4/23/2018

Pediatric Epididymitis Associated with Testicular Pain (Acute Epididymitis)

Louis J. Wojcik, MD, FAAP CHKD Pediatric Urology

 I have no conflicts of interest to report.

The Challenge:

 Seems easy to tell you what it is.  However, you must exclude a whole lot of other things as well!

• And they want me to do this in a ridiculously short timeframe (I was asked for 15min and booked for 20min – and we could spend hours)

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Differential Dx of Hot Scrotum (You have not nailed the diagnosis till you exclude mimics!)

 Epididymitis (common in kids, less common in adults)  Epididymo-orchitis (common in adults, less common in kids)  Testicular Torsion  Torsion of a ‘scrotal’ appendage  Trauma  Infection (bacterial; mumps orchitis; fungal infections)  Inguinal Hernia/Hydrocele  Varicocele  Testicular Tumors  Idiopathic Scrotal Edema  HSP

Frequent Causes of Acute Pediatric Epididymitis (personal bias based on experience)  #1 – Don’t know  #2 – Don’t know  #3 – Don’t know  #4 – Misdiagnosis

 Torsion (testis or appendix T or E)

 Trauma (pendulous scrotum, squished ‘nad)  #FarOutThere – Infection

Age Seems to Matter

 Infants, Children (the single digit kids)

 Think GU abnormalities • ARM (anorectal malformations) • VATER (dysfunctional bladder) • Ectopic vas or ureter  Older kids (pubertal)

 Trauma, infection, STD

 But little kids with anatomic issues do grow up, so remember the patient history!

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Anatomy

Hinman’s Atlas of UroSurgical Anatomy, Figure 17-29

Embryology

Pediatric Urology, 2nd Ed (2010), Fig 1-3; 1-5

And your beeper goes off …

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Everything was fine until:

Scrotal / Testicular / Groin / Abdomen: Pain and/or Swelling and/or Redness was noticed by the patient / parent / MD

WOW! THIS IS SO NONSPECIFIC!!!!

We’re Doctors, so what we do next is not a mystery

 History  Physical Exam  Minimal lab work:

 UA, UCx, possible CBC

 Gram stain / culture any urethral discharge  Imaging (scrotum and kidneys!)

 In this day and age, that means a color doppler ultrasound!

The Ultimate Diagnostic Test

 Surgery!

 Not the first choice unless there is no other option

 Sometimes have to differentiate acute epididymitis vs intermittent torsion with inflammation, and this is how you do it.

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History

 What was happening when pain started  Acute (quick) vs Sub-acute (slower onset)  Severity (Smiley Face Scale)  Constant vs Intermittent  Alleviating vs Aggravating Factors  Localization; Radiation of pain  Previous episodes  Hematuria, Dysuria, Discharge, Sexual history  PMH (ARM, SCI, spina bifida, severe hypospadias)  Screen for voiding issues

Physical Exam

 Overall condition of the patient

 I walk in the room and look at the patient to see if he is ‘toxic’ or not.  The “usual suspects” (heart, lungs, etc)  Abdominal and inguinal exam  Penile exam (discharge)  Scrotal exam

 Save the most painful part for last

Scrotal Exam

 Size  Symmetry  Erythema  Lesions  Feel (induration, fluctuance)  Transillumination (or not)  Cremasteric Reflex  Localization of pain (testis, epididymis, groin)  Prehn’s Sign = Elevation of the testis decreases pain in epididymitis, not torsion

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Cremasteric Reflex

 Stroking the upper inner thigh causes contraction of the cremasteric muscle, and this raises the testicle  Sensory from the ilioinguinal and femoral branch of the genitofemoral n.  L1/L2 spinal level reflex arc  Genital branch of GF nerve causes contraction of the cremasteric reflex

Cremasteric Reflex

 Present in most, but not all, normal boys with no symptoms whatsoever

 Most reliable in the 3-12 year old boy  May be present very early in torsion  Absent later in torsion (100% absent in Rabinowitz’ series of torsion)

Prehn’s Sign

 Elevation of the testis relieves pain in epididymitis, but not testicular torsion

 The theory is that taking tension off the epididymis decreases the pain of epididymitis

 Frankly, I haven’t found this helpful

6 4/23/2018

FIRST: RULE OUT TORSION!

 Horizontal Lie of Testis

 When present with pain…. • Boston Children’s group found this to be significantly (p<0.05) associated with a bell-clapper deformity at surgery.

Intermittent testicular torsion: diagnostic features and management outcomes. J Urol 2005 Oct;174(4 part 2):1532-5.

FACT: You are Going to Get A Color Doppler Ultrasound

 Sensitive (88%) and Specific (93%) with regards to testicular torsion  Defines ANATOMY and BLOOD FLOW  Defines OTHER PATHOLOGY  However, blood flow to the normal prepubertal testis is low, which can result in a ‘false positive’  NOTE: We at CHKD always image the kidneys when we do a CDUS (looking for the anatomic!)

