What Are Some Criteria For Varicocele Evaluation?

Patient Presentation
A 16-year-old male came to clinic for his health supervision visit. He was a wrestler who had had a shoulder strain and an auricular hematoma the previous season that were now resolved. He and his parents had no concerns. The review of systems was negative.

The pertinent physical exam showed a well-developed male with normal vital signs. Weight was in the 25% and length was in the 50%. Both were consistent with previous measurements. His examination was Tanner V for pubic hair and testicular size. His examination was normal except for a 2×2 cm “bag of worms” mass that was palpable in the upper scrotum that decreased when the patient was lying supine and increased when standing and performing a valsalva maneuver. The patient had been unaware of it and denied any pain. The testicles appeared to be the same size and no other masses or abnormalities were noted. The diagnosis of an asymptomatic varicocele was made. The physician discussed the varicocele with the family and originally was going to monitor it along with the family as it did not appear be causing any problems at the time. After reviewing a PUBMED search, the pediatrician talked with the family and referred the patient to a pediatric urologist for a more accurate testicular volume measurement and future monitoring.

Discussion

Varicoceles are caused by high venous back pressure which causes a tortuous dilatation of the testicular veins (pampiniform plexus) of the spermatic cord. They occur more on the left than right because the left renal vein has a higher pressure than the inferior vena cava which drain the left and right gonadal veins respectively. Varicoceles are not very common in young children (3% in < 10 years old) but increase during the adolescent years when the incidence is ~15% which is similar to the adult population. Most varicoceles do not cause problems, but can. The most worrisome problem is male infertility. "It is estimated that 85% of men with varicocele will not encounter male factor infertility." However for those with male factor infertility, varicocele occurs in up to 40% of men. "In contrast, most adolescents who present with varicocele are asymptomatic and their fertility future is unknown." Therefore evaluation and management for adolescent males with asymptomatic varicocele is controversial.

Varicoceles should reduce in size when the patient is supine. If the varicocele does not reduce when supine, a pelvic/abdominal mass should be considered. Varicoceles are graded with the patient standing:

    i. Palpable with valsalva
    ii. Palpable at rest
    iii. Grossly visible

Subclinical varicoceles are those that are found incidentally such as scrotal ultrasound. Subclinical varicoceles do not have an impact on fertility but can progress over time and may require long-term followup.

Learning Point

Some criteria for evaluation include:

  • Scrotal pain or discomfort that is chronic and not improved by support
  • Testicular volume loss or discrepancy – as assessed by orchiometer or ultrasound is important. Ultrasound is the most sensitive but orchiometer is less expensive.
    Testicular volume loss or discrepancy is often the primary determinant of potential treatment.

  • Additional urological problems

Evaluation can include initial and serial testicular volume measurement, semen analysis, and hormonal analysis. Indication for surgery, embolization or sclerotherapy treatment are also controversial with combinations of factors weighting the decision. One author states, “Varicocele treatment for infertility is not indicated in patients with either normal semen quality or a subclinical varicocele. Varicocele repair in adolescents should be considered when there is objective evidence of reduced ipsilateral testicular size.” Abnormal semen analysis or hormone levels also are factors in the decision making.

Questions for Further Discussion
1. What is included in the differential diagnosis of scrotal masses?
2. What are causes of testicular pain? A review can be found here.
3. Describe the differences between inguinal and femoral hernias?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Testicular Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Garcia-Roig ML, Kirsch AJ. The dilemma of adolescent varicocele. Pediatr Surg Int. 2015 Jul;31(7):617-25.

Kolon TF. Evaluation and Management of the Adolescent Varicocele. J Urol. 2015 Nov;194(5):1194-201.

Casey JT, Misseri R. Adolescent Varicoceles and Infertility. Endocrinol Metab Clin North Am. 2015 Dec;44(4):835-42.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

What are Potential Health Problems Associated with Polycystic Ovary Syndrome?

