groin pain, adolescent male

testicular cancer risk factors

-genetics: Klinefelter's (47xxy)--> germ cell tumors, first deg relatives -family hx -cryptorchidism: 20-40x risk -environmental: industrial occupations, drug exposures like DES, agent orange, and solvents to clean jets and ochratoxin A -prior testicular tumor

HSP

- characterized by nonthrombocytopenic purpura, arthralgia, renal disease, abdominal pain, gastrointestinal bleeding, and occasionally scrotal pain. -The onset of scrotal pain may be acute or insidious. -In boys who lack other characteristic findings of HSP, sonography can usually distinguish HSP from testicular torsion. Treatment of HSP is supportive.

testicular torsion

- testicle rotates around its vascular supply -Surgical emergency with a 4-12 hrs after onset of pain to save the testicle by untwisting the spermatic cord. Timely diagnosis and treatment are vital for survival of the testis. -Most common in neonates and post pubertal boys, with the majority of cases of testicular torsion occurring between the ages of 12-18 years. -Relatively uncommon condition. -Symptoms: scrotal, inguinal, or lower abdominal pain which usually begins abruptly. The pain is severe, and the patient appears uncomfortable. It can occur several hours after vigorous physical activity or minor testicular trauma and there may be associated nausea and vomiting. There may be prior similar episodes that might suggest intermittent testicular torsion. -Physical findings: swollen, tender scrotum and absent cremasteric reflex -Testicular torsion causes the orientation of the testis to change, causing a "transverse lie" although this may be difficult to appreciate in a very swollen and tender patient.

types of testicular tumors

-germ cell tumors (seminomatous vs. nonseminomatous): 95% of tumors. nonseminomatous: teratomas, embryonal (pure cell NSGCT), mixed GCTs , yolk sac tumors-malignant>benign, choriocarcinoma (most lethal, least common) -non-germ cell tumors: Leydig cell and Sertoli cell tumors. malignant 10% of time -extragonadal: lymphoma, leukemia, melanoma metastasis

varicocele

-A varicocele is a collection of dilated and tortuous veins in the pampiniform plexus surrounding the spermatic cord in the scrotum. -Varicoceles L>>R because the left spermatic vein enters the left renal vein at a 90 degree angle, whereas the right spermatic vein drains at a more obtuse angle directly into the inferior vena cava, facilitating more continuous flow. -Varicocele is seen commonly in adult men but can be seen in adolescents; approximately 10-25 percent of adolescent boys have a varicocele. -Varicocele is associated with infertility, although the precise mechanism by which this occurs has been the subject of considerable research and is currently thought to be due to increased testicular temperature. -Patients with varicocele can be asymptomatic or may complain of a dull ache or fullness of the scrotum upon STANDING. -A varicocele is mass-like and nontender or mildly tender to palpation on exam.-

Topics addressed by GAPS (Guidelines for Adolescent Preventive Services)

-Preventing hypertension -Promoting parents' ability to respond to the healthcare needs of their adolescents -Preventing hyperlipidemia -Preventing the use of tobacco products -Preventing the use and abuse of alcohol and other drugs -Preventing severe or recurrent depression and suicide -Preventing physical, sexual, and emotional abuse -Preventing learning problems -Preventing infectious diseases -Promoting adjustment to puberty and adolescence -Promoting safety and injury prevention Promoting physical fitness -Promoting healthy dietary habits and preventing eating disorders and obesity -Promoting healthy psychosexual adjustment and preventing the negative health consequences of sexual behaviors (does not address diabetes. ADA recommends fasting glucose checks every 2 yrs in high risk children beginning age 10)

USPSTF screenings for adolescents

-Rubella susceptibility: Routine screening strongly recommended for all females of childbearing age. -Chlamydia: Screen women younger than 25 years and others at increased risk -Gonorrhea: Screen women younger than 25 years and others at increased risk -HIV: Screen sexually active men at increased risk for HIV infection. -Syphilis: Screen sexually active men at increased risk for syphilis infection.

diagnosing testicular torsion

-color doppler US: if pain is less severe and not sure. Decreased/absent intratesticular blood flow, enlarged testicle -radionuclide scintigraphy: radioisotope to visualize blood flow (decreased uptake) *scintigraphy is more sensitive but US is faster...

known causes of testicular torsion

-congenital anomaly (bell clapper deformity): absent normal posterior anchoring of gubernaculum, epididymis and testis -undescended testis : often occurs with testicular tumor -recent trauma or vigorous physical exercise -no reason

hydrocele

-cystic painless scrotal fluid collection and is the most common cause of painless scrotal swelling. -Light should be visible through the scrotum when it is illuminated with a strong light source (positive transillumination). -Hydroceles are generally asymptomatic unless associated with trauma or infection, although patients may report a slowly growing mass that causes a pulling or dragging sensation.

