Anne Whitehead MD, Inova Fairfax Medical Center
Maybelle Kou, Inova Fairfax Medical Center

The Case
This is a case of an 8 year old male with lower abdominal and scrotal pain x 1 week who had an extensive work-up prior to presentation. The challenge of this case was how to address and work up his continued pain.

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Denouement
Our differential diagnosis initially included intermittent torsion, renal colic, or worsening epididymitis. The ultrasounds were completed during an episode of acute pain, were normal, and essentially ruled out these diagnoses. We considered an enema in the ED, but the elevated liver enzymes and inflammatory markers suggested something other than constipation or functional abdominal pain.

The patient was admitted to the hospitalist service for further work up and pain control. During admission he underwent a bowel cleanout which improved his symptoms minimally. He was seen by both urology and neurology  (due to concerns for possible neuropathic pain), and it was during consultation with neurology that the patient reported he had flopped down onto his front-side multiple times while playing with a boogie board at the beach. An MRI pelvis was done and revealed strained adductor muscles, pelvic floor edema, and pubic symphysis inflammation, consistent with trauma. His pain improved with gabapentin and NSAIDs, and he was ultimately discharged home after a 4 day admission.

Teaching Points

• Residual testicular edema is usually present on scrotal ultrasound after torsion resolves, making ultrasound a useful test even if a patient is not currently having testicular pain.
• When a patient’s pain does not fit with any particular disease process or dermatomal distribution, consider direct trauma as a potential etiology.