May 2007

A 15-year-old boy was admitted to the hospital with the chief complaint of scrotal pain.

The history of this problem began five days earlier when the patient was walking on a fence and then slipped, falling down straddling the fence, which resulted in pain to his left groin area.

The pain subsided later in the day, only to be followed by increasing pain in the left side of his scrotum, radiating down his left leg and up into his abdomen the next day.

He was then taken to an urgent care clinic where an abdominal radiograph was obtained. His parents said they were told it showed a loop of bowel that had excess gas, therefore explaining the abdominal pain.

Nothing substantial was seen on examination at that time, and the history of the previous injury was not obtained.

However, before we pile-on the provider that saw him, one must understand the difficulties and limitations of obtaining a medical history from an adolescent boy. Obviously, boys this age are not likely to report to their parents every time they injure themselves, especially an injury to their groin. In fact, speaking as a former 15-year-old, parents are not likely to hear much of anything regarding this area of a boy’s anatomy.

Over the next two days, the patient’s pain gradually increased, joined by a sore throat, headache and fever with chills. By the day prior to admission, the pain became more localized to the left side of his scrotum, which he reported was aggravated significantly by movement.

He denied any urethral discharge, dysuria or urgency, and his urine looked normal. Except for a sore throat, the patient denied any other symptoms, such as nausea, vomiting, diarrhea, congestion or cough, and the abdominal pain essentially resolved.

A review of systems was otherwise normal, except for some mild developmental delay with poor school performance.

He denied being sexually active and had no known sick contacts. His immunizations were documented up to date.

Examination revealed normal vital signs, even though there was a recent history of some fever. The patient’s HEENT exam revealed an apparent herpes simplex lesion (fever blister) on the right side of his upper lip (figure 1) and an inflamed posterior pharynx with some exudate (figure 2). His abdominal exam was normal, but his genitourinary exam showed moderate swelling with erythema of his left scrotum (figure 3), which was markedly tender to palpate, revealing a mildly enlarged testicle with a lumpy-feeling mass. Exam was accompanied by moderate scrotal pain on movement that was much less as long as he remained motionless in bed. The cremasteric reflex was normal bilaterally. The rest of his examination was normal, except for having delayed puberty with a sexual maturation scale of stage I (Tanner stage I).

Preliminary laboratory tests revealed an elevated white blood cell count of 17,000. His urine analysis was normal, and culture is pending. A rapid group A streptococci test of his throat was positive.

What’s your diagnosis?

1. Group A streptococci cellulitis of scrotum
2. Epididymitis
3. Orchitis
4. Testicular torsion

Answer

The answer is B, epididymitis.

Several clues point toward this diagnosis, such as the preceding injury days earlier, the relatively normal sized testicle with an intact cremasteric reflex — which tends to be absent with testicular torsion — and a lumpy-feeling, painful mass on the testicle. Of course, nowadays, a testicular ultrasound is used to rapidly diagnose torsion, resulting in fewer unnecessary trips to the operating room for other causes of scrotal pain.

Treatment of epididymitis should usually be with antibiotics and scrotal support for pain control. There are devices similar to an athletic supporter designed for support of the scrotum, as shown in figure 4 (another adolescent with epididymitis on the right).

The mechanism of injury in a case like this (straddle injury) causes damage to the anterior urethra (bulb), resulting in swelling and stricture, which causes some retrograde flow of urine back through the ejaculatory ducts. Many experts refer to this type of epididymitis as chemical or sterile epididymitis and hold off on using empiric antimicrobial therapy. However, when they are going to be used, the choice of antibiotic(s) should be based on age and other circumstances, such as trauma, recent instrumentation (surgical or self-inflicted), congenital abnormalities and severity of illness.

Making the diagnosis

Just as with common urinary tract infections, epididymitis is often caused by Gram-negative bacilli but can be caused by Staphylococcus aureus, Streptococcus pneumoniae and enterococcus. One should strongly consider sexually transmitted infections, such as Neisseria gonorrhea and Chlamydia trachomatis, in sexually active adolescents and young adults. If there has been instrumentation of the penis or bladder, think of unusual organisms, like pseudomonas.

When epididymitis occurs in infants or young children, the child should be evaluated for congenital abnormalities. A reasonable choice of antibiotics for a child with fever and significant inflammation would be a combination of a third-generation cephalosporin (such as ceftriaxone) plus an aminoglycoside intravenously. However, if S. aureus is a significant possibility, one should pick an antibiotic effective against methicillin-resistant S. aureus. In my community, I would select clindamycin, as the vast majority of strains of MRSA are clindamycin-sensitive, but all efforts should be made to recover the bug. Unfortunately, in most cases, an organism is not recovered.

Orchitis, or inflammation of the testicle, can result from extension of a bacterial epididymitis but is usually caused by a virus, specifically an enterovirus since mumps is rarely seen today. For those patients, supportive care is usually all that is needed.

Cellulitis involving the scrotum, as seen in figure 5, is usually the result of a break in the skin, such as an insect bite. This will typically involve the scrotal skin without causing infection of the scrotal contents and will have erythema spreading beyond the groin to one side or the other.

This is usually due to staph and frequently associated with abscess formation, for which the treatment is always drainage (figure 6). In the case presented, the group A streptococci found in the throat was probably unrelated, but it should be considered when deciding on which antibiotics to use.

If one is really unlucky, this can progress to a necrotizing infection referred to as Fournier’s gangrene (figure 7, courtesy of my son, James C. Brien, MD, a third-year urology resident at Penn State Medical Center in Hershey, Pa.). This severe infection involving the scrotum often has its origin as a perirectal infection that tracts up the perineum, but it can also begin through any port-of-entry in the area and usually requires radical surgical debridement along with aggressive broad-spectrum antibiotics against Gram-positive cocci and Gram-negative rods to control the spread (figure 8). Fortunately, this is fairly rare — but not unheard of — in children, but rather found mostly in compromised adults (diabetics, alcoholics, immunocompromised, etc).

You can find more details and references about this complication in the February 2004 issue of Infectious Diseases in Children.

Commentary

The 41st Annual Uniformed Services Pediatric Seminar (USPS) was held in Bethesda, Md., this past March. An AAP accredited event with up to 24.75 hours of continuing medical education credit, the USPS has a solid tradition of excellent general pediatric CME coupled with research competitions, a 5K Fun Run and a “Jeopardy”-style competition between the services, with four-person teams from the Army, Navy and Air Force. Each member of the audience sits with his or her service to cheer the team on, complete with souvenir service flags provided to each member of the audience to wave.

This event is called the James W. Bass Challenge Bowl. In the early years of the meeting, this was done as a College Bowl-style competition, but it morphed into a “Jeopardy”-style game several years ago. Nonetheless, it is a fun way to get to know some of these outstanding uniformed pediatricians. Unfortunately, the Army team lost again, this time to the Navy team (figure 9), under the leadership of Navy Capt. Joe Lopreiato, who was affectionately cheered on by his Navy cheering section as J-Lo.

As in previous years, the current president of the AAP (this year Jay E. Berkelhamer, MD, FAAP) was in attendance to acknowledge the Uniformed Services Section of the Academy (figure 10, shown presenting the Outstanding Service Award to Lee Poth, a professor of pediatrics at the Uniformed Services University of the Health Sciences [USUHS], along with Maj. Gen. Eric Schoomaker, the new commander of Walter Reed Army Medical Center) and the executive director of the AAP, retired COL. Errol Alden, MD (figure 11, shown with his wife, Judi, and Ildy M. Katona, MD, professor and chair of the department of pediatrics at USUHS). So, if you want to get to know some of the AAP leadership up close and personal, the USPS is a great venue to do so.

There is one other individual who is always in attendance of the USPS who needs special mention: retired COL. James E. Shira, MD (figure 12, shown with Andy Margileth on the right, for whom one of the USPS research awards was named). Why single out this retired Army pediatrician? Dr. Shira happens to be one of the two candidates for the next president of the AAP. I will have more to say about this outstanding individual in the next issue.

The next meeting will be held in Honolulu at the Waikiki Beach Marriott on March 10-13, 2008. However, attendees will want to come early and stay past the meeting. I am told that the special meeting rate for the rooms will be up to three days before and three days after the meeting. So, plan accordingly, and I will see you there. More information about the next USPS can be found at the AAP website later this year.