小儿阴囊急症的临床诊治经验

Diagnosis and treatment in acute scrotal problems in children

目的 总结小儿阴囊急症各种疾病的发病特点及诊治经验.方法 回顾性分析2010年10月至2014年3月收治的314例阴囊急症患儿的临床资料,均以发现单侧阴囊疼痛或伴局部红肿就诊,体格检查单侧阴囊触痛或伴局部红肿.①睾丸扭转63例.新生儿9例,1个月～1岁11例,1岁1个月～4岁12例,4岁1个月～7岁11例,7岁1个月～10岁10例,10岁1个月～13岁10例.左侧58例,右侧5例.鞘外扭转5例,均为新生儿;隐睾扭转4例;鞘内睾丸扭转54例,均为左侧.病程2h～15d.病程＜10h者,阴囊触痛明显,睾丸位置明显上移,局部皮肤无发红;10h～10 d者,阴囊红肿,睾丸位置轻度上移;＞10 d者,阴囊局部触痛不明显.超声检查示患侧睾丸无血流或血流减少,病程＞24 h者可见睾丸实质呈裂隙状改变.②睾丸附件扭转130例.1个月～1岁1例,1岁1个月～4岁5例,4岁1个月～7岁24例,7岁1个月～10岁32例,10岁1个月～13岁68例.病程12h～8d.彩色多普勒超声检查示70例睾丸上极与附睾间有非均质回声团块;60例未见非均质回声团块,但附睾头肿胀,睾丸血流正常.③附睾炎99例,左侧45例,右侧54例.新生儿6例,1个月～1岁45例,1岁1个月～4岁40例,4岁1个月～7岁5例,7岁1个月～10岁3例.病程6h～5d.彩色多普勒超声检查示50例睾丸血供正常或较对侧稍丰富,附睾头体尾均明显增粗,余49例睾丸血供较对侧减少或探及不清.④睾丸炎2例,均为左侧.1例7岁,以左侧阴囊红肿热痛3d入院,合并腮腺炎,彩色多普勒超声检查示睾丸血流丰富;1例12岁,以左侧阴囊红肿疼痛3周入院,彩色多普勒超声检查示左侧阴囊内未见正常睾丸形态,中下部可见4 cm×3 cm×2 cm大小非均质团块,该团块上方可见薄片状类似睾丸回声,白细胞22.6×10^9/L,中性粒细胞0.88.⑤鞘膜炎17例.新生儿4例,1个月～1岁6例,1岁1个月～4岁7例.13例发病前存在腹泻病史,病程均＞24 h.14例彩色多普勒超声检查示睾丸血流不清.⑥睾丸鞘膜囊内出血3例,均为新生儿,单侧阴囊颜色发蓝,彩色多普勒超声检查示鞘膜囊内密集点状回声及不均质回声团块.结果 睾丸扭转63例,6例病程4～11h的患儿行睾丸复位＋双侧睾丸固定术后,随访5例睾丸血供好,形态正常,1例出现睾丸部分萎缩;54例因睾丸坏死行睾丸切除术＋对侧睾丸固定术;3例病程＞10 d,睾丸已萎缩,因家长拒绝而未行手术治疗.睾丸附件扭转130例中,82例行睾丸附件切除术,48例口服抗生素治疗.附睾炎99例中,49例血供较对侧减少或探及不清者行睾丸探查并鞘膜囊切开减压术,余50例口服或静脉应用抗生素及外敷止痛消炎软膏治疗.睾丸炎1例7岁患儿行抗感染及局部外敷止痛消炎软膏治疗,另1例12岁患儿行坏死组织剔除术.鞘膜炎17例中,14例超声检查示血流不清者行鞘膜囊切开减压术,余3例行抗感染治疗治愈.睾丸鞘膜囊内出血3例中,2例行鞘膜囊内血肿清除术,1例行止血、预防感染治疗.所有手术患几经治疗后均顺利恢复.结论 小儿阴囊急症以睾丸附件扭转最常见,7 ～13岁发病率高,睾丸扭转发病最急,鞘内睾丸扭转以左侧发病占绝对优势,鞘外扭转多发生于新生儿,睾丸炎发病率极低,附睾炎和鞘膜炎好发于3岁以内,鞘膜炎与腹泻关系密切.对于不能排除睾丸扭转的阴囊急症患儿应积极手术探查.

Objective To summarize the clinic characteristics and surgical strategy in children＇s acute scrotum disease.Methods The clinical data in 314 cases with acute scrotum disease were retrospectively study between October 2010 and March 2014.All boys were found one sided scrotal pain or with local redness.The physical examination showed unilateral scrotal swelling or with a haphalgesia.Among them,63 cases were diagnosed as testicular torsion （TF）,including 58 cases at left side,and 5 cases at right side.The age of onset covered newborn 9 cases,1 m-1 y in 11 cases,1 y1m-4 y in 12 cases,4 y1m-7 y 11 cases,7 y1m-10 y in 10 cases,and 10 y1m-13 y in 10 cases.Five cases of testicular torsion outside sheath that were all newborn,4 cases of cryptorchidism torsion,54 cases of testicular torsion inside sheath,which occured all on the left side.The onset time ranged from 2 hours to 15 days.The physical examination showed scrotal haphalgesia and testicular position moved up obviously in the boys whose onset time were less than 10 hours,and scrotal skin redness and swelling beginning to appear,testicular position slightly upward were shown between 10 hours and 10 days,the scrotal skin redness and swelling were disappeared in more than 10 days.The pre-operative ultrasound showed testicular blood flow decreased or disappeared and displayed testis fissure shaped changing when the onset time exceeded 24 hours.130 cases were diagnosed as testicular appendage torsion （TAT）,including 1 m-1 y in 1 case,1 y1m-4 y in 5 cases,4 y1m-7 y in 24 cases,7 y1 m-10 y in 32 cases,10 y1 m-13 y in 68 cases.The onset time ranged from 12 hours to 8 days.The color Doppler ultrasound examination showed a heterogeneous mass between the upper pole of testis and the head of epididymis in 70 cases,and the rest of 60 cases hadn＇t been found the similar mass.but the heads of epididymis were all swelling and the testicular blood flow were normal.Ninety-nine cases were diagnosed as epididymitis,including 45 cases at left side,and 54 cases at right side,whose age of onset covered 6 cases of newborn,1 m-1 y in 45 cases,1y1m-4 y in 40 cases,4 y1m-7y in 5 cases,7 y1m-10 y in 3 cases.The onset time ranged from 6 hours to 5 days.The color doppler ultrasound examination showed testicular blood flow were normal and whole body of epididymis was enlargement with rich blood flow in 50 cases,the rest of 49 cases showed testicular blood flow reduced or unclear.The orchitis was found in 2 cases,including one 7 years old case mergered with mumps,whose color doppler ultrasound showed testicular blood flow was rich,and one 12 years old case,whose ultrasound showed 4cm × 3cm × 2cm heterogeneity echo of mass and testicular like tissue instead of the normal testis.The sheath membrane inflammation was found in 17 cases,including newborn in 4 cases,1 m-1 y in 6 cases,1 y1 m-4 y in 7 cases.Thirteen cases existed diarrhea before onset and the onset time were more than 24 hours.The ultrasound in 14 cases showed that testicular blood flow were unclear.Testicular sheath membrane hemorrhage was diagnosed in 3 cases,which were all the newborn.Unilateral scrotum showed blue color.Ultrasound showed densely dotted echo and heterogeneity mass.Results In 63 cases of TT,54 cases were received unilateral testis resection and opposite side proceeded fixation due to the esticular necrosis.Six cases were received the testis reversion and bilateral fixation whose onset time were from 4 hours to 11 hours.One case appeared testicular atrophy.In 130 cases with TAT,82 cases were underwent testicular appendage resection,48 cases adopted conservative treatment of oral antibiotics.Forty-nine cases of epididymitis which proceeded testicular exploration and testicular membrane decompression,the rest of 50 cases received oral or intravenous antibiotics therapy and topical analgesic anti-inflammatory ointment treatment.1 case with orchitis was given conservative treatment and the other underwent necrotic tissue removed.In 17 cases with sheath membrane inflammation,14 cases,whose ultrasound showed vague blood flow,were underwent testicular membrane decompression and other 3 cases received anti-infection conservative treatment.1 case with sheath within membrane hemorrhage was given hemostatic conservative treatment and other 2 cases accepted evacuation of hematoma.Conclusion TAT was the commonest cause of acute scrotum disease in children,whose onset peak ranged from 7 to 13 years old.TT was the most urgent type,in which left side occupied absolute morbidity,TT outside sheath happened at the newborn frequently.The incidence of orchitis was extremely low.epididymitis and sheath membrane inflammation often occurred in less than 3 years old which is related to the diarrhea.We advocated a positive exploration for the acute scrotum that can＇t be ruled out from TT.