A 6-month-old boy is brought to the emergency department for fussiness. Last night, the patient became irritable and developed nonbloody, nonbilious vomiting after breastfeeding. His mother gave him acetaminophen, which improved his fussiness. Overnight, he woke up crying and is now inconsolable. The patient was born at term and has a history of constipation, for which he takes prune juice. He has had daily soft bowel movements for the last 2 weeks. Temperature is 37.1 C (98.8 F), pulse is 150/min, and respirations are 48/min. The patient appears irritable and is difficult to console. The anterior fontanel is soft. Bilateral tympanic membranes and oropharynx are clear. The neck is supple. Bowel sounds are present. The patient writhes and is inconsolable on deep palpation of the lower abdomen. No organomegaly or abdominal mass is palpated. Genitourinary examination shows an uncircumcised penis. No testis is palpable in the right scrotum. The left testis is normal. There is no mass in the inguinal canal. Which of the following is the most likely diagnosis?
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This infant, who is inconsolable to abdominal palpation, has an acute abdomen. His undescended testis raises concern for torsion of an intraabdominal testis, a potential complication of cryptorchidism. Torsion is 10 times more likely in an undescended testis compared with that of a scrotal testis. Torsion of an intraabdominal testis typically presents with acute, severe abdominal pain and vomiting, as in this patient. Although older children may localize pain, infants may have irritability and inconsolable crying because of the pain. Torsion of an undescended testis in the inguinal canal can cause inguinal swelling and pain.
Emergency surgical detorsion and orchiopexy are indicated to salvage the testis. Torsion of undescended testes has a lower salvage rate than torsion of scrotal testes.
In general, testes that do not descend by age 6 months are unlikely to descend on their own. Therefore, elective surgical correction of cryptorchidism is recommended as early as 4 months to avoid testicular torsion and reduce the risk of subfertility and testicular cancer associated with uncorrected cryptorchidism.
(Choice A) Acute appendicitis presents with pain in the right lower quadrant abdomen, fever, and vomiting. It is uncommon at age <5, and the incidence is not increased in patients with cryptorchidism.
(Choice B) Cryptorchidism is often associated with inguinal hernia. A nonreducible, incarcerated hernia can cause irritability and vomiting in infants, but a tender, swollen inguinal mass would be palpable (not seen in this patient).
(Choice C) Pyelonephritis can present with irritability and vomiting in infants but is unlikely in the absence of fever.
(Choice D) Pyloric stenosis typically presents at age 3-6 weeks with recurrent, nonbilious projectile vomiting immediately after feeds and a palpable olivelike mass in the upper abdomen. It is unlikely in this infant age 6 months who has had only a single episode of emesis.
(Choice E) Stool impaction, or large amounts of hardened stool throughout the large intestine, may cause abdominal pain and distension but is unlikely in a patient with daily soft stools.
Educational objective:
Intraabdominal testicular torsion should be suspected in a patient with cryptorchidism and an acute abdomen. Infants may have irritability, inconsolable crying, and pain with abdominal palpation.