Camille Wu: Testicular Troubles at DFTB17

Cite this article as:
Team DFTB. Camille Wu: Testicular Troubles at DFTB17, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16080

This talk was recorded live on the final of DFTB17 in Brisbane. If you missed out in 2017 then why not book your leave for 2018 now. Tickets are on sale for the pre-conference workshops as well as the conference itself at www.dftb18.com.

Camille Wu is a paediatric surgeon based out of Sydney. Here she talks about those things that make grown men go weak at the knees.

Post circumcision bleeding

Cite this article as:
Andrew Tagg. Post circumcision bleeding, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.3159

Sam, a 9-day old boy, is rushed into the paediatric emergency room by his distraught parents.  Bright red blood is soaking through the front of his cloth nappy.

 

Bottom Line

  • The incidence of neonatal circumcision is on the decline though it may still be performed for religious reasons.
  • Circumcision reduces the transmission of HIV and HPV and reduces the risk of UTI’s.
  • The commonest complications are pain, bleeding and later infection.

 

What is a bris?

A brit milah, or bris, is the traditional Jewish circumcision ceremony that usually takes place on the 8th day of life.  It is carried out by a mohel. The mohel may not be a medical practitioner.  Followers of Islam are also circumcised (Khitan) though there is no prescribed time after birth in which must take place as long as it is before the age of 10.

What proportion of newborn boys are circumcised?

Whilst a number of religions including Islam and Judaism require newborn boys to be circumcised the proportion of boys that undergo the procedure is declining.  Currently, about 10-20% of boys born in Australia and less than 10% in New Zealand are circumcised.

The Royal Australasian College of Physicians’ policy statement on male circumcision states that “there is no evidence that the benefits outweigh the risk of the procedure”. The American Academy of Pediatrics holds the opposite view.

 

Other than religious reasons, why might a boy be circumcised?

  • Treatment of true phimosis
  • Prevention of recurrent balanoposthitis
  • Prevention of recurrent UTI’s
  • Prevention of STI transmission

A 2009 Cochrane meta-analysis found that male circumcision in sub-Saharan Africa reduced male-to-female rates of HIV transmission by 36-66%. Males who have been circumcised are unlikely to pass on HPV to their partners in life and will not get skin cancer of the penis.

 

Are there any contraindications to circumcision?

It is generally contraindicated if there is any genital developmental abnormality such as hypo- or epispadias or if the patient has ambiguous genitalia.  It is also not recommended in the children of parents with haemophilia until the child has been tested. It goes without saying that it should not be performed on the sick or jaundiced infant either.

 

What are the possible acute complications of such a circumcision and how would you treat them?

  • Pain
  • Bleeding
  • Infection

Complications occur following approximately 1 in 500 procedures. The tip of the penis is often crusted and inflamed. Sucrose should be used prior to the removal of the dressing in the neonate.

If there is profuse bleeding this may be a marker of an underlying coagulopathy and so should be tested for.  Bleeding may be due to a snipped vessel or localized inflammation/infection.  Direct pressure with a surgical dressing such as Kaltostat should halt the bleeding. Very rarely a single suture is needed to tie off a bleeding vessel.

Should there be any cellulitis to the penis in the neonate then they should be admitted for IV antibiotics.

 

Outcome

Once the nappy was removed it was obvious that there was active bleeding to the area where the foreskin had been removed.  After giving some sucrose the vaseline gauze dressing was removed and a bleeding point identified.  When the application of a surgical dressing failed to stop the bleeding a penile block was placed and a single stitch tied off the guilty blood vessel. The clotting profile was normal and Sam was discharged to follow up with his primary care provider.

 

References

Royal Australasian College of Physicians, Paediatrics & Child Health Division. Circumcision of infant males. [cited 2013 Jul 22]

American Academy of Pediatrics Task Force on Circumcision. Male circumcision. Pediatrics. 2012 Sep;130(3):e756-85.

Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database Syst Rev. 2009 Apr 15;(2).

Penile problems

Cite this article as:
Andrew Tagg. Penile problems, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.2922

A 5-year-old boy, Kayden, is brought in by his mother as she is concerned that there is something wrong with his penis – every time he tries to pass urine it balloons in his foreskin and goes all over the floor.

 

Bottom Line

  • A non-retractile foreskin may be present in up to 10% of 4-year-olds
  • Parents should not try to forcibly retract the foreskin of their child as it may lead to paraphimosis
  • Most cases of phimosis resolve with time
  • Paraphimosis occurs when a retracted foreskin is unable to be returned to its normal position due to oedema of the glans and prepuce
  • Good hygiene and avoidance of irritants are the mainstays in treating balanitis

 

What is phimosis?