Does color doppler sonography improve the clinical assessment of patients with acute scrotum. Eur J Radiol 2006 Oct;60(1):120-4.

Normal Pre-pubertal Testis

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Diagnostic Mandate

 Prevent testicular loss  Preserve net testicular function

 (really means preserve future fertility potential as best possible)

(Although these may seem redundant at first glance, they really are complementary.)

Causes of the “Hot” Scrotum

 Epididymitis  Epididymo-orchitis  Testicular Torsion  Torsion of a ‘scrotal’ appendage  Trauma  Infection  Inguinal Hernia/Hydrocele  Varicocele  Testicular Tumors  Idiopathic Scrotal Edema  HSP

Causes of Painful Scrotum (4 different studies)

Testicular Torsion 26%, 47%, 12%, 26%

Epididymitis 26%, 44%, 44%, 10%

Torsion of Appendage 47%, 9%, 18%, 45%

Acute scrotum in children: analysis of 265 consecutive cases, Pediatr Med Chir 1994 Nov-Dec;16(6):521-6. Clinical presentation of acute scrotum in young males. Kaohsiung J Med Sci 2007 Jun;23(6):281-6. Acute epididymitis in Greek Children: a 3-year retrospective study. Eur J Pediatr 2008 Jul;167(7):765-9. A 19-year review of paediatric patients with acute scrotum. Scand J Surg. 2007;96(10):62-6.

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Testicular Torsion

 First peak under age 2 years (mini puberty)  Second peak in adolescence (10-19 years)

 (peak age is 14 years)  Incidence: approximately 1/4000-20000 boys

 Simply need:

 Volume (mass) of testis to twist

 appropriate anatomy to allow twist • (Bell-clapper deformity)

Bell-Clapper Deformity

 Autopsy series of Caesar and Kaplan in 51 boys (101 testicular dissections)  Findings:

Normal 76 75%

Equivocal 13 13%

Bell-Clapper 12 12%

Testicular Torsion Presentation

 Pain (most common symptom)

 Usually takes pain to get a boy to mention his testicles to a parent.  Absent ipsilateral cremasteric reflex (99%)

 Ipsilateral cremasteric may be preserved very early in torsion!  Hemiscrotal Swelling (~50%)  Abnormal lie (high, horizontal)  Induration (later)  Erythema (infrequent and much later)

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Causes of Testicular Loss

 Review of 179 cases of testis torsion  Most common causes for loss:

 Delay in presentation (58%)

 Initial incorrect diagnosis (29%) • Often mistaken as epididymitis!!!

 Delay in treatment elsewhere (13%) • Interestingly, the literature suggests that transfer from an outlying hospital not a risk factor for testicular loss.

Testicular torsion in the armed services: twelve year review of 179 cases. Br J Surg 1986;73:624-6.

A much larger view of testis loss…  1998 nationwide inpatient sample  436 evaluable patients, ages 1-25 years  149 (34%) resulted in orchiectomy  Risk Factor: AGE

 Odds ration increase of 1.08/year

 Risk doubles for each decade age increase

Testicular torsion and risk factors for orchiectomy. Arch Pediar Adolesc Med 2005 Dec;159(12):1167-71.

Time Matters!

 < 6 hours => 90% salvage

 12+ hours => 50%

 24+ hours => <10%

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Intermittent Testis Torsion

 Testis twists / untwists on mesorchium  Acute pain … that goes away

 Often labelled “epididymitis” for lack of a better diagnosis at the time!  Recurrent ’suggestive but not diagnostic’ episodes strongly correlate with torsion!

 Elective OR = 100% testicular preservation

 Emergency OR = 47% testicular preservation

Intermittent testicular pain: fix the testis. BJU Int 2003 Mar;91(4):406-8. Intermittent torsion of the spermatic cord portends an increased risk of acute testicular infarction. J Urol 2008 )ct;180(4 Suppl):1729-32.

Intermittent Torsion Profile

 Mean age 12.2 years (similar to torsion)  Mean # previous pain episodes (4.3)  Severe pain of rapid onset and recovery  Nausea / emesis in 25%  Resolution of symptoms in majority (97% in the 3/4ths with recorded follow-up)

Intermittent testicular torsion: diagnostic features and management outcomes. J Urol 2005 Oct;174(4 part 2):1532-5.

