“It Hurts Down There”

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Clinical Case

                “It Hurts Down There”
                  Patty Lynch

       Pediatrics

       Urgent Care (Pediatric & Adult Walk-in)

       Allergies & Asthma

       Behavioral Health
       Sunrise Office
        - Pediatrics - 7 MDs, 2 PNPs, Lactation Consultant
        - Convenience Care – 2 MDs, 4 PA-C, 4 FNP
        - Allergy & Asthma – 1 MD, 2 MAs

       Bonney Lake Office
        - Pediatrics – 5 MDs, 1 PNP

       Puyallup Office
        - Behavioral Health – 1 Psychiatrist, Psychologist,
          Social Worker, & Crisis Counselor
        - Pediatrics – 4 MDs, 1 PNP
        - Convenience Care – 3MDs, 3 PA-C, 3 FNPs

       Diagnostics (Puyallup) – Onsite blood draw. MRI,CT, radiology, U/S
        across the street.
+ Clinical Presentation
    Patient Data “J.L.”
     - 18 year old Caucasian male.
     - Arrived at clinic by himself.
     - Mode of transportation – skateboard

    Chief Complaint
     Cough, “no, hurts down there”
    History - HPI

       Painful left testicle x2 days

       Swollen area above left testicle, swelling noticed with onset
        of pain, worse this morning.

       Pain is dull, constant. Not relieved with position changes.
        Worse standing up.

       Denies: feeling ill, penile discharge, genital skin changes,
        dysuria, N/V/D, change in bowel habits, muscular skeletal
        problems, or fever. Slight ABD pn, LLQ.

       No known trauma
+ History
Sexual History

   One lifetime partner, 2 yrs ago

   Not sexually active at this time

   Always uses condoms

   No PMH STIs

Past Medical History

   Not significant for trauma, major illnesses, chronic health issues

   NO PCP of record. Immunization status unknown.

Past Surgical History

   No previous surgeries

   No hx of hernia
+ History
 Family History
    Lives with parents. Attending school.

    Works out 2-3x week.
    Weightlifting this week. Had “super weird feeling” with weight
     lifting “down there” in past couple of weeks.
    Non-smoker, no alcohol use or illicit drug use
    No hot tub use
    No piercings or tatoos in genital area
    Objective Data
   Vital Signs
    Wt: 151 lbs., Ht.: 72 in., BMI: 20.55, Temp: 98.4F, Pulse: 58, BP 122/82,
    O2 Sat 99%.

   No apparent distress, breathing unlabored

   ABD: no tenderness, no organomegaly. BT x 4 quadrants.

   GU: (pt. standing)
     - circumcised penis, w/o lesions
    - no penile discharge, edema, erythema
    - rt. testicle within normal limits – no mass or edema, nontender
    - left testicle with edema, without atrophy, slightly eyrthematous,
      very tender to palpation, no mass.
    - no pain relief with elevation of testicle (neg Prehn’s sign)
    - negative hernia exam
    - intact cremasteric reflex bilaterally

   Diagnostic: UA normal, culture pending
    Anatomy Review
     Differential Diagnosis
     (Scrotal Pain & Swelling)
1.   Testicular torsion (twisting of
     spermatic cord resulting in
     compromised testicular blood flow)
     R/I: diffuse scrotal pain, neg UA,
     scrotal edema, lower Abd pn., no
     discharge, no N/V (50% pts), no
     dysuria, neg Prehn’s sign (+ = pain
     relief with elevation of testicle)
     R/O: no acute distress, sudden
     onset of pain, not in early puberty, +
     cremasteric reflex (although
     appendiceal torsion would have
     +cremasteric reflex), absence of
     “blue dot” sign @ superior aspect
     of testicle, testes not retracted,
     epididymis not displaced (Gales,
    Differential Diagnosis
    (Scrotal Pain & Swelling)
Epididymitis (inflammation of epididymis)
   R/I: onset of pain insidious, high incidence in adolescence, +
   cremasteric reflex, no palpable mass
   R/O: + for diffuse pain w/o epididymal tenderness, rarely
   associated with heavy lifting or straining (Richardson, B. 2006),
   negative Prehn’s sign
   +/-: UA, urethral discharge, N/V rare, voiding sx, fever, bilateral

Hydrocele (collection of peritoneal fluid trapped between the parietal
   and visceral layers of the tunica vaginalis)
   R/I : edema (light reflex not tested), unilateral swelling w/o skin
   R/O: primary occurrence in neonatal period, idiopathic
   occurrence later in life typically associated with neoplasm, torsion,
   injury, infection. PM edema not increased over AM swelling,
   idiopathic hydroceles often asymptomatic.
    Differential Diagnosis
    (Scrotal Pain & Swelling)
    Testicular tumor
       R/I: most common tumor in males (15y-30y), L Abd pn.
       Sensation of heaviness (“super weird feeling?”)
       R/O: absence of firm, painless mass.

