What's Your Diagnosis? Pediatric Scrotal Pain

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got the previous case on Pediatric Gastrointestinal Bleeding: Identification and Management in the Emergency Department right.

Case Presentation: Emergency Department Management of Acute Scrotal Pain in Pediatric Patients

A previously healthy 13-year-old boy with 3 hours of lower abdominal and groin pain presents to your rural community ED…

The boy has no fever, dysuria, or hematuria. He is not sexually active and denies trauma. He has vomited twice.
On examination, the boy appears uncomfortable and rates his pain as 9/10. His abdomen is soft, with mild lower left quadrant tenderness. A testicular examination is notable for a swollen, erythematous, high-riding left testicle that feels indurated compared to the right testicle. You cannot elicit a cremasteric reflex on either the right or the left. You begin to consider your management priorities…

Case Conclusion

You calculated a TWIST score of 7. While ordering a Doppler ultrasound, you called the closest children’s hospital transfer center and were connected with a pediatric urologist and the ED physician. The Doppler ultrasound confirmed left testicular torsion. You started an IV, gave morphine, and attempted manual detorsion using the open-book technique. The patient had immediate relief of pain. You transferred the patient, the urologist met the patient on arrival to the ED, and the patient was in the operating room within 30 minutes. The total time to the operating room was 6 hours. The spermatic cord had a 180° twist, and the testicle was dusky at the time of detorsion, but normal color returned quickly. Bilateral orchiopexy was performed, and the patient was discharged home from the post-anesthesia care unit.