Triage: Left testicle pain for 3 weeks

History of Present Illness: An 11-year-old presents to the ED for a month of intermittent left testicle pain.  The other two times it resolved after about 20 minutes but today has lasted more than an hour and he feels like he might vomit.  He denies fever, dysuria or other complaints and is otherwise healthy.

Vital Signs: Pulse 92, BP 145/83, Resps 18, temp 98.1

Physical Exam: Has bilaterally descended testicles with both testicles riding a bit high and symmetric cremaster.

 

What should you do next?

  • A) ultrasound
  • B) UA
  • C) nuke med
  • D) none of the above

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

 

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What should you do next?

  • A) ultrasound – study of choice AFTER detorsion.  Often shows false flag findings like epididymitis or hydrocele.
  • B) UA – OK to include
  • C) nuke med – an option if ultrasound not available
  • D) none of the above – CORRECT – You should attempt manual detorsion.

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

CASE CONCLUSION: complete relief of pain after detorsion.  Open book failed so closed book done and succeeded.  Ultrasound had false positive results (not uncommon after restoration of flow)

                                                                           Sagittal View

FINDINGS: Normal Doppler flow. No evidence of torsion. Asymmetrically enlarged heterogeneous left epididymis.  Small left hydrocele.

IMPRESSION: FINDINGS SUSPICIOUS FOR MILD LEFT EPIDIDYMITIS.

CASE LESSONS:

  • If your male patient is too young to drive he is too your for epididymitis or an STD (rare exceptions)
  • After spontaneous or therapeutic detorsion US may show epididymitis and/or hydrocele from reperfusion hyperemia.  These are false flags!
  • Detorse early.  Better to have a useless test than a useless testicle