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PEDIATRIC EMERGENCY MEDICINE PRACTICE AN EVIDENCE-BASED APPROACH TO PEDIATRIC EMERGENCY MEDICINE ▲ EMPRACTICE.NET Urogenital Emergencies In Boys: An Evidence-Based Approach To Sensitive Issues A 12-year-old male reports that his left testicle has been hurting for the last 3 hours. He appears to be very uncomfortable and has vomited twice. He has no significant history of trauma, although he wrestles around with his younger brothers quite frequently. In another room, the anxious parents of a 1-year-old, uncircumcised boy report that over the last 2 days his penile foreskin has become red and swollen. He is afebrile, but a bit fussy. B Lance Brown, MD, MPH, FACEP, Chief, Division of Pediatric Emergency Medicine; Associate Professor of Emergency Medicine and Pediatrics; Loma Linda University Medical Center and Children’s Hospital, Loma Linda, CA. Editorial Board Jeffrey R. Avner, MD, FAAP, Professor of Clinical Pediatrics, Albert Einstein College of Medicine; Director, Pediatric Emergency Service, Children’s Hospital at Montefiore, Bronx, NY. Beverly Bauman, MD, FAAP, FACEP, Assistant Chief, Pediatric Emergency Services, Oregon Health & Sciences University, Portland, OR. T. Kent Denmark, MD, FAAP, FACEP, Residency Director, Pediatric Emergency Medicine; Assistant Professor, Departments of Emergency Medicine and Pediatrics; Loma Linda University Medical Center and Children’s Hospital, Loma Linda, CA. Michael J. Gerardi, MD, FAAP, FACEP, Clinical Assistant Professor, Medicine, University of Medicine and Dentistry of New Jersey; Director, Pediatric Emergency Medicine, Children’s Medical Center, Atlantic Health System; Department of Emergency Medicine, Morristown Memorial Hospital. Ran D. Goldman, MD, Associate Professor, Department of Pediatrics, University of Toronto; Division of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto. Martin I. Herman, MD, FAAP, FACEP, Associate Professor, Pediatrics, Division Critical Care and Emergency Services, UT Health Sciences, School of Medicine; Assistant Director Emergency Services, Lebonheur Children’s Medical Center, Memphis TN. Marilyn P. Hicks, MD, FACEP, Director, Pediatric Emergency Medicine Education, Department of Emergency Medicine, WakeMed, Raleigh, NC; Adjunct Assistant Professor, Department of Emergency Medicine, University of North Carolina, Chapel Hill, Chapel Hill, NC. Mark A. Hostetler, MD, MPH, Assistant Professor, Department of Pediatrics; Chief, Section of Emergency Medicine; Medical Volume 1, Number 4 Authors Floyd S. Ota, MD Fellow of Pediatric Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX. Robert A. Wiebe, MD Professor and Director, Division of Emergency Medicine, Department of Pediatrics, Sarah M. and Charles E. Seay Distinguished Chair in Pediatric Medicine, University of Texas Southwestern Medical Center, Dallas, TX. Peer Reviewers OYS frequently present to the ED with a wide variety of complaints about their external genitalia. These cases can be quite challenging. Given cultural sensitivities and general discomfort with talking about genitals, new parents may have difficulty discussing their questions or concerns with a physician. This may lead to a delay in seeking care. In some cases, families are simply unable to talk about genitals and use euphemisms to describe “down there.” Older, school-aged children may notice problems and be too embarrassed to bring the problem to the attention of their parents. Sexually active adolescents may want to conceal their sexual activity from their parents and avoid asking to see a doctor. All of these issues can lead to delays in care and miscommunication among boys, parents, teachers, and health care providers. Although many physical conditions associated with the penis and scrotal contents in boys are quite benign and require little more than reassurance, some of these conditions require emergency intervention. The emergency physician must not add further delays to those already inherent in patient presentation. If not addressed properly and expeditiously, these clinical problems may have serious sequelae involving future reproductive potential and sexual function. Social and litigious ramifications of a missed diagnosis require the emergency physician to be vigilant in the care of these patients. However, it can be difficult to determine which patients require simple reassurance and which require a more extensive workup. IdentifyEditor-in-Chief November 2004 Grace Kim, MD, FAAP Assistant Professor of Emergency Medicine and Pediatrics, Loma Linda University Medical Center and Children’s Hospital, Loma Linda, CA. Daniel M. Cohen, MD, FAAP, FACEP Medical Director, Urgent Care Associate Director, Emergency Medicine Children’s Hospital of Columbus, Associate Professor of Pediatrics, Ohio State University, Columbus, OH. CME Objectives Upon completing this article, you should be able to: 1. discuss the role of ultrasound in the diagnosis of testicular torsion; 2. describe the diagnostic approach to the boy with a swollen penis; 3. discuss the limitations of the physical examination in evaluating acute scrotal pain; and 4. list male genitourinary conditions that require prompt treatment to avoid serious sequelae. Date of original release: November 30, 2004. Date of most recent review: November 19, 2004. See “Physician CME Information” on back page. Director, Pediatric Emergency Department, The University of Chicago, Pritzker School of Medicine, Chicago, IL. Alson S. Inaba, MD, FAAP, PALS-NF, Pediatric Emergency Medicine Attending Physician, Kapiolani Medical Center for Women & Children; Associate Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine, Honolulu, HI; Pediatric Advanced Life Support National Faculty Representative, American Heart Association, Hawaii & Pacific Island Region. Andy Jagoda, MD, FACEP, Vice-Chair of Academic Affairs, Department of Emergency Medicine; Residency Program Director; Director, International Studies Program, Mount Sinai School of Medicine, New York, NY. Brent R. King, MD, FACEP, FAAP, FAAEM, Professor of Emergency Medicine and Pediatrics; Chairman, Department of Emergency Medicine, The University of Texas Houston Medical School, Houston, TX. Robert Luten, MD, Professor, Pediatrics and Emergency Medicine, University of Florida, Jacksonville, Jacksonville, FL. Ghazala Q. Sharieff, MD, FAAP, FACEP, FAAEM, Associate Clinical Professor, Children’s Hospital and Health Center/ University of California, San Diego; Director of Pediatric Emergency Medicine, California Emergency Physicians. Gary R. Strange, MD, MA, FACEP, Professor and Head, Department of Emergency Medicine, University of Illinois, Chicago, IL. COPYRIGHTED MATERIAL—DO NOT PHOTOCOPY OR DISTRIBUTE ELECTRONICALLY WITHOUT WRITTEN CONSENT OF EB PRACTICE, LLC ing those children who require immediate and definitive care is perhaps the most important role of the emergency physician in the care of these children. In this issue of Pediatric Emergency Medicine PRACTICE, we will examine the evidence pertaining to complaints involving the male genitalia. hormonally regulated and may be terminated at any point, resulting in an undescended testicle. Pillai et al noted that the location of an abnormally positioned testicle was; inguinal (63%), prescrotal (24%), ectopic (12%), and intraabdominal (8%).3 A capsule of fibrous tissue called the tunica albuginea surrounds each testicle. This is covered by the visceral and parietal layers of the tunica vaginalis, a sac formed from the process vaginalis, a bulge of peritoneum that extends into the inguinal canal during testicular decent. In their final resting place, the testes, epididymis, and distal spermatic cord lie with the posterior aspect of the epidydimis attached to the inner wall of the scrotum by a bare area not covered by peritoneum. The arterial supply to the scrotal sac arises from three sources: the testicular artery, the cremasteric artery, and the artery to the ductus deferens. Venous blood leaves the scrotum via the pampiniform plexus to drain into the testicular veins. Finally, these blood vessels, along with the nerves, lymphatic vessels, and ductus deferens, are housed by a structure of loose connective tissue called the spermatic cord. Testicular torsion occurs when the spermatic cord becomes twisted, obstructing venous and arterial blood flow to the testicle. Testicular torsion is divided into two categories; intra-vaginal torsion and extra-vaginal torsion. Extra-vaginal torsion is seen mainly at birth and within the first year of life, and occurs when the entire testes and tunica vaginalis twists on the spermatic cord in a vertical axis resulting from an incomplete fixation of the gubernaculum to the scrotal wall during testicular decent. Intra-vaginal torsion is more commonly found during adolescence and is often associated with the “bell-clapper anomaly.” In children who have the bell-clapper anomaly, the testes, epididymis, testicular artery, and spermatic cord can “twist” on its axis completely within the confines of the tunica vaginalis. This anomaly was found in 12% of patients upon general autopsy in one series.4 It is postulated that the bell-clapper anomaly may predispose a child to torsion; however, torsion of the testicle is seen in much less than 12% of the population. Thus, additional factors must be contributing to its occurrence, and an anatomic abnormality alone does not completely explain why testicular torsion occurs in some children and not others. Other contributing factors to testicular torsion noted in previous review articles are cold temperatures and scrotal trauma.5,6 Another group of authors found results to suggest a link between low ambient temperature and testicular torsion, postulating that low temperature may incite cremasteric muscle spasm.7 However, other investigators found no difference in the incidence during different temperate seasons, and a clear connection remains unproven.8,9 Testicular torsion is a recognized entity in the setting of acute scrotal trauma.10,11 Among one retrospective series of 138 children who presented with an acute scrotum, 5% of the patients demonstrated testicular torsion, and 10% of those with torsion of the appendix testis had a history of trauma.10 Critical Appraisal Of The Literature The Acute Scrotum The critical issue addressed by the literature on the acute scrotum is early recognition and treatment of testicular torsion and differentiating this entity from other, less emergent causes of testicular pain. The current literature is largely based on evidence from retrospective cohort studies and case reports. The most recent observational studies appear to be moving away from routine scrotal exploration when there is low suspicion of testicular torsion, to more conservative management with the addition of various imaging modalities. There are currently no randomized, prospective studies, nor are there any published guidelines from any national or international medical groups. Penile Complaints The current literature pertaining to problems dealing with penile swelling and pain is limited. The evidence is mostly based on small cohort studies and case reports that describe how the authors have managed the varied clinical problems “in their experience.” There are currently no randomized, prospective studies, nor are there any published guidelines from any national or international medical committees. There are, however, a few prospective studies pertaining to the medical treatment of phimosis that indicate the high efficacy of topical steroids for the resolution of this condition. The bulk of the literature pertaining to this topic has been observational. Epidemiology, Etiology, And Pathophysiology The Scrotum Of the causes of acute scrotal complaints, testicular torsion is the most serious, as testicular viability is dependent on prompt diagnosis and surgical treatment. Testicular torsion occurs at an annual incidence of 1 in 4000 males under the age of 25 years.1 There is a bimodal distribution with the first peak during infancy and a second, larger peak around puberty (13 years old).2 Knowledge of testicular anatomy and embryology is useful in understanding the causes of the acute painful scrotum. The testicles must descend from an intra-abdominal existence into the scrotum during fetal development. This process occurs in two distinct phases. The first phase initiates at around 6 weeks gestation, allowing the testes to migrate from within the abdominal cavity to the internal inguinal ring. The second phase begins around the 28th week of gestation, and the testes complete their descent into the scrotum. Most commonly, the left testicle will descend prior to the right. This process is thought to be Pediatric Emergency Medicine Practice 2 EBMedPractice.net •November 2004 The newborn foreskin cannot be retracted over the glans