Urology Case Presentation – Scrotal Click to edit Master subtitle style Mass

An Emergency Case!

Year 4 Medical Student | Hakimah Khani Binti Suhaimi| Nor Aini Binti Mohamad

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Chief Complaint

Mr P, 17 year-old male, presented to ED with the chief complaint of

painful scrotal mass 3 hours prior to admission.

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The Scrotal Mass: Ensuring a Correct Diagnosis

The Canadian Journal of CME / February 2007

Fur ther Histor y
Painful scrotal swelling

3 hours prior to admission Sudden onset Constant Severe Sharp Right hemiscrotum Radiated to right suprapubic region Gradually became swollen One bout of vomiting

Several prior episodes have occurred in the past, but have always only lasted a few minutes.

No history of trauma

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No urinary symptoms

Approaching Scrotal Mass Key Qs
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Age of patient?

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Is pain present and what has been its duration? Timing of pain onset – gradual vs. sudden? Have there been similar episodes in the past? Is there a history of STD’s, urinary tract infections, or recent urethral discharge?

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Is there a history of recent scrotal or perineal trauma? Have there been systemic symptoms such as fever, emesis, anorexia or weight loss and lymphadenopathy?

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Has there been fluctuation in the size of the scrotal mass/swelling?

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Has the patient experienced any voiding symptoms?

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Physical Examination
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On Examination . . .
On examination, the right testis appears to have assumed a horizontal lie and is considerably higher in the scrotum. The cremasteric reflex is absent. Both the testis and epididymis are tender. The cord can only be palpated high in the scrotum.
Consistency?

Transillumination is negative.

Phren’s sign?

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Summar y
Mr P, 17, presented with 3 hours history of sudden, constant, severe pain in right hemiscrotum radiated to suprapubic region assoc. with one episode of vomiting. No history of trauma and no urinary symptoms. Had similar episodes of pain with shorter

duration.
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Possible Diagnoses?
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Testicular torsion Testicular appendiceal torsion Epididymo-orchitis Orchitis Acute Hematocele Incarcerated inguinal hernia Varicocele

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Investigations
Investigations done on this patient:

Urinalysis reveals a few blood cells and minimal pyuria.

Waiting for further confirmation by ultrasound is ill advised.

Upon urgent referral for urologic assessment, Mr P is immediately taken to the OR for exploration.

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Investigations

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Treatment

Seven hours after the onset of pain, the testis is found to be but ischemic ultimately and dusky in its appearance recovers

viability with detorsion.

It is orchiopexed as is the contralateral testicle to prevent further torsion.

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Discussion
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Epidemiology
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Testicular torsion has a bimodal distribution
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extra-vaginal torsion affecting neonates intra-vaginal torsion affecting males of any age but most commonly adolescent boys.

extravaginal; (B) intravaginal.
(A)

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In males <25 years of age, the annual incidence of torsion is 1 in 4000 in the US
BMJ last updated: Sept

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Risk factors
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Inversion – transverse testis or upside-down testis

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High investment of tunica vaginalis – clapper in a bell testis

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Separation of epididymis from body of testis

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Pathophysiology
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The twisting of the testicle causes
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venous occlusion  engorgement arterial occlusion  ischemia and infarction The degree of torsion the testicle endures may play a role in the viability of the testicle over time.

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If the testes remain torsed >10-12 hours  ischaemia and irreversible testicle damage are likely After 12 hours, necrosis most likely has occurred.

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Diagnosis is Critical!

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Take-home Messages
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Sudden onset of severe scrotal pain demands urgent urological attention to rule out torsion or hemorrhagic tumour

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Clinical suspicion is crucial. Do not miss pertinent symptoms and signs

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If clinical suspicion for torsion is high, waiting for an ultrasound is not advisable

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Medic ogal!! le !

Click to edit Master subtitle style

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References
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The Scrotal Mass: Ensuring a Correct Diagnosis The Canadian Journal of CME / February 2007

http://www.stacommunications.com/journals/cme/2007/February%202007/0
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Bailey & Love’s Short Practice of Surgery 25th Edition Browse’s Introduction to The Symptoms and Signs of Surgical Disease

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Failure to Diagnose Testicular Torsion Clinical Practice: Risk Management / AFP July 2003

British Medical Journal (BMJ) / Sept 2011 4/24/12
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Thank you
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