Andrew, a 17-year-old male with right scrotal pain

You are working with Dr. Nayar at an inner-city office adjacent to a small hospital. He has asked you to see Andrew, a 17-year-old male with right scrotal pain, who was brought in by his mother. Dr. Nayar tells you, "Andrew is the third child of Ms. Deborah Hailey, a single mother who works as a home attendant and is also a patient of mine. Before you go in the room, let's look at the chart to review his history. I have known him since his birth and have been seeing him regularly for health care maintenance. His last visit was more than a year ago for a sports preparticipation physical. He has been a good student, but had behavioral issues during his early teenage years. His mother really struggled with this as Andrew is quite different from her other two children. I provided some counseling to the family to help them adjust to and manage Andrew's issues." You take a look at the problem list in Andrew's medical chart. Problem list: 1. Viral gastroenteritis at age 1 year 2. Upper respiratory infection at age 5 years 3. Appendectomy at age 12 years 4. Behavior problems at age 14 years When you have finished looking at the chart, you and Dr. Nayar discuss some issues that might come up during an interview with family members present. You enter the exam room and find Andrew lying down in an uncomfortable position on the exam table. His mother, Ms. Hailey, is sitting next to her son visibly worried and anxious. You introduce yourself and explain, "I understand you are not feeling well. Would it be okay if I get some information about how you're feeling? First, I would like to talk with you and your mom; then I would like to talk to you by yourself for a bit." You ask, "Can you tell me more about your pain?" Andrew is having a hard time talking, but he states, "I have really bad pain in the right side of my groin. I was all right in the morning. It started suddenly about four hours ago while I was playing football. The pain started in my groin and at first, it was off and on, but now it's moved to the right side of my scrotum and it's been sharp and constant for the last couple of hours." He adds," I don't think I did anything unusual in the football practice." You note that Andrew has already told you the location, quality, character, onset, and duration of his pain. You still have a few more questions to ask: "Do you have other concerns, like nausea, sweating, chills, vomiting, or fever?" "I feel very nauseated but I don't have any fever or vomiting." You have a few more questions: "How bad is the pain? On a scale from 1-10, with 1 being the slightest pain and 10 being the worst pain you have ever felt?" Andrew grunts, "It is the worst pain I have ever had. I would give a score of 10." "Does anything make it worse? What happens if you . . .?" Andrew getting annoyed with these multiple questions and interrupts "It is already worse." You reply, "I am very sorry for bothering you with all these questions. I need this information to find out what is going on with you. "Has anything made it better?" "Nothing is relieving the pain." Ms. Hailey interjects, "He had similar pain few months ago and it was relieved without any treatment." She looks worried, "I hope he didn't hurt himself while playing." You complete the history. Andrew denies any increased urinary frequency, dysuria, urethral discharge, abdominal pain, or vomiting. Ms. Hailey wants to know, "Could you tell me what is going on with Andrew?" You respond, "Well, I have to ask Andrew a few more questions and then examine him before I could tell you anything. Can you please excuse us for now and I will call you back as soon as we are done." After obtaining information about his pain you want to inquire about his sexual history. Before Mrs. Hailey leaves the room, you reassure Andrew by saying, "What you and I talk about is confidential, which means that I am not going to tell your mother anything we talk about unless I am worried that you are hurting yourself, hurting someone else, or someone is hurting you." Mrs. Hailey leaves the room, and you begin your conversation: "You must be in eleventh grade. How is school going?" Andrew responds, "My schoolwork is going pretty well. I am getting As and Bs. Next month I am going to take the SAT." "Do you have a romantic or sexual relationship with anyone?" Andrew reports that he has been sexually active with a single female partner for the past year and uses condoms sometimes for protection. "Have you ever been pressured to do something sexually that you didn't want to do?" Andrew denies being subjected to any kind of pressure. On further questioning, he denies past history of sexually transmitted diseases, urological/surgical procedures (aside from the appendectomy), or congenital anomalies. You ask him about his diet and he tells you that he maintains a healthy diet and feels satisfied with his current weight and shape. He adds, "I have never experimented with dietary supplements or steroids, although I know of some kids on the football team that have tried them." During the conversation, Andrew notes, "Several of my friends have begun to smoke cigarettes, but I don't like the taste of them." You then excuse yourself while Andrew undresses for the physical exam. You ask him if he would like to have his mother in the room while he is being examined. While waiting for Andrew to undress, you quickly go to Dr. Nayar to update him on the case so far. After you have discussed the differential diagnosis, Dr. Nayar tells you, "Before we go back in to see Andrew, let's review the basics of the scrotal exam. This exam will help us narrow the differential." TEACHING POINT Scrotal Exam Findings Cremasteric reflex Cremasteric reflex can be assessed by lightly stroking or pinching the superior medial aspect of the thigh. An intact cremasteric reflex causes brisk ipsilateral testicular retraction. Absence of the cremasteric reflex is a sensitive but nonspecific 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. 