Diagnostic value of urine studies in children presenting with acute scrotum
Narjes Jaafar, MD, Eveline Hitti, MD, Bassel G. Bachir, MD, Yaser El-Hout, MD.
American University of Beirut Medical Center, Beirut, Lebanon.
BACKGROUND: Acute scrotum (AS) is a common complaint and a possible surgical emergency in children presenting to the Emergency Department (ED). The most common diagnoses encountered are testicular torsion, torsion of the appendix testis and epididymo-orchitis. Caregivers are put at a dilemma between the need for immediate and accurate diagnosis and therapy to prevent gonadal loss versus the need to minimize costly unnecessary negative surgical explorations, scrotal imaging and even urine studies. Obtaining urine studies in children with AS is arguably a routine practice that may not be warranted. We sought to analyze the diagnostic value of urine studies in children presenting with AS. METHODS: This is a retrospective, single-center chart review of pediatric patients (< 18 years) who presented with AS to the ED at a tertiary referral center between January 2012 and March 2018. The clinical presentation, laboratory and imaging studies, management and discharge diagnosis were recorded. Positive urinalysis was defined per American Urological Association as pyuria (≥ 4-6 WBCs), Leukocyte esterase (≥ 75), and abnormal Nitrites value. Positive Urine Culture was defined as bacterial growth (> 100,000 CFU) confirmed within 48 hours of incubation. RESULTS: There were 260 patients included in this study. The most common diagnosis was acute epididymitis in 83 patients (31.9%) followed by soft tissue injury in 54 patients (20.8%) then testicular torsion in 27 patients (10.4%). Among studied patients, 176 (68%) children had urine analysis ordered and 108 (41%) had urine cultures. Only 8/176 patients (4.5%) had a positive urinalysis and only 3/108 (2.8%) had positive cultures. Compared to Doppler ultrasound of testes, considered the gold standard diagnostic test in AS, the sensitivity of urinalysis was 9.1%, with a positive predictive value of 16.7%. The most common etiologies were not significantly associated with positive urine studies (p-value=0.05). The majority of children 230/260 (88%) were managed conservatively: 18 (8%) rest and scrotal elevation only, 170 (74%) (analgesics/NSAIDs), 42 (18%) antibiotics. Surgical exploration was performed in 30 (12%), with only two patients requiring orchiectomy. CONCLUSIONS:
Urine studies were found to be of marginal value in the diagnosis and management of children presenting to the ED with AS, incurring unnecessary additional costs and possible delays in a time sensitive diagnosis.
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