A non-retractile foreskin is the norm in neonates and may be present in 60% of boys under one year of age.  By 4 years of age, 90% of boys are able to retract their foreskin. The majority of cases that present to either primary care or the emergency department are physiological phimosis.  True phimosis is caused by forcible retraction of the foreskin leading to a tight circular band of scar tissue.  Some studies suggest an increased incidence of balanitis xerotica obliterans (BXO).

 

Phimosis

When is phimosis a problem?

  • The foreskin is non-retractable by puberty
  • Previously retractable foreskin gets stuck
  • Presence of ballooning of urine under foreskin on micturition

How do you treat phimosis?

Application of 0.05% betamethasone ointment bd applied to the tip of the foreskin for 4-6 weeks reduces localized inflammation and helps loosen any inner preputial adhesions from the underlying tissue thus making it easier to retract.  The majority of children with phimosis will not need any surgical intervention.  Children with BXO may be referred early for circumcision though it may recur.

 

What is paraphimosis?

When the foreskin is left in the pulled back position it can impair venous return from the glans leading to oedema. This may lead to ischaemia and necrosis if left untreated.  It is commonly related to previous phimosis where a ring of tough fibrous scar tissue forms around the foreskin.  Whilst its presentation is usually obvious do not forget to consider the diagnosis of a hair tourniquet.

 

Paraphimosis

How do you treat paraphimosis?

The foreskin should be returned to its normal position as quickly as possible. The pain should be relieved with parenteral/intranasal analgesia.  Often lignocaine jelly (similar to that used for catheterisation) is enough to numb the pain whilst an ice pack is applied to help reduce oedema. Once these have had ten minutes to work use the thumb of your dominant hand to push down on the glans whilst sliding the foreskin back in place. If this does not work a flexible, self-adhering bandage may be used to compress oedema.

What surgical options are available?

In the majority of occasions, the simple measures described above should be effective for returning the foreskin to its natural position. For completeness sake, it is worth being aware of some of the surgical options available but these should only be carried out by experienced practitioners. For the older child, it may be necessary to perform a penile block (under sedation) in order to aid reduction.  More brutal surgical techniques have been described, including multiple punctures of the glans to reduce oedema or performing a dorsal slit (cutting the fibrous ring of tissue).  The child should then be referred to a paediatric surgeon for consideration for circumcision as a later date.

How can I remember which is which?

PARAchutes come down and so does the foreskin in PARAphimosis.

What is balanitis?

Balanitis is inflammation of the glans of the penis that is often accompanied by inflammation of the overlying foreskin.  It is more common in boys that have not been circumcised.

 

What causes balanitis?

Balanitis may be either

  • Contact or irritant balanitis – presents as generalized redness and swelling and is often due to detergents or bubble baths
  • Candidal balanitis – often presents as redness around the glans with sparing of the meatus and  cottage cheese-like debris that is easily rubbed off
  • Bacterial balanitis – presents as redness and pain with a purulent exudate.  It may be caused by Staph. aureus or Group A beta haemolytic strep species

A penile skin swab is not needed as the majority of cases clear up with empiric treatment.

How can it be treated?

  • General methods – Parents should be advised to carefully wash in lukewarm, saltwater baths and dry the penis without forcibly retracting the foreskin.  They should avoid detergents and bubble baths and if the boy is still in nappies they should change him frequently
  • Suspected irritant balanitis with/without candidal colonisation – topical hydrocortisone cream 1% with added imidazole (miconazole/clotrimazole) bd for 14 days or until settled
  • Suspected bacterial balanitis – Oral flucloxacillin for 7 days ± topical hydrocortisone 1% for discomfort.  Topical antibiotics have no proven efficacy.

Most cases of balanitis are irritant in origin and respond well to simple measures.  It can be tough to distinguish between irritant and infective forms and so treatment may need to be escalated if simple hygiene methods fail. If the symptoms are not improving after 7 days then a penile skin swab should be taken

Children with recurrent or chronic balanitis should be referred to a paediatrician or a dermatologist.

 

Kayden is diagnosed with phimosis and is prescribed four weeks of topic steroid cream.  When he is seen for another matter a month later you enquire as to his problem and find that he no longer misses his target.

 

References

McGregor TB, Pike JG, Leonard MP. Pathologic and physiologic phimosis:approach to the phimotic foreskin. Can Fam Physician. 2007 Mar;53(3):445-8.

Shahid SK. Phimosis in children. ISRN Urol. 2012;2012:707329.

