The acute pediatric scrotum

Scrotal collections: pictorial essay correlating sonographic with magnetic resonance imaging findings

The present study is aimed at describing scrotal collections observed at ultrasonography and magnetic resonance imaging. The authors describe the main features of hydrocele, hematocele and pyocele, as well as the most common causes, clinical manifestations and associated diseases, with a brief review of the embryology and anatomy of the scrotum. Collections are frequently found in the evaluation of the scrotum, which is often performed on an emergency basis, and in most cases can be differentiated by means of imaging studies. With the consolidation of magnetic resonance imaging as the method of choice complementary with ultrasonography, the authors also describe magnetic resonance imaging findings of scrotal collections as well as the situations where such method is indicated.

Acute scrotum in Kawasaki disease: two case reports and a literature review

Acute scrotum is a rare complication of acute Kawasaki disease (KD), less well recognized than other disease manifestations. We describe the cases of two patients, aged 59 months and 19 months, with hydrocele testis in the acute phase of KD. Scrotal ultrasound and trans-illumination were used in the diagnosis of hydrocele testis. One patient underwent eventual surgical intervention. We reviewed the literature for a better understanding of the pathogenesis of scrotal symptoms in acute KD and investigated the clinical importance of hydrocele testis. Careful further clinical observation may elucidate the true incidence of this extracardiac symptoms, thereby clarifying the diagnostic value of this possible complication in acute KD.

Testicular torsion unravelled

Testicular torsion is a true vascular emergency-prompt diagnosis and surgical management is critical. If treatment is not instigated within 4-6 hours of the onset of pain, irreversible testicular infarction may result, necessitating orchidectomy. This review presents the key features, management principles and medicolegal considerations of this serious condition.

Medicolegal aspects of testicular torsion

OBJECTIVES

Testicular torsion is an active area of medical malpractice litigation because of the diagnostic uncertainty, delays in diagnosis and treatment, diagnostic errors, and resultant testicular loss. We reviewed this topic to determine the nature of patient claims and their clinical and legal outcomes.

METHODS

All closed case files of a large medical malpractice insurance company based in New Jersey involving testicular torsion from the years 1979 to 1997 were retrospectively reviewed. The following data were collected: patient demographics, timing of presentation, initial complaints, diagnosis given, consultations obtained, radiographic studies, treatment provided, outcomes, and indemnity payments.

RESULTS

Thirty-nine cases consisting of 58 individual claims were reviewed. Indemnity payments were made in 26 cases (67%), of which 25 (96%) were settlements, and 13 cases (33%) ended in favor of the physicians. Five cases went to trial, with only one verdict in favor of the plaintiff. The median indemnity payment was $45,000. Urologists were named most frequently (48%), and a misdiagnosis of epididymitis (61%) was most commonly cited. The mean patient age was 24.3 years. Atypical initial complaints were common (46%). Late presentation (greater than 8 hours) did not affect the medicolegal outcome. The major liabilities for paid claims were an error in diagnosis (74%), a delay in or lack of referral (48%), lack of radiologic examination (19%), failure to explore (13%), error in surgical technique or judgment (13%), and falsified records (10%).

CONCLUSIONS

Testicular torsion litigation most often focuses on the urologist. Claims are more common in older patients and those with atypical complaints. Settlement is the most common outcome, with a fairly standard indemnity payment rewarded. The initial treating physician must have a high index of suspicion for the diagnosis and refer promptly. In lieu of a definitive radiologic study, or when the diagnosis is in question, the urologist should strongly consider exploration and should perform contralateral exploration when torsion is found.

Henoch-Schönlein purpura: four cases and a review

Henoch-Schönlein Purpura (HSP) is a common, usually self-limited, vasculitis affecting children and young adults. Manifested by a characteristic rash, the course of HSP is typically a benign one, but may be accompanied by varying degrees of abdominal pain, arthritis or arthralgia, gastrointestinal bleeding, and nephritis. The various manifestations of HSP may present at any stage during the illness and mimic other disease processes, some of which may be life threatening. Thus, the emergency physician must consider the diagnosis of HSP in order to detect complications and avoid needless intervention in what usually is an otherwise benign process. We present four cases and a brief review of the literature to highlight HSP in the differential diagnosis of patients who present with any of the typical clinical signs and symptoms.