Acute Scrotum in Children- and a word about bilious vomiting

Acute Scrotum- Age is critical, Ultrasound is useless.

Neonates

Testicular torsion is associated with high levels of sex hormones and so occurs in this age group (consider the relatively enourmous genitalia of the newborn compared to the older baby). It is usually diagnosed late due to the poor quality of the history from the patient. The scrotum should be examined in unsettled male infants brought to hospital for assessment.

Infants

Epididymitis occurs in the first 12 months of life as a complication of UTI.

Primary School Children

These kids have pre-pubertal genitalia. Torsion of the appendage is the most common cause of an acute scrotum and is associated with the oestrogen surge that marks the beginning of puberty (the testicular appendage is a remnant of the Mullerian duct). There is often a history of minor trauma but its role is doubtful at best. The pain is usually not severe and presentation is usually late. Look for a blue spot.

High School Children and Young Adults

These people have adult genitalia and are developing adult habits. Testicular torsion occurs in this group associated with the testosterone surge of late puberty. Epidydimitis due to STI does occur in older adolescents and young adult but is relatively uncommon. An acute scrotum between the ages of 14 and 25 requires surgical exploration.

Other causes of acute scrotum include:

Trauma
Idiopathic scrotal oedema- crosses the midline, extends off the scrotum, testes are normal.
HSP- bleeding may occur into epididymis, there will be other clues in most cases
Mumps- occurs in outbreaks where there is a population resistant to immunisation or where there has been a problem with immunisation quality control.

Bile Vomit in the Infant

Malrotation and volvulus

This presents as a bile vomit in a fairly well kid. 4 hours later after onset of the volvulus the child is unsalvageable.

If there is no serious illness apparent to explain bile vomit (meningitis for example) you must look for maltotarion with a barium meal urgently (now, at 2 in the morning, seek senior help to deal with the politics, the child's life depends upon it). Look for a hernia first. Remove the urine bag to do so.

 

Many thanks to Professor Beth Pennington for her session on this topic.