563274
research-article2014
CPJXXX10.1177/0009922814563274Clinical PediatricsKannikeswaran et al
Brief Report Clinical Pediatrics 2015, Vol. 54(11) 1113–1116 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814563274 cpj.sagepub.com
A Kick in the Groin
Nirupama Kannikeswaran, MBBS1, Ami Shah, MBBS1, Utkarsh Fichadia, MBBS2, and Rajan Arora, MBBS1 Case A 16-year-old adolescent male presented to our emergency department (ED) with the chief complaint of left testicular pain. He was accidentally kicked in his left groin 1 hour prior to presentation by his classmate’s tennis shoe. The pain was described as sharp, 10/10 with no radiation. He noted immediate swelling of the left scrotum but denied any bruising or skin breakdown. He felt nauseous at the time of impact but did not have any episodes of vomiting. He had voided after the incident and denied any dysuria or hematuria. He is sexually active with 1 partner and the last sexual intercourse was 1 month prior to presentation to the ED. He had noted a clear penile discharge 2 weeks prior to this ED visit for which he did not seek any treatment. The penile discharge cleared spontaneously after a few days according to him. He denied any history of fever, abdominal or back pain. His past medical history was unremarkable. He denied history of any previous sexually transmitted diseases. On physical examination, vital signs were as follows: temperature 36.8°C, heart rate of 76 beats/min, respiratory rate of 22 breaths/min, and blood pressure of 163/91 mm Hg secondary to 10/10 pain. Examination of genitalia showed Tanner stage 5 male genitalia, penile synechiae on the right dorsum, no urethral discharge, no swelling of penis. The left side scrotal skin was swollen, indurated without any bruising, erythema, or warmth. The left testis had normal vertical lie but was swollen, hard, and indurated. Cremasteric reflex was present on both sides. The right testis was completely normal. The rest of the physical examination was within normal limits. The patient received a dose of morphine for pain. Ultrasound of testes with duplex scan revealed an enlarged left testis with coarse texture with absent flow consistent with left testicular torsion (Figure 1). There were also bilateral hydroceles noted. Urology was consulted. The patient underwent emergent scrotal exploration with detorsion of the left testis, fixation of bilateral testes, and excision of penile synechiae.
the spermatic cord. The testes are a pair of organ enclosed from the outside to inside by scrotal skin, dartos muscle, tunica vaginalis, and tunica albuginea. An adult testis has a volume of 20 to 25 mL each with the left testis lying slightly lower than the right one. The epididymis lies posterior to the testis extending as vas deferens in the spermatic cord. The spermatic cord is composed of structures that pass to and from the testes and contain the vas deferens, testicular artery and vein, lymph vessels, nerves, and remnants of processus vaginalis (Figure 2). Important testicular appendages include appendix testis and appendix epididymis, which are embryologic remnants of paramesonephric (mullerian) and mesonephric (wolffian) duct, respectively. The appendix testis lies on the superior pole of testes whereas the appendix epididymis lies on the head of epididymis. A testicular examination includes the examination of inguinal region, scrotum, testicles, and the penis. This can be performed in the standing or supine position. The inguinal area is examined for any bruising or swelling and the spermatic cord should be palpated for any swelling or tenderness. An external exam of the scrotal skin should be performed for any bruising or laceration and both the testicles palpated for any masses. Normal testis is palpated as a smooth ovoid structure within the scrotal sac. Clinical examination of the scrotum and testes can be difficult following blunt trauma secondary to swelling and associated pain. It is prudent to examine the normal side first and compare it with the other side in case of ipsilateral trauma. If scrotal swelling is noted, a transillumination test is performed to differentiate masses from clear fluid filled cysts. The cremestric reflex should be checked bilaterally. The penis is inspected for size, appearance, presence or absence of prepuce, and the site of urethral opening. Any bleeding or discharge from the urethral meatus should be noted.
1
Children’s Hospital of Michigan, Detroit, MI, USA Mary Bridge Children’s Hospital, Tacoma, WA, USA
2
Discussion The scrotum is an expansion of the perineum and contains the testes, epidydimis, and the initial portion of
Corresponding Author: Nirupama Kannikeswaran, Children’s Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI 48201, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at UNIV NEBRASKA LIBRARIES on September 10, 2015
1114
Clinical Pediatrics 54(11)
Figure 1. Ultrasound of testes showing normal flow to right testis and absent flow to left testis.
