes, patients with "acute scrotum" undergo immediate exploration after clinical evaluation. Because testicular torsion (TT) accounts only for a fraction of these cases, most infants can be treated conservatively.

METHODS

We performed a retrospective study of all patients treated at our institute from January 2008 to December 2009 for the diagnosis of "acute scrotum." Differences between groups were calculated using the chi-square test or analysis of variance and Mann-Whitney-Wilcoxon test for univariate or multivariate analysis, expressed as odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

The data from 138 patients were analyzed. The mean age was 9 years, 8 months. Of the 138 patients, 19 (13.8%) had TT. This group was compared with the boys without TT at exploration. The patients with TT were older on average (11 years, 1 month vs 9 years, 1 month, p = .035). Pain for <24 hours (OR 4.2, 95% CI 1.3-13.4), nausea and/or vomiting (OR 21.6, 95% CI 4.9-93.4), abnormal cremasteric reflex (OR 4.8 95% CI 0.7-35.2), and a high position of the testis (OR 18.0 95% CI 1.8-177.1) were associated with an increased likelihood of torsion. In the group of boys with ≥ 2 of these findings present, 100% had TT at exploration, with 0% false-positive results.

CONCLUSION

TT is uncommon among the group of boys treated for "acute scrotum." In particular, a pain duration <24 hours, nausea or vomiting, a high position of the testis, and an abnormal cremasteric reflex had a positive prognostic value for TT. A clinical score might help to avoid unnecessary explorations. In the future, we intend to test the diagnostic set described combined with ultrasonography.