+ Clinical Case Presentation “It Hurts Down There” Patty Lynch N584 + Clinical Setting Pediatrics Urgent Care (Pediatric & Adult Walk-in) Allergies & Asthma Behavioral Health + Woodcreek Healthcare 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, wait...it 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. Habits 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, 1999). + 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 changes 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 viruses) 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. 2004) 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 torsion. Gray-scale U/S not useful for R/O torsion. Color doppler U/S preferred. $200-300 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. + Plan 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 cycle References Belman, B. 2004. The adolescent varicocele. Pediatrics, Vol 114(6), pp 1669-1670. Eyre, R. 2009. Evaluation of nonacute scrotal pathology in adult men. Retrieved November 1, 2009 from www.uptodate.com 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.