testicular cancer

-most common malignancy in males 15-35 yo, but accounts for only 1% of all cancers in men. -most common among African-Americans -present as a nodule or as a painless swelling of the testicle, 30-40% may present with dull ache or heavy sensation in the lower abdomen, perianal area, or scrotum areas. Acute pain is the presenting symptom in ten percent of cases. -The swelling is solid so should NOT transilluminate. Usually non tender to palpation . -no evidence to support routine screening for testicular cancer in asymptomatic adolescents and young adults.

Epididymitis

-most frequent cause of sudden scrotal pain in adults. -typically slowly progressive sxs over several days rather than abrupt. -bacterial infection of the epididymis, typically from a UTI or STI -The patient may appear comfortable except when examined. -Severe swelling and exquisite pain are present on the involved side, often accompanied by high fever, rigors, and irritative voiding symptoms. -Patients may have had preceding symptoms suggestive of a urinary tract infection or sexually transmitted disease. -On exam, the scrotum is tender to palpation and edematous on the involved side. The cremasteric reflex PRESENT, and the testis is in its normal location and position.

treatment of testicular torsion

-non-surgical: manuel detorsion attempted but difficult bc of pain. still need to do orchiopexy in immediate future -surgical: unwind testis, inspect for viability (if not viable, remove). Orchiopexy of other testis. -testicular viability depends on duration of scrotal pain (6 hrs: 90%, 12 hrs: 50%, 24+ hrs: 10%)

indirect inguinal hernia

-result of a persistent process vaginalis. The inguinal canal begins in the intra-abdominal cavity at the internal inguinal ring, located approximately midway between the pubic symphysis and the anterior iliac spine. The canal courses down along the inguinal ligament to the external ring, located medial to the inferior epigastric arteries, subcutaneously and slightly above the pubic tubercle. Contents of this hernia then follow the tract of the testicle down into the scrotal sac.

Torsion of the testicular appendages

-testicular appendages =appendix epididymis and appendix testis -occurs less commonly and is associated with less morbidity than torsion of the testis. -Appendix testis is a small vestigial structure (embryonic remnant of Mullerian duct) located on the anterosuperior aspect of the testis. -Typically occurs in younger patients 7-14 yo. -Presents with abrupt onset of pain that is typically less severe than in testicular torsion and is localized to the region of the appendix testis without any tenderness in the remaining areas of the testes. -As in epididymitis, the patient may appear comfortable except when examined. Presence of a bluish discoloration in the scrotum at the upper pole of the testis (blue dot sign) is produced by testicular appendiceal torsion.

characteristics of patient centered medical home

1. personal physician 2. physician directed medical practice 3. whole person orientation 4. care is coordinated and/or integrated

cremasteric reflex

=lightly stroking or pinching the superior medial aspect of the thigh --> brisk ipsilateral testicular retraction. Absence of the cremasteric reflex is a sensitive but non-specific finding for testicular torsion. It can be absent on physical exam in normal testes. It should be assessed after inspection and before palpation of the testicles.

direct inguinal hernia

A direct inguinal hernia usually occurs due to a defect or weakness in the transversalis fascia area of the Hesselbach triangle. The triangle is defined inferiorly by the inguinal ligament, laterally by the inferior epigastric arteries, and medially by the conjoint tendon.

referred pain to scrotum

Boys who have the acute onset of scrotal pain without local inflammatory signs or a mass on examination may be suffering from referred pain to the scrotum. The scrotal pain is caused by three somatic nerves that travel to the scrotum: the genitofemoral, ilioinguinal, and posterior scrotal nerves. Retrocecal appendicitis is an important and a rare cause of referred scrotal pain in children and adolescents.

HEEADSSS

Home Education / Employment Eating Activities Drugs Sexuality Suicide / Depression Safety / Violence

Prehn sign

Prehn reported that physical lifting of the testicles relieves the pain caused by epididymitis but not pain caused by testicular torsion. A positive Prehn sign is pain that is relieved by lifting of the testicle (--> EPIDIDYMITIS); if present this can help distinguish epididymitis from testicular torsion.

blue dot sign

Tenderness limited to the upper pole of the testis suggests torsion of a testicular appendage, especially when a hard, tender nodule is palpable in this region. A small bluish discoloration known as the "blue dot sign", may be visible through the skin in the upper pole. This sign is virtually pathognomonic for appendiceal torsion when tenderness is also present.