Just another case of vomiting? By Dr Subramaniam

A 14 year old boy is brought in by his mother on Saturday at 9.00am because he woke her up at 6.00am vomiting clear liquid and complaining of lower abdominal pain. You start taking the history from the young man, but he seems uncomfortable with pain and prefers his mother speak to you. You order some ibuprofen while talking to the mother. She says he’s been well with no fevers. She says he has not been traveling, has been having regular home cooked meals and has been voiding without pain and stooling regularly with no change in bowel movements.

He has no medical or surgical history, not on any medication, is fully immunized and was fine yesterday. No one at home has this problem and all his regular school friends have been fine according to the boy.

You examine his HEENT, heart, lungs and abdomen and are surprised with how benign the exam actually is. Rovsings and are Obturator negative, and he tolerates the mashing of your hand on his belly and costovetebral angles. His skin is well perfused and he has a normal neurological and MSK exam.

1. What has the resident forgot to examine in this male child with lower abdominal pain?

Answer: His scrotum and testes! Always take a quick look at this vital male organ in any boy with abdominal pain or vomiting. Younger children may not be able to accurately describe their pain and older males may be too embarrassed to talk about the pain in their genitalia

2. The attending completes the exam and beckons you over to look at his finding. Click the answer below to see what the attending discovers.

3. Based on the exam, what are you most concerned about? After pain control, NPO, and IVF, what are your two next steps in management?

You consult urology emergently and arrange for an ultrasound testes with Doppler. When a child with testicular pain has many of the findings of testicular torsion (e.g high riding testis, lateral lie, skin color change, tender to palpation, absent Cremasteric reflex and negative Prehn’s sign) and you believe the pretest probability of torsion to be high then do not delay the urologist assessment by awaiting arrangement or results of the ultrasound. Get their service to assess the patient ASAP. Help facilitate a smooth OR transition by obtaining basic labs if they require it at your facility and make the patient NPO with IV fluids at maintenance.

Timing is key here as the urologist can surgically explore the area and if done within 6 hours of pain onset, 90% of testes are salvageable. After the first 12 hours, this drops to 20%. The procedure involved is called an orchiopexy and will be completed on both testes as a prophylactic measure to prevent a future episode of torsion.

4. The results say the testis has normal flow now, but there is a reactive hydrocele present around the left testes.

This is a tricky situation. Occasionally this can be due to torsion detorsion syndrome. When there is evidence of reactive hyperemia and hydrocele or visible swelling on examination, or you highly suspect torsion occurred during the episode of pain, the urologist should see the patient in the ED. Occasionally these patients may be admitted for observation or discharged with close follow up. They may require repeat ultrasounds or outpatient elective orchiopexy depending on the urologist recommendations.

5. Assume this was a 17 y/o sexually active male. What other differential should you think of based on the picture above?

Epididymo-orchitis secondary to either C. trachomatis (more common pathogen) or N. gonorrhea. This is now high on the differential. However an ultrasound should always be completed in any patient with testicular pain, especially if there are findings on the exam. This is because the most common misdiagnosis of testicular torsion is the physician assuming it is epididymitis and discharging the patient on antibiotics.

Testicular torsion ranks as one of the top 5 malpractice suits that pediatric physicians face.

Now assume that the examination actually revealed the sign above. How would you manage the patient?

This is most likely torsion of the appendix testis. Although it is clearly visible on the exam here, this is rare. Most children have acute onset pain that can be indistinguishable from that of true testicular torsion. As a result, most should have an ultrasound to document normal flow to the affected testis. Occasionally the ultrasound may be able to identify a focused hypoechoic area that represents the necrotic appendix testis.

This case hopefully introduced you to the signs and symptoms of the various testicular pathology that children and adolescents face, the use of ultrasound to evaluate the testis and when and why urology should be consulted.