Answer Explained

It is crucial to rule out testicular torsion in any boy with abdominal pain. You need to make sure you examine the testicles as part of your initial assessment.

If you can’t feel the testicles, and the child has abdominal pain, then consider the patient to have torsion until proven otherwise. Or, if the testicles are tender, high riding, fixed, or abnormal in any other way, it is also torsion until proven otherwise.

Testicular torsion is time critical. The longer the testicle is torted, the less likely it is to survive. A testicle can become non-viable within a matter of a few hours.

An USS is not always necessary, particularly in ‘classic’ cases. These can be diagnosed by clinical findings only, and often go straight to theatre. If there is any degree of uncertainty, I would always discuss it with the Urology Registrar on call first (or General Surgery Registrar on call if your hospital doesn’t have Urology on call).

In this instance, I think there is a degree of uncertainty, and an USS is a reasonable option. However, I am not a surgeon, and I would always seek a surgical review first – it may save time (and save the testicle) if they go to theatre without the USS if there is enough clinical certainty about the diagnosis.

Why is this the most likely diagnosis?

After torsion, the main differential is a lymph node in the groin. Clinically these can feel very similar. Factors that would make lymphadenopathy more likely would include:

  • Multiple nodes (‘lumps’) present
  • An obvious cause for raised nodes (lower limb infection or recent trauma)
  • Gradual onset
  • Nodes less painful and / or less tender than a torted testicle
  • Testicles are present in the scrotum!

In the absence of the inguinal mass, other differentials would include UTI, appendicitis and mesenteric adenitis. Diagnosing appendicitis can also sometimes be tricky. In the case of severe RLQ pain and tenderness (at McBurney’s point) it can be diagnosed clinically, but often blood tests (mainly for CRP and WCC) are conducted, and sometimes an USS. In a well child with RLQ pain who does not have clinical appendicitis, a ‘watch and wait’ approach can be taken, sometimes at home, sometimes with admission to surgical ward overnight for observation.

A raised node in the groin is from a cause the lower limb, or sexual organs (think STI in adults), and usually does not have an abdominal cause

Intussusception is very unlikely in this age group and usually occurs in infants and younger children <4 years old. Can occur in older children but is rare.

Mesenteric adenitis is more of a diagnosis of exclusion. This causes pain due to enlarged intra-abdominal lymph nodes, usually secondary to a viral infection. It can be difficult to tell apart from early appendicitis. Abdominal pain is often diffuse, intermittent and there are few clinical signs. It is often diagnosed clinically, although it can sometimes be distinguished on a CT scan – and is usualyl an incidental finding when a CT has been done to rule out more serious pathology.

The Real Story

This is a real case. On the night in question, a whole load of slices of Swiss Cheese collided, and the diagnosis was missed.

The patient was seen by a tired junior doctor who didn’t feel very well, but had come to work anyway not to let anybody down. They thought it seemed like a lymph node, so they wrote ‘?lymph node’ in the notes. Later on the rushed surgical registrar came to examine the patient and agreed – it did seem like a lymph node. The scrotum was never examined. A USS was ordered. It suggested a firm hard rubbery thing which looked like a lymph node, and because the request said ‘?lymph node’ then nobody thought that it might be a testicle.

He was a tough kid. He didn’t seem to be in much pain. It wasn’t a textbook case. But nobody is a textbook case.

The mistake was discovered the next morning by the day team when the patient was re-assessed.
He went to theatre ASAP. The testicle was dead.

Lessons

– ALWAYS examine the scrotum of a boy with abdominal pain. ALMOST ALWAYS examine the scrotum of a man with lower abdominal pain (especially if a young man). If you don’t examine the scrotum you’d better have a good reason why not. This isn’t the OSCE anymore. “Yes Mr Examiner I would always examine the scrotum for completeness”. Examine the bloody scrotum.
– When you think you know what it is, think what else it might be, and write it down. When you request a test, list your differentials on the referral so that the radiologist / pathologist / other investigation person known exactly what to rule out.
– If you are handed over a patient – especially if the diagnosis is uncertain – then start again. Take a history. Examine the patient. Work out what YOU think. Don’t take anything for granted.

 

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