penis. This “physiologic phimosis” occurs as a natural adherent to the surface of the penis. Smegma, a collection consisting of glandular secretions and epithelial cell debris, forms between the prepuce and the glans penis. Sometimes the smegma can collect at the tip of the penis and easily be mistaken for pus. As time progresses the physiologic adherence of the foreskin resolves spontaneously due to intermittent erections and normal movement. Usually physiologic phimosis will resolve by the age of 3 to 5 years.12 In younger children retraction of the foreskin is not required for basic hygiene. Forced retraction of the foreskin can result in tearing, which may lead to scarring and true phimosis. By the time a boy reaches puberty the foreskin should be easily retracted and replaced over the glans. The genital area should be cleaned like any other area of the body. The Acute Scrotum The differential diagnosis for the acute scrotum in childhood is relatively short. (See Table 1.) The 3 most common causes of a scrotum that has become acutely swollen, painful, or both, are testicular torsion, torsion of the appendix testis, and epididymitis. Of these diagnoses, testicular torsion is the most important to identify, due to the timesensitive and invasive nature of the treatment. Multiple retrospective cohort studies of children who present with an acute scrotum have attempted to document the incidence of these common etiologies. The results are quite variable. However, testicular torsion was consistently reported in about 12-25% of all children presenting with an acute scrotum. (13-20) Other causes, such as a hydrocele, varicocele, idiopathic scrotal edema, Henoch-Schönlein purpura, Kawasaki’s disease, minor blunt testicular Table 1. The Differential Diagnosis Of The Acute Scrotum Diagnosis Symptoms Physical Exam Testicular torsion • • • • Acute onset of pain Nausea Vomiting Teenager or infant • • • • Testicular tenderness Absent cremasteric reflex Hide-riding testicle Bell-clapper anomaly Epididymitis • • • • • Gradual onset of pain Fever Recent viral infection Dysuria Late childhood • Swollen and tender spermatic cord Torsion of a testicular appendage • • • Gradual onset of pain No fever Middle to late childhood • • Tenderness often localized to superior pole of testicle Blue dot sign Testicular rupture • • Clear history of trauma Severe pain • • • Full scrotal sac Ecchymosis Irregular testicle Hydrocele • Nonpainful • • Transillumination May change with position Varicocele • • Heavy feeling to scrotum Teenager • “Bag of worms” Henoch-Schönlein Purpura • • • • Abdominal pain Scrotal pain Joint pain Hematuria • • Joint swelling Palpable purpura Kawasaki's Disease • • Prolonged fever (> 5 days) Irritability • • • • • • • Fever Non-purulent conjunctivitis Oral lesions Cervical lymphadenopathy Swollen/red extremities Cutaneous rash Urethral meatitis Idiopathic scrotal edema • Unclear onset • Swollen scrotum Testicular tumor Signs of early puberty • • • Gynecomastia Precocious puberty Hard, nontender scrotal mass Systemic vasculitis November September2004 2003••EBMedPractice.net www.empractice.net 3 Pediatric Emergency Medicine Practice COPYRIGHTED MATERIAL—DO NOT PHOTOCOPY OR DISTRIBUTE ELECTRONICALLY WITHOUT WRITTEN CONSENT OF EB PRACTICE, LLC Differential Diagnosis The Penis COPYRIGHTED MATERIAL—DO NOT PHOTOCOPY OR DISTRIBUTE ELECTRONICALLY WITHOUT WRITTEN CONSENT OF EB PRACTICE, LLC trauma, and testicular tumors, are also important sources of scrotal complaints, but rarely need to be managed within hours of the onset of symptoms and typically don’t require surgery. from testicular torsion. However, children who present late often have symptoms that make the etiologies clinically indistinguishable. Testicular Torsion Epididymitis has an annual incidence of about 1.2 per 1000 boys, according to one study from Israel.25 The condition appears to be rare in early childhood and more frequent in late childhood and adolescence. Children will often present with fever and symptoms of an acute scrotum. The literature is varied in citing the incidence of epididymitis, as it was previously thought to be rare in the pediatric population. Previous retrospective studies found a low incidence, about 5-7% of children who presented with an acute scrotum.18,20 However, one retrospective review reported that the incidence of acute epididymitis may be increasing, as they found 65% of children with an acute scrotum to have epididymitis.26 A similarly high percentage of patients (71%) were also found by Kadish and Bolte in their review.16 In multiple cohort studies, torsion of a testicular appendage and epididymitis, which were once thought to be less common causes than testicular torsion, was found in variable incidences: 14%-53% for testicular appendage, and 6%-71% for epididymitis.13-20 The variability may be due to the retrospective study design, as well as the difficulty in clearly defining the diagnosis of each entity. Often it is not easy to differentiate retrospectively between the two conditions. The cause of epididymitis in childhood is different from the cause in sexually active adolescents and adults. Epididymitis in adolescents who are sexually active is most commonly caused by Chlamydia trachomatis and Neisseria gonorrhoeae. In childhood, epididymitis is thought by some investigators to be linked with urogenital tract abnormalities. One review of 47 children with epididymitis found abnormalities of the urogenital tract in 47% of prepubertal children. There were 4 children less than 1 year old in this population, and 3 of the 4 had urogenital anomalies.27 It was hypothesized that abnormalities of the urogenital tract, such as retrograde voiding, ectopic ureter, or posterior urethral valves may cause inflammation of the epididymitis due to reflux of urine and resulting ascending infection. However, results of other studies conflict with those findings, suggesting a low incidence of structural abnormalities in children with epididymitis.1,19,28 One report cited that children without a circumcision may be at higher risk for epididymitis, and another cited dysfunctional voiding.29,30 Most recently, it appears that nonspecific epididymitis in childhood is postulated to be a postinfectious inflammatory phenomenon. A prospective study in 44 non-sexually active children with epididymitis found elevated titers to mycoplasma, enterovirus, and adenovirus when compared to a group of same-aged controls.25 Epididymitis Patients with testicular torsion often present with an acute onset of scrotal pain, abdominal pain, nausea, and vomiting. Classical teaching states that testicular torsion more commonly occurs in the left testes. One retrospective study confirmed this clinical finding; however, other retrospective studies found no difference.2,21 Nausea and vomiting may be helpful in distinguishing testicular torsion from other diagnoses. One retrospective study of patients with scrotal pain found that nausea and vomiting had, respectively, a 96% and a 98% positive, predictive value for recognizing children with testicular torsion. However, the overall sensitivity for nausea (69%) and vomiting (60%) was low, and thus absence of these findings cannot rule out the diagnosis.22 Another retrospective study of 100 children found vomiting in 45% of children with testicular torsion, while no patients with torsion of a testicular appendage and only 6% of children with epididymitis had vomiting.15 The duration of time from the onset of symptoms may also be helpful in making the diagnosis of testicular torsion. Children with testicular torsion may present on average within a shorter time period than those with nonsurgical etiologies. Mushtaq et al found a mean time for presentation of testicular torsion to be 9.5 hours (range 3.5 hours-72 hours) versus 48 hours (range 14 hours-72 hours) for torsion of a testicular appendage, and 22 hours (range 11hours-48 hours) for epididymitis.20 Clearly, time of presentation alone cannot distinguish between etiologies. However, those children with a shorter onset of symptoms should be identified and taken seriously, as shorter time periods do directly increase the prognosis for testicular salvage.1,18,20 A prompt and expeditious evaluation with a high suspicion for testicular torsion should be initiated for any child with a painful scrotum who presents with nausea and/or vomiting. Torsion of Testicular Appendices Torsion of appendix testis occurs when this appendage becomes twisted at its base, resulting in venous congestion, subsequent edema, and arterial obstruction. The most commonly torsed appendage is the appendix testes, or hydatid of Morgani, found at the superior pole of the testicle, a remnant of the Mullerian duct. There is also an appendix epididymis that is a remnant of the Wolffian duct and found at the head of the epididymis. This is the second most commonly torsed testicular appendage.3 The peak incidence of torsion of a testicular appendage is slightly earlier than that of testicular torsion, as it appears to peak at about 7-12 years of age.23 A child with torsion of a testicular appendage will usually present later than one with testicular torsion, due to the lower severity and the gradual onset of the pain.20,24 Children with early torsion of a testicular appendage may have localizing findings on physical exam, which helps to differentiate this condition Pediatric Emergency Medicine Practice Trauma Direct, blunt trauma to the scrotum seldom requires emergent management. However, there is an association between testicular torsion and scrotal trauma. Although 4 EBMedPractice.net •November 2004 found on the left side, as the testicular vein enters the left renal vein at a more acute angle than the right testicular vein enters the inferior vena cava. On physical exam a varicocele feels like “a bag of worms.” They are often found in early adolescence, and they should be referred to a urologist for follow-up, as they can decrease fertility and may require surgical intervention. Henoch-Schönlein Purpura Henoch-Schönlein purpura (HSP) is a systemic vasculitis of unknown etiology. This entity is common in children and presents with a palpable purpuric rash — most often on the buttocks and lower extremities — and concordant arthralgia/arthritis, abdominal pain, and nephritis. Other urogenital manifestations of HSP include: ureteritis with hydronephrosis, calcified ureter, hematoma of the bladder wall, and hemorrhagic spermatic cord.32 Scrotal involvement is fairly common, as one series found that 24% of 93 children with HSP had scrotal involvement.33 In this retrospective review, no child had testicular torsion, and the scrotal involvement was thought to be caused by the vasculitis. In this series, 8 children eventually did undergo scrotal explorations, due to the inability to clinically rule out testicular torsion. Unfortunately, the simultaneous involvement of testicular torsion within the context of HSP has been reported in a single case report.34 Despite this extremely rare coincidence, most authors do recommend a conservative approach when presented with a child with scrotal involvement and HSP.32,33,35,36 However, in the setting of significant scrotal pain in a child with HSP, the diagnosis of testicular torsion must be seriously considered. Since the presence of testicular torsion with HSP is extremely rare, but can occur, scrotal exploration may be indicated if the suspicion of its presence is high enough. Of note, another systemic vasculitis of childhood, Kawasaki’s disease, can also rarely present with scrotal swelling. This syndrome presents as a constellation of symptoms, including prolonged fever, non-purulent conjunctivitis, oral lesions, cervical lymphadenopathy, swelling and/or erythema of the distal extremities, and cutaneous skin rash. Idiopathic Scrotal Edema Idiopathic scrotal edema is a self-limiting condition that usually resolves without sequelae. The exact etiology is unclear, but it is thought to be due to a hypersensitivity response, perhaps a variant of angioedema.37 One retrospective study of 44 children found onset at an average age of 6.2 years, with an overall resolution of symptoms within 1-4 days. Interestingly, 8 patients had eosinophilia; otherwise, blood cell count and urine analysis were normal.37 Testicular Tumors Testicular tumors are rare in childhood. They have a bimodal age distribution and occur primarily before the age of 5 years and during puberty. The most common testicular tumors are germ cell tumor, yolk sac tumors, and teratomas. They may be associated with systemic findings, such as precocious puberty or gynecomastia. On physical exam they are usually found as painless, scrotal masses. Penile Complaints The differential diagnosis of the child with penile complaints is quite limited. (See Table 2 on page 6.) Often children will seek medical