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THE JOURNAL OF UROLOGV

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1998 by AM2RICAN UROLOGICAL ASSOCIATION, INC.

Pediatric Articles NEONATAL ADRENAL HEMORRHAGE PRESENTING AS SCROTAL HEMATOMA GEORGE P. GIACOIA

AND

JERE D. CRAVENS

From the Division of Neonatology, Department of Pediatrics, University of Oklahoma Medical College, Tulsa, Oklahoma

ABSTRACT

A neonate with hemorrhage of the right adrenal gland who presented with bilateral scrotal masses is described. The difficulty in establishing the diagnosis and ruling out testicular torsion is outlined. The differential diagnosis of scrotal swelling is listed. Adrenal hemorrhage can produce hemoperitoneum but this case is unique in that hemoperitoneum was not associated with signs of peripheral circulatory insufficiency and/or abdominal distension, and was manifested only by bilateral scrotal hematomas. The implication of these findings is emphasized. (J. Ural., 143: 567-568, 1990) Neonatal adrenal hemorrhage is a relatively common and well documented condition frequently associated with perinatal hypoxia. 1- 3 The clinical manifestations vary, the most common being an abdominal mass alone or associated with jaundice.'· 5 However, some infants are totally asymptomatic. We describe a patient with hemorrhage of the right adrenal gland who presented with a scrotal mass mistakenly diagnosed as torsion of the testes. CASE REPORT

A 4,260 gm. white male newborn was the 40-week gestational product of a 29-year-old woman whose pregnancy and vaginal delivery were normal. The Apgar scores were 4 and 7 at 1 and 5 minutes, respectively. No resuscitation, besides administration of oxygen, was needed. Pertinent findings at the initial physical examination were marked molding of the head and a small hydrocele in the right scrotum. At 30 hours after birth the skin of the right hemiscrotum was slightly edematous and purplish in color, and a distinct 2 cm. mass was noted. The mass did not transmit light. The left testicle was of normal size and consistency. Because of the clinical of testicular torsion, an ultrasound examination of the scrotal contents was done. Both testes were identified and no was noted. testicular torsion could not be ruled out. Testicular radionuclide angiography revealed At this time a bluish discoloration of the left hemiscroturn was noted. Because of was done. At operation bidiagnostic uncertainty lateral inguinal scrotal hematomas were found, more prominent on the right than on the left side. The hematomas were within the tunica vaginalis surrounding the testicles. Both testes were normal. On day 2 the hematocrit was 36.5% and hemoglobin was 12.9 gm./dL The coagulation studies, including prothrombin time, partial thromboplastin time, factor XIII and fibrinogen levels, were all normal. Computerized tomography (CT) of the abdomen identified a suprarenal hemorrhage that produced a depression of the superior portion of the kidney (see figure). No other abnormalities were noted. At 24 hours the urinary 3-methoxy-4-hydroxymandelic acid level was 0.2 mg. (normal Oto 10 mg./24 hours), homovanillic acid 0.1 mg. (normal less than 15 mg./24 hours) and catecholamines 4 mg. (normal O to 115 mg./24 hours). At 1 month Accepted for publication October 20, 1989.

CT scan of abdomen shows right adrenal hemorrhage (H)

abdominal radiography revealed typical triangular shaped right adrenal calcifications. DISCUSSION

The difficulty in differentiating torsion of the testes, epididymis and testicular appendages from other causes of scrotal swelling remains unabated despite great strides in imaging techniques. It is recommended to consider an acute scrotal incident with swelling and bluish discoloration as torsion of the testes until proved otherwise and to intervene nr,,n-nrmm to improve testicular salvage rates. The unreliability of medical history and physical examination to distinguish torsion from other scrotal disorders has been cited frequently in the literature. 6 Nuclear scans are considered the method of choice for the diagnosis of testicular torsion. In older children and adults the correlation between testicular torsion and decreased blood flow approaches 100%. 7 Unfortunately, experience in the newborn period is limited. In our patient a false positive interpretation illustrates the difficulty in ruling out testicular torsion. In addition to torsion, scrotal swelling in the newborn may be due to hydrocele, scrotal edema, inguinal hernia, hematocele, testicular tumor, orchitis, meconium peritonitis, testicular edema and traumatic hematoma. 8 - 10 Also, neonatal inguinoscrotal or scrotal hematoma has been linked to the use of plastic umbilical clamps. 11 In older children and adults, scrotal hematoma has been reported as a complication of invasive procedures, such as transfemoral cardiac catheterization 12 and renal biopsy. 13 Scrotal hematoma also can

