Morning Report

FEBRUARY 1, 2012 DAVID LEVY

HPI: 16 year-old male with right groin pain. Pain started 4 days ago but has worsened over past 2 days and is present daily. Feels like pain is worst lateral to right of pubic symphysis, on "tube" connecting to right testicle, and minimally on right testicle. Not worse with any particular activity. Minimal redness, no swelling. No history of trauma. Urination normal without dysuria or hematuria. Intermittent tactile fevers for past 3 days. No back pain. No fevers. No penile discharge. PMH: No hospitalizations. No surgeries. ROS: No recent weight gain or weight loss. No headaches. No blurry vision. Stool pattern normal without constipation or diarrhea. Otherwise normal. Meds: Ibuprofen twice since pain started. Allergies: None Imm: Up to date. Has received flu vaccine this year. FHx: No history of genitourinary disorders. SHx: In 10th grade. Never sexually active. No tobacco, alcohol, or recreational drug use. No recent travel.

PE VS: Wt 64.5kg (56%), Ht 178cm (67%) T 97.5, HR 72, RR 18, BP 104/58, SO2 96% on RA Gen: Awake, alert, pleasant on exam. HEENT: NC/AT. Conjunctiva clera, sclera anicteric. Ear canals clear, TMs gray with normal landmarks bilaterally. Nares patent, no nasal discharge. MMM, tonsils without erythema or exudate. Neck: Supple, no thyromegaly. Resp: Normal WOB with good air entry. CTA bilaterally. CV: Regular rate and rhythm, normal S1, S2. No murmur. Pedal pulses 2+. Cap refill 2 seconds. Abd: Soft, non-tender, non-distended. Bowel sounds positive. No hepatosplenomegaly. GU: Circumcised. Tanner 4 hair and testicular volume with enlarged scrotum. No erythema. Minimal tenderness on palpation of superior aspect of right scrotum. Prehn sign equivocal. No discharge. No CVA tenderness. Extr: Warm, well-perfused. No cyanosis. No edema. Neuro: CN 2-12 grossly intact. Strength 5/5 for UE and LE bilaterally. Patellar reflex 2+. Cremaster reflex intact. No apparent deficitis.

Differential?

Lab: UA: SpGr <1.05, nitrite neg, leuk est neg, glucose neg, protein neg, RBC 0, WBC 0, bacteria neg Imaging:

Varicoceles
Etiology: Dilated and tortuous veins in the pampiniform plexus around the spermatic cord Primary: venous valvular incompetence due to anatomic alterations in veins of internal spermatic plexus Secondary: Due to other cause, most frequently renal or retroperitoneal mass Exam: Patient should be supine and standing to distinguish from idiopathic and secondary causes Secondary does not get much smaller with position change Grading: I: Small- palpable only with Valsalva maneuver II: Moderate- Palpable upon standing, not visible on inspection III: Large- visible on gross inspection Of note: Much more common on left (85-95%) because left spermatic vein enters left renal vein at 90 degree angle, whereas right spermatic vein drains at a more obtuse angle Other testing Hormonal studies: FSH, LH after GnRH stimulation can be useful to detect early testicular damage, although wide range of normal Seminal fluid analysis: can be requested when pt has reached adult testicular volume (15mL) ; should be repeated in 6-8 weeks There might be a few problems with this

Varicoceles
When to image: Evaluate for causes of IVC obstruction (thrombus, abdominal mass) If persists in supine position Acute onset Right sided Management Usually observed Consider referral for possible surgery when Discrepancy between affected testicular volume and unaffected testicle (at least 1020%) Associated with decreased sperm count Symptom relief Bilateral varicoceles If abnormal semen analysis Repair might improve semen in adolescents Unilateral testis Hx of surgery for cryptorchidism

References Korets R, Woldu SL, Nees SN, Spencer BA, Glassberg KI. Testicular symmetry and adolescent varicocele--does it need followup Journal of Urology 2011. 186: 1614-8. De Sanctis V, Marsella M. Unilateral asymptomatic testis enlargement in children and adolescents. Georgian Med News 2011. 193:25-29. Glassberg KI, Badalato GM, Poon SA, Mercado MA, Raimondi PM, Gasalberti A. Evaluation and management of the persistent/recurrent varicocele. Urology 2011. 77: 1194-8. Glassberg KI, Korets R. Update on the management of adolescent varicocele. F1000 Med Rep 2010. 12:25. Poon SA, Gjertson CK, Mercado MA, Raimondi PM, Kuzakowski KA, Glassberg KI. Testicular asymmetry and adolescent varicoceles managed expectantly. J Urol 2010. 183: 731-4. Kumanov P, Robeva RN, Tomova A. Adolescent varicocele: who is at risk? Pediatrics 2008: 121:853-7. Lavan JS, Haans LC, Mali WP. Effects of varicocele treatment in adolescents: a randomized study. Fertil Steril 1992. 58: 756. Kaplan GW. Scrotal swelling in children. Ped in Review 2000. 21:311-4. Robison SP, Hampton LJ, Koo HP. Treatment strategy for the adolescent varicocele. Urol Clin North Am 2010. 37: 269-78.

Images from http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/19121.jpg http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/15855.jpg http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/19472.jpg http://www.mayoclinic.com/images/image_popup/r7_hydrocele.jpg http://en.wikipedia.org/wiki/File:Gray1148.png http://us.123rf.com/400wm/65/255/mantonino/mantonino0804/mantonino08040 0183/2863392-shocked-young-boy-with-wide-eyes-over-black-background.jpg