attention for balanitis, balanoposthitis, paraphimosis, phimosis, and trauma, often due to zipper entrapment or hair tourniquet. Of these, it is important to identify paraphimosis, as this entity requires expeditious reduction to avoid serious sequelae to the glans penis and foreskin. Paraphimosis Paraphimosis is a true urological emergency that requires prompt and definitive care. This condition is not due to an infection, but it occurs when the foreskin is pulled over the coronal sulcus of the glans penis and cannot return to its previous position. When the foreskin is trapped, it may form a tight, constricting band that may impede blood flow to and from the glans and prepuce, resulting in ischemic injury and vascular engorgement.38 A paraphimosis is often caused by the retraction of the foreskin to examine the penis, but can also rarely occur due to an erection. Hydroceles and Varicoceles Hydroceles can be found in many pediatric patients. They are usually painless, will transilluminate with light, and will often resolve by 1 to 2 years of age. Hydroceles can be divided into two types: communicating and non-communicating hydroceles. The non-communicating type is, by definition, a collection of fluid around the testicle, but within the process vaginalis that does not communicate with the peritoneum. This will usually resolve as the boy grows older. A communicating hydrocele, by definition, has a communication with the peritoneal cavity via a patent process vaginalis. This communication allows for an exchange of fluid and causes size variability, depending on the position of the patient. Both types of hydroceles require close primary care follow-up; however, communicating hydroceles require a surgical referral, as the presence of an indirect inguinal hernia is likely present. Varicoceles are thought to be a defect in the valves of the venous plexus of the testicle. They are more commonly November September2004 2003••EBMedPractice.net www.empractice.net Balanitis and Balanoposthitis Balanitis — inflammation of the glans penis — or balanoposthitis — inflammation of the prepuce and glans penis — can be caused by trauma, local irritation, or infection.39 Most commonly this problem affects males between the ages of 2-5 years. The presence of a foreskin may have a role in increasing the incidence of balanitis. In a retrospective survey of 545 boys aged 4 months to 12 years; 272 uncircumcised boys had balanitis diagnosed in 6% versus 5 Pediatric Emergency Medicine Practice COPYRIGHTED MATERIAL—DO NOT PHOTOCOPY OR DISTRIBUTE ELECTRONICALLY WITHOUT WRITTEN CONSENT OF EB PRACTICE, LLC a minor testicular contusion may have occurred, this may be the precipitating event for testicular torsion. Testicular rupture is also seen and is a urologic emergency. The pain and swelling will often be significant, and the scrotal sac will be ecchymotic and tender.31 COPYRIGHTED MATERIAL—DO NOT PHOTOCOPY OR DISTRIBUTE ELECTRONICALLY WITHOUT WRITTEN CONSENT OF EB PRACTICE, LLC 3% of circumcised males; however, the difference in these findings was not statistically significant.40 Penile irritation may be accentuated by local colonization of Candida albicans, or gram-positive anaerobic and aerobic bacteria, such as Group A Streptococcus.39,41,42 A single case report cited acute balanitis in association with a child who developed Staphylococcal toxic shock syndrome.43 In the sexually active adolescent, Chlamydia trachomatis and Neisseria gonorrhoeae are more commonly the causative agents. Inflammation can also be caused by external irritation from soap, laundry detergents, and antistatic sheets.39 In one retrospective study of 64 boys with penile trauma, 2% of the cases were due to zipper injuries, and 16% were caused by hair tourniquets.48 These entities appear self explanatory, but the literature is scant on these topics. Zippers from the boys’ trousers often entrap the prepuce or penile shaft when a child fastens or releases the zipper without the protection of underwear. This will often cause significant pain and discomfort for the child, and the parents eventually bring the child to the ED after the attempt at release is unsuccessful at home. Phimosis Phimosis is a condition that occurs when the foreskin cannot be retracted over the glans penis. This often is the result of local irritation or inflammation. As described previously, primary phimosis is physiologic and will usually resolve by the age of 5 years. Secondary phimosis, or an inability to retract the prepuce over the glans, when previously it was retractable, is due to chronic scar tissue formation. The incidence has been reported to be 0.4 cases per 1000 boys per year, or 0.6% of all boys by the 15th birthday.44 This condition may be due to irritation, infection, or possibly a chronic inflammatory condition of unknown etiology called balanitis xerotica obliterans (BXO), also known as lichen sclerosis et atrophicus. In a prospective study in 100 prepubertal males undergoing elective circumcision due to phimosis, balanitis, or recurrent balanitis, 14 were found to have histological evidence of lichen sclerosis et atrophicus.45 Another prospective study involving 23 cases of phimosis in boys aged 4-11 years, found that 20 out of 21 histological specimens had evidence of lichen sclerosis et atrophicus.46 Human hair is very strong and, when wet, will stretch in length. As it dries, it can form a tight, constricting band around a penis. This is the same mechanism as that described for toes. Sometimes a child may present with inconsolable crying of unclear etiology when, upon examination of the genitals, a hair tourniquet may be found constricting the penis. This “hair tourniquet syndrome” is a rare entity that may be mistaken for balanitis, if a careful search for the offending agent is not performed. Since properly circumcised children can’t sustain a paraphimosis, by definition, and are less likely to contract balanitis, a hair tourniquet must be considered in the differential diagnosis of a circumcised boy who presents to the ED with a swollen penis.49 Urethral fistulas and auto-amputation of the glans have been described as serious sequelae of prolonged hair tourniquets around the penis.47,49 The origin of these injuries in children is unclear; however, one review reported that playful experimentation, warding off evil sprits, the prevention of nocturnal enuresis, and child maltreatment were all causes previously stated in the literature.47 Zipper Injuries Prehospital Care Hair Tourniquet Finally, entrapment injury to the penis can occur. This is commonly due to zipper injuries and hair tourniquets.47 There is little information on the role of paramedics in the management of acute scrotal and penile complaints. Given Table 2. The Differential Diagnosis Of Acute Penile Complaints Diagnosis Symptoms Signs Paraphimosis • • History of retracting foreskin Painless to painful • Constricting ring of edema around coronal sulcus Balanoposthitis/Balanitis • • Painful Pruritic • • • Red Swollen +/- purulent discharge Phimosis • • • Pruritic Dysuria Abnormal voiding • • • Inability to retract the foreskin Minimal swelling Chronic skin changes Zipper injury • Occurs with fastening or removal of pants zipper without underwear • Zipper may entrap foreskin, penile shaft, and/or glans Hair tourniquet • History of circumcision • • Red and swollen distal to hair Hair may not be easily seen if inflammation is severe Pediatric Emergency Medicine Practice 6 EBMedPractice.net •November 2004 ED Evaluation The Acute Scrotum History In the ED, the history should be directed toward identifying testicular torsion and increasing the probability of testicular salvage.50,51 The time of the onset of symptoms should be immediately determined. Was the onset of pain gradual or acute? The pain of testicular torsion has an acute onset, as if someone suddenly pressed the “on” button. Are there any other accompanying symptoms, such as abdominal pain, nausea, or vomiting? Was there any antecedent trauma? A history of intermittent pain with spontaneous resolution could suggest intermittent testicular torsion.52 Even a previous history of orchiopexy does not rule out testicular torsion, as re-torsion has been reported after testicular fixation.53 It is important to quantify and characterize the child’s pain, as most often nonemergent etiologies of the acute scrotum present with modest or no pain. Symptoms such as dysuria, recent viral symptoms, fever, or urethral discharge may be more suggestive of epididymitis. However, distinguishing between etiologies by history alone may be difficult, and thus a careful physical exam is well worth the effort. Physical Examination The physical exam of the child with an acute scrotum can be difficult at times. Consoling an irritable child can be trying, but all attempts should be made to comfort the child. Start with observation of the child in the room. How much pain is he actually experiencing? It is important to examine the testes of young boys with abdominal pain, as embarrassed or nonverbal children may express this as their chief complaint, rather than complain of pain in their scrotum. Palpation of the scrotum should begin with evaluation of the uninvolved side, taking care to notice the testicular position and the level of where the testicles lie. A horizontal lie indicates a bell-clapper deformity, and high-riding testicles on the involved side are red flags for testicular torsion. The testicles should be examined for the exact area of tenderness, swelling, and redness. A tender, swollen spermatic cord is suggestive of epididymitis. Classical signs such as relief of scrotal pain with elevation of the involved side may suggest, but is not diagnostic for, epididymitis (Prehn’s sign), and a blue dot on the scrotum with localized tenderness at the superior pole of the testicle suggests the diagnosis of torsion of a testicular appendage (blue dot sign). However, these findings may not be present, or are difficult to determine in younger children. It is important to observe the child’s genitals in both the supine and upright positions, if possible. This may reveal a previously hidden inguinal hernia or hydrocele. Sometimes having the child blow into a glove or party balloon will increase intra-abdominal pressure enough to produce the needed clinical findings. A varicocele may feel like a “bag of worms” and have a bluish appearance through the November September2004 2003••EBMedPractice.net www.empractice.net Penile Complaints History The most important aspect of the history is to determine if the child has been circumcised. A boy who has not undergone circumcision is more likely to have an emergent condition, such as paraphimosis. The history should then focus on the onset of the symptoms. Did the swelling occur after retraction of the prepuce? Are there any symptoms, such as discomfort with voiding, an inability to void, fever, sore throat, or urethral discharge? Was there a clear history of trauma? Is the boy sexually active? Physical Examination School-aged children may be apprehensive or embarrassed about their swollen penis, so make all attempts to make the child comfortable. Examine the foreskin and glans for redness and swelling, the hallmark of balanitis 7 Pediatric Emergency Medicine Practice COPYRIGHTED MATERIAL—DO NOT PHOTOCOPY OR DISTRIBUTE ELECTRONICALLY WITHOUT WRITTEN CONSENT OF EB PRACTICE, LLC skin of the scrotum. The presence of “palpable” purpura in the lower extremities and/or buttocks suggests a diagnosis of HSP. A child with a ruptured testicle will have a full scrotum, with tenderness and ecchymosis. The testicle itself may be irregular, however this may be difficult to assess due to the swelling.31 The most clinically useful physical finding is the cremasteric reflex.55 This reflex is produced by stroking the inner aspect of the thigh, causing a reflex loop involving the spinal nerve segments L1-L2, inciting the cremasteric muscle contraction, pulling the ipsilateral testicle closer to the body. Many experienced practitioners feel that the lack of this finding is diagnostic for testicular torsion in the setting of an acute scrotum. This is a very reliable clinical finding, as the cremasteric reflex is consistently present in older children. In one study of 225 children who presented for non-urogenital problems, all children (100%) older than 30 months (54 children) had an intact cremasteric reflex. However, as the population decreased in age, the presence of the reflex was less consistent, as 48% of newborn children and 45% of children less than 30 months old had a cremasteric reflex on physical exam.54 Three retrospective studies that included a total of 444 boys with an acute scrotum found testicular torsion in 91 boys. In these studies all children (100%) with testicular torsion had an absent cremasteric reflex.2,14,16 In a