BLADDER STIMULATION TECHNIQUES FOR NEWBORN CLEAN CATCH URINE COLLECTION

An infant presents with fever. The parents do not want a catheter placed in his penis. You want to check for urine infection. The resident suggests placing a bag. Are there any other options?

 

In 2013 Herreros-Fernendez described a technique of coaxing the child to urinate. She would tap the bladder at a rate of 100 taps per minute, and massage the low back. 86% of the time the child would urinate, with a median of 45 seconds. The population was strictly those less than 30 days of age, so it may not apply to older babies. The idea was inspired by bladder stimulation techniques used in adults with neurological diseases. There may be some element of a frontal lobe “release” reflex involved in the phenomenon.

 

The original study stacked the odds in their favor by feeding the babies, but follow-up studies all showed a greater than 50% success rate within 5 minutes. Thus, this technique is well worth trying in a low risk population.

 

Of note, the bladder tapping was 100 taps per minute. It is supposed to be gentle but the parents may quickly throw in the towel and ask for the catheter.

 

Take Home Points

-For the infant with a low suspicion of urinary tract infection, consider massage and bladder tapping to elicit a urination reflex

 

Herreros Fernández ML et al. A new technique for fast and safe collection of urine in newborns. Arch Dis Child. 2013;98:27-9.

INTACT CREMASTERIC REFLEX DOES NOT RULE OUT SPERMATIC CORD TORSION

A patient presents with acute testicular pain. You were concerned about spermatic cord (testicular) torsion but find an intact cremasteric reflex. Do you send the patient home?

 

In 1984 Rabinowitz introduced the cremasteric reflex as diagnostic of spermatic cord torsion. Stroking the inner thigh near the testicle produces ipsilateral contraction of the cremasteric muscle, with retraction of the testis. About half of newborns do not have this reflex, but by the age of 3, it is thought that 100% of boys with normal testicles have this reflex(Caesar RE J Urol. 1994). Elderly men can lose the reflex (DeJong’s The Neurologic Examination)

 

A hundred years ago this sign was known for being prominent in sciatica, and offered a theoretical means of testing L1 and L2 function, but it was more of a curiosity than a critical part of physical examination. Interestingly, in one of the early case reports of spermatic torsion from 1894, the cremasteric reflex was performed but its significance would not be appreciated for another 90 years (Warbasse JP. Ann Surg. 1894)

 

For about two decades after Rabinowitz’ 1984 article, the cremasteric reflex was thought to be 100% sensitive for spermatic cord torsion. Van Glabeke’s report in 1999 of only 60% sensitivity should have put that illusion to rest, but the significance of his findings was not always appreciated in subsequent textbooks and lectures. Case reports continued to accumulate illustrating limitations in the sensitivity of the cremasteric reflex for spermatic cord torsion, which should not have surprised anyone. What made Van Glabeke’s report most convincing is that they operated on 98% of children with the acute scrotum (544 out of 556 patients). Thus, this article was least susceptible to incorporation bias. Competing studies that showed high sensitivity for the cremasteric reflex often used different gold standards, such as the documented loss of arterial flow by ultrasound.

 

So how should we use the cremasteric reflex? A prospective study showed that of 12 patients with spermatic cord torsion, only 8 had a positive cremasteric reflex (Boettcher BJU Int 2013). The same group 2 years prior found that it was only 21% sensitive in 19 torsion cases.(Boettcher Urol 2012) The range can vary but omitting extremes, a rough estimate would say that about 2/3 of cases of torsion will have a pathologic cremasteric reflex and1/3 will be normal.

 

Back to the bedside. Armed with this information, the normal cremasteric reflex does not call off your concern for torsion and you continue your evaluation.

 

Take Home Points:

An absent or diminished cremasteric reflex is approximately 60-70% sensitive for spermatic cord torsion.

Studies with different gold standards may exaggerate the sensitivity of the cremasteric reflex.

MANUAL REDUCTION OF SPERMATIC CORD (TESTICULAR) TORSION

A patient presents with right-sided testicular pain and swelling for 1 hour, associated with nausea and vomiting. Physical examination shows tenderness and swelling in both the epididymis and testicle itself. The epididymis is anterior to the testicle, and palpation of the spermatic cord reveals a 1cm nodule about 2 cm above the testicle.

 

You call the urologist because the patient has spermatic cord torsion. While waiting you apply color Doppler ultrasound which confirms no flow. You try to untwist the testicle laterally but there is resistance and increase of pain. Should you wait for the urologist? Is there anything else you can do?

 

The idea that all torsion is medial, treated by “opening the book,” has been demonstrated to be false in every generation, yet the over-simplified teaching persists. Thanks to Sessions’ 2003 excellent article showing 1/3 incidence of lateral torsion, awareness is improving.

 

You go the opposite direction, detorsing medially. The patient experiences relief. Color Doppler ultrasound now shows arterial flow. Torsion can be up to 3 full turns so the patient still needs to go to the operating room. But you have restored arterial flow and improved the patient’s chance of testicular salvage.

 

Endpoints of manual reduction:

-lack of resistance to the reduction

-relief of pain

-resolution of abnormal lie

-testicle drops lower in the scrotum to a normal position

-may feel a “snap” into place (Hinman’s Atlas of Pediatric Urologic Surgery)

-untwisting of spermatic cord knot

-return of color ultrasound flow

 

Take Home Points:

-Torsion can occur in either direction, so use resistance and relief as your first endpoints

-Palpate the spermatic cord knot and note the lie and length as additional endpoints

-Use color Doppler ultrasound as the ultimate endpoint

SPERMATIC CORD TORSION (TESTICULAR TORSION): PALPATE THE CORD

Most people use the term “testicular torsion,” but throughout history it has also been called “spermatic cord torsion.” Many urologists prefer this term. One introduced it as “acute spermatic cord torsion, more commonly and not so exactly named testicular torsion (TT)…”(Drlik M. J Ped Urol 2013)

The reason spermatic cord torsion is a better term is that it accurately identifies the pathologic organ. By neglecting to call it by its right name, we don’t necessarily realize that we can palpate the actual pathology in this disease.

That is why it took until 2011 for an article to assess the sensitivity and specificity of palpation of the spermatic cord knot.(Al-Terki A. Spermatic Cord Knot: A Clinical Finding in Patients with Spermatic Cord Torsion. Adv Urol 2011) With a reported 86% sensitivity and 100% specificity in 46 patients, this is worth our attention.

The knot of spermatic cord torsion may be located in the inguinal canal in neonates, but it is usually in the scrotum in adolescents and adults. We should palpate the spermatic cord in the acute scrotum. If the results of this first article are replicated, this may turn out to be the most important part of the physical examination of the acute scrotum.

Take Home Points:

-“Spermatic cord torsion” is a more accurate term than testicular torsion

-Spermatic cord torsion can often be felt as a knot on physical examination

References:

Spermatic cord knot: a clinical finding in patients with spermatic cord torsion. Al-Terki A…Adv Urol. 2011

Article located for free at:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3235495/