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. 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; if present this can help distinguish epididymitis from testicular torsion. TEACHING POINT Scrotal Exam Techniques Inspection On inspection, look for erythema, swelling, discoloration, skin integrity, and position of the testicle. Palpation The skin of the scrotum should be palpated for edema, fluid collection, tenderness, and subcutaneous emphysema. Begin palpation of scrotal contents with the unaffected side. The normal testis is mobile, and the spermatic cord and epididymis are palpable posteriorly. 1. By gently grasping the testis between the thumb and first two digits, the testicle is examined from its inferior pole, superiorly. 2. Then palpate the testicle for size, tenderness, (localized or diffuse), lie (high or low within scrotum-the left testicle normally sits slightly lower than the right), and axis (horizontal or vertical). The epididymis should be examined for size, position, tenderness, and swelling. The epididymis should be palpable as a soft, smooth ridge posterolateral to the testis. To complete the intra-scrotal evaluation, palpation of all scrotal contents should occur. This includes examination of the spermatic cord to the superficial inguinal ring for tenderness or a "knot" which suggests testicular torsion and any localized fluid collections, such as a hydrocele or spermatocele. Transillumination Transillumination may help you determine the etiology of a lesion. For example, a light source shines brightly through a hydrocele. You knock on the door to ensure Andrew is ready, then enter the room to perform the physical examination. Andrew's mother is seated in the corner because he has requested her presence. Dr. Nayar greets Andrew and his mother, and expresses concern about Andrew's pain, then proceeds to perform a physical exam with you. Physical Exam Vital signs: • Temperature: 98.7 Fahrenheit • Heart rate: 90 beats/minute • Respiratory rate: 14 breaths/minute • Blood pressure: 130/82 mmHg • Weight: 145 lbs • Height: 5' 9" • Body Mass Index: 21 kg/m2 • Pain score: 10/10 General: Well-built male in moderate to severe discomfort. Head, eyes, ears, nose and throat (HEENT): No conjunctival icterus or pallor. Cardiac: Regular, Normal S1 and S2. No pleural rubs, murmurs, or gallops. Lungs: Clear to auscultation bilaterally. Abdomen: No distension. Active bowel sounds; No abdominal bruits. There is no guarding or rebound tenderness. No rigidity. No palpable masses or hepatosplenomegaly. Back: No costovertebral angle or spine tenderness. Extremities: Femoral and pedal pulses are strong and equal. Genitourinary: Inspection of his genitals reveals a swollen and erythematous right scrotum. His right testicle is exquisitely tender, swollen and has no palpable masses. Elevation of the testis results in no reduction in pain (negative Prehn sign). The left scrotum and the testicle are normal. Epididymis and other scrotal contents were within normal limits. The scrotum does not transilluminate. Cremasteric reflex is present on the left side but absent on the right. There is no penile discharge, inguinal lymphadenopathy, or hernias. Rectal: Nontender. Stool medium brown, heme negative. Prostate gland normal size, smooth and nontender. After completing the examination, you and Dr. Nayar excuse yourselves from the room in order to give Andrew a chance to put his clothes back on. You and Dr. Nayar return together to the exam room. He sits down in a chair and explains, "Andrew has a condition called testicular torsion." Ms. Hailey asks, "What do you mean by testicular torsion?" Dr. Nayar takes a paper and pen and draws a diagram of a normal testicle and its blood supply and explains, "Here is a picture of the blood supply to the testicle. In testicular torsion, a testicle gets twisted and the blood supply to the stalk is blocked." "How did Andrew get this?" "The cause of testicular torsion usually is not clear." Andrew interjects, "How can you tell that I have testicular torsion?" "You have severe pain in your scrotum. Your right testicle is swollen and is higher in the scrotum than the other testicle. Infection, cancer, or an injury also can cause pain in the scrotum. However based on your history and physical findings we strongly suspect testicular torsion," Dr. Nayar answers. Dr. Nayar continues, "I know this is a lot to process, but it can be treated. You will need immediate surgery to untwist the testicle. I will call the urologist who will be performing the surgery and they will make sure the testicle does not twist again. They also will make sure the other testicle doesn't twist." Dr. Nayar hurriedly says, "Now if you don't have any further questions I need to send you to the emergency room for further testing and to prepare Andrew for surgery." He reassures them that he will come to the emergency room to follow up on the tests and to further explain the management plan. You accompany Andrew to the emergency department. The attending, Dr. D'Souza, quickly places him in one of the adolescent rooms and begins to evaluate him. Intravenous access is established. She sends blood and urine samples for further testing, and pages the urologist. By now, Andrew's pain has become much more intense and he asks for pain medication. Dr. D'Souza gives him 2 milligrams of intravenous morphine, which provides some relief. You wait patiently for the results to come back, while at the same time, you are trying to reassure Ms. Hailey. The urologist, Dr. Greenburg, arrives quickly, examines Andrew, and confirms the