Surgery MCQs Q10

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PEDIATRICS • UROLOGY

A 4-month-old boy presents with irritability and unilateral scrotal swelling. He is febrile (38°C). Examination shows an enlarged, red, firm, and tender testis. Urine analysis reveals protein, nitrites, and leukocytes.

What is the most likely diagnosis?

A Direct inguinal hernia

B Epididymo-orchitis

C Hydrocele

D Testicular torsion

E Undescended testis

B. Epididymo-orchitis. The combination of fever, a tender/swollen testis, and positive urine infection markers (nitrites/leukocytes) in an infant strongly points toward infection-related inflammation.

Decoding Clue

1

CLUE "Infant + fever + tender swollen testis"

TRANS This indicates an inflammatory or infectious process (not just structural).

2

CLUE "Nitrites + Leukocytes in urine"

TRANS Points to UTI, the most common trigger for pediatric epididymo-orchitis.

Explanation

B. Epididymo-orchitis: Correct. Results from ascending infection. The presence of nitrites/leukocytes confirms a UTI, which is the key differentiator from torsion.

D. Testicular torsion: A major differential. While it causes pain/swelling, it typically has a sudden onset and sterile urine (no nitrites/leukocytes). It is a surgical emergency.

A & C. Hernia/Hydrocele: Usually presents as painless swelling. Hydrocele transilluminates; Hernia might have bowel sounds or be reducible, neither causes fever/UTI.

E. Undescended testis: Presents as an empty scrotal sac, not an acute inflamed swelling within it.

🧠 Torsion vs. Epididymo-orchitis

Feature	Torsion	Epididymo-orchitis
Onset	Sudden/Acute	Gradual/Subacute
Fever	Usually absent	Present
Urine Analysis	Normal (Sterile)	Pyuria / Positive Nitrites
Cremasteric Reflex	Absent	Present

Integrated Clinical Questions

1. Most important test to differentiate torsion vs epididymo-orchitis?

Answer: Doppler ultrasound (blood flow assessment).

2. Most common cause of epididymo-orchitis in children?

Answer: Urinary tract infection (Gram-negative bacteria like E. coli).

3. Most common cause in sexually active adults?

Answer: Chlamydia trachomatis / Neisseria gonorrhoeae.

4. Management of epididymo-orchitis?

Answer: Antibiotics + scrotal support + analgesia.

5. Why torsion is more dangerous than epididymo-orchitis?

Answer: Ischemia leading to testicular necrosis within hours (surgical emergency).

⚡ Exam Pearls

• Pain + fever + UTI markers → Epididymo-orchitis.
• Pain without UTI → Assume Torsion until proven otherwise.
• Urinalysis is the single most useful clinical discriminator in the ER.
• Always rule out anatomical abnormalities (like PUV) in infants with first UTI/orchitis.

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