USMLE STEP 3 MCQ 3

Question:
An 8 year old boy has testicular pain of gradual onset over the last three days. The pain is localized to the upper pole with a positive cremasteric reflex. A hard, tender nodule of less than 5mm in size is palpable in this region. On inspection there is a small bluish discoloration and localised tenderness in the upper pole of the testes. Doppler ultrasonography reveals a small nodule adjacent to the upper pole of the testis and normal vascularity. The most appropriate next step would be


a) prompt surgical exploration
b) needle aspiration
c) ceftriaxone and doxycycline
d) nonsteroidal anti-inflammatory agents
e) radionuclide scintigraphy

Correct Answer: D


Explanation:

Urgent operation is unnecessary in those in whom a tender nodule is found (pathognomonic of a torted appendage) and in those presenting after more than 24h of pain with scrotal erythema and oedema. The likely diagnosis in this case is a torted appendage and in cases of torsion of the testis there is no prospect of salvage at this stage. Torsion of the appendix testis is the most common cause of testicular pain in boys between 2 and 11 yr but is rare in adolescents. The appendix testis is a stalklike structure that is a vestigial embryonic remnant of the mullerian (paramesonephric) ductal system that is attached to the upper pole of the testis. When it undergoes torsion, progressive inflammation and swelling of the testis and epididymis occurs, resulting in testicular pain and scrotal erythema. The onset of pain is usually gradual. Palpation of the testis usually reveals a 3-5 mm tender indurated mass on the upper pole . In some cases, the appendage that has undergone torsion may be visible through the scrotal skin, termed the blue dot sign. In some boys, distinguishing torsion of the appendix from testicular torsion is difficult. In such cases, a testicular flow scan or color Doppler ultrasonography may be helpful. The natural history of torsion of the appendix testis is for the inflammation to resolve in 3-10 days. Nonoperative treatment is recommended, including bed rest and analgesia with nonsteroidal anti-inflammatory medication for 5 days. If the diagnosis is uncertain, scrotal exploration is recommended