Pediatric emergency medicine trisk 1180 1180

reveals normal or increased blood flow to the testis, and may demonstrate a low
echogenicity structure with a central hypoechogenic area. Diagnostically, a
surgical exploration may be required to be certain that torsion of the testis is not
present.
The treatment of a torsed testicular or epididymal appendage is supportive with
rest, support of the scrotum, and analgesic/anti-inflammatory medications. The
pain usually resolves in 7 to 10 days. Rarely, removal of the torsed appendage
occurs when there is severe or prolonged pain. Contralateral scrotal exploration is
not indicated.

Epididymitis/Orchitis
Epididymitis is an infection or inflammation of the epididymis which occurs
more frequently in sexually active adolescents and adults. In sexually active
adolescents, it is most commonly associated with Chlamydia trachomatis, but
Neisseria gonorrhea, Escherichia coli, Mycobacterium, and viruses are other
important etiologies. In HIV-infected males, Mycobacterium, cytomegalovirus,
and Cryptococcus must also be considered. Less frequently, epididymitis does
occur in prepubertal and nonsexually active adolescent boys, primarily associated
with Mycoplasma pneumoniae, enterovirus, and adenovirus infections. Bacterial
epididymitis is uncommon, but related to urinary tract infections with coliform
organisms caused by structural abnormalities of the urinary tract.
The onset of swelling and pain is typically more gradual than with torsion of
the testis or a testicular appendage, but can be abrupt in onset. Associated
symptoms of urinary frequency, dysuria, penile discharge, or fever may be
present. Scrotal edema and erythema are often present. The testicle should have a
normal lie and the cremasteric reflexes should be intact. Early on, the epididymis
may be selectively enlarged and tender, readily distinguished from the testis. With
time, inflammation spreads to the testis (orchitis) and surrounding scrotal wall,
making localization difficult. Although elevation of the scrotum may relieve pain
in epididymo-orchitis (Prehn sign) it is not considered as reliable.
Although pyuria is seen more often in epididymitis than in torsion, it is not

consistently present. The urinalysis can be normal, and urine cultures are often
negative in epididymitis, but are still recommended. The Centers for Disease
Control and Prevention recommends a Gram stain and culture of urethral
discharge or intraurethral swab, or nucleic acid amplification tests for N.
gonorrhea and C. trachomatis which can be done on urine or an intraurethral
swab, and a urinalysis and culture. Color Doppler sonography typically
demonstrates an increase in size and blood flow to the testis and epididymis ( Fig.
61.6 ).