Patient Presentation
A new patient, 16-year-old female came to clinic with bilateral knee pain for 2 weeks. She said her knees hurt more as the day went on and with more physical activity. They felt better when she rested or in the morning. She denied any trauma and said that they “just hurt all over” and could not indicate any point tenderness. She denied any joint stiffness, other joint pain, swelling, redness, rashes, or visual problems. She was obese and had not lost weight. She had gained ~20 pounds per report since her last visit to another physician 9 months previously. The past medical history was remarkable for being diagnosed 14 months ago with polycystic ovary syndrome (PCOS) after an evaluation for hirsutism and oligomenorrhea. The patient was supposed to be taking some medications, but she and her mother said that they really didn’t understand why she was taking the medicines so they just stopped a few months after starting them. They had moved and had not re-established care until presentation for the knee pain. The family history was positive for obesity, diabetes, and heart disease. The mother denied any gynecological problems in the family.

The pertinent physical exam showed an obese female who was slow to move around the room. Vital signs were pulse of 94, respiratory of 20, blood pressure of 136/72, weight of 197 lbs with a BMI of 32.1. Her skin examination showed significant acanthosis nigricans and comedomal acne. Her thyroid had no masses. Heart was regular rate and rhythm without murmur. Abdomen was obese with no hepatomegaly. Her joint examinations were normal without edema, erythema and general normal range of motion that was only limited by her weight. Her knees had no specific point tenderness, joint line tenderness and medial and cruciate ligaments were intact.

The diagnosis of deconditioning and joint pain secondary to weight gain was made. As the patient and family did not understand her underlying diagnosis of PCOS the patient was referred to a pediatric endocrinologist for patient education, evaluation and monitoring. The patient also had a well-child examination appointment made as it had been more than a year since her last one. She was also referred to a physical therapist to help with the joint pain and conditioning. The family also agreed to meet with the clinic social worker to help coordinate appointments, transportation, obtaining medical records and also helping the mother to establish medical care for herself and the other children in the family.

Discussion
Polycystic ovary syndrome (PCOS) affects 6-8% of reproductive-age women making it the most common endocrinopathy in this age group. There is no consensus on the specific diagnostic criteria for PCOS in adolescents as many of the characteristics overlap with normal adolescent physiology. However, patients should have evidence of hyperandrogenism, oligo- or amenorrhea, and potentially polycystic ovaries. PCOS has a genetic component although a specific gene has not been identified. Incidence of PCOS is 20-40% for a woman with a family history.

Hyperandrogenism
Androgen levels change during puberty therefore actual measurement and interpretation can make the diagnosis more difficult. Obesity increases androgens. Puberty is associated with a 25-50% decrease in insulin sensitivity. Therefore evidence of hyperandrogenism can be difficult to document.

Acne and hirsutism are common presentations. Hirsutism is the presence of terminal hairs in androgen dependent areas (i.e.male pattern) and is evidence of hyperandrogenism. Hypertrichosis is increase in vellus hair in non-male patterned areas such as forearms and lower legs and needs to be distinguished from hirsutism. Hypertrichosis is not evidence of hyperandrogenism. Patients may also have an increase in muscle mass or voice deepening.

Oligo- or amenorrhea
Anovulatory cycles are normal in pubertal girls so oligomenorrhea ( 2 years or have amenorrhea past the normal menarche should be considered for evaluation. This is especially true if hyperandrogen symptoms are present or if there is a family history of PCOS.

Polycystic ovaries
Multicystic ovaries are part of normal physiology for adolescent girls so diagnosis may overlap with adult criteria. Transvaginal ultrasound is a better imaging modality than transabdominal ultrasound for visualizing the ovaries. But many adolescents require transabdominal ultrasound because they are virginal or will not tolerate the procedure. Obesity also limits the adequacy of the transabdominal study.

