Pediatrics - Acute Scrotum, Varicicele and Small lip Synechiae PDF

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Pediatrics Summary of Diseases Affecting Children: Acute Scrotum, Varicicele and Small lip Synechiae....

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ACUTE SCROTUM, VARICICELE AND SMALL LIP SYNECHIAE ACUTE SCRO SCROTUM TUM

Definition. Acute scrotal pain can be caused by testicular torsion, testicular appendage torsion, or epididymitis. The great challenge is the difficulty in differentiating these diagnoses, since the findings are not exuberant and spermatogenic damage secondary to testicular torsion starts after 6 hours of evolution.

→Testicular torsion: corresponds to the twisting of the spermatic cord over the testicle, interrupting its blood supply, which can lead to necrosis. →Testicular appendix torsion: corresponds to the torsion of the embryonic remains from the regression of the Muller and Wolff ducts. →Epididymitis: is the inflammatory or infectious process of the epididymis, which can also affect the testis (orchitis/orchiepididymitis). Epidemiology. Testicular torsion accounts for 50-60% of cases of acute scrotum in adolescents and for 25-30% of all pediatric cases. Testicular appendix torsion is more common between 7 and 10 years of age, and the distribution is the same between the two sides. Epididymitis causes 20% of cases in adolescents and less than 1% in prepubertal boys. Clinical condition. In cases of testicular torsion, the patient presents with sudden pain, and, often, the indication of the location can be precise. There are usually no reports of urinary symptoms or urethral discharge. On physical examination, the testicle is elevated in relation to the contralateral one, and the cremasteric reflex is absent. The patient is usually uncomfortable and not in a resting position, and may present vomiting. When the testicular appendix twists, the pain is usually also sudden, but the patient locates the pain in only one specific point of the testicle, which is usually at its apex. It is not accompanied by nausea or vomiting. On physical examination, we find this localized pain point and, on transillumination, a “blue spot” is seen, which corresponds to the twisted testicular appendix. In patients with epididymitis, the onset of pain is usually insidious. In sexually active adolescents, there is usually an associated sexually transmitted infection. In these cases, urethral discharge and urinary symptoms are common. When there is no associated infection, the diagnosis is impaired. It does not usually present with nausea or vomiting. Physical examination of the patient with early-stage epididymitis shows an enlarged, soft mass posterior to the testis. With evolution, it becomes more difficult to differentiate the epididymis from the testis, thus becoming very similar to the presentation of testicular torsion.

Subsidiary exams. A common urinalysis is usually normal in the patient with testicular torsion as well as in the patient with torsion of the testicular appendix; in patients with epididymitis with an infectious cause, there may be numerous leukocytes. In these cases, a cultural can also help. It is very important to clarify testicular flow to differentiate between testicular torsion and epididymitis. There are two tests capable of measuring testicular flow: testicular echography with color Doppler and testicular scintigraphy. Both have a sensitivity around 90%, but in advanced cases there may be false positives, so that neither is accurate enough to differentiate the two causes of acute scrotum in these advanced conditions. When the exams delay the surgery, surpassing the testicular damage risk period, they should not be performed. During testicular color Doppler ultrasound, the two types of torsion can be distinguished.

Treatment. In cases of doubt about the cause of the testicular pain, testicular exploration is indicated, with the aim of preserving the testicle. When there is a diagnosis of testicular torsion, a manual distortion maneuver can be performed before surgery to relieve symptoms, even though surgery is indicated. This maneuver consists of rotating the testicle from medial to lateral, as many times as necessary to relieve symptoms. Testicular exploration is performed through an incision in the scrotal raphe, with an initial approach on the twisted side, performing the detortion and warming the testicle with warm compresses. If, after 30 minutes, the testicle has not recovered, an orchiectomy should be performed. When there is recovery, this testicle should be fixed with a non-absorbable suture. Regardless of this, fixation of the contralateral testis is required. In cases of torsion of the testicul testicular ar appendi dixx , in general the use of analgesics and anti-inflammatory drugs, and sometimes antibiotics, is sufficient. In more advanced cases, testicular exploration may be indicated to differentiate from testicular torsion. In patients with epididymitis, the use of analgesics and anti-inflammatory drugs is also sufficient. In sexually active adolescents or when there is an etiological diagnosis, it is indicated to treat the specific cause. A scrotal brace can help relieve symptoms.

VARICOCELE Definition. It is the dilation of the pampiniform venous plexus and the internal spermatic vein.

Epidemiology →Occurs in 19-26% of adolescents – 90% of cases on the left side →6% at 10 years →85% are fertile despite the risk →In infertile adults, 19-41% have varicocele

Etiology. It is usually caused by incompetence of the venous valves. For this reason, it is more common on the left, since, on that side, the left internal spermatic vein flows at a right angle into the left renal vein, which causes difficulty in draining the vein. When there is varicocele only on the right or when it is bilateral, an organic cause (abdominal mass) must be excluded.

Pathophysiology. There are three causes involved in the development of testicular dysfunction in patients with varicocele: increased testicular temperature, hypoxia secondary to venous stasis, and reflux of renal and adrenal metabolites.

Clinical conditi condition. on. When there is a complaint, it is a painless enlargement on the side of the testicle after puberty. It is usually an incidental finding on physical examination and is not usually accompanied by pain. On physical examination, plexus dilatation can be visualized or palpated. When it is only possible to palpate the dilation using the Valsalva maneuver, the varicocele is grade I; when it is palpable regardless of maneuvers, it is grade II, and when it is visible regardless of palpation, it is called grade III.

Subsidiary exams. Physical examination is sufficient for diagnosis, but an ultrasound scan of the scrotum can help in doubtful cases and may be useful to assess the size of the testicle, since differences greater than 3 mL between the testicles indicate surgery. An abdominal ultrasound may be necessary if the varicocele is suspected to be secondary to an abdominal mass. In adults, the spermogram is widely used to assess the testicular exocrine function, thus helping to indicate surgery. In teenagers, however, sperm collection as well as reference values are still not well defined.

Treatment. Regardless of grade, patients with varicocele should undergo an annual physical examination to assess testicular size. In grade III cases, in which there is testicular atrophy, surgery is indicated. Despite being controversial, there are authors who indicate surgery for patients with recurrent testicular pain. There is also an indication for surgery for patients with altered spermocytogram. When indicated, surgical correction can be performed by inguinal exploration with ligation of veins, by the high retroperitoneal approach by laparoscopy, or by the subinguinal approach with microsurgery. In patients with recurrent varicocele, angiographic embolization may be indicated.

SMALL LIP SYNECHIAE Definition. Fusion of the labia minora by adhesions, which occur from the posterior furcula towards the clitoris.

Epidemiology. It affects more girls between the neonatal period and 2 years of age and after between 6 and 7 years of age.

Etiology. In prepubertal girls, due to the low amount of estrogens, there is a tendency for adhesion between the labia minora after trauma or infections with dermatitis.

Clinical conditio condition. n. They are usually asymptomatic. When they present symptoms, they may be due to an associated urinary infection, with dysuria, pollakiuria or difficulty in urination.

Treatment. In incomplete synechiae, the initial treatment is conservative, since most of them spontaneously regress at puberty. In cases of complete or symptomatic synechiae, 1% conjugated estrogen creams can be used, applied 2×/day between 2 and 4 weeks. It is important to emphasize that the prolonged use of estrogen can cause vulval pigmentation, hyperesthesia and breast growth. In cases of dense synechiae that do not respond to the use of estrogen, surgical section under sedation and in an outpatient setting is indicated. Postoperative care should add, in addition to estrogen, sitz baths and creams with vitamin A and D....