single case report, testicular torsion was present in a child with an intact cremasteric reflex.56 Van Glabeke et al reported 3 infants with testicular torsion who had intact cremateric reflexes. In these cases the testes were not found to be ischemic, and the cord was twisted only once. In this series an absent cremasteric reflex had a 60% sensitivity and a 93% negative predictive value in determining testicular torsion. One problem with these values is that not all of the patients are accounted for, as some data are missing, due to the retrospective nature of the study.17 Despite these few cases, it appears that the presence of testicular torsion with an intact cremasteric reflex is extremely rare, and in its absence emergent scrotal exploration should be seriously considered. that most of these boys can walk, it is relatively unusual for EMS to be dispatched for these problems. COPYRIGHTED MATERIAL—DO NOT PHOTOCOPY OR DISTRIBUTE ELECTRONICALLY WITHOUT WRITTEN CONSENT OF EB PRACTICE, LLC and balanoposthitis. With these conditions the foreskin may be swollen, but not retracted. In sexually active adolescents, milk the penis for urethral discharge that would suggest a sexually transmitted disease. Paraphimosis presents with a swollen prepuce that forms a tight ring around the coronal sulcus proximal to the glans penis. If the entrapment is recent, minimal redness will be present, and the glans should appear viable. Delays in seeking treatment or in making the diagnosis may result in necrosis of the glans penis and prepuce. Phimosis will present with an inability to retract the prepuce over the glans, and erections may incite pain. There should be little to no swelling, but there may be signs of chronic irritation and scarring at the distal end of the prepuce. In infants and young children, look for a hair tourniquet that may be the cause of the swelling. This may not be immediately apparent if the degree of swelling is great. However, if a hair tourniquet is there, careful examination may prevent serious sequelae from a missed diagnosis. If a zipper has entrapped the child’s penis, look to see what structures are involved, and minimize the amount of movement until the child can receive adequate analgesia. This finding can be misleading, despite the presence of pyuria; if the child clinically has testicular torsion, it must be ruled out surgically. If hematuria is present, it may suggest nephritis associated with Henoch-Schönlein purpura. If Henoch-Schönlein purpura is suspected, further clinical correlation may prevent unnecessary scrotal explorations. Urine culture should be done on all children with an acute scrotum. A urine culture may be of help in children diagnosed with epididymitis. All children with epididymitis should receive antibiotic therapy if their cultures grow significant quantities of a single organism. However, it should be up to the consulting pediatric surgeon or urologist to pursue further studies to rule out an underlying urogenital abnormality. Imaging Studies (Scintigraphy and Ultrasound) The use of nuclear scintigraphy and color Doppler ultrasonography to identify testicular torsion is common practice.60-62 These tests are very good screening modalities for assessing the presence or absence of testicular blood flow.60,63-65 They are able to show decreased testicular blood flow in cases of testicular torsion, and find increased testicular blood flow in cases of epididymitis and torsion of a testicular appendage. Some authors advocate using both tests, if one test yields equivocal results.66 Anderson found that scintigraphy could reliably differentiate between torsion from other acute scrotal problems.67 Another study found nuclear scintigraphy to be even more accurate than color Doppler ultrasound; however, the number of cases was small.65 Currently in our center, color Doppler ultrasound is the screening modality of choice, when the clinical diagnosis is in doubt, for assessing the pediatric acute scrotum. One study reviewed 65 cases of acute scrotal disease and found color Doppler ultrasound to have a positive predictive value of 73%, sensitivity of 100%, and a negative predictive value of 100% in diagnosing testicular torsion.68 Another study of 110 patients who did not undergo immediate scrotal exploration found a sensitivity of 88.9%, specificity of 98.8%, and a false positive of 1% for testicular torsion.69 In the context of Henoch-Schönlein purpura, in one study of 93 boys with HSP, color Doppler ultrasonography demonstrated normal testicular flow in all 7 boys with scrotal involvement. All 7 of the boys did well and had no complications.70 However, one study cautioned the use of color Doppler ultrasonography as the sole determiner of the presence of testicular torsion, as it might yield false-positive results.71 This study population consisted of 50 normal boys. Blood flow was found bilaterally in 58%, only unilaterally in 8%, and no flow was detected in 34% of patients. However, the main issue for these diagnostic modalities is the small number of reported false-negative results, and the resulting concern for missing the diagnosis of a testicular torsion.72-75 Falsenegative sonograms may be the result of torsion without arterial compromise, such as happens early on in the process, or with a mild (180-degree) twist of the cord. A study comparing color Doppler to nuclear scintigraphy found an equal incidence of false-negative results. Prospectively Diagnostic Studies The Acute Scrotum Serum Studies There are currently no serum studies that clearly help in the workup of the pediatric acute scrotum. Acutephase reactants, such as white blood cell count (WBC) and C-reactive protein, have been found to be elevated in epididymitis, as compared to other causes of the acute scrotum. One study of children with epididymitis found an elevated WBC (>10,000) in 44 % of children; however, another study found an elevation in only 7% of patients.28,37 Other studies have looked at WBC in the acute scrotum; however, since most studies are retrospective, often this test was not ordered on all of the patients, and it is difficult to draw a clear conclusion. A study in adults found that there was a 4-fold elevation of C-reactive protein in patients with epididymitis, compared with conditions such as testicular tumor or testicular torsion.57 These results have not been validated in the pediatric population, and the causes of epididymitis in the adult and pediatric populations differ. It is not routinely recommended that serum studies be sent for a child with an acute scrotum, and precious time may be wasted waiting for results. Urinanalysis and Urine Culture Urine analysis has been the cornerstone of the workup of a child with an acute scrotum. However, the clinical yield is often low, and actually may add to the confusion. Finding pyuria is often linked to the diagnosis of epididymitis; however, studies of children with epididymitis found pyuria in only 7-24% of the patients.25,58 Furthermore, children with testicular torsion can also have pyuria, but the incidence of this is much less than in epididymitis.59 Pediatric Emergency Medicine Practice 8 EBMedPractice.net •November 2004 Penile Complaints There are currently no laboratory or imaging studies that aid in the evaluation of a boy with a penile complaint, except in sexually active adolescents. Urethral culture in sexually active adolescents may help to determine an exact etiology, but should not change the acute management. In most cases of the acutely swollen penis, no ancillary studies are needed to provide appropriate care in the ED. Treatment The Acute Scrotum Surgical Exploration Emergent scrotal exploration is the current gold standard to diagnose and treat acute testicular torsion. Surgical treatment serves two purposes. The first purpose is to re-establish circulation to the ischemic testicle, and the second purpose is to perform an orchiopexy to both testicles to prevent further episodes. It has been clearly documented that expeditious scrotal exploration increases chances of testicular salvage.1,18,20 In these retrospective reviews, children who presented within 12 hours of the onset of scrotal pain had salvage rates ranging from 88-100%. These studies also found that, after 12 hours, testicular salvage rates dropped dramatically — to 22%-36%. In Closed Manual Detorsion Manual, manipulative detorsion is not recommended for the emergency physician, as torsion can often recur, and scrotal exploration is still required.78 One study suggests that the classic teaching of torsion occurring medially may be misleading, as lateral rotation of the cord occurred in 33% of their cases.21 Attempts at manual detorsion in these Continued on page 12 Cost- And Time-Effective Strategies For Eurogenital Emergencies In Boys 1. Diagnostic imaging for the assessment of a painful and swollen scrotum can be costly and does not ensure 100% accuracy. Doppler ultrasonography, should be reserved for equivocal cases where the diagnosis is in question and unnecessary surgery can be avoided by further imaging studies. 2. A carefully performed physical examination followed by timely exploratory surgery and the avoidance of unnecessary studies is the prudent approach to take whenever there is a high suspicion for testicular torsion. 4. Delays in obtaining definitive surgical correction carry a high morbidity. 5. The value in obtaining imaging studies should always be weighed against the risks caused by time delays. ▲ 3. Diagnostic studies, such as scintigraphy and color November September2004 2003••EBMedPractice.net www.empractice.net 9 Pediatric Emergency Medicine Practice COPYRIGHTED MATERIAL—DO NOT PHOTOCOPY OR DISTRIBUTE ELECTRONICALLY WITHOUT WRITTEN CONSENT OF EB PRACTICE, LLC another study, even if the testicle was salvaged, on longterm follow-up, the presence of testicular atrophy directly correlated with the duration of symptoms before surgical intervention.76 Not only does duration of symptoms play a role in saving the testicle, it may also play a role in its long-term viability. Only one study has prospectively looked at using a set protocol for determining scrotal exploration. This protocol called for emergent exploration for any child presenting within 24 hours of onset of scrotal pain, unless there was a palpable, tender nodule to suggest torsion of a testicular appendage. Using these criteria, 20 boys were prospectively studied, with 10 out of 20 boys presenting within 24 hours of symptoms. Of the early group, 8 of the 10 children were surgically explored, and testicular torsion diagnosed in 6, with torsion of the testicular appendage in 2. The other 2 children in the early group had palpable, tender nodules and were conservatively managed, as were the 10 children who presented after 24 hours of symptoms. None of the conservatively managed children had testicular atrophy on follow-up at 4-6 weeks, with complete resolution of symptoms.24 How the power of this study was determined was not mentioned in the article, so the significance of the results is not clear. This protocol needs to be carried out on a larger scale; however, it does give us something to think about. It is possible that some testicles may be salvageable beyond 24 hours of the onset of symptoms, and a single case report showed a viable testicle even after 7 days of symptoms.77 This case report, however, only illustrated intra-operative re-perfusion of the testicle and did not comment on its long-term viability. in 46 children, the investigators found flow in 3 out of 14 children in each group who had testicular torsion, finding sensitivity 78.6 and 78.6 and specificity 96.9 and 90.6 for color Doppler ultrasonography and scintigraphy, respectively.74 It appears that both modalities are similar in accuracy and are not infallible. Color Doppler ultrasonography is quicker, less invasive, and requires no radiation when compared to nuclear scintigraphy. The downside to both modalities is that they require skilled personal to complete and interpret the procedures. These resources may not be readily available to the general emergency practitioner, and the time it takes to carry them out may be the difference between testicular salvage and the need for orchiectomy. For equivocal cases, these imaging modalities may decrease the incidence of unnecessary scrotal explorations of the pediatric acute scrotum.64,65,68 Acute onset of painful scrotum YES ➤ Absent cremasteric reflex, abnormal testicular orientation within the scrotum, and acute onset? ➤ YES Emergent Surgical Exploration (Class I) NO 1. ➤ ➤ Onset < 24 hours? YES ➤ 2. Emergent Surgical Exploration (Class II) Imaging with ultrasound or scintigraphy (Class II) NO ➤ • • Doppler Ultrasound (US) Nuclear Scintigraphy (NS) Decreased blood flow to testicle? ➤ YES Surgical Exploration (Class II) NO ➤ Localized tenderness to the superior pole of the testes YES for torsion of appendix ➤ Treat testes (Class II) NO ➤ Fever/tender spermatic cord YES ➤ Treat for epididymitis (Class II) NO ➤ COPYRIGHTED MATERIAL—DO NOT PHOTOCOPY OR DISTRIBUTE ELECTRONICALLY WITHOUT WRITTEN CONSENT OF EB PRACTICE, LLC Clinical Pathway: The Acute Scrotum Consider alternative diagnoses and treat based on the most likely diagnosis. (See Table 1.) The evidence for recommendations is graded using the following scale. For complete definitions, see back page. Class I: Definitely recommended. Definitive, excellent evidence provides support. Class II: Acceptable and useful. Good evidence provides support. Class III: May be acceptable, possibly useful. Fair-to-good evidence provides support. Indeterminate: Continuing area of research. This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care. Copyright ©2004 EB Practice, LLC. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Practice, LLC. Pediatric Emergency Medicine Practice 10 EBMedPractice.net •November 2004 Swollen or Painful Penis YES ➤ Circumcised? ➤ YES Look for hair tourniquet and treat if found (Class II) NO ➤ Constricting band around coronal sulcus? ➤ YES Paraphymosis • Analgesia (Class II) • Reduction (Class II) • Circumcision (Class II) NO ➤ Zipper present? YES ➤ NO Zipper Injury • Analgesia (Class II) • Mineral oil (Class II) Cut median bar of zipper (Class II) • • Circumcision (Class II) ➤ Erythema to foreskin with or without purulent discharge? YES NO ➤ Balanitis/Balanoposthitis • Topical steroids (Class II) • Oral antibiotics (if discharge present) (Class II) • Antihistamines (Class II) ➤ Chronic inflammation and non-retractable foreskin? YES ➤ Phimosis • Topical steroids (Class I) • Urology follow-up NO ➤ Consider alternative diagnoses and treat based on the most likely diagnosis. (See Table 1.) The evidence for recommendations is graded using the following scale. For complete definitions, see back page. Class I: Definitely recommended. Definitive, excellent evidence provides support. Class II: Acceptable and useful. Good evidence provides support. Class III: May be acceptable, possibly useful. Fair-to-good evidence provides support. Indeterminate: Continuing area of research. This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care. Copyright ©2004 EB Practice, LLC. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Practice, LLC. November 2004 • EBMedPractice.net 11 Pediatric Emergency Medicine Practice COPYRIGHTED MATERIAL—DO NOT PHOTOCOPY OR DISTRIBUTE ELECTRONICALLY WITHOUT WRITTEN CONSENT OF EB PRACTICE, LLC Clinical Pathway: Penile Complaints COPYRIGHTED MATERIAL—DO NOT PHOTOCOPY OR DISTRIBUTE ELECTRONICALLY WITHOUT WRITTEN CONSENT OF EB PRACTICE, LLC Continued from page 9 penile block with 1% plain lidocaine is a good addition for pain reduction. Once adequate analgesia is attained, simple manual reduction is usually successful for correcting paraphimosis. Manual reduction involves holding the distal foreskin and penile shaft with constant pressure down on the head of the glans penis. Ice and compression can often be helpful in reducing edema and facilitating manual reduction. The inverted finger of a large surgical glove placed over the penis for compression and the glove filled with ice can be a helpful edema-reducing technique. Additional substances, such as injection of 1 cc haluronidase (150 Units/cc) into the edematous prepuce, have been reported to help with reduction. Haluronidase acts by breaking down ground substance in connective tissue, enhancing the diffusion of the liquid between tissue planes.80 Holding the edematous prepuce in granulated sugar for 2 hours to osmotically decrease edema has also been found to be a helpful adjunct to manual reduction.81 Other, more invasive measures have been described, such as the puncture technique. This technique involves making a series of small punctures around the swollen prepuce with a, 21G needle, followed by gentle compression of the swollen foreskin to express the edematous fluid. Manual reduction is then attempted.82-84 A technique using only a single needle puncture has been described, as well.85 As a last resort, dorsal slit or complete circumcision may be completed by a pediatric surgeon, if these other measures fail to reduce the entrapped foreskin. cases may actually worsen the ischemia. We recommend that all children who present within 24 hours of acute scrotal pain with a high suspicion of testicular torsion (ie, nausea, vomiting, and no cremasteric reflex) receive rapid pediatric surgical consultation or be transported to a children’s hospital where such consultation is available for scrotal exploration. Imaging modalities such as ultrasonography and scintigraphy have no role in assessing these patients, as they will only delay care and increase bad outcomes. It is unclear if children who present late with testicular torsion constitute an “emergency,” as salvage rates beyond 48 hours are already extremely poor. One caveat to this is future viability and productivity of the remaining uninvolved testicle. Anderson et al studied semen quality in a group of 16 males who underwent scrotal exploration — 9 males treated with detorsion and orchiopexy, and 7 with orchiectomy. The quality of the semen from the single remaining testicle was significantly decreased from that of age-appropriate controls when the patients required an orchectomy. However, when scrotal exploration was able to salvage the involved testicle, the quality of semen showed no significant difference. They concluded that early intervention produces better long-term outcomes in terms of fertility that go beyond just simply saving the involved testicle.79 Antibiotics and Analgesics In children who are at low risk for torsion or who present later than 24 hours after the onset of symptoms, imaging modalities may be helpful. These children should have a color Doppler ultrasound or nuclear scintigraphy to help further rule out testicular torsion. Children with torsion of a testicular appendage should receive ibuprofen, 10 mg/kg every 6-8 hours until the pain subsides, and they should wear supportive underwear. Children with epididymitis should receive the same treatment as those with a torsed appendage testis, and if pyuria is present, then antibiotics to target gram-negative enteric organisms should be prescribed. If the urine analysis is normal, no antibiotics should be required.58 Topical and Oral Treatments The treatment of acute balanitis and balanoposthitis is dependent on the clinical findings. Local inflammation and swelling without a purulent discharge suggest the cause may be due to a local irritant, and a topical 1% hydrocortisone cream may be applied 2-3 times daily for 7-10 days. In the younger child, if a purulent discharge is present on exam, then treatment to target Group A Streptococcus and Staphylococcus aureus should also be initiated. Oral antibiotics, such as cephalexin 25 mg/kg per dose 3 times per day, amoxicillin-clavulanate 25 mg/kg per dose twice daily, or clindamycin 10 mg/kg per dose 3 times per day may be given. Diphenhydramine 1.25 mg/kg per dose every 6 hours as needed is often helpful to decrease pruritus associated with the inflammation. In the sexually active adolescent, testing for sexually transmitted diseases (typically urethral cultures) should be performed, and the most recently recommended treatments for Chlamydia trachomatis and Neisseria gonorrhoeae should be initiated in the ED (eg, azithromycin 1 gram orally once plus ceftriaxone 1 gram intramuscularly or intravenously). If there is high fever and/or severe involvement of the penile shaft and groin, hospital admission for intravenous antibiotics and observation may be indicated. Fortunately, this clinical scenario is quite rare. Adolescent boys with balanitis whose sexual partners have vaginal yeast infections may have good clinical resolution of their symptoms when given a single dose of fluconazole 150 mg given orally. There is little to do for a child with secondary Penile Complaints Paraphimosis Reduction The treatment of a child with paraphimosis involves reduction of the edema and replacement of the foreskin to its normal position. Preferably this process is completed expeditiously to prevent ischemic injury to the glans and prepuce. There are currently no prospective, blinded studies pertaining to this topic. However, multiple case reports and a few cohort studies describe multiple methods of foreskin reduction. Prior to reduction, oral or IV analgesia should be provided to the patient. Morphine sulfate, 0.1mg/kg IV, or Hydrocodone, 0.2 mg/kg PO with acetaminophen, are good choices. The addition of proper analgesia to the procedure is crucial to its success, as a relaxed child will be more easily reduced. A dorsal Pediatric Emergency Medicine Practice 12 EBMedPractice.net •November 2004 study, Huntley et al found an 81% success rate for topical steroids in 31 children initially treated medically for phimosis.88 One limitation to these studies is the lack of a control arm to compare the efficacy of therapy. However, one small prospective, double-blinded study showed that topical steroid was superior to placebo in the treatment of phimosis. Two groups of 20 males (N=40) were treated with 0.05% Betamethasone cream or placebo cream twice daily for 4 weeks. In the treatment group 19 out of 20 boys had complete reduction of the foreskin at 4 weeks, compared to 4 out of 20 in the control group (p<0.001).89 Clearly, topical steroids should be a first-line treatment for secondary phimosis in pediatrics. Follow-up should be arranged by the primary care physician, so that a surgical specialist can ensure that no further complications arise. Ten Pitfalls To Avoid 1. “I want this patient to get a color Doppler ultrasonography of the scrotum, because I am pretty sure this is testicular torsion.” An ultrasound is very helpful in working up cases of moderate or low suspicion for testicular torsion. If the diagnosis is certain or near certain, the best approach is to contact the surgeon with the expectation of prompt surgical exploration. If the suspicion for testicular torsion is high, further imaging only decreases the chance of testicular viability by possibly delaying definitive care. testicular torsion, only to find epididymitis or torsion of a testicular appendage, should not lead to legal action. Aggressive treatment has been the rule for many years, and it is still a good standard if the diagnosis is in question. 6. “I did not look in the genital area because the child’s chief complaint was abdominal pain and vomiting.” Children may not complain of their genitals hurting, but rather complain of abdominal pain or nausea. It is good practice to examine the scrotum on any boy with acute abdominal pain to rule out scrotal etiologies. 2. “The ultrasound showed arterial flow, so this child cannot have testicular torsion.” Early testicular torsion and intermittent torsion may yield a false-negative result on ultrasound. Studies report the incidence of this finding to be about 1%. If time is a factor and the suspicion is high for testicular torsion, emergent scrotal exploration is indicated. The diagnosis should be made at the bedside. 7. “I thought that the swelling from paraphimosis was due to an infection.” The 2 key questions are: “Is this child circumcised?” and “How did it happen?” Both of these questions help to rule in paraphimosis. Paraphimosis cannot occur in properly circumcised individuals, and often the entrapment of the foreskin can be blamed on a single incident of retracting it. 8. “I did not see the hair tourniquet.” Hair tourniquets can easily be missed and mistaken for balanitis, if a close examination of the penis is not performed. Also, any male infant who presents with crying or irritability should be examined for hair tourniquets of the digits, including the penis. 3. “No follow-up is needed since the ultrasound does not show testicular torsion.” All children should be followed closely over the next few days. It is easy to mistakenly discharge an intermittent or an early testicular torsion. Prolonged monitoring in the ED is indicated, or close follow-up with the pediatrician and good instructions for when to return should be given. 9. “There’s no way this 13-year old could be sexually active.” In any child in the teen years, a sexual history can be very important to identify sexually transmitted diseases and the etiology of epididymitis. 4. “The urinanalysis has leukocytes, so this child has epididymitis.” Boys with testicular torsion can also have leukocytes in their urine. Although pyuria is seen more commonly in epididymitis, the overlap with testicular torsion can be misleading. 