The differential diagnosis of PCOS includes:

  • Congenital adrenal hyperplasia, late onset
  • Cushing syndrome
  • Hyperprolactinemia
  • Hypothyroidism
  • Pregnancy
  • Primary ovarian failure
  • Tumors – adrenal or ovary
  • Acromegaly

Treatment includes lifestyle modifications to improve obesity, insulin insensitivity and dyslipidemia. Oral contraceptives, usually combination medications, can improve menstrual irregularities, decrease androgens and improve hirsutism. Androgen receptor blockers such as spironolactone, also have similar effects. Insulin sensitizers such as metformin can improve insulin sensitization, menstrual irregularities and decrease androgens. Cosmetic methods of hair removal, and treatment of acne can also be helpful additional treatment for PCOS patients.


Learning Point

Potential health problems in PCOS include:

  • **Irregular menses
  • Infertility
  • Endometrial cancer
  • Obesity
  • Hyperlipidemia
  • Non-alcoholic fatty liver disease
  • Sleep apnea
  • **Acne
  • **Hirsutism
  • Insulin insensitivity, hyperglycemia
  • Type 2 diabetes
  • Acanthosis nigricans
  • Dyslipidemia
  • Hypertension

  • Emotional/psychiatric problems

** Common presentations of PCOS in adolescents

Questions for Further Discussion
1. What evaluation for PCOS should be considered?
2. What specialists help to manage PCOS?

Related Cases

    Symptom/Presentation: Pain

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Polycystic Ovary Syndrome and Knee Injuries and Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Irizarry KA, Brito V, Freemark M. Screening for metabolic and reproductive complications in obese children and adolescents. Pediatr Ann. 2014 Sep;43(9):e210-7.

Hecht Baldauff N, Arslanian S. Optimal management of polycystic ovary syndrome in adolescence. Arch Dis Child. 2015 Nov;100(11):1076-83.

Rosenfield RL. The Diagnosis of Polycystic Ovary Syndrome in Adolescents. Pediatrics. 2015 Dec;136(6):1154-65.

Morris S, Grover S, Sabin MA. What does a diagnostic label of ‘polycystic ovary syndrome’ really mean in adolescence? A review of current practice recommendations. Clin Obes. 2016 Feb;6(1):1-18.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

What Picky Eaters Really Don’t Eat?

Patient Presentation
A 2-year-old female came to clinic for her health supervision visit.
Her mother was concerned that over the past 2 months, she had started to refuse to eat many of the regular table foods that were eaten by the family. Specifically she was now refusing to eat anything that had a sauce or dressing on it including pasta, tacos, mashed potatoes with gravy, and even jelly on toast. She sometimes would eat it if it was presented “on the side” of the plate separate from the other foods. Her mother said that more often now she seemed to have one favorite food for a few days and then abruptly refused to eat it when served. Her mother said she was concerned about her not eating very much and so she would make her other preferred foods and would let her eat whenever she wanted to during the day. Her mother asked about any vitamins she could give her to help her appetite. The mother denied any emesis, diarrhea, loose stools, or obvious weight loss. “She’s never been very big, but she looks skinnier to me,” her mother said. Developmentally she was saying 1-3 word sentences, would scribble on the chalkboard in the room, would use a spoon and cup, and could run and jump. She got along well with her 3.5 year old brother and other children in her daycare class. The past medical history was non-contributory. The family history was negative for any gastrointestinal diseases. There was some generalized anxiety in the mother and other maternal relatives. The review of systems was otherwise negative.

The pertinent physical exam revealed a well-appearing female. Her weight was 10.6 kg (10% for age) which was only 200 grams up from her 18 month visit (= 10.4 kg, 25%). Her length was 82.5 cm (25%) and her head circumference was 47 cm (25-50%). The rest of her physical examination was normal.

