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F E B R U A R Y 1 , 2 0 1 2

D A V I D L E V Y

Morning Report

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HPI: 16 year-old male with right groin pain. Pain started 4 days ago but hasworsened over past 2 days and is present daily. Feels like pain is worst lateral to rightof pubic symphysis, on "tube" connecting to right testicle, and minimally on righttesticle. Not worse with any particular activity. Minimal redness, no swelling. Nohistory of trauma. Urination normal without dysuria or hematuria. Intermittenttactile fevers for past 3 days. No back pain. No fevers. No penile discharge.

PMH: No hospitalizations. No surgeries.

ROS: No recent weight gain or weight loss. No headaches. No blurry vision. Stoolpattern normal without constipation or diarrhea. Otherwise normal.

Meds:Ibuprofen twice since pain started.

Allergies: None

Imm: Up to date. Has received flu vaccine this year.

FHx: No history of genitourinary disorders.

SHx:In 10th grade. Never sexually active. No tobacco, alcohol, or recreational drug

use. No recent travel.

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PE

VS:Wt 64.5kg (56%), Ht 178cm (67%)T 97.5, HR 72, RR 18, BP 104/58, SO2 96% on RA

Gen: Awake, alert, pleasant on exam.HEENT: NC/AT. Conjunctiva clera, sclera anicteric. Ear canals clear, TMs gray withnormal landmarks bilaterally. Nares patent, no nasal discharge. MMM, tonsils withouterythema or exudate.Neck: Supple, no thyromegaly.

Resp: Normal WOB with good air entry. CTA bilaterally.CV: Regular rate and rhythm, normal S1, S2. No murmur. Pedal pulses 2+. Cap refill 2seconds.Abd: Soft, non-tender, non-distended. Bowel sounds positive. No hepatosplenomegaly.GU: Circumcised. Tanner 4 hair and testicular volume with enlarged scrotum. Noerythema. Minimal tenderness on palpation of superior aspect of right scrotum. Prehnsign equivocal. No discharge. No CVA tenderness.Extr: Warm, well-perfused. No cyanosis. No edema.Neuro: CN 2-12 grossly intact. Strength 5/5 for UE and LE bilaterally. Patellar reflex 2+.Cremaster reflex intact. No apparent deficitis.

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Differential?

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Lab:UA: SpGr

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Varicoceles

Etiology:Dilated and tortuous veins in the pampiniform plexus around the spermatic cord Primary: venous valvular incompetence due to anatomic alterations in veins of internal

spermatic plexus Secondary:Due to other cause, most frequently renal or retroperitoneal mass

Exam:Patient should be supine and standing to distinguish from idiopathic and secondarycauses

Secondary does not get much smaller with position change

Grading: I: Small- palpable only with Valsalva maneuver II: Moderate- Palpable upon standing, not visible on inspection III: Large- visible on gross inspection

Of note: Much more common on left (85-95%) because left spermatic vein enters left renal vein

at 90 degree angle, whereas right spermatic vein drains at a more obtuse angle

Other testing Hormonal studies: FSH, LH after GnRH stimulation can be useful to detect early

testicular damage, although wide range of normal Seminal fluid analysis: can be requested when pt has reached adult testicular volume

(15mL) ; should be repeated in 6-8 weeks

There might be a few problems with this

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Varicoceles

When to image: Evaluate for causes ofIVC obstruction (thrombus, abdominal mass)

If persists in supine positionAcute onset Right sided

Management Usually observed Consider referral for possible surgery when

Discrepancy between affected testicular volume and unaffected testicle (at least 10-20%)Associated with decreased sperm count

Symptom relief Bilateral varicoceles If abnormal semen analysis

Repair might improve semen in adolescents

Unilateral testis Hx of surgery for cryptorchidism

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ReferencesKorets R, Woldu SL, Nees SN, Spencer BA, Glassberg KI. Testicular symmetry and adolescent varicocele--doesit need followup Journal of Urology 2011. 186: 1614-8.

De Sanctis V, Marsella M. Unilateral asymptomatic testis enlargement in children and adolescents. Georgian

Med News 2011. 193:25-29.

Glassberg KI, Badalato GM,Poon SA, Mercado MA, Raimondi PM, Gasalberti A. Evaluation and managementof the persistent/recurrent varicocele. Urology 2011. 77: 1194-8.

Glassberg KI, Korets R. Update on the management of adolescent varicocele.F1000 Med Rep 2010. 12:25.

Poon SA, Gjertson CK, Mercado MA, Raimondi PM, Kuzakowski KA, Glassberg KI. Testicular asymmetry and

adolescent varicoceles managed expectantly.J Urol2010. 183: 731-4.

KumanovP, Robeva RN, Tomova A. Adolescent varicocele: who is at risk?Pediatrics 2008: 121:853-7.

Lavan JS,Haans LC, Mali WP. Effects of varicocele treatment in adolescents: a randomized study.Fertil Steril1992. 58: 756.

Kaplan GW. Scrotal swelling in children.Ped in Review 2000. 21:311-4.

Robison SP, Hampton LJ, Koo HP. Treatment strategy for the adolescent varicocele. Urol Clin North Am 2010.37: 269-78.

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Images fromhttp://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/19121.jpghttp://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/15855.jpghttp://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/19472.jpg

http://www.mayoclinic.com/images/image_popup/r7_hydrocele.jpghttp://en.wikipedia.org/wiki/File :Gray1148.pnghttp://us.123rf.com/400wm/65/255/mantonino/mantonino0804/mantonino080400183/2863392-shocked-young-boy-with-wide-eyes-over-black-background.jpg