Hot Seat #64: 8 year old with scrotal pain
Posted on: October 28, 2015, by : Anne Whitehead
Anne Whitehead MD, Inova Fairfax Medical Center
Maybelle Kou, Inova Fairfax Medical Center
The Case
An 8 year old male presents with lower abdominal and scrotal pain that started 1 week ago while he was on vacation at the beach. Parents initially took him to a local ED where ultrasound of the testicles was unremarkable, CT abdomen/pelvis were normal, including appendix, and was discharged. He continued to have pain, and on return home 3 days later presented to a local ED. Initial work up including CBC, BMP, UA and AXR did not reveal a cause for his symptoms, though ESR and CRP were mildly elevated, and he was admitted for pain control. RLQ ultrasound did not visualize the appendix, however MRI enterography was normal except for trace free fluid in the pelvis. A repeat scrotal ultrasound revealed a mildly enlarged right epididymis, and he was sent home on trimethoprim-sulfamethoxazole for this.
He represented to the ED 2 days later, 1 week after symptom onset, with continued pain despite round the clock ibuprofen and hydrocodone/apap. The night prior to ED evaluation, he was “up screaming all night” with severe pain. He is reported to have spells of severe pain, with constant moderate pain in the lower abdomen and scrotum without laterality, worse with ambulation, relieved partially with scrotal support. Parents and patient deny trauma, but are concerned that the “shark repellent” he wore tied to his waist band while swimming may have something to do with his symptoms.
ROS: no fever or chills. +nausea/vomiting, usually associated with pain. +chronic constipation. +scrotal pain, no dysuria or increased frequency. no rashes. no unusual bruising or bleeding. remaider of ROS otherwise unremarkable.
PE: HR 89 | BP 105/56 mmHg | Resp 24 | SpO2 100 % | Temp 97.8 °F (36.6 °C)
Constitutional: well appearing, no acute distress- playing video game throughout history, looking up briefly for exam
HEENT: oropharynx moist, no lesions appreciated
Respiratory: clear and equal to auscultation bilaterally
Cardiovascular: regular rate and rhythm, no murmurs
Abdomen: abdomen soft and mildly tender in lower quadrants bilat with slight guarding in lower quadrants bilat. No rebound. No HSM.
GU: normal external genitalia, no swelling or lesions and testicles/epididymis non-tender bilat, cremasteric reflex intact
Neurological: moving all extremities equally, coordination grossly intact and gait normal
Skin: warm, dry, without rashes
Lymphatic: no cervical or inguinal adenopathy
Questions for you:
Update:
Initially the patient declined pain medication, however while in ultrasound he started screaming in pain which subsequently improved with morphine and ketorolac.
Doppler ultrasound of the scrotum was normal without evidence of epididymitis. Appendix was visualized and normal, and renal ultrasound was also normal. KUB showed no obstruction, but significant stool burden throughout the colon. CBC and CMP were normal except AST (274), ALT (281). ESR (55) and CRP (6.4). Coags were added-on and normal.
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.
When I was reading the case, I was waiting for the skin exam to reveal lower torso and/or LE petechial/purpuric lesions c/w HSP. HSP is the only thing that I can quickly come up with to explain the intermittant colicky abdominal pain and GU symptoms — intermittant small bowel intussusception and vasculitis of testicle/epididymus. Alas, my thoughts led me astray…
Crohn’s disease can present with isolated scrotal pain or swelling. Don’t understand the pathophysiology but I’ve seen it twice. This would certainly explain inflammatory markers. Can’t quite explain the tramsaminitis unless it’s unrelated like in NASH etc. I can’t imagine this is anything infectious without fevers or diarrhea.
Hsp causes scrotal swelling but not pain to my knowledge.
Leukemia can also do this but usually with recurrence not initial presentation and often has swelling.
When things are weird, getting a good travel history wouldn’t hurt. Every once and a while you’ll get a case of schistosomiasis ;). But I think that causes epididymis with swelling and not isolated pain but those little guys are sneaky!
They use MR enterograohy now to replace the old UGI WITH SBFT, so this would be my next test to evaluate for crohns strictures or liver disease. It can be done outpatient.
Persistent testicular pain in this patient – who has a persistenly normal exam, and a sequence of sonograms and radiographs that are normal – really doesn’t seem like it’s attributable to the usual suspects, e.g. torsion, epidiymitis, trauma, infectious/inflammatory orchitis. Time to think of other stuff.