The diagnosis of a healthy child with picky eating habits and declining weight percentiles was made. The pediatrician recommended that the child be offered 3 meals and 2-3 snacks during the day. Each meal should have at least 2 hours between the meals. The meals were to be served with the child sitting down to eat with appropriate plates, cups and utensils for the meal, trying to keep the meal a quiet and pleasant social time between the child and other family members. “Even if you are out and about, you can all sit down and enjoy a snack for a short time together,” he noted. He recommended that the child be offered the meal and then 1/2 way through the meal offer any beverage so the child wouldn’t fill up on only the liquid. “A serving should be the size of her palm or fist. She doesn’t need a lot, so don’t try to give her too much because then she might be overwhelmed with too much food on her plate,” he mentioned. “I also recommend using a big plate because then the food amount looks small. Just like anyone wants some choices in their foods, she can have them too but there are limits. Generally I recommend 2 choices for a snack. She can be offered the same meal that the rest of the family is having. If after 10-15 minutes she hasn’t eaten her meal, then you can just put it away. The food doesn’t come out again until the next meal or snacktime. Then you can re-serve the previous meal’s food if it is appropriate,” he also recommended. “I want to see her back in about a month to recheck on her weight and see how you all are doing”

The patient’s clinical course at one month showed her weight to be 10.95 kg (10-25%). Her mother reported that they had stopped letting her eat between her meals but weren’t always good about not offering her several choices of food when she refused to eat. They also weren’t as good about sitting down to eat a meal and her mother would feed her while in the car or stroller many times too. The pediatrician praised the mother for starting to make some changes and having appropriate weight gain over the month. He reiterated that she would learn healthy eating practices from the mother, and re-recommended taking a break to sit down for a meal and fewer food choices. During a sick visit ~10 weeks later, the child’s weight was now 11.5 kg (10-25%) and tracking. The mother said that they still didn’t sit down for all the meals but did for more than before, plus the child only got two choices for a snack. “Sometimes I still let her have a sandwich at dinner instead of what we are having,” she confided.

Discussion
Picky eating does not have one definition and is a broad term. In general, picky eaters are described as limiting the amount and types of food, and a refusal to eat novel foods.

Normal healthy children often will reject different types of food they have accepted before in their second year of life. They tend to place more value on food properties such as the color or texture. Feeding problems occur in 25-45% of normally developing children and in up to 80% of developmentally delayed children. Most of the problems are acute issues and resolve within a short time with reasonable guidance and interventions. Most children have resolution of picky eating behaviors by 6 years of age.

Parents and other caregivers can become quite stressed about the picky eating. They worry about the child’s health, as potentially picky eating can cause poor nutrition or the child to become underweight. They also are worried about behavioral or emotional problems such as tantrums, aggression, being oppositional, depression, anxiety and social withdrawal. Studies have been mixed regarding being a picky eater as a child and correlation with eating disorders as an adolescent or adult. Risk factors such as having unpleasant meals or conflicts around meals/eating, food avoidance, and eating slowly which do occur for some picky eaters, are the same risk factors for eating disorders.

Though most picky eaters will have resolution quite quickly, others will last longer but resolve within 1-2 years. Still others will be persistently picky with > 3 years duration of picky eating behaviors. One study was able to identify children who were more likely to be persistently picky eaters (>3 year duration) using a questionnaire with 3 key questions: “Is your child a picky eater? (Yes), does s/he have strong likes with regard to food? (Yes), and does your child accept new foods readily? (No)”

Learning Point
Using data from the 2008 Feeding Infants and Toddler’s Study of children up to 48 months, researchers in 2016 reported that picky eaters ate:

  • Lower amount of meats/protein including eggs
  • Lower amount of vegetables especially raw vegetables
  • Lower calories when eating mixed dishes (i.e. casserole, burrito, etc.)
  • Less of certain food textures such as mushy or slimy or highly textured requiring more chewing. Texture resistance was highly correlated with picky eating.

Fruit, grain, milk or other beverages, and sweet intake was not different for picky or non-picky eaters. Bitter taste also was not different between the groups. Other studies have also shown picky eaters tend to consume less fat.