10. “I thought he probably had gastroenteritis. He was vomiting. How could he have had testicular torsion?” Presumably, due to the abrupt onset of substantial pain, testicular torsion commonly presents with vomiting. Due to embarrassment or lack of insight, boys may be reluctant to offer a history of testicular pain, if the questions are not asked directly or if the genitals are not examined. ▲ 5. “An unnecessary scrotal exploration could result in medical litigation.” Going to the operating room to definitively rule out November September2004 2003••EBMedPractice.net www.empractice.net 13 Pediatric Emergency Medicine Practice COPYRIGHTED MATERIAL—DO NOT PHOTOCOPY OR DISTRIBUTE ELECTRONICALLY WITHOUT WRITTEN CONSENT OF EB PRACTICE, LLC phimosis in the ED. However, medical treatment may be implemented while awaiting outpatient urological follow-up. Numerous studies have shown that topical application of steroids is efficacious in the resolution of secondary phimosis. Medium-strength topical steroids, such as betamethasone or triamcinolone, have been proven to be efficacious in the resolution of phimosis when used consistently for 4-6 weeks. In a retrospective review of 69 boys aged 3-13 years, Webster et al found that 82% had complete resolution of phimosis with the application of triamcinolone cream twice daily for 6 weeks.86 In a prospective study on 194 males under 16 years old with phimosis, Ashfield et al successfully avoided circumcision in 87% by using topical 0.1% betamethasone ointment applied twice daily.87 Most recently, in a prospective COPYRIGHTED MATERIAL—DO NOT PHOTOCOPY OR DISTRIBUTE ELECTRONICALLY WITHOUT WRITTEN CONSENT OF EB PRACTICE, LLC Controversies / Cutting Edge Zipper Injury Treatment When a foreskin is entrapped by a zipper, further manipulation is often painful. By the time the patient presents to the ED, the parents have most likely attempted removal on their own without success. The least invasive maneuver described in the literature is to apply mineral oil to the area in the hopes of helping to lubricate the skin, so that moderate traction is now enough to free the penis from the zipper.90 The use of bone cutters or a small hacksaw to cut the medial bar of the zipper has also been described with good success.91-93 This measure breaks the zipper into 2 parts releasing the trapped prepuce. Lastly, surgical consult for complete circumcision of the entrapped area is an alternative, if these other measures fail. Two articles specifically explored the use of bedside color Doppler ultrasonography by the emergency physician to rapidly make the correct diagnosis in patients with an acute scrotum.95,96 One small retrospective review found a 95% sensitivity and a 94% specificity for making the correct diagnosis in 36 cases of an acute scrotum, when compared to the official radiology reading or surgical exploration.96 However, a large prospective study is lacking at this time. As bedside ultrasonography becomes more readily available, and emergency practitioners become more comfortable and skilled in its use, this screening modality may provide the most timely and effective tool for diagnosis of testicular torsion. Hair Tourniquet Treatment Disposition There are no studies that describe the best way to remove a hair tourniquet from a swollen penis. Often, if the swelling is not severe, the hair may simply be untangled or cut from the penile shaft. Soaking the area in 8% calcium thioglycollate (Nair) for 15 minutes has been suggested.94 However, this is contraindicated if the tourniquet is not made of human hair. Timely treatment is important, since inflammation and skin breakdown will occur. If the swelling is marked or there is evidence of gangrene, emergent urological consult should be considered prior to any attempts at removal. The removal might be performed in the operating room, if there is any suspicion that a repair to the glans or urethra may be necessary. Often, surgeons may need to make a lateral incision perpendicular to the tourniquet, at the level of the lateral-inferior depressed area that lies between the corpus cavernosum and corpus spongiosum. This allows avoidance of the urethra and dorsal neurovascular bundle.47 Most children who do not have testicular torsion are discharged home. All children with acute scrotal pain who do not receive surgical intervention should have close follow-up with either their pediatrician or a urologist experienced in the care of children within 1-2 days. The child’s pediatrician should be contacted to assure follow-up on all urine cultures, as children with epididymitis and positive urine cultures may require urology follow-up and further studies to rule out underlying urogenital abnormalities. All children with an acutely swollen penis should be reexamined by their pediatrician or by a physician in the ED within 48 hours of treatment. The patients with acute balanitis and balanoposthitis require very close monitoring. Worsening of the swelling and pain may be indicative of antibiotic-resistant organisms or a missed diagnosis. Children who have a reduced paraphimosis, or who have had a hair tourniquet or zipper entrapment removed, may Key Points For Urogenital Emergencies In Boys • The treating emergency practitioner must have a very high suspicion for testicular torsion with any child who presents with testicular pain. coexist. The trauma patient with an absent cremasteric reflex should have emergent surgical consultation. • Children with HSP and scrotal involvement can usually be managed conservatively. However, if testicular torsion cannot be ruled out, then diagnostic imaging is of great benefit. • Children in whom there is a high suspicion of testicular torsion that present within 24 hours of the onset of symptoms should receive surgical consultation for a possible emergent scrotal exploration. • Children with epididymitis and torsion of a testicular appendage can be managed with supportive care and close follow-up. • Children with equivocal findings for testicular torsion should undergo an imaging modality, such as color Doppler ultrasonography or nuclear scintigraphy, to further help to rule out testicular torsion. For those cases in which imaging is either unreliable or unavailable, and the patient presents within 12-24 hours of the onset of symptoms, scrotal exploration should be considered. • Children with paraphimosis should be expeditiously reduced to prevent serious sequelae. • The emergency physician must have a high suspicion for a hair tourniquet in a circumcised child with a swollen penis. ▲ • Trauma to the testicle and torsion of the testicle may Pediatric Emergency Medicine Practice 14 EBMedPractice.net •November 2004 Toilet Seat Injury Although it is certainly possible for toilet seats to accidentally fall down while young boys urinate, it is quite unusual for injuries due to this phenomenon to require an ED visit.102 If penile fracture is suspected, or if swelling is sufficient to obstruct urinary outflow, prompt urologic consultation is probably prudent. Summary Although most boys with urogenital complaints are discharged home from the ED, prompt identification and treatment for testicular torsion and paraphimosis are the keys to a successful ED visit for these boys. Having confidence in the management of other urogenital complaints allows the emergency physician to treat these boys appropriately and goes a long way toward reassuring anxious parents. ▲ References Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report. To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available. Special Circumstances 1. Anderson JB, Williamson RCN. Testicular Torsion in Bristol: A 25 year review. Br J Surg. 1988;75:988-992. (Retrospective; 670 patients) 2. Melekos MD, Asbach HW, Markou SA. Etiology of Acute Scrotum in 100 Boys with Regard to Age Distribution. J Urol. 1987;139:1023-1025. (Retrospective; 100 patients) 3. Pillai SB, Besner GE. Pediatric Testicular Problems. Pediatr Clin North Am. 1998; 45:813-829. (Review) 4. Caesar RE, Kaplan GW. Incidence of the Bell Clapper Deformity in an Autopsy Series. Urology. 1994;44:114-116. (Prospective; 51 patients) 5. Noske H, Kraus SW, Weidner W, et al. Historical Milestones Reguarding Torsion of the Scrotal Organs. J Urol. 1998;159:13-16. (Review) 6. Shergill IS, Foley CL, Mundy AR, et al. Testicular Torsion Unraveled. Hosp Med. 2002;63:456-459. (Review) 7. Shukula RB, Kelly, DG, Guiney EJ, et al. Association of Cold Weather with Testicular Torsion. Br Med J. 1982;285:14591460. (Retrospective; 46 patients) 8. Preshaw RM. Seasonal Frequency of Testicular Torsion. Can J Surg. 1984;27:404-405. (Retrospective; 272 cases) 9. Willams CR, Heaven KJ, Joseph DB. Testicular Torsion: Is there a Seasonal Predilection for Occurrence? Urology. 2003;61:638-641. (Retrospective; 135 patients) 10. Elsaharty S, Pranikkoff K, Suprin G, et al. Traumatic Torsion Priapism In Sickle Cell Disease Priapism is a well-described complication of sickle cell disease. In one survey, 35% of men with sickle cell disease had experienced priapism at some point in their lives, and the mean age of onset was 15 years.98 Recommendations for treatment of prolonged erections in boys with sickle cell disease range from conservative fluid and pain management at home, to intravenous hydration in the ED, to intracavernosal aspiration.99 There is no evidence-based management plan that is widely accepted. Consultation with the patient’s hematologist is probably prudent. Foreign Bodies And Piercings Sexual exploration in adolescence is well recognized. Although we were not able to identify any specifically pediatric literature describing urethral foreign bodies and genital piercings in adolescent boys, these have been described in relatively young adults.100,101 If encountered in the ED, each instance will need to be managed on a caseby-case basis, due to the paucity of information on these topics. November September2004 2003••EBMedPractice.net www.empractice.net 15 Pediatric Emergency Medicine Practice COPYRIGHTED MATERIAL—DO NOT PHOTOCOPY OR DISTRIBUTE ELECTRONICALLY WITHOUT WRITTEN CONSENT OF EB PRACTICE, LLC require oral analgesia. Further, supportive local wound care with topical antibiotic ointments and warm sitz baths may also be of help. Lastly, children diagnosed with phimosis with initiation of topical steroid treatment should be seen by their pediatrician in 1-2 weeks to monitor progress and make the proper surgical referral. Unfortunately, the acute pediatric scrotum poses a difficult clinical problem for the emergency physician, as a missed testicular torsion can result in legal action. Misdiagnosis of testicular torsion is an active area of litigation for many reasons: the problem requires emergent diagnosis and treatment, there is occasionally diagnostic uncertainty, there is a relatively high rate of poor outcomes (orchiectomy), and the psychological impact of a lost testicle can be significant.97 Matteson et al retrospectively reviewed 39 closed cases of 58 individual claims made against individual physicians regarding missed testicular torsion between the years 1979-1997. In this series, 26 out of 39 (67%) resulted in indemnity payments, and 9 out of 39 were concluded with no payment on the behalf of the physician. The remaining 4 claims went to trial with findings in favor of the defendant. The mean defense cost was $10,785 per case, and the physician most often sued was the urologist. The most common reasons for litigation payments against non-surgeons were improper referral or not ordering imaging studies. Interestingly, there was no difference in the rate of payment between those patients who presented within 8 hours of symptoms, those that presented later than 8 hours, and those whose time of presentation could not be determined. Apparently, the welldocumented fact that a delayed presentation decreases the rate of testicular salvage did not affect legal outcomes in this study population.97 COPYRIGHTED MATERIAL—DO NOT PHOTOCOPY OR DISTRIBUTE ELECTRONICALLY WITHOUT WRITTEN CONSENT OF EB PRACTICE, LLC of the Testes. J Urol. 1984;132:1155-1156. (Retrospective; 138 patients) 11. Lrhorfi H, Manunta A, Lobel B, et al. Trauma Induced Testicular Torsion. J Urol. 2002;168:2548. (Case report) 12. Gairdner D. The Fate of the Foreskin. Br Med J. 1949;2:14331437. (Review) 13. *Lewis AG, Bukowski TP, Sheldon CA, et al. Evaluation of Acute Scrotum in the Emergency Department. J Pediatr Surg. 1995;20:277-281. (Retrospective; 238 patients) 14. 15. circumcision factor. J Urol. 1998;160:1842-1844. (Retrospective; 128 patients) 30. Bukowski TP, Lewis AG, Reeves D, et al. Epididymitis in Older Boys: dysfunctional voiding as an etiology. J Urol. 1995;154:762-765. (Retrospective; 36 patients) 31. Kadish H. The Tender Scrotum. Clin Pediatr Emerg Med. 2002;3:55-61. (Review) 32. Caldamone AA, Valvo JR, Rabinowitz R. Acute Scrotal Swelling in Children. J Pediatr Surg. 1984;19:581-584. (Retrospective; 150 patients) Ben-Chaim J, Korat E, Goldwasser B, et al. Acute Scrotum Caused by Henoch Schönlein Purpura with immediate Response to Short-Term Steroid Therapy. J Pediatr Surg. 1995;10:1509-1510. (Case report) 33. Hegarty PK, Walsh E, Corcoran MO. Exploration of the Acute Scrotum: a retrospective analysis of 100 consecutive cases. Ir J of Med Sci. 2001;170:181-182. (Retrospective; 100 patients) *Ioannides AS, Turnock R. An Audit of the Management of the Acute Scrotum in Children with Henoch Schönlein Purpura. J R Coll Surg Edinb. 