Pohlman GD, Phillips JM, Wilcox DT. Simple method of paraphimosis reduction revisited: point of technique and review of the literature. J Pediatr Urol. 2013 Feb;9(1):104-7.

 

Testicular trouble

Cite this article as:
Andrew Tagg. Testicular trouble, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.2728

Jaxxon, a 13-year-old boy, forgot to wear his box whilst at cricket training and was hit in the groin by a high-speed ball. He thought nothing of it as the pain disappeared after an hour or so but presented to your emergency department a day later as the pain returned and was more intense.

Bottom Line

  • Testicular torsion is a true surgical emergency
  • Do not neglect the inguino-scrotal exam in the inconsolable infant
  • No part of the history or clinical exam can rule out torsion with 100% reliability
  • Doppler US can aid diagnosis in equivocal cases but if not immediately available should not prevent a trip to the OR

What is your differential diagnosis?

What is the incidence of testicular torsion and who is at risk?

Torsion occurs in 1 in 4000 men less than 25 years old. It has a bimodal distribution. 65% of cases occur during puberty due to hormone-induced changes in size.

10% of cases occur in boys under one year of age. Some of these torsions may have occurred before delivery!

An undescended testis is at increased risk of torsion as is a testicle subjected to trauma.
 

What is a bell-clapper deformity?

The tunica vaginalis extends over the epididymis and spermatic cord forming a cavity in which the testicle can hang and swing freely – like the clapper of a bell.

They have an increased risk of torsion.

12% of men have this deformity at post mortem.

What factors on history or examination may help you rule out torsion?

Nothing in the history can reliably let you rule out a torsion. The pain is often acute in onset and unremitting. It may wake the patient in the middle of the night and be associated with nausea and vomiting.

Pain due to trauma should settle within an hour or so.

They may also give a history of previous similar incidents when the testis has torted and detorted spontaneously.

The classical exam finding is of an exquisitely tender, high riding testicle with a horizontal lie though  secondary hydrocele may mask this.

What is Prehn’s sign?

This is the absence of the cremasteric reflex on the side of the affected testicle. It was once thought that if the cremasteric reflex was present then it could not be torsion. Unfortunately, a number of case reports have since refuted this. Relying on the presence of the reflex to rule out torsion will lead to trouble.

What about imaging to rule out torsion?

Ischemia and infarction of the testis may occur within 4 hours of torsion though one study has suggested a 90% salvage rate if operated on within 6 hours of onset.

Rates of success drop to 50% by 12 hours.

Time is testicle and if you have a high degree of clinical suspicion then the patient should go to the operating room (regardless of fasting state) for surgical exploration.

If the history is greater than 12 hours and there is some diagnostic doubt then two methods of imaging modalities may be considered.

Colour-flow doppler ultrasound has a quoted sensitivity of 88% and a specificity of 90% and may also be useful in making alternative diagnoses such as epididymo-orchitis, rupture, or bleeding. However, if the testicle has spontaneously detorted the resultant hyperaemia on ultrasound can be confused for epididymo-orchitis. Tc-99 scintigraphy is 100% sensitive but is not widely available.

Is there anything I can try whilst waiting for the surgeons?

You could try to externally detort the testis.  This does not negate the need for scrotal exploration but may buy you some time.

The key is good procedural sedation and the rotating the affected testicle as if you were opening the pages of a book.

What about a torsion of the appendix of the testicle?

The hydatid of Morgagni (one of five possible testicular appendages) is an embryological remnant of the Mullerian system found in the upper pole of the testis. As puberty hits raging hormones make this, and other appendages swell.  This makes them more likely to twist on their precarious blood supply.

The pain of a torted hydatid is supposed to be more insidious in onset and less intense. As it becomes more ischaemic it can be visible as a small blue dot on the testicle though this may be masked by a reactive hydrocele.

Treatment is conservative with supportive underwear and NSAID’s but the diagnosis can be hard to make and so exploration is often needed.

Given the greater than 24 hour history and the possibility of testicular rupture, a colour-flow Doppler was performed. This confirmed the presence of a large haematocoele and a non-viable testis. It was removed in the operating room later the same day.

Selected references

Ringdahl E, Teague L. Testicular torsion. Am Fam Physician. 2006 Nov 15;74(10):1739-43. Review. Free full text

Cuckow PM, Frank JD. Torsion of the testis. BJU Int. 2000 Aug;86(3):349-53.

Mellick LB. Torsion of the testicle: it is time to stop tossing the dice.Pediatr Emerg Care. 2012 Jan;28(1):80-6. Free full text