1 How is the diagnosis of testicular torsion made?

A torsed testis is typically swollen and tender and lies higher in the scrotum than that on the contralateral side. Erythema of the scrotal skin may or may not be present. Edema increases with time. In the case of complete torsion, the cremasteric reflex is absent. The presence of a brisk cremasteric reflex with a 2- to 3-cm testicular shift makes the diagnosis of testicular torsion very unlikely. Pain may be referred to the abdomen. Systemic symptoms (nausea, vomiting, diaphoresis) may also occur. Color Doppler ultrasonography has become the imaging study of choice. Its availability increases its value as compared with scintigraphy. No clinical findings, laboratory tests, or radiographic studies can approach the sensitivity of surgical exploration.

2 How is testicular torsion differentiated from torsion of the appendix testis?

Although it can happen at any age, torsion of the appendix testis is most common from ages 7 through 12 years. Pain in torsion of the appendix testis is reportedly not as severe as that seen in testicular torsion. Classically, the blue dot sign on the scrotum indicates the site of the infarcted appendage, although as edema increases this may become obscured. In the early stages, pain may be localized initially to the upper pole of the testis, with the remainder of the testis nontender. Doppler ultrasonography reveals normal or increased blood flow to the affected testis in the case of torsion of the appendix testis, whereas arterial blood flow is absent or diminished in the case of testicular torsion. None of these studies is perfect, and changes in blood flow may be missed, especially in the case of intermittent torsion. Treatment for torsion of the torsed appendix includes analgesics or anti-inflammatory medications and rest. Pain should resolve in 2–5 days.

3 Why does epididymitis occur more frequently in adolescent males?

Epididymitis indicates the presence of inflammation of the epididymis. It generally results from infection, which may lead to an enlarged and tender epididymis on palpation. Patients may also have evidence of urinary tract infection (UTI), including dysuria and frequency. Most cases in young men are caused by sexually transmitted organisms, predominantly Chlamydia trachomatis, followed by Neisseria gonorrhoeae and Ureaplasma urealyticum. These organisms are common among adolescent boys. Patients should be treated for both chlamydia and gonorrhea. Epididymitis is extremely rare among prepubertal boys; if it is diagnosed, further investigation is warranted to rule out structural abnormalities of the urinary tract.

4 Can epididymitis be treated on an outpatient basis?

Patients who are febrile and toxic-appearing should be admitted to the hospital for treatment with IV antibiotics, and possibly for further diagnostic tests to exclude a scrotal or testicular abscess (e.g., testicular ultrasonography). Otherwise, outpatient therapy is appropriate. Treatment for sexually transmitted disease–related epididymitis includes a single dose of ceftriaxone, 250 mg intramuscularly, and doxycycline, 100 mg orally twice daily for 7–10 days. Also evaluate and treat the patient’s sexual partner(s).

5 Describe the difference between phimosis and paraphimosis

Both of these conditions are seen in the uncircumcised male. Phimosis occurs when the distal foreskin is too tight to retract over the glans penis. Paraphimosis occurs when the foreskin is left in the retracted position, becomes swollen and edematous, and is then unable to be reduced (Fig. 49-1). Phimosis is not generally a problem in children, and is normal in boys younger than 6 months. Frequent retraction of the foreskin should not routinely be attempted in infants. In contrast, paraphimosis should be reduced. This is generally accomplished by application of lidocaine gel to the swollen foreskin, followed by steady pressure on the glans. Then pull the foreskin forward while pushing the glans backward with the thumb, as you would to turn a sock inside out. A dorsal penile block with local anesthetic may make the patient more comfortable, but it is generally not needed.

Figure 49-1 Paraphimosis. (Photo by John Lorselle, MD, with permission.)

6 What is balanoposthitis?

Balanoposthitis occurs in uncircumcised boys. It is an infection of the foreskin that may also affect the glans. If the foreskin is irritated as the result of poor hygiene, a break in the skin may occur, allowing bacteria to establish cellulitis. Treatment includes warm soaks and oral antibiotics (amoxicillin). Voiding may be more comfortable while the patient is sitting in a tub of warm water. True phimosis may occur as a complication, resulting from scarring after the inflammatory reaction. Circumcision may be necessary to avoid recurrent infections. The term balanitis is used to describe an infection involving only the glans penis.

7 What are other causes of penile swelling in children?

Penile swelling is usually painful and results from infection, sickling of red blood cells, or trauma. Other considerations in the presence of isolated, nontender penile swelling include insect bite (look for the lesion), allergic reaction, or more generalized edematous states, including renal, cardiac, or hepatic problems.

