January 24, 2025

A 2-year old boy presents to the ED with left hemiscrotal swelling

By Med-Challenger · 1 minute read

A 2 yo boy presents to the ED with left hemiscrotal swelling. The parents have noticed intermittent mild swelling over the past several weeks, but tonight in the bath, they noticed that the swelling was significantly larger. The patient seems a little uncomfortable to the parents, but he has not had any vomiting, fever, or difficulty urinating. His exam is notable for tense left hemiscrotal swelling. Cremasteric reflexes are intact, and the testicular lie is vertical, but it is difficult to assess the size of the testis due to the swelling. There is no overlying discoloration. An ultrasound is obtained with an image shown below.

image (70)

Photo courtesy of Kathleen Kieran, MD

What is the most appropriate next step?

Arrange for a testicular biopsy as an outpatient
Follow up with a surgeon for elective repair
No further work-up or management is indicated
Obtain a urinalysis with culture

The correct answer is:

Follow up with a surgeon for elective repair

Follow up with a surgeon for elective repair. This US demonstrates a hydrocele, a communication of fluid around the testicle within the tunica vaginalis. The history of intermittent swelling is consistent with a communicating hydrocele. While most spontaneously resolve by age 18 months, persistence at age 2 years is an indication for surgical repair. A biopsy would be indicated for concern for testicular tumor, but without masses palpated on exam or abnormal findings on US, this is not indicated. Urinalysis and culture are not useful in this scenario. [5-Min PEM pp 458-9]

This question appears in Med-Challenger Pediatric Emergency Medicine 3rd Edition Exam Review with CME

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