2001;46:98-9. (Retrospective; 22 patients) 34. Loh HS, Jalan OM. Testicular Torsion in Henoch-Schönlein Syndrome. Br Med J. 1974;13:96-97 (Case report) 35. Turkish VJ, Traisman HS, Marr TJ, et al. Scrotal Swelling in the Schönlein-Henoch Syndrome. J Urol. 1976;115:317-319. (Case report) 36. Hara Y, Tajiri T, Matsuura K, et al. Acute Scrotum caused by Henoch-Schonlein Purpura. Int J Urol. 2004;11:578-580. (Case report) 37. Klin B, Lotan G, Efrati Y, et al. Acute Idiopathic Scrotal Edema in Children-Revisited. J Pediatr Surg. 2002;37:12001202. (Retrospective; 44 patients) 38. Choe JM. Paraphimosis: current treatment options. Am Fam Physician. 2000;62:2623-2626. (Review) 39. Schwartz RH, Rushton HG, Acute Balanoposthitis in Young Boys. Pediatr Infect Dis J. 1996;15:176-177. (Case report) 16. *Kadish HK, Bolte RG. A Retrospective Review of Pediatric Patients with Epididymitis, Testicular Torsion, and Torsion of Testicular Appendages. Pediatrics. 1998;102:73-76. (Retrospective; 90 patients) 17. *Van Glabeke E, Khairoumi A, Larroquet M, et al. Acute Scrotal Pain in Children: results of 543 surgical explorations. Pediatr Surg Int. 1999;15:353-5-357. (Retrospective; 543 patients) 18. Corbett HJ, Simpson ET. Management of the Acute Scrotum in Children. ANZ J Surg. 2002;72:226-228. (Retrospective; 182 patients) 19. *McAndrew HF, Pemberton R, Gollow I, et al. The Incidence and Investigation of Acute Scrotal Problems in Children. Pediatr Surg Int. 2002;18:435-437. (Retrospective; 100 patients) 20. *Mushtaq I, Fung M, Glasson MJ. Retrospective Review of Pediatric Patients with Acute Scrotum. ANZ J Surg. 2003 JanFeb;73(1-2):55-8. (Retrospective; 110 patients) 40. 21. *Sessions AE, Rabinowitz R, Mevorach RA. Testicular Torsion; direction, degree, duration, and disinformation. J Urol. 2003;169:663-665. (Retrospective; 200 patients) Herzog LW, Alvarez SR. The Frequency of Foreskin Problems in Uncircumcised Children. Am J Dis Child. 1986;140:254-256. (Retrospective; 545 patients) 41. 22. *Jefferson RH, Perez LM, Joseph DB. J Urol. 1997;158:11981200. (Retrospective; 115 patients) Kyriazi NC, Costenbader CL. Group A B-Hemolytic Streptoccal Balanitis: it may be more common than you think. Pediatrics. 1991;88:154-155. (Case report) 42. 23. Kass EJ, Lundak B. The Acute Scrotum. Pediatr Clin North Am. 1997;44:1251-1266. (Review) Orden B, Martin R, Franco A, et al. Baanitis Caused by Group A ß-Hemolytic Streptococci. Pediatr Infect Dis J. 1996 Oct;15(10):920-921. (Case series; 12 patients) 24. *Hastie KJ, Charlton CA. Indications for Conservative Management of Acute Scrotal pain in Children. Br J Surg. 1990;77:309-311. (Mixed Design with Retrospective component with 43 patients and a Prospective component with 20 patients) 43. Daher A, Fortenberry JD. Staphloccocus-Induced Toxic Shock following Balanitis. Clin Pediatr. 1995 Mar;34(3):172174. (Case report) 44. Shankar KR, Rickwood AMK. The incidence of phimosis in boys. BJU Int. 1999 Jul;84(1):101-102. (Retrospective; 62 patients) 25. Somekh E, Gorenstein A, Serour F. Acute epididymitis in Boys; evidence of a post-infective etiology. J Urol. 2004;171:391-394. (Prospective; 44 patients) 45. 26. Klin B, Zlotkevich L, Lotan G, et al. Epididymitis in Childhood; a clinical retrospective study. Isr Med Assoc J. 2001 Nov;3(11):833-835. (Retrospective; 65 patients) Chalmers RJ, Burton PA, Bennet RF, et al. Lichen Sclerosus et Atrophicus. Arch Dermatol. 1984 Aug;120(8):1025-1027. (Prospective; 100 patients) 46. 27. Siegel A, Snyder H, Dickett JW. Epididymitis in Infants and Boys: underlying urogenital abnormalities and efficacy of imaging modalities. J Urol. 1987;138:1100-1103. (Retrospective; 47 patients) Rickwood AM, Hemalatha V, Batcup G, et al. Phimosis in Boys. Br J Urol. 1980 Apr;52(2):147-149. (Prospective; 23 patients) 47. Haddad FS. Penile Strangulation by Human Hair. Urol Int. 1982;37:375-388. (Review; 60 case reports) 28. Gislason T, Norohha RF, Gregory JG. J Urol. 1980;124:533-534. (Retrospective; 25 patients) 48. El-Bahnasawy MS, El-Sherbiny MT. Pediatric Penile Trauma. BJU Int. 2002 Jul;90(1):92-96. (Retrospective; 64 patients) 29. Bennett BT, Gill B, Kogan SJ. Epididymitis in Children: the 49. Kirtane JM, Samuel KV. Hair Coil Strangulation of the Penis. J Pediatr Surg. 1994 Oct;29(10):1317-1318. (Retrospective; 15 patients) Pediatric Emergency Medicine Practice 16 EBMedPractice.net •November 2004 Rampaul MS, Hosking SW. Testicular Torsion: most delays occur outside the hospital. Ann R Coll Surg Engl. 1998;80:169172. (Retrospective; 50 patients) 51. Bennett S, Nicholson MS, Little TM. Torsion of the Testis: why is the prognosis so poor? Br Med J. 1987;294:824. (Retrospective; 83 patients) 52. Stillwell TJ, Kramer SA. Intermittent Testicular Torsion. Pediatrics. 1986;77:908-911. (Case reports) 53. Sells H, Moretti KL, Burfield GD. ANZ J Surg. 2002;72:46-48. (Case reports) 54. Testicular Torsion. Pediatrics. 2000;105:604-607. (Retrospective; 130 patients) 70. Ben-Sira L, Laor T. Severe Scrotal Pain in Boys with HenochSchonlein Purpura: incidence and sonography. Pediatr Radiol. 2000; 30:125-128. (Retrospective; 93 patients) 71. Ingram S, Hollman AS. Colour Doppler Sonography of the Normal Paediatric Testis. Clin Radiol. 1994;49:266-267. (Prospective; 50 patients) 72. *Caesar RE, Kaplan GW. The Incidence of the Cremasteric Reflex in Normal Boys. J Urol. 1994;152:779-780. (Prospective; 225 patients) Allen TD, Elder JS. Shortcomings of Color Doppler Sonography in the Diagnosis of Testicular Torsion. J Urol. 1995;154:1508-1510. (Case series; 5 patients) 73. 55. *Rabinowitz R. The Importance of the Cremasteric Reflex in Acute Scrotal Swelling in Children. J Urol. 1984;132:89-90. (Prospective; 245 patients) Steinhardt GF, Boyarsky S, Mackey R. Testicular Torsion; pitfalls of color Doppler sonography. J Urol. 1993;150:461-462. (Case report) 74. 56. Nelson CP, Williams JF, Bloom DA. The Cremasteric Reflex: a useful but imperfect sign in testicular torsion. J Pediatr Surg. 2003;38:1248-1249. (Case report) *Nussbaum Blask AR, Bulas D, Shalaby-Rana E, et al. Color Doppler sonography and scintigraphy of the testis: a prospective comparative analysis in children with acute scrotal pain. Pediatr Emerg Care. 2002;18:67-71. (Prospective; 46 patients) 57. Doehn C, Fornara P, Jocham D, et al. Value of Acute Phase Proteins in the Differential Diagnosis of Acute Scrotum. Eur Urol. 2001;39:215-221. (Retrospective; 104 patients) 75. Middleton WD, Siegel BA, Melson GL, et al. Acute Scrotal Disorders; prospective comparison of color Doppler US and testicular scintigraphy. Radiology. 1990;177:177-181. (Prospective; 28 patients) 58. *Lau P, Anderson PA, Giacomantonio JM, and Schwarz RD. Acute Epididymitis in Boys: are antibiotics indicated? Br J Urol. 1997;79:797-800. (Prospective; 43 patients) 76. 59. Anderson PA, Giacomantonio JM. The Acutely Painful Scrotum in Children: review of 113 consecutive cases. Can Med Assoc J. 1985;132:1153-1155. (Retrospective; 113 patients) Tryfonas G, Violaki A, Avtzoglou P, et al. Late Postoperative Results in Males Treated for Testicular Torsion. During Childhood. J Pediatr Surg. 1994;29:553-556. (Prospective; 25 patients) 77. 60. Sidhu PS. Clinical and Imaging Features of Testicular Torsion: role of ultrasound. Clin Radiol. 1999; 54:343-352. (Review) Barbalias GA, Liatsikos EN. Testicular Torsion: can the testicle be saved one week later? Int Urol Nephrol. 1999;31:247251. (Case report) 78. 61. Dogra VS, Gottleib RH, Oka M, et al. Sonography of the Scrotum. Radiology. 2003;227:18-36. (Review) Haynes BE, Hynes VE. Manipulative Detorsion: beware of the testes that does not turn. J Urol. 1987;137:118-119. (Case reports) 79. 62. Hormann M, Balassy C, Pumberger W, et al. Imaging of the Scrotum in Children. Eur Radiol. 2004;14:974-983. (Review) Anderson MJ, Dunn KJ, Coburn C, et al. Semen Quality and Endocrine Parameters After Acute Testicular Torsion. J Urol. 1992:1545-1550. (Retrospective; 16 patients) 63. Lerner RM, Mevorach RA, Rabinowitz R, et al. Color Doppler US in the Evaluation of Acute Scrotal Disease. Radiology. 1990;176: 55-358. (Prospective; 27 patients) 80. DeVries CR, Miller AK, Packer MG. Reduction of Paraphimosis with Hyaluronidase. Urology. 1996;48:464-465. (Case report) 64. Kravchick S, Cytron S, Leibovici O, et al. Color Doppler Sonography; its real role in the evaluation of children with highly suspected testicular torsion. Eur Radiol. 2001;11:10001005. (Prospective; 38 patients) 81. Kerwat R, Shandall A, Stephenson B. Reduction of Paraphimosis with Granulated Sugar. Br J Urol. 1998;82:755. (Case report) 82. Handy FC, Hastie KJ. Treatment for Paraphimosis; the Puncture technique. Br J Surg. 1990;77:1186. (Case report) 83. Waters TC, Sripathi V. Reduction of Paraphimosis. Br J Urol. 1990;66:666. (Case report) 84. Kumar V, Javle P. Modified Puncture Technique for Reduction of Paraphimosis. Ann R Coll Surg Engl. 2001;83:126-127. (Retrospective; 37 patients) 85. Barone JG, Fleisher MH. Treatment of Paraphimosis using the “Puncture” Technique. Pediatr Emerg Care. 1993;9:298-299. (Case Report) 86. Webster TM, Leonard MP. Topical Steroid Therapy for Phimosis. Can J Urol. 2002;9:1492-1495. (Retrospective; 69 patients) 87. Ashfield JE, Nickel KR, Nickel JC, et al. Treatment of Phimosis with Topical Steroids in 194 Children. J Urol. 2003;11061107. (Prospective; 194 patients) 65. Wu HC, Sun SS, Lee CC, et al. Comparison of Radionuclide Imaging and Ultrasonography in the Differentiation of Acute Testicular Torsion and Inflammatory Testicular Disease. Clin Nucl Med. 2002;27:490-493. (Retrospective; 20 patients) 66. Atkinson GO, Patrick LE, Ball TI, et al. The Normal and Abnormal Scrotum in Children. Am J Roentgenol. 1992;158:613617. (Prospective; 32 patients) 67. Anderson PA, Giacomantonio JM, Schwartz RD. Acute Scrotal Pain in Children: Prospective study of diagnosis and management. Can J Surg. 1989;32:29-32. (Prospective; 36 patients) 68. 69. *Weber DM, Rosslein R, Fliegel C. Color Doppler Sonography in the Diagnosis of Acute Scrotum in Boys. Eur J Pediatr Surg. 2000;10:235-241. (Prospective; 65 patients) Baker LA, Sigman D, Docimo SG. An Analysis of Clinical Outcomes Using Color Doppler Testicular Ultrasound for November September2004 2003••EBMedPractice.net www.empractice.net 17 Pediatric Emergency Medicine Practice COPYRIGHTED MATERIAL—DO NOT PHOTOCOPY OR DISTRIBUTE ELECTRONICALLY WITHOUT WRITTEN CONSENT OF EB PRACTICE, LLC 50. COPYRIGHTED MATERIAL—DO NOT PHOTOCOPY OR DISTRIBUTE ELECTRONICALLY WITHOUT WRITTEN CONSENT OF EB PRACTICE, LLC 88. of the tunica vaginalis, leading to this anomaly. Huntley JS, Bourne MC, Wilson-Storey D, et al, Troubles with the foreskin: one hundred consecutive referrals to pediatric surgeons. J R Soc Med. 2003;96:449-451. (Prospective; 100 patients) 89. Golubovic Z, Milanovic D, Perovic S, et al. The Conservative Treatment of Phimosis in Boys. Br J Urol. 1996;78:786-788. (Prospective, randomized, double blinded, placebo controlled; 40 patients) 90. Kanegaye JT, Schonfeld N. Penile Zipper Entrapment: a simple and less threatening approach to using mineral oil. Pediatr Emerg Care. 1993;9:90-91. (Case report) 91. Saraf P, Rabinowitz R. Zipper Injuries to the Foreskin. Am J Dis Child. 1982;136:557-558. (Case report) 92. Strait RT. A Novel Method for Removal of Penile Zipper Entrapment. Pediatr Emerg Care. 1999;15:412-413. (Case report) 93. Nolan JF, Stillwell TJ, Sands JP. Acute Management of the Zipper Entrapped Penis. J Emerg Med. 1990;8:305-307. (Case report) 94. Douglas DD. Dissolving hair wrapped around an infant’s digit. J Pediatr. 1977;91:162. (Case report) 95. Blaivas M, Batts M, Lambert M. Ultrasonographic Diagnosis of Testicular Torsion by Emergency Physicians. Am J Emerg Med. 2000;18:196-200. (Case reports) 96. Blaivas M, Sierzenski P, Lambert M. Emergency Evaluation of Patients Presenting with Acute Scrotum Using Bedside Ultrasonography. Acad Emerg Med. 2001;8:90-93. (Retrospective; 36 patients) 97. Matterson JR, Stock JA, Nagler HM, et al. Medicolegal Aspects of Testicular Torsion. Urology. 