8 How do a “communicating” and a “noncommunicating” hydrocele differ?

A hydrocele is an accumulation of fluid within the tunica vaginalis surrounding the testis. Although it may arise in the case of torsion, trauma, tumor, or epididymitis, a simple hydrocele may be present in the absence of any underlying testicular abnormality. Infants may be left with a simple noncommunicating hydrocele when fluid is trapped around the testis after the processus vaginalis has closed during development. The baby presents with painless scrotal swelling of constant size. Management consists of observation only, as most are resorbed by the age of 12–18 months.

If the history is of scrotal swelling that “comes and goes,” especially with crying or exertion, the same fluid may be present, but the processus vaginalis has not closed. This allows “communication” between the scrotum and the abdominal cavity. Treatment in this case is surgical exploration with ligation of the processus vaginalis and drainage of the hydrocele.

Brenner J, Ojo A: Causes of painless scrotal swelling in children and adolescents: www.uptodate.com

9 In an infant, how can a hydrocele be differentiated from an inguinal hernia?

The history given with an inguinal hernia is generally that the parents have observed a nonpainful, nonerythematous scrotal and inguinal swelling in males, or inguinal swelling in females. The swelling typically occurs when the baby is crying or straining. Sometimes bowel sounds can be heard over the mass. In contrast, the swelling of a hydrocele, though it may extend toward the inguinal canal, should not be felt as a mass at the internal inguinal ring.

Transillumination with a high-intensity light does not definitively make the distinction. Although the mass of a hydrocele generally does transilluminate, transillumination of a hernia can be variable.

10 What should be done to reduce an inguinal hernia?

First determine that the testes are bilaterally descended. Apply steady, gentle pressure to the mass in the direction of the inguinal ring. Often the mass will slip easily back into the abdominal cavity. It may take several minutes of steady pressure to accomplish this goal. If the hernia remains difficult to reduce, it may be necessary to sedate the child (e.g., with midazolam), and place him or her in the Trendelenburg position. This may be enough to allow the child to relax and the hernia to reduce.

11 What is a ureterocoele?

A ureterocele is a dilation of the distal ureter that produces a cystic structure within the bladder. Ureteroceles can prolapse out of the bladder neck, and in doing so may cause bladder outlet obstruction. In a female, a ball valving ureterocele is the most common cause of bladder outlet obstruction. These patients will present with a painless pink cystic structure that is bulging out between the labia. This may be reduced by placing a feeding tube within the bladder. Ureteroceles should be managed by urologists, who will usually opt to carry out an endoscopic puncture and decompression of the obstructed system.

12 How can one distinguish between a prolapsed ureterocoele and a prolapsed urethra?

The differentiation of a prolapsed ureterocele and urethral prolapse can usually be made by physical examination. A urethral prolapse appears as a red or purplish doughnut-shaped mass. It is usually not tender and is 1–2 cm in diameter. A small central dimple indicates the lumen of the urethra. Rarely, there may be a dark ring of necrotic tissue around the edge of the prolapse. In contrast, the prolapsed ureterocele is a cystic swelling of the terminal ureter and appears as a cystic mass protruding from the urethra. They are frequently associated with ureteral duplication.

13 What is the most common cause of severe obstructive uropathy in children?

Posterior urethral valves is most common and occurs only in boys. If the condition is not diagnosed in utero, the infant presents with a palpably distended bladder and a weak urinary stream. Urgent urologic consultation is indicated.

14 What is the first evaluation to do for a patient with “blood in the urine”?

Confirm that the red urine actually contains blood. Urine can appear red as the result of ingestion of a number of foods (blackberries, beets, red Kool-Aid drink, Fruit Loops cereal), substances (aniline dyes, urates), or drugs (phenazopyridine, phenolphthalein). A urine dipstick test can quickly and easily determine whether blood is present. If the result is positive, send the urine for microscopic analysis to determine the presence or absence of red blood cells. Myoglobin will also give a positive result for blood on the dipstick. The presence of > 5–10 red blood cells/high-powered field should be considered hematuria, often warranting further work-up.

15 Describe the differences among bacteriuria, cystitis, pyelonephritis, and urethritis

Bacteriuria refers to the presence of bacteria anywhere in the urinary tract. It may or may not cause symptoms.

Cystitis and pyelonephritis are part of the continuum of UTIs. Cystitis is bacteriuria with invasion of the bladder mucosa. Patients with cystitis present with urgency, frequency, and dysuria, and may on occasion develop a low-grade fever.

Pyelonephritis occurs when the UTI has localized within the renal parenchyma and causes systemic symptoms; thus, it is the most serious of UTIs. Children present with fever (temperature often > 39° C) pyuria, and bacteruria, often accompanied by nausea, vomiting, leukocytosis, flank pain, and tenderness.

Urethritis indicates inflammation or an infection localized to the urethra. There is usually a discharge, and in adolescents, urethritis generally is a manifestation of a sexually transmitted disease (C. trachomatis or N. gonorrhoeae infection). Urethritis can also result from noninfectious causes, including local irritation from detergents, fabric softeners, soaps, or bubble baths, as well as minor injury.