Just one more curve ball in the game of medicine.There are several common themes that run throughout these PedEM Morsels (apparently I am not creative enough to develop other ideas). We have discussed how we must be “ever vigilant” for the significant pediatric illness masquerading as other conditions. Additionally we have covered the importance of clinical diagnostic skills (distinct from the ubiquitous and often distracting White Blood Cell Count). We have also highlighted how our jobs are incredibly challenging. Here is a brief case to illustrate how a condition like HSP and make Testicular Pain even more challenging .
School-aged boy presents with acute scrotal pain. His hemi-scrotum is swollen with thickened skin, enlarge testicle, and mild redness. It is exquisitely tender. Seems simple enough. Order the Ultrasound, give pain meds, and consult Urology promptly. But wait… what is that non-blanching, palpable rash on his legs? What is the significance of the family stating that he was just evaluated a few days ago for significant abdominal pain that no one could determine the cause of? Do the answers to those questions make you think twice about calling your Urologist in emergently?
Henoch-Schonlein Purpura (HSP) and Testicular Pain
We are familiar with the dominant features of HSP… let’s review though:
- Classically palpable purpura on lower extremities
- Sine qua non
- Abdominal Pain
- ~65% of cases have abdominal pain, which may precede rash!
- Intussusception is known, but rare complication (2-6%)
- Angioedema of scalp, eyelids, feet, back, perineum
- Less common in older children.
- May not develop for weeks – months later, so needs monitoring.
- ~40% of cases
- ~75% of cases
- Can be very painful. Often involves knees and ankles.
- May also precede rash.
What about Testicular Pain?
- Often scrotal involvement with HSP is underappreciated.
- Studies report that between 2% – 38% of those diagnosed with HSP had scrotal involvement. That is a big range… likely from retrospective nature of these studies.
- Likely due to localized vasculitis and bleeding into the testis.
- Testicular Torsion is highly unlikely (last case of documented Testicular Torsion associated with HSP was in 1974).
- Like the arthritis and abdominal pain, the testicle pain may preced the rash (making diagnosis very difficult).
- Most cases are self-limited.
Management of Testicular Pain in patient with HSP
- RULE OUT Testicular Torsion
- Yes, we just said that torsion is very unlikely with HSP; however, it is the most critical condition that needs to be considered.
- Obtain the ultrasound to evaluate for blood flow to the testicle.
- Knowing that ultrasound is not perfect, many cases reports describe surgical exploration – however, no exploration revealed torsion.
- Testicular U/S of pt with HSP often demonstrates enlargement of the epididymidis, scrotal thickening, and hydrocele.
To send to OR or To Not to send to OR?
- To OR:
- Scrotal pain without rash or clinical signs of HSP
- Tender scrotum with spermatic cord shortening, absence of cremasteric reflex, or abnormal testicle position
- You are not confident in your diagnosis of HSP – you have to rule out the worst-case scenario first.
- NOT to OR:
- Scrotal pain with normal blood flow on U/S along with clinical picture of HSP.
- Bilateral hemi-scrotum swelling, swelling of the penis, and normal cremasteric reflexes are more consistent with alternative diagnosis other than Torsion.
- In some cases, Technetium Tc 99m pertechnetate radionucleotide scrotal scanning can be used to help define testicular perfusion.
- It is invasive and expensive.
- Honestly, if I am considering this… I am having my Urologist make this decision at the bedside.
- To OR:
- Treat the Pain!! And add steroids for the vasculitis.
- RULE OUT Testicular Torsion
So, while we are appropriately concerned for testicular torsion when the patient arrives with scrotal pain, recall that with the improvement in modern imaging, the previous approach of surgical exploration for all of these patients is not advocated by the surgical specialties any longer. Use your masterful clinical skills and make sure to only do things that will benefit the patient.
Tae-Sun Ha, Jin-Seok Lee. Scrotal involvement in childhood Henoch-Schonlein Purpura. Acta Paediatrica. April 2007; 96(4): 552-555. Soreide K. Surgical management of nonrenal genitourinary manifestations in children with Henoch-Schonlein purpura. Journal of Pediatric Surgery. 2005; 40: 1243-1247. Chamberlain RS, Greenberg LW. Scrotal involvement in Henoch-Schonlein Purpura: A case report and review of the literature. Pediatric Emergency Care; 8(4): 213-215