    Orchitis (swelling of one or both testes, caused by bacteria or
       R/I: pain and swelling, may be associated with
       epididymitis, L. testicle slightly erythematous
       R/O: commonly associated with mumps, w/ onset 4-5 days
       afterwards, low STI risks (GC), no discharge, no sx illness
    Differential Diagnosis
    (Scrotal Pain & Swelling)
    Varicocele (dilated plexus of
      scrotal veins above testicle)

      R/I: non-acute onset of pain, sx in
      left testes, + cremasteric reflex,
      onset in older adolescence,
      sensation of heaviness, increased
      pn with wt lifting (Ragano, E.

      R/O: “bag of worms” not
      palpable, no bluish discoloration,
      not relieved by recumbancy, no
      unilateral testicular atrophy
Diagnostic Data: Ultrasound
  Torsion – surgical exploration used
  to be the standard. Recent studies
  have shown that only 16-42% of
  boys with acute scrotum have

  Gray-scale U/S not useful for R/O
  torsion. Color doppler U/S preferred.

  Varicoceles can be reliably
  diagnosed with U/S. The use of color
  Doppler is a particularly easy
  technique to evaluate varicoceles.
  Performing a valsalva maneuver
  during an ultrasound examination
  can improve diagnostic confidence.
    Varicocele, Scrotal (ICD-456.4)
       Patient DC to home

       Called patient with diagnosis

       Treatment Plan:
        - scrotal support
        - NSAID q 6-8 hrs for scrotal pain
        - Apply cold pack to area
        - avoid exercise and movements that increase
          abdominal pressure
        - provided information for Urology consult
        - Encouraged to call for consult
        - Pt education: condition may be self-resolving, or may
         require surgery
        - Discussed association with infertility and importance of F/U
+ Things To Know About Varicoceles
   Present in about 15%-20% of all adult & adolescent males

   Its rare before age 10yrs – may be indicative of malignancy

   Varicocele is the most common cause of adult male infertility
    (elevated temp, hypoxia due to stasis, suboptimal conc of intratesticular
    testosterone via dilutional effect all impact sperm)

   Palpable unilateral varicoceles occur on left side 85%-95%.
    (left spermatic vein enters renal vein at rt angle. Pressure in L renal vein is >
    R, because its compressed btwn aorta and superior mesenteric artery,
    thereby increasing presssure in left gonadal vein (e.g., “nutcracker effect”).
    Causes dilation & incompetence of valve leaflets. Increased with valsalva.

   If palpable rt side, then usually occurs bilaterally.

   Later research says 87% are actually bilateral (Gat, 2003). Bilateral more
    damaging to infertility (Kapes, B. 2001)

   Rarely unilaterally on R. Think pathological problems in rt renal vein. (Eyre,
    R. 2009)
+ Things to Do
   Key to diagnosing varicocele is an accurate PE. Teens are usually
    asymptomatic, so most detected at annual PE

   Examine in standing position to accentuate dilation. Keep room warm. Know
    your landmarks, check illumination. Use valsalva.

   Document Grade
    Subclinical – not detectable by PE (ultrasound, venography- best, but
    expensive and invasive)
    Grade I palpable only with valsalva
    Grade II easily palpable w/o valsalva
    Grade III visible through skin

   Hallmark of testicular damage is atrophy (but growth arrest is reversible in
    most pts)

   Measure Vol (mL) = .523xLxWxD, >2ml = damage. Min for surgery

   Examine supine – varicocele thickend cord resolves. One associated with a
    lipoma will not change.            (Uphold & Graham, 2003)
    Ethical – Medical Issues
                We Don’t Check Closely Enough At Annual Exams

       Infertility r/t size of varicocele and length of time present

       Majority of Pediatricians do not routinely perform PEs for
        varicoceles, despite being aware of significance of condition
        (Kubal,A. et al. 2004).

       Examination of adolescent male to identify presence of
        varicocele should be routine for pediatrician. Detection of
        condition warrants prompt referral of pediatric urologist (Belman,
        B. 2004)

       Annual PE ($250), Varicocelectomy/Embolism $4,000, IVF $20,000
Belman, B. 2004. The adolescent varicocele. Pediatrics, Vol 114(6), pp
Eyre, R. 2009. Evaluation of nonacute scrotal pathology in adult men. Retrieved
    November 1, 2009 from
Gales, L. and Kass, E. 1999. Diagnostic and treatment of the acute scrotum.
    American Family Physician Feb 15
Gat, Y. 2003. Adolescent Varicocele: Is it a unilateral disease? Pediatric Urology,
    62(4): 742-747
Kapes, B. 2001. Are bilateral varicoceles more damaging to fertility? Urology
    Times, January, Vol 29(1).
Kabal, A. et al. 2003. The adolescent varicocele: diagnostic and treatment
    patterns of pediatricians. A public health concern? Journal of Urology,
   Jan; Vol 171(1) pp 411-113.
Rigano E, et al. 2004. Varicocele and sport in the adolescent age. Preliminary
    report on the effects of physical training. J Endocrinol Invest. Feb
   27(2): 130-2.
Skoog, S. et al. 1997. The adolescent varicocele: What’s new with an old
    problem in youngpPatients? Pediatrics, July 100(1).
Uphold, C. and Graham, M. 2003. Clinical Guidelines, 4th Edition.Barmarrae
    Books, Inc., 655-66 pp.

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