Trauma

 No real diagnostic dilemma here  Hit or kick to the scrotum results in blunt force injury to the testis and/or epididymis.  Really looking for things which need OR

 Rupture of the testis

 Expanding hematoma

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Trauma Can Cause Epididymitis

 Sometimes it’s obvious

 Soccer ball to the ‘nads incidents  Often this is hard to prove …  However, if you push, you can often (but certainly far from always) get a history of a minor whack to the scrotum a few hours to day or two before clinical epididymitis  Maturing inflammation = Epididymitis

Severe Trauma is Hard to Miss

Acute Pediatric Epididymitis

 The pediatric patient usually presents with epididymitis, not epididymo-orchitis.

 If the patient also has ORCHITIS, you have to consider:

 Trauma (good ole whack to the nut!)

 Bacterial infection (really bad actor)

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Presenting Symptoms

 Pain (76%)  Hemiscrotal swelling (88%)  Erythema (37%)

 Common early finding (unlike in torsion)  Occasionally fever (16%)  Symptoms usually present longer (days) than in those boys with torsion (hours)

A 19-year review of paediatric patients with acute scrotum. Scand J Surg 2007;96(1):62-6.

Antibiotics?

 Routine antibiotics not necessary

 (Acute epididymitis in boys: are antibiotics indicated?, Lau etal, Br J Urol. 79:797-800 1997)  However… Antibiotics are useful when:

 More than a little swelling / erythema

 Pyuria

 Urethral discharge/drainage

 Known UTI

 Known congenital GU anomalies / ARM

 US abnormalities other than just increase flow

Ibuprofen

 Cheap  Readily available  Great anti-inflammatory  Seems to shorten time of symptoms

 (personal observation)

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Swollen, Hyperemic Epididymis

Thickened Tunica Vaginalis

Bacterial Epididymitis

 Typically associated with UTI (coloforms)  Dysuria, Fever, Leukocytosis  Associated with structural abnormalities

 Anorectal malformations

 Posterior Urethral Valves

 Neurogenic bladder

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Bacterial Epididymo-orchitis

 All of the above applies  In my experience, there is a 100% testicular loss (appropriate high dose IV antibiotics over many days just does not work well)

 That said, I’ve seen two cases in 20 years

Torsion of Appendix T or E

 Actually, relatively common  Vestigial remnants of the mullerian (appendix testis) or wolffian (appendix epididymis) ducts  Present, but small, in over half of boys  Usually incidental surgical finding  “Classic”, but rarely seen, ‘blue dot sign’  After a while they get reactive epididymitis

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Scrotal Infections

 Pain usually in association with induration (swelling, edema) and erythema.  Look for obvious source

 Have to look UNDER the scrotum, too! • There are a lot of butt abscesses in kids, and things can track forwards  Hidradenitis doesn’t usually present till puberty or pre-puberty

Inguinal hernia/hydrocele

 Most of these are asymptomatic  Widespread access to good medical care means than very few hernias and hydroceles become acutely painful.

 However, incarcerated hernias can present with a painful, swollen scrotum and be mistaken for acute epididymitis

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Varicocele

 In my personal experience, pain is an infrequent symptom of varicoceles, but responds well (>95% resolution) to surgical repair of the varicocele.

 In my experience, varicocele pain has been associated with strenuous activity or sexual intercourse.

Idiopathic Scrotal Edema

 Acute onset scrotal swelling (erythema not usually present)  Pain usually mild  Diagnosis of exclusion (doesn’t exclude causes, just ‘known’ causes)

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Henoch-Schonlein Purpura

 Nonthrombocytopenic systemic vasculitis  Clinically, manifests as some combination of abdominal/joint pain, skin lesions (purpura), nephritis  Scrotal involvement in up to 35%

Case #1

 13 year old boy with over 12 hours of right testicular pain.  Sent in to hospital for scrotal US to confirm clinical suspicion that this was NOT torsion

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Case #2

 13 year old boy with 2 visits to the emergency department in the past few months.  Both times he had the onset of acute pain that resolved by the time he was seen by the ER physician, and long before color doppler US was performed (therefore, two normal studies were available for review).

Shorter mesorchium, but still conducive for torsion

Case #3

 Teenager playing baseball and hit in the scrotum 4 days prior.

 INITIALLY written off as ‘traumatic epididymitis’!

 Pain and swelling less, but still there so PMD made urgent office referral.

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Case #4

 3y boy, hx high imperforate anus, s/p right nephrectomy for poorly functional kidney with reflux and pyelonephritis.  (Bit of history I’m not going to give you)  Now at 3y age he has a culture documented UTI with left epididymitis  ARM, hx VUR, UTI/epididymitis

 = repeat VCUG

Vas Ectopic to Ureter!

Courtesy Dr. J Upadhyay

Case #4

 13y boy with a history of VATER syndrome  Had a perineal hypospadias repair as infant  Presented with fever, dysuria, pyuria, and right scrotal pain swelling  Had a right complex hydrocele drained  Progresses despite appropriate abx

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Hot Outside, Cold Inside

Bacterial Orchitis – Not Good!

Thank you!

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