Questions for Further Discussion
1. What recommendations do you offer to caretakers of picky eating toddlers?
2. What are your criteria for further medical or psychological evaluation or treatment for picky eaters?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Toddler Nutrition and Child Nutrition.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Toyama H, Agras WS. A test to identify persistent picky eaters. Eat Behav. 2016 Jul 15;23:66-69.

Machado BC, Dias P, Lima VS, Campos J, Gonçalves S. Prevalence and correlates of picky eating in preschool-aged children: A population-based study. Eat Behav. 2016 Aug;22:16-21.

van der Horst K, Deming DM, Lesniauskas R, Carr BT, Reidy KC. Picky eating: Associations with child eating characteristics and food intake. Appetite. 2016 Aug 1;103:286-93.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

What Can You Do About Tinnitus?

Patient Presentation
An 8-year-old male came to clinic approximately 4 weeks after having left otitis media. His mother was concerned because he had said several times over the past week that he had sounds in his ears. He described the sounds as “popping” or sometimes “crunchy” like rice cereal. He said it wasn’t high pitched but was like a voice tone; it wasn’t too loud or soft. The sounds lasted only a few seconds but he wasn’t sure if it was associated with jaw movement or yawning. He denied ear pain, sore throat, or vertigo. He had normal balance and mentation. “It just sounds kind of weird for a few seconds and then goes away,” he described. He was not bothered by the sounds and denied having any similar problems in the past. He denied any trauma but did use headphones when he was playing videogames. The past medical history showed some upper respiratory tract infections including 2 otitis media infections in the past. He had not head trauma in the past. The family history was negative for any ear, nose or throat problems.

The pertinent physical exam showed a healthy boy with normal vital signs and growth parameters in the 75-90%. HEENT showed some clear fluid behind the left tympanic membrane with bubbles within the fluid. The tympanic membrane was in a normal position with normal landmarks. His right ear was normal. He had some very mild clear rhinorrhea. Yawning or other jaw movements did not reproduce the sounds. Neurological examination was normal including tests for balance. The diagnosis of a resolving middle ear effusion was made. The pediatrician counseled that it was most likely that the sounds were caused by the eustachian tube opening and closing causing air to move into the middle ear as the effusion was resolving. He recommended monitoring the problem and keeping a symptom diary with a followup appointment in 4 weeks if the problem was not resolving and sooner if it was becoming more frequent, painful or was affecting his activities including sleep or balance. He did not return for the followup appointment.

Discussion
Tinnitus is derived from the Latin word tinnire which means to ring but in general practice it means any perceived sound that is not generated externally. It is a common problem in adults. In children it is described as being commonly overlooked as children do not spontaneously report it. It is felt that children may consider the sound normal, or are easily distracted and therefore forget about it. Children can accurately describe the sounds they hear and use words such as buzz, ring, hum, swish, whish, blow or beep. Spontaneously reported tinnitus is ~6.5% and increases to 34% when children are specifically questioned in one study. Prevalence has been reported in up to 36% of children with normal hearing and rises to up to 66% in children with hearing loss. Constant tinnitus (43%) is reported more commonly than intermittent tinnitus (31.5%) and bilateral (69%) is more common than unilateral (31%). Tinnitus that affects quality of life is not reported in studies but studies in adults show ~33% will report tinnitus but only 0.4-1% report it affecting their quality of life. Reported problems in children with tinnitus include sensory perception problems, emotional/psychological problems, headache, dizziness and vertigo, fatigue, and sleep problems.

One study found no association between childhood hearing disorders and adult tinnitus after adjusting for adult hearing thresholds. Another study of adolescents found a high prevalence of tinnitus in those who had significant exposures to high sounds volume for long periods of time such as attending nightclubs or parties, headphone use for music or using cellphone headsets in the ear.

Learning Point
The cause of tinnitus is unclear but it has been associated with otitis media, myoclonus of the muscles of the palate or middle ear, acoustic trauma, arteriovenous malformations, and intracranial hypertension. Evaluation by an audiologist and otolaryngologist may uncover ear pathology. Treatment includes amplification if there is a hearing loