Case 27 - 17 yo male with groin pain

Question 1

patient centered medical home

Answer 1

Set of values that describes relationship between patient and physician:

• personal physician with good relationship
• physician-directed medical practice
• whole person orientation
• care is coordinated and/or integrated
• quality and safety

Question 2

Can adolescents legally consent to health care on their own?

Answer 2

In most states, certain types of care are up to the consent of the patient itself including STI and HIV testing

Question 3

USPTF screening tests recommendations for adolescents

Answer 3

• rubella susceptibility screening
• chlamydia - women under 25
• gonorrhea - women under 25
• HIV - sexually active men
• syphillis - sexually active men

Question 4

Chlamydia and gonorrhea symptoms and diagnosis

Answer 4

Sx: dysuria, discharge, pain with sex, abdominal or testicular pain
Diagnosis: NAAT test of urine, endocervical or urethral sample

Question 5

Trichomonas symptoms and diagnosis

Answer 5

sx: vaginal discharge with odor or itching
dx: saline wet mount

Question 6

Testicular tumors epidemiology

Answer 6

most common malignancy in men 15-35

most common among african americans

Question 7

Testicular tumors classification

Answer 7

3 main types:

• germ cell tumor - 95% of primary testicular tumors
• non-germ cell - 5%
• extragonadal

Question 8

Testicular tumor presentation

Answer 8

often present as a nodule or painless swelling of testicle, sometimes dull ache or heavy sensation

Question 9

Testicular tumor screening

Answer 9

USPTF recommends against testicular cancer screening

Question 10

Testicular tumor risk factors

Answer 10

• genetics - Klinefelters (XXY), down syndrome
• family history
• cryptorchidism
• environmental hazards
• testicular cancer

Question 11

HEEADSSS

Answer 11

Home
Education/employment
Eating
Activities
Drugs
Sex
Suicidality
Safety

Question 12

Physical exam for scrotal edema

Answer 12

• inspection - look for erythema, change in testicular orientation
• palpation - palpate for edema, tenderness, lie and axis, also palpate epididymis
• transillumination (light shines brightly thru hydrocele)
• cremasteric reflex (often absent in testicular torsion)
• Blue dot sign - tenderness limited to upper pole of testis suggestive of torsion of a testicular appendage
• Prehn’s sign - physical lifting of testicles relieves pain in epididymitis but not testicular torsion

Question 13

Differential diagnosis for groin pain with radiation to testicles

Answer 13

1. Trauma
2. Testicular torsion - timely diagnosis is essential, presents as painful testicular swelling, pain is severe and can be associated with n/v, sometimes have prior similar episodes, risk factors include congenital anomaly, undescended testes, recent trauma
3. Epididymitis - most often develops in post-pubertal boys, pts present with pain and swelling of epididymis, often UTI sx,
4. Hydrocele - painless cystic scrotal fluid collection, genearlly asx, positive transillumination
5. Torsion of testicular appendages - usually occures in prepubertal boys, abrupt onset of pain localized to the region of the appendix testis, on physical exam see bluish discoloration in scrotum at upper pole of testis
6. Tumor - often painless, no transillumination
7. Varicocele - dilated and tortuous veins, can be asx or dull ache/fullness, occur more frequently on left side due to anatomy of gonadal vein, incidence of adolescent varicoceles is 15%
   Less likely: inguinal hernia, indirect hernia, direct hernia, HSP, referred pain

Question 14

Studies for testicular torsion

Answer 14

• color doppler ultrasonography - blood flow to testicle will be decreased of absent (used more often because more readily available)
• radionuclide scintigraphy - radioisotope used to visualize testicular blood flow, if torsion present, decreased radiotracer in ischemic testicle
• blood tests, U/A

Question 15

Management of testicular torsion

Answer 15

• IMMEDIATE surgery - w/i six hours of onset of pain, delay can lead to loss of testis, w/i 6 hours 90% chance testis is viable
• testis must be detorsed in surgery, and then orchiopexy should be performed to prevent recurrence (plus contralateral side too!)
• manual detorsion can be attempted but is usually difficult because of acute pain during the manipulation, if successful orchiopexy should still be done
• pts should avoid contact sports for one month following surgery