diagnosis of testicular torsion based on a history and physical findings. He then discusses the results of the tests and a management plan with Andrew and Ms. Hailey. "Andrew, your complete blood count (CBC) is normal. Your urine analysis is also normal. However, we ordered urine tests for infection that will not be back for a couple of days. At this point, we do not suspect an infection as a cause for your symptoms." Dr. Greenberg explains the risks and benefits of surgical intervention and general anesthesia, obtains informed consent from Ms. Hailey and prepares for immediate surgical exploration. TEACHING After Dr. Greenburg has finished his preparations, while he awaits the anesthesiologist, he reviews the procedure with you. TEACHING POINT Complications of Testicular Torsion: Testicular Loss The most significant complication of testicular torsion is loss of the testis, which may lead to impaired fertility. Common causes of testicular loss after torsion are: • delay in seeking medical attention (58%) • incorrect initial diagnosis (29%) • delay in treatment at the referral hospital (13%) The viability of a testis depends on the duration of torsion and pain: Duration of scrotal pain Percentage of testicular viability 6 hours 90% more than 12 hours 50% more than 24 hours 10% TEACHING POINT Treatment of Testicular Torsion There are two approaches to treating torsion of the testes. Nonsurgical approach Manual detorsion of the torsed testes, may be attempted, but it is usually difficult because of acute pain during the manipulation. This nonoperative distorsion is not a substitute for surgical exploration. If the maneuver is successful, orchiopexy (surgical fixation of both testes to prevent retorsion) must still be performed. This should be done in the immediate future, preferably before the patient leaves the hospital. If full manual reduction of torsion cannot be performed or if there is doubt about the diagnosis and reason to suspect torsion, the scrotum must be explored. Surgical approach The testis must be unwound at operation and inspected for viability. If it is not viable, it should be removed. If the testis is viable then orchiopexy should be performed to prevent recurrence. Whether the affected testis is removed or conserved, the contralateral one should undergo orchiopexy as the risk of recurrence on the other side is otherwise high. After Andrew is taken to surgery, you and Dr. Nayar bid Ms. Hailey goodbye for now and head off towards the family medicine clinic. On the way back, Dr. Nayar praises you, "You did a nice job today. Andrew's mother told me she was relieved to have your assistance. I am impressed with how well you facilitated effective communication between the family and the emergency physician, and the urologist. You made what could have been an extremely overwhelming situation for Andrew and his mother into an opportunity to forge a strong partnership with them." You thank Dr. Nayar for his kind words and say, "I'm really glad I got to come over. I enjoyed helping to coordinate Andrew's care." "You've demonstrated a firm grasp on an important premise in family medicine that can be difficult to teach, as it has not been articulated all that well until a couple of years ago. I'm talking about The Patient Centered Medical Home, an approach to primary care that really emphasizes the value of relationships between physicians and patients when providing quality care," Dr. Nayar tells you. Dr. Nayar tells you how the principles of the Patient Centered Medical Home apply in Andrew's case: 1. Personal physician: "For example, I have been taking care of Deborah and her family for the past 18 years. I provided prenatal care when Deborah was pregnant with Andrew. And I have taken care of all the family's health care needs since. This allows a solid, long term relationship which maximizes my ability to assist the family in all health care issues." 2. Physician directed medical practice: "For example, the nurse who obtained Andrew's chief concern and vitals assists in Andrew's care by maximizing how I spend my time with him. The nurse practitioner at the clinic who saw Andrew for his upper respiratory infection a few years ago, assisted with that aspect of his care -- but I was available if my expertise had been needed. We have people at our clinic who help coordinate diabetes care and other complex chronic health issues." 3. Whole person orientation: "In other words, when Andrew came in with acute scrotal pain, we addressed this issue, but we also used the opportunity to tackle other issues that are important in taking care of Andrew's whole person, such as quickly assessing some other lifestyle factors besides sexual activity, including drugs and smoking." 4. Care is coordinated and/or integrated: "In Andrew's case, we recognized he likely had testicular torsion which required immediate intervention. We effectively coordinated not only his visit to the emergency room, but his urology care as well. Furthermore, we kept the channels of communication open with Andrew's mother, allowing her the information and reassurance she needed." TEACHING POINT Patient Centered Medical Home Leading primary care physicians organizations* described the characteristics of the Patient Centered Medical Home as follows: 1. Personal physician: Each patient should have an ongoing relationship with one personal physician. So when a patient needs medical attention, they rely on a doctor they have established a long-term relationship with who will help them get whatever care they need. 2. Physician directed medical practice: The personal physician has assistance from the team of individuals at the family practice clinic who collectively take responsibility for ongoing care of patients. 