Referred pain from some distant problem is worth thinking about, like an incomplete inguinal hernia squishing the proximal spermatic cord, making it hurt. No specific mention of a hunt for a hernia here. Constipation probably wouldn’t do this, but sometimes a retained stool burden is the result of something else, like a lower abdominal mass. Sono and MR enterography should have found this, but . . .
You can’t ignore the inflammatory markers here. Time to think of a collagen vascular disease, early and still occult. Google quickly provides references to case studies of polyarteritis, Wegener’s, other vasculitides that have testicular pain associated – all older folks, but gets your though process rolling. Crohn’s and UC need to be thought of here – maybe the pain is intestinal, and “referred,” or somehow or another felt by the kid as being in the testicle. I voted to admit; the workup could certainly be done as an outpatient, but there’s been a several week process already, getting nowhere, so time to consolidate things – more easily done in hospital.
There are such things as stones that form in the various tubes and tubules in the spermatic duct system. Of course, sono would probably show these, but there was a case of this recently at the EMTC where it seemed that Radiology and Urology disagreed about the significance of such stones – they were either harbingers of something terrible, or were normal variant, not to worry. Anyway, when I talked to a Urologist offline later, I got the impression that the “normal variant” concept was more accepted, to the point that sometimes they go unreported on sonography. So maybe just recheck with radiology.
OK folks. My initial (grievances) thoughts are that it is such a bummer to come into a case that has already been worked up by numerous caregivers and at this point, when all the diagnostics have been done(admission of fallibility).
And, on top of coming in late, Dewesh and Dave have (stolen) informed you of most of the glory points, and Michael has added other great suggestions so I will attempt to summarize here:
Day 1, ED Visit 1: 8 year old male with lower abdominal and scrotal pain.
US testicles “unremarkable”
CT Abd/Pelvis (UGH) normal
Day 4, ED visit 2:
CBC,CMP, Ua, AXR “OK”
ESR, CRP elevated
RLQ ultrasound: appendix not visualized.
MRI Enterography: NORMAL except trace free fluid.
Admitted for pain control:
Repeat scrotal US: R epididymitis.
TMX-SMZ initiated. Discharged.
Day 7, ED visit 3: Continued pain.
Normal VS.
Normal exam. Really normal.
Repeat scrotal US: no evidence of epididymitis
AXR: “significant” Colonic stool burden
CBC and CMP normal except AST/ALT.
ESR and CRP still elevated.
Normal coagulation studies.
Normal exam. No fever.
Significant stool burden.
Back to the drawing board: Differential
Appendicitis
Testicular torsion/Intermittent torsion
Intussusception
Trauma
Epididymitis from a variety of reasons (sterile/infectious/not likely to be STI)
Orchitis/ Orchalgia (I once spoke with a urologist about a teen I had seen who had several visits for testicular pain, all studies were normal, and he attributed the pain to “orchalgia” which he said could take some “time” to resolve.)
HSP (good thought, no rash)
Internal hernia (he would be sicker)
Vasculitis (he would be sicker especially after one week, other “Adult” diagnoses would include things like vascular dissections and what not but he appears too well for that.)
Bowel infarction from malrotation/ embolic phenomena (he would definitely look sick)
IBD (normal MRI enterography done 3 days ago really doesn’t make me think Crohns is super likely, plus might have seen bowel wall something on the first CT)
Constipation (the SCOURGE of the ED visit for abdominal pain) In fairness, with the epidemic of constipation now presenting to EDs everywhere at all times of the day/night, demanding at least a $3K visit for the minimum number of r/o appy/torsion tests (I would hate to see the bill for these visits) how bad can the pain from constipation be?
Bad.
Constipation can cause urinary retention too.
Think think think.
Renal colic (pain can refer to the testicle and be missed on contrast CT, non obstructing stones may be radiolucent and also not cause hydronephrosis)
As for elevated transaminases, I believe Bactrim does cause that.
So as for the elevated CRP and ESR, I also don’t know whether there was tick exposure or whether this pain is dermatomal at all, as Lyme can present in very odd ways.
Back to the patient:
He appears well and there does not seem to be imminent danger to testicle nor any concern for abdominal catastrophe.
I would suggest an enema, urologic phone consultation for his orchalgia, and further work up for Lyme. An outpatient MRI could re-look at the appendix. I believe he could be discharged home safely unless having repeated episodes of pain. Narcotics are not going to help, so NSAIDs may be preferable.