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Testicle Pain

UnFiNiShEd CaSe CoMe BaCk LaTeR

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History of Present Illness:

A 12-year-old male presents to the ED for 10 hours of right testicle pain.  He vomited twice    He denies  or other complaints

Vital Signs & Physical Exam:

Vital signs are normal.  Physical exam is normal except for a very firm but only slightly enlarged right testicle.  There is no visible abnormality

Initial Differential Diagnosis:

  • Epididymitis
  • Testicular torsion
  • Appendix testis torsion

Initial Diagnostic Testing:

  • EKG: none
  • Labs: none ordered
  • Imaging: none

QUESTIONS:

  1. What does the case image show?  
  2. What should you do next?  
  3. Want a 1-minute consult/tutorial on this case? 
  4. Want to know what happened with this patient?

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ANSWERS:

  1. What does the case image show?  The image shows .
  2. What should you do next?  Order a urology consult and a stat ultrasound.  Detorse as soon as possible.
  3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  4. Want to know what happened with this patient?  See case conclusion below tutorial page.

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

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CASE CONCLUSION: The pain improved but did not completely resolve with manual bedside detorsion.  The patient was taken to the OR before ultrasound called for him.  He had bilateral orchiopexy and did well.

CASE LESSONS:

  1. Be leery: For any male under age 16 be very leery about attributing testicle pain to anything other than torsion even when there is vascular flow and some other imaging abnormality.  Epididymitis is very rare unless a teen is sexually active, and even then be leery.
  2. Consult early: call urology early when suspicious, preferably simultaneously with ordering an ultrasound.
  3. Don’t delay detorsion: it’s better to have a patient with a useless ultrasound than one with a useless testicle.  Don’t delay treatment for unnecessary tests.  Imaging should be reserved for equivocal cases or when requested by urology.  The treatment is detorsion in the ED or the OR.
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