3. Whole person orientation: The personal physician is responsible for providing all health care needs at all stages of life. Including acute care, chronic care, preventive services, and end of life care. 4. Care is coordinated and/or integrated: The personal physician doesn't have the expertise to take care of every medical issue their patients may encounter, so the personal physician needs to understand when to refer for subspecialty care. The personal physician also needs to be able to utilize all domains of the health care system, facilitated by registries, information technology, health information exchange and other means, in order to ensure that the patient gets the indicated care where and when they need it. Furthermore, the personal physician needs to be able to communicate health care issues effectively to family members when appropriate. Quality and safety are also hallmarks of the medical home. Andrew has returned for his follow-up visit. You review his inpatient records including the operative and post operative course using his electronic medical record (EMR). EMR review reveals that Andrew had surgical exploration of the scrotum through the midline scrotal raphe. The ipsilateral scrotal compartment was entered and the testes was untwisted. The testes was found to be viable (Signs of a viable testes after detorsion include, a return of color, return of Doppler flow, and arterial bleeding after incision of tunica albuginea). To prevent subsequent torsion, the gonads were fixed to the scrotal wall with nonabsorbable sutures. The contra lateral testes was explored and anchored through the same incision. The post-operative period was uneventful. Andrew was discharged from the hospital 48 hours after the surgery. He also had a follow-up visit with Dr. Greenburg a week later. You and Dr. Nayar visit with Ms. Hailey and Andrew. You discover that Andrew is doing well, but needs to get a clearance letter from Dr. Nayar before he can return to school. Dr. Nayar asks Ms. Hailey to leave the room so that he can perform the physical examination. After she leaves, you examine Andrew. He shyly asks you, "Can I have sex again now? Do I need to take any precautions?" Your answer is, "The surest way to prevent contracting a sexually transmitted infection (STI) is to abstain from any type of sexual activity. However, if you are sexually active, the most important thing to remember to reduce your risk of getting an STI is to use a condom every single time you are sexually active. Do you know how to use a condom correctly?" "Um, yeah I do." You hesitate to pursue the matter further, as Andrew is not indicating any need for further advice, but you understand that he may be too embarrassed to ask for help in this arena so you reply: "Well, it is still something I like to review. It is much more likely for the condom to break if it is used incorrectly. It is important to put the condom on when the penis is erect and to make sure to pinch the tip, and then roll down the condom over the whole penis. Make sure to hold the base of the condom when taking the condom off, and to take it off while the penis is still erect. Do you have any questions about any of that?" "Well, sort of. Should I wear a condom for any type of sex?" "That's a really good question," you assure him, "To protect yourself from STIs, you should wear a condom for every sexual act - oral, anal, or vaginal sex." "Feel free to come back any time to discuss these issues with me." reassures Dr. Nayar. While in the exam room with Andrew, Dr. Nayar discusses recommendations for Chlamydia and Gonorrhea screening, and HIV screening. Based on your conversation with Dr. Nayar, you recommend that Andrew have a hepatitis B vaccination, if not immunized. Since he is not at high risk for syphilis, you do not need to recommend syphilis screening. After completing the physical examination, you call Ms. Hailey back to the room and continue the conversation. "Andrew's surgical wound has healed well," Dr. Nayar explains to Ms. Hailey, "and he is ready to go back to school." She looks relieved and asks, "What are the other testicular disorders we need to worry about?" Dr. Nayar attempts to set Ms. Hailey's mind at ease by telling her that since he received treatment in a timely manner, Andrew has escaped the most dangerous complication of testicular torsion, which is losing a testicle. He explains, "There are other conditions such as testicular tumors, torsion of the appendix epididymis, epididymitis, and trauma could cause similar pain and these conditions should be treated as soon as possible. But," he assures them, "Andrew is at no greater risk of these testicular conditions now than he was before he had a torsed testicle." You and Dr. Nayar tell Mrs. Hailey that if there is any swelling or any pain occurs or recurs, you need to seek medical attention immediately. Andrew wants to know if he can participate in the upcoming football game. Dr. Nayar counsels that it is best to avoid contact sports for another month, but he can participate in noncontact drills. You help Dr. Nayar complete the medical clearance form to return to school. Ms. Hailey once again thanks both you and Dr. Nayar for all the assistance in taking care of Andrew's health and for coordinating his care. She makes the follow-up appointment to see Dr. Nayar in six months, and she and Andrew leave the office looking content. Testicular Cancer: Prevalence, Presentation, & Screening Recommendations Testicular cancer is the most common malignancy affecting males between the ages 15 and 35, although it accounts for only one percent of all cancers in men. These tumors could 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. There is no evidence to support routine screening for testicular cancer in asymptomatic adolescents and young adults.
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