Scrotal trauma can be either blunt (secondary to falls, kicks, motor vehicle collisions), penetrating (stab wounds, gunshot wounds, animal or human bites, selfemasculation injuries), or degloving injuries.1 Sporting activities and motor vehicle accidents are the most common causes of blunt trauma to the scrotum in children.2 Blunt trauma can cause benign injuries such as scrotal or testicular contusion, hematocoele, or injuries with significant morbidity such as testicular torsion, dislocation, avulsion, fracture, or rupture. Scrotal/testicular contusion or hematocoele can cause pain, swelling, and bruising of the area. Minor scrotal or testicular contusion and scrotal hematocele can be treated conservatively with warm compresses and scrotal elevation. Urology consultation and surgical exploration are recommended in patients with severe pain and/or expanding swelling secondary to ongoing bleeding and for scrotal hematoceles >5 cm in size. Large hematoceles can impede testicular blood flow secondary to pressure and mimic testicular torsion. The incidence of posttraumatic testicular torsion has been reported to be between 4% and 8% in studies.3,4 Posttraumatic torsion is usually intravaginal in nature.5 The most common abnormality is a bell-clapper deformity wherein tunica vaginalis completely encircles the testis and is present in approximately 12% of the male population. Cremasteric muscle spasm in the presence of high investment of the tunica vaginalis is believed to cause a rotational effect on a freely mobile testis leading to posttraumatic torsion.1 The initial vascular insult is
venous congestion followed by swelling and eventual compromise to the arterial flow of testis. The usual mode of presentation is acute, severe unilateral testicular pain and swelling. There is associated nausea and emesis. On examination, the affected side is swollen, red, and extremely tender. Boettcher et al6 reported that 100% of children with ≥2 of the following symptoms and signs had testicular torsion: pain for 80%.10 Testicular dislocation is very rare especially in children after blunt trauma. The mechanism of injury involves a direct force that propels the testis out of the scrotum after rupture of external, cremasteric, and internal fasciae of the spermatic cord. The most location of displacement is in the superficial inguinal pouch. Testicular dislocation can be diagnosed solely on physical exam. There is an empty scrotal sac and a palpable swelling commonly in the inguinal area. Ultrasound can aid in the diagnosis of
Downloaded from cpj.sagepub.com at UNIV NEBRASKA LIBRARIES on September 10, 2015
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Clinical Pediatrics 54(11)
the location and viability of the dislocated testis. Closed manual reduction can be attempted but has been reported to be successful in only 15% of patients. Surgical intervention is usually required in most cases. Traumatic epididymitis is an uncommon injury and usually seen with testicular injury. This presents as testicular pain, swelling and may be associated with lower abdominal pain and urinary symptoms. A urinalysis and ultrasound can guide in the diagnosis of this condition. This condition is mostly managed conservatively with scrotal elevation and nonsteroidal anti-inflammatory drugs. Penetrating and degloving injuries to the scrotum or the testis usually require surgical exploration. Superficial laceration can be sutured in the emergency department using 4-0 or 5-0 fast absorbing gut. Laceration is considered superficial if the dartos layer is intact. Urological consultation is recommended in case of penetrating injuries.
Summary Although scrotal trauma is rare in children it can be a significant cause of morbidity. A good physical examination along with ultrasound can assist in accurate diagnosis and management. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Chinegwundoh FI. The post-traumatic painful testis. Postgrad Med J. 1996;72:251-252. 2. Bhatt S, Dogra VS. Role of US in testicular and scrotal trauma. Radiographics. 2008;28:1617-1629. 3. Elsaharty S, Pranikoff K, Magoss IV, Sufrin G. Traumatic torsion of the testis. J Urol. 1984;132: 1155-1556. 4. Seng YJ, Moissinac K. Trauma induced testicular torsion: a reminder for the unwary. J Accid Emerg Med. 2000;17:381-382. doi:10.1136/emj.17.5.381. 5. Cos LR, Rabinowitz R. Trauma-induced testicular torsion in children. J Trauma. 1982;22:244-246. 6. Boettcher M, Bergholz R, Krebs TF, Wenke K, Aronson DC. Clinical predictors of testicular torsion in children. Urology. 2012;79:670-674. 7. Lam WW, Yap TL, Jacobsen AS, Teo HJ. Colour Doppler ultrasonography replacing surgical exploration for acute scrotum myth or reality? Pediatr Radiol. 2005;35: 597-600. 8. Visser AJ, Heyns CF. Testicular function after torsion of the spermatic cord. BJU Int. 2003;92:200-203. 9. Cornel EB, Karthaus HF. Manual derotation of the twisted spermatic cord. BJU Int. 1999;83:672-674. 10. Herrera F, Coimbra R. Blunt pelvic trauma resulting in unilateral ruptured testicle: a case report and review of the literature. Internet J Urol. 2008;6:3852.
