In abdominal pain, performing acomplete examination, including examination of the genitals, is important

Author: Caroline Rassbach, MD

What to Do - Gather Appropriate Data

Testicular torsion and ectopic pregnancy present similarly to appendicitis, and both have serious morbidity if not quickly diagnosed.

The differential diagnosis for a child with abdominal pain is extensive. It includes problems from organs within the abdomen as well as from organs outside of the abdomen. Both testicular torsion and ectopic pregnancy can present with abdominal pain that mimicks appendicitis, and both can lead to significant morbidity if not quickly diagnosed. As a result, it is important to always perform a complete physical examination, including examining the genitals, when a child presents with abdominal pain.

Testicular torsion requires prompt diagnosis and intervention if the testicle is to be saved. Spermatogenesis may be lost within 4 to 6 hours of absentblood flow.It is the mostcommoncauseof testicular pain in boysolder than 12 years, and is uncommon in boys younger than 10 years. Testicular torsionoccursinatestisthatisinadequatelyfixatedinthescrotumbecauseof a redundant tunica vaginalis. This anatomical abnormality is called the bell- clapper deformity and is often bilateral. Testicular torsion usually presents with testicular pain and swelling, although in some cases may present with abdominal pain. The pain usually begins abruptly and without precipitating event. Occasionally there is a report of genital trauma prior to the onset of pain. The pain may be accompanied by nausea and vomiting. Physical examination will reveal swelling and erythema of the scrotal sac. The testis will be in a horizontal rather than vertical position and the cremasteric reflex will almost always be absent. Torsion of an undescended testis will present as abdominal pain; examination of the genitals will reveal an empty scrotal sac.

Suspicion of testicular torsion should lead to prompt intervention. In equivocalcases,aDopplerultrasoundmaybeusefulandmayrevealdecreased blood flow to the affected testis. A 99mTc-pertechnetate testicular flow scan is a good alternative to Doppler ultrasound. False-negative studies can occur; therefore, highly suspicious cases should be treated immediately without waiting for radiologic imaging. When diagnosis occurs within 6 hours of the onset of torsion, as many as 90% of testes can be saved through either manual or surgical detorsion. Survival of the gonad depends on the amount of time elapsed since the onset of torsion, and on the degree of torsion. If the degree of torsion is <360 degrees, the testis may still be viable after 24 to 48 hours. Manual detorsion may be successful in approximately 25% of cases. Attempts at manual detorsion should not delay surgical consultation. Surgical intervention is indicated for failed manual detorsion, for removal of a nonviable testis, or as a first-line intervention for detorsion. Following detorsion, bilateral orchiopexy is necessary to prevent future episodes of torsion.

Ectopicpregnancyisanotherseriousproblemonthedifferentialdiagnosis for abdominal pain. If a delay in diagnosis occurs, the ectopic pregnancy may rupture leading to blood loss, hypotension, and possibly death. The mortality of patients with ectopic pregnancy is 5 in 10,000. Ectopic pregnancy occurs most often in sexually active patients with a history of pelvic inflammatory disease. As a result of pelvic inflammatory disease, these patients have inflammation, scarring, and adhesions in their fallopian tubes, leading to inability of the fertilized egg to pass to the uterus. Patients with a history of tubal surgery are also at risk for ectopic pregnancy.

Ectopic pregnancy can mimic appendicitis in presentation. Patients most often present with abdominal pain approximately 7 weeks after their last menstrual period, often with vaginal bleeding or spotting. Physical examination will reveal a normal or slightly enlarged uterus. Vaginal bleeding, anadnexalmass,andpelvicpainwithmanipulationofthecervixsignificantly increase the likelihood of ectopic pregnancy. A ruptured ectopic pregnancy may present with hypotension, significant abdominal pain, rebound, and guarding.

Ectopic pregnancy cannot be reliably excluded by physical examination alone. In order to diagnose ectopic pregnancy, a test for the ß subunit of human chorionic gonadotropin (hCG) should be performed initially. This testturnspositivewithin1weekofconception,beforeanexpectedmenstrual period is missed. Following a positive β-hCG, the patient should undergo ultrasound examination to determine whether the pregnancy is intrauterine or ectopic. Ectopic pregnancy should be suspected if the β-hCG level is >1,500 IU/L and the transvaginal ultrasound does not show an intrauterine gestational sac. Serial quantitative β-hCG levels can be used as an adjunct to diagnose ectopic pregnancy. With an intrauterine pregnancy, β-hCG levels will increase by at least 50% every 48 hours during the first 6 weeks of gestation. With an ectopic pregnancy, however, β-hCG levels do not rise to the same degree. Serial β-hCG levels may be helpful; however, diagnosis of ectopic pregnancy by this information alone is neither sensitive nor specific.

Once an ectopic pregnancy is diagnosed, it may be managed in several ways. An ectopic pregnancy with a low and declining hCG level, no fetal heartbeat, good follow-up care, and an ectopic mass <3 cm may be managed expectantly. When intervention is indicated, a nonruptured ectopic pregnancy may be treated medically with methotrexate or with surgery. Surgery is indicated in the case of ruptured ectopic pregnancy.

Both testicular torsion and ectopic pregnancycan cause significant morbidity if they are not quickly diagnosed. Both can present with abdominal painandshouldbeonthedifferentialdiagnosisforacuteappendicitis.Therefore, a complete physical examination, including examination of the genitals, is necessary in the evaluation of abdominal pain in children.

Suggested Readings

Elder JS. Disorders and anomalies of the scrotal contents. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 17th ed. Philadelphia: Saunders; 2004:1817– 1820.
Hartmann GE. Acute appendicitis. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 17th ed. Philadelphia: Saunders; 2004:1283–1285. Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician. 2005;72(9):1707–1714.
Paradise JE, Grant L. Pelvic inflammatory disease in adolescents. Pediatr Rev. 1992;13(6):216– 223.
Ringdahl E, Teague L. Testicular torsion. Am Fam Physician. 2006;74(10):1739–1743.

Book Source Details

• Book Title: Avoiding Common Pediatric Errors
• Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
• Year of Publication: 2008
• Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6

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