2001;57:783-786. (Retrospective; 39 cases) 98. Adeyoju AB, Olujohungbe AB, Morris J, et al. Priapism in sickle-cell disease; incidence, risk factors and complications - an international multicentre study. BJU Int. 2002;90:898-902. (Questionnaire/Survey; 130 patients) 99. Maples BL, Hagemann TM. Treatment of priapism in pediatric patients with sickle cell disease. Am J Health Syst Pharm 2004;61:355-363. (Review) epididymitis A condition characterized by fever and symptoms of an acute scrotum. Believed to be caused by urogenital anomalies. hair tourniquet occurs when a hair forms a tight, constricting band around a penis Henoch-Schönlein purpura a systemic vasculitis of unknown etiology; presents with a palpable purpuric rash — most often on the buttocks and lower extremities — and concordant arthralgia/arthritis, abdominal pain, and nephritis hydrocele a collection of fluid around the testicle Kawasaki’s disease a systemic vasculitis of unknown etiology; presents with prolonged fever, non-purulent conjunctivitis, oral lesions, cervical lymphadenopathy, swollen/red extremities, cutaneous rash, urethral meatitis paraphimosis Occurs when the foreskin is pulled over the coronal sulcus of the glans penis and cannot return to its previous position. When the foreskin is trapped, it may form a tight, constricting band that may impede blood flow to and from the glans and prepuce, resulting in ischemic injury and vascular engorgement. A true urological emergency. testicular torsion a condition caused when the spermatic cord becomes twisted, obstructing venous and arterial blood flow to a testicle (most common in the left testes) 100. Jones SA, Flynn RJ. An unusual (and somewhat piercing) cause of paraphimosis. Br J Urol 1996;78:803-804. (Case report) toilet seat injury any trauma to the genitalia due to a falling toilet seat 101. MacLeod TM, Adeniran S. An unusual complication of penile piercing: a report and literature review. Br J Plast Surg 2004;57:462-464. (Case report) varicocele a defect in the valves of the venus plexus of the testicle; may feel like “a bag of worms” 102. Gazi MA, Ankem MK, Pantuck AJ, et al. Management of penile toilet seat injury - report of two cases. Can J Urol. 2001;8:1293-1294. (Case series; 2 patients) Physician CME Questions Glossary balanitis Inflammation of the glans penis 49. Which of the following statements is true regarding the “bell-clapper anomaly”? a. All boys with a bell-clapper anomaly eventually develop testicular torsion b. Boys with a bell-clapper anomaly will be infertile c. Boys with a bell-clapper anomaly make a ringing sound when they walk d. Boys with a bell-clapper anomaly have a propensity to develop intra-vaginal torsion balanoposthitis Inflammation of the prepuce and glans penis bell-clapper deformity The testes, epididymis, testicular artery, and spermatic cord can “twist” on its axis completely within the confines Pediatric Emergency Medicine Practice 18 EBMedPractice.net •November 2004 56. Balanitis refers to: a. injury to the testicles b. inflammation of the glans c. parasitic scrotal infection d. abrasion from zipper injury e. precocious puberty 57. Which of the following typically requires the most prompt treatment? a. neonatal phimosis b. paraphimosis c. balanoposthitis d. bell-clapper anomaly e. torsion of appendix testis 51. Which of the following is most consistent with testicular torsion? a. Absence of the cremasteric reflex b. Frequent dysuria c. Poor urinary flow at night d. Foul penile discharge e. Testicles low in the scrotum 58. Which of the following is usually the most important historical feature when evaluating boys with a penile complaint? a. travel history b. family history c. social history d. circumcision history e. type of underwear worn 52. Which of the following symptoms is most helpful in differentiating testicular torsion from other causes of acute scrotal pain? a. chills b. headache c. myalgias d. paresthesias e. vomiting 59. Which of the following is considered the most helpful in the evaluation of penile complaints? a. physical examination b. nuclear scintigraphy c. Doppler ultrasound d. penile specific antigen 53. Which of the following organisms is most commonly identified in cases of epididymitis in older adolescents? a. Haemophilus influenzae b. Methicillin Resistant Staphylococcus aureus (MRSA) c. Chlamydia trachomatis d. Rickettsia rickettsiae e. Streptococcus epididymitidae 60. Which of the following is a recommended treatment for balanitis? a. intracavernosal injection of alpha blocker b. cephalexin c. Doppler ultrasound d. immediate manual reduction 61. Which of the following is true regarding litigation for cases of testicular torsion? a. testicular torsion rarely results in litigation because boys have two testicles b. cases generally are won or lost based on the time from symptom onset to treatment c. emergency physicians and the physicians most commonly named in the lawsuit d. legal outcomes do not appear to be related to duration of symptoms before presentation 54. Which of the following most likely explains the scrotal findings in cases of Henoch-Schönlein purpura? a. testicular torsion b. torsion of the appendix testis c. vasculitis d. Müllerian degeneration e. epididymitis 55. Which of the following is most commonly associated with testicular tumors? a. severe pain on palpation b. a painless testicular mass c. recurrent epididymitis d. inguinal hernia e. bewildering fever November September2004 2003••EBMedPractice.net www.empractice.net 62. Which of the following conditions is most strongly associated with sickle cell anemia? a. balanitis b. priapism c. zipper injury d. paraphimosis e. testicular torsion 19 Pediatric Emergency Medicine Practice COPYRIGHTED MATERIAL—DO NOT PHOTOCOPY OR DISTRIBUTE ELECTRONICALLY WITHOUT WRITTEN CONSENT OF EB PRACTICE, LLC 50. Which of the following is true regarding the development of the foreskin? a. It is normal for the foreskin to be easily retractable at birth b. The presence of smegma is pathognomonic for sexual abuse c. If the foreskin cannot be retracted easily at birth, prompt circumcision is indicated d. Most boys should be able to retract their foreskin by the time they enter school e. Circumcised boys cannot contract balanitis COPYRIGHTED MATERIAL—DO NOT PHOTOCOPY OR DISTRIBUTE ELECTRONICALLY WITHOUT WRITTEN CONSENT OF EB PRACTICE, LLC Physician CME Information 63. Which of the following is an accepted treatment for phimosis? a. surgical exploration b. 1% hydrocortisone cream c. sitz baths d. manual detorsion This CME enduring material is sponsored by Mount Sinai School of Medicine and has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education. Credit may be obtained by reading each issue and completing the printed post-tests administered in December and June or online single-issue post-tests administered at EBMedPractice.net. Target Audience: This enduring material is designed for emergency medicine physicians. 64. Which of the following is the most serious sequela of paraphimosis? a. ischemic injury to the glans penis b. sickle cell anemia c. testicular torsion d. gynecomastia e. sepsis Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians. Date of Original Release: This issue of Pediatric Emergency Medicine Practice was published November 30, 2004. This activity is eligible for CME credit through November 1, 2007. The latest review of this material was November 19, 2004. Discussion of Investigational Information: As part of the newsletter, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product. Disclosure of Off-Label Usage: This issue of Emergency Medicine Practice discusses no off-label use of any pharmaceutical product. Coming in Future Issues: Accidental Poisoning • Vomiting And Diarrhea Faculty Disclosure: In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Ota, Dr. Wiebe, Dr. Kim, and Dr. Cohen report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Class Of Evidence Definitions Each action in the clinical pathways section of Pediatric Emergency Medicine Practice receives a score based on the following definitions. Class I • Always acceptable, safe • Definitely useful • Proven in both efficacy and effectiveness Level of Evidence: • One or more large prospective studies are present (with rare exceptions) • High-quality meta-analyses • Study results consistently positive and compelling Class II • Safe, acceptable • Probably useful Level of Evidence: • Generally higher levels of evidence • Non-randomized or retrospective studies: historic, cohort, or case• control studies • Less robust RCTs • Results consistently positive Class III • May be acceptable • Possibly useful • Considered optional or alternative treatments Level of Evidence: • Generally lower or intermediate levels of evidence • Case series, animal studies, consensus panels • Occasionally positive results Accreditation: Mount Sinai School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. Indeterminate • Continuing area of research • No recommendations until further research Credit Designation: Mount Sinai School of Medicine designates this educational activity for up to 4 hours of Category 1 credit toward the AMA Physician’s Recognition Award. Each physician should claim only those hours of credit actually spent in the educational activity. Pediatric Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category 1 credit (per annual subscription). Pediatric Emergency Medicine Practice has been approved by the American Academy of Family Physicians as having educational content acceptable for Prescribed credit. Term of approval covers issues published within one year from the distribution date of July 1, 2004. This issue has been reviewed and is acceptable for up to 4 Prescribed credits. Credit may be claimed for one year from the date of this issue. Pediatric Emergency Medicine Practice has been approved for 48 Category 2-B credit hours by the American Osteopathic Association. Level of Evidence: • Evidence not available • Higher studies in progress • Results inconsistent, contradictory • Results not compelling Significantly modified from: The Emergency Cardiovascular Care Committees of the American Heart Association and representatives from the resuscitation councils of ILCOR: How to Develop Evidence-Based Guidelines for Emergency Cardiac Care: Quality of Evidence and Classes of Recommendations; also: Anonymous. Guidelines for cardiopulmonary resuscitation and emergency cardiac care. Emergency Cardiac Care Committee and Subcommittees, American Heart Association. Part IX. Ensuring effectiveness of community-wide emergency cardiac care. JAMA 1992;268(16):2289-2295. Earning Credit: Two Convenient Methods • Print Subscription Semester Program: Paid subscribers with current and valid licenses in the United States who read all CME articles during each Pediatric Emergency Medicine Practice six-month testing period, complete the post-test and the CME Evaluation Form distributed with the December and June issues, and return it according to the published instructions are eligible for up to 4 hours of Category 1 credit toward the AMA Physician’s Recognition Award (PRA) for each issue. You must complete both the post-test and CME Evaluation Form to receive credit. Results will be kept confidential. CME certificates will be delivered to each participant scoring higher than 70%. • Online Single-Issue Program: Paid subscribers with current and valid licenses in the United States who read this Pediatric Emergency Medicine Practice CME article and complete the online post-test and CME Evaluation Form at EMPractice.net are eligible for up to 4 hours of Category 1 credit toward the AMA Physician’s Recognition Award (PRA). You must complete both the post-test and CME Evaluation Form to receive credit. Results will be kept confidential. CME certificates may be printed directly from the Web site to each participant scoring higher than 70%. Pediatric Emergency Medicine Practice is not affiliated with any pharmaceutical firm or medical device manufacturer. Publisher: Robert Williford. Executive Editor: Cheryl Strauss. Direct all editorial or subscription-related questions to EB Practice, LLC: 1-800-249-5770 • Fax: 1-770-500-1316 • Non-U.S. subscribers, call: 1-678-366-7933 EB Practice, LLC • 305 Windlake Court • Alpharetta, GA 30022 E-mail: [email protected] • Web Site: http://EBMedPractice.net Pediatric Emergency Medicine Practice (ISSN 1549-9650) is published monthly (12 times per year) by EB Practice, LLC, 305 Windlake Court, Alpharetta, GA 30022. Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication is intended as a general guide and is intended to supplement, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not be used for making specific medical decisions. The materials contained herein are not intended to establish policy, procedure, or standard of care. Pediatric Emergency Medicine Practice is a trademark of EB Practice, LLC. Copyright 2004 EB Practice, LLC. All rights reserved. No part of this publication may be reproduced in any format without written consent of EB Practice, LLC. Subscription price: $299, U.S. funds. (Call for international shipping prices.) Pediatric Emergency Medicine Practice 20 EBMedPractice.net •November 2004