Downloaded from cpj.sagepub.com at UNIV NEBRASKA LIBRARIES on September 10, 2015
research-article2014
CPJXXX10.1177/0009922814563274Clinical PediatricsKannikeswaran et al
Brief Report Clinical Pediatrics 2015, Vol. 54(11) 1113–1116 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814563274 cpj.sagepub.com
A Kick in the Groin
Nirupama Kannikeswaran, MBBS1, Ami Shah, MBBS1, Utkarsh Fichadia, MBBS2, and Rajan Arora, MBBS1 Case A 16-year-old adolescent male presented to our emergency department (ED) with the chief complaint of left testicular pain. He was accidentally kicked in his left groin 1 hour prior to presentation by his classmate’s tennis shoe. The pain was described as sharp, 10/10 with no radiation. He noted immediate swelling of the left scrotum but denied any bruising or skin breakdown. He felt nauseous at the time of impact but did not have any episodes of vomiting. He had voided after the incident and denied any dysuria or hematuria. He is sexually active with 1 partner and the last sexual intercourse was 1 month prior to presentation to the ED. He had noted a clear penile discharge 2 weeks prior to this ED visit for which he did not seek any treatment. The penile discharge cleared spontaneously after a few days according to him. He denied any history of fever, abdominal or back pain. His past medical history was unremarkable. He denied history of any previous sexually transmitted diseases. On physical examination, vital signs were as follows: temperature 36.8°C, heart rate of 76 beats/min, respiratory rate of 22 breaths/min, and blood pressure of 163/91 mm Hg secondary to 10/10 pain. Examination of genitalia showed Tanner stage 5 male genitalia, penile synechiae on the right dorsum, no urethral discharge, no swelling of penis. The left side scrotal skin was swollen, indurated without any bruising, erythema, or warmth. The left testis had normal vertical lie but was swollen, hard, and indurated. Cremasteric reflex was present on both sides. The right testis was completely normal. The rest of the physical examination was within normal limits. The patient received a dose of morphine for pain. Ultrasound of testes with duplex scan revealed an enlarged left testis with coarse texture with absent flow consistent with left testicular torsion (Figure 1). There were also bilateral hydroceles noted. Urology was consulted. The patient underwent emergent scrotal exploration with detorsion of the left testis, fixation of bilateral testes, and excision of penile synechiae.
the spermatic cord. The testes are a pair of organ enclosed from the outside to inside by scrotal skin, dartos muscle, tunica vaginalis, and tunica albuginea. An adult testis has a volume of 20 to 25 mL each with the left testis lying slightly lower than the right one. The epididymis lies posterior to the testis extending as vas deferens in the spermatic cord. The spermatic cord is composed of structures that pass to and from the testes and contain the vas deferens, testicular artery and vein, lymph vessels, nerves, and remnants of processus vaginalis (Figure 2). Important testicular appendages include appendix testis and appendix epididymis, which are embryologic remnants of paramesonephric (mullerian) and mesonephric (wolffian) duct, respectively. The appendix testis lies on the superior pole of testes whereas the appendix epididymis lies on the head of epididymis. A testicular examination includes the examination of inguinal region, scrotum, testicles, and the penis. This can be performed in the standing or supine position. The inguinal area is examined for any bruising or swelling and the spermatic cord should be palpated for any swelling or tenderness. An external exam of the scrotal skin should be performed for any bruising or laceration and both the testicles palpated for any masses. Normal testis is palpated as a smooth ovoid structure within the scrotal sac. Clinical examination of the scrotum and testes can be difficult following blunt trauma secondary to swelling and associated pain. It is prudent to examine the normal side first and compare it with the other side in case of ipsilateral trauma. If scrotal swelling is noted, a transillumination test is performed to differentiate masses from clear fluid filled cysts. The cremestric reflex should be checked bilaterally. The penis is inspected for size, appearance, presence or absence of prepuce, and the site of urethral opening. Any bleeding or discharge from the urethral meatus should be noted.
1
Children’s Hospital of Michigan, Detroit, MI, USA Mary Bridge Children’s Hospital, Tacoma, WA, USA
2
Discussion The scrotum is an expansion of the perineum and contains the testes, epidydimis, and the initial portion of
Corresponding Author: Nirupama Kannikeswaran, Children’s Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI 48201, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at UNIV NEBRASKA LIBRARIES on September 10, 2015
1114
Clinical Pediatrics 54(11)
Figure 1. Ultrasound of testes showing normal flow to right testis and absent flow to left testis.
Scrotal trauma can be either blunt (secondary to falls, kicks, motor vehicle collisions), penetrating (stab wounds, gunshot wounds, animal or human bites, selfemasculation injuries), or degloving injuries.1 Sporting activities and motor vehicle accidents are the most common causes of blunt trauma to the scrotum in children.2 Blunt trauma can cause benign injuries such as scrotal or testicular contusion, hematocoele, or injuries with significant morbidity such as testicular torsion, dislocation, avulsion, fracture, or rupture. Scrotal/testicular contusion or hematocoele can cause pain, swelling, and bruising of the area. Minor scrotal or testicular contusion and scrotal hematocele can be treated conservatively with warm compresses and scrotal elevation. Urology consultation and surgical exploration are recommended in patients with severe pain and/or expanding swelling secondary to ongoing bleeding and for scrotal hematoceles >5 cm in size. Large hematoceles can impede testicular blood flow secondary to pressure and mimic testicular torsion. The incidence of posttraumatic testicular torsion has been reported to be between 4% and 8% in studies.3,4 Posttraumatic torsion is usually intravaginal in nature.5 The most common abnormality is a bell-clapper deformity wherein tunica vaginalis completely encircles the testis and is present in approximately 12% of the male population. Cremasteric muscle spasm in the presence of high investment of the tunica vaginalis is believed to cause a rotational effect on a freely mobile testis leading to posttraumatic torsion.1 The initial vascular insult is
venous congestion followed by swelling and eventual compromise to the arterial flow of testis. The usual mode of presentation is acute, severe unilateral testicular pain and swelling. There is associated nausea and emesis. On examination, the affected side is swollen, red, and extremely tender. Boettcher et al6 reported that 100% of children with ≥2 of the following symptoms and signs had testicular torsion: pain for 80%.10 Testicular dislocation is very rare especially in children after blunt trauma. The mechanism of injury involves a direct force that propels the testis out of the scrotum after rupture of external, cremasteric, and internal fasciae of the spermatic cord. The most location of displacement is in the superficial inguinal pouch. Testicular dislocation can be diagnosed solely on physical exam. There is an empty scrotal sac and a palpable swelling commonly in the inguinal area. Ultrasound can aid in the diagnosis of
Downloaded from cpj.sagepub.com at UNIV NEBRASKA LIBRARIES on September 10, 2015
1116
Clinical Pediatrics 54(11)
the location and viability of the dislocated testis. Closed manual reduction can be attempted but has been reported to be successful in only 15% of patients. Surgical intervention is usually required in most cases. Traumatic epididymitis is an uncommon injury and usually seen with testicular injury. This presents as testicular pain, swelling and may be associated with lower abdominal pain and urinary symptoms. A urinalysis and ultrasound can guide in the diagnosis of this condition. This condition is mostly managed conservatively with scrotal elevation and nonsteroidal anti-inflammatory drugs. Penetrating and degloving injuries to the scrotum or the testis usually require surgical exploration. Superficial laceration can be sutured in the emergency department using 4-0 or 5-0 fast absorbing gut. Laceration is considered superficial if the dartos layer is intact. Urological consultation is recommended in case of penetrating injuries.
Summary Although scrotal trauma is rare in children it can be a significant cause of morbidity. A good physical examination along with ultrasound can assist in accurate diagnosis and management. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Chinegwundoh FI. The post-traumatic painful testis. Postgrad Med J. 1996;72:251-252. 2. Bhatt S, Dogra VS. Role of US in testicular and scrotal trauma. Radiographics. 2008;28:1617-1629. 3. Elsaharty S, Pranikoff K, Magoss IV, Sufrin G. Traumatic torsion of the testis. J Urol. 1984;132: 1155-1556. 4. Seng YJ, Moissinac K. Trauma induced testicular torsion: a reminder for the unwary. J Accid Emerg Med. 2000;17:381-382. doi:10.1136/emj.17.5.381. 5. Cos LR, Rabinowitz R. Trauma-induced testicular torsion in children. J Trauma. 1982;22:244-246. 6. Boettcher M, Bergholz R, Krebs TF, Wenke K, Aronson DC. Clinical predictors of testicular torsion in children. Urology. 2012;79:670-674. 7. Lam WW, Yap TL, Jacobsen AS, Teo HJ. Colour Doppler ultrasonography replacing surgical exploration for acute scrotum myth or reality? Pediatr Radiol. 2005;35: 597-600. 8. Visser AJ, Heyns CF. Testicular function after torsion of the spermatic cord. BJU Int. 2003;92:200-203. 9. Cornel EB, Karthaus HF. Manual derotation of the twisted spermatic cord. BJU Int. 1999;83:672-674. 10. Herrera F, Coimbra R. Blunt pelvic trauma resulting in unilateral ruptured testicle: a case report and review of the literature. Internet J Urol. 2008;6:3852.
Downloaded from cpj.sagepub.com at UNIV NEBRASKA LIBRARIES on September 10, 2015