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occur in association with hemoperitoneum whenever the processus vaginalis remains patent. The passage of blood down the inguinal canal and into the scrotum is manifested as scrotal ecchymosis, often combined with bluish discoloration of the overlying abdominal skin or groin. 14 Abdominal distension and signs of anemia or circulatory collapse almost always are present. Putnam reported a case of an unsuspected adrenal hemorrhage in a newborn who presented with a right scrotal mass, abdominal distension, vomiting and anemia. 15 In our case the lack of abdominal symptoms or signs of peripheral circulatory insufficiency and the prolonged interval before the appearance of a left scrotal hematoma indicate that the amount of blood in the peritoneum was relatively small. Therefore, intraperitoneal bleeding should be considered in the differential diagnosis when any neonate presents with scrotal swelling, even when shock, anemia and abdominal distension are absent or minimal. Knowledge of this unusual presentation suggests that when the diagnosis of torsion is in doubt CT of the abdomen or an abdominal sonogram may provide the necessary diagnostic clue. It should be stressed that more than 1 condition may coexist. A previous report of a newborn with hemoperitoneum secondary to a hepatic tear and concomitant torsion of a testicle illustrates this point. 16 The pathological anatomy of scrotal lesions can elude reasoned presumptive diagnosis. Mininberg and Dattwyler anticipated torsion of the spermatic cord in a newborn and found an ectopic adrenal tumor instead. 17 It cannot be overemphasized that consideration of different diagnostic possibilities should not delay prompt operative intervention when testicular torsion cannot be ruled out. REFERENCES 1. DeSa, D. J. and Nicholls, S.: Haemorrhagic necrosis of the adrenal gland in perinatal infants: a clinico-pathological study. J. Path., 106: 133, 1972. 2. Black, J. and Williams, D. I.: Natural history of adrenal haemorrhage in the newborn. Arch. Dis. Child., 48: 183, 1973. 3. Kuhn, J., Jewett, T. and Munschauer, R.: The clinical and radio-

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graphic features of massive neonatal adrenal hemorrhage. Radiology, 99: 647, 1971. Dickerman, J. D. and Tampas, J. P.: Adrenal hemorrhage in the newborn. The phenomenon of 'enclosed' hemorrhage as a cause of neonatal jaundice and later adrenal calcifications. Clin. Ped., 16: 314, 1977. Rose, J., Berdon, W. E., Sullivan, T. and Baker, D. H.: Prolonged jaundice as presenting sign of massive adrenal hemorrhage in newborn. Radiographic diagnosis by IVP with total-body opacification. Radiology, 98: 263, 1971. Haynes, B. E., Bessen, H. A. and Haynes, V. E.: The diagnosis of testicular torsion. J.A.M.A., 249: 2522, 1983. Stage, K. H., Schoenvogel, R. and Lewis, S.: Testicular scanning: clinical experience with 72 patients. J. Urol., 125: 334, 1981. Chiles, D. W. and Foster, R. S., Jr.: Torsion of the appendix testis in the newborn. Initial report of this disorder in a neonate. Amer. J. Dis. Child., 118: 652, 1969. Behrman, R. E. and Mangurten, H. H.: Birth injuries. In: NeonatalPerinatal Medicine Diseases of the Fetus and Infant, 2nd ed. Edited by R. E. Behrman, J.M. Driscoll, Jr. and A. E. Seeds. St. Louis: The C. V. Mosby Co., chapt. 18, pp. 146-170, 1977. Meares, E. M., Jr. and Kempson, R. L.: Fibrous histiocytoma of the scrotum in an infant. J. Urol., 110: 130, 1973. Rodriguez-Alarcon, J., Vargas, L. M. and Solaun, M. R.: Neonatal inguinoscrotal lesion produced by plastic umbilical clamp. J. Ped., 93: 1024, 1978. Borden, T. A., Rosen, R. T. and Schwarz, G. R.: Massive scrotal hematoma developing after transfemoral cardiac catheterization. Amer. Surg., 40: 193, 1974. Rathi, A. K., Gupta, S. N., Gupta, V. and Mehrotra, S. N.: An unusual complication of renal biopsy. Indian Ped., 18: 259, 1981. Amoury, R. A., Barth, G. W., Hall, R. T., Rhodes, P. G., Holder, T. M. and Ashcraft, K. W.: Scrotal ecchymosis: sign of intraperitoneal hemorrhage in the newborn. South. Med. J., 75: 1471, 1982. Putnam, M. H.: Neonatal adrenal hemorrhage presenting as a right scrotal mass. Letter to the Editor. J.A.M.A., 261: 2958, 1989. Heydenrych, J. J.: Haemoperitoneum and associated torsion of the testicle in the newborn. S. Afr. Med. J., 48: 2221, 1974. Mininberg, D. T. and Dattwyler, B.: Ectopic adrenal tumor presenting as torsion of the spermatic cord in a newborn infant. J. Urol., 109: 1037, 1973.

Neonatal adrenal hemorrhage presenting as scrotal hematoma.

A neonate with hemorrhage of the right adrenal gland who presented with bilateral scrotal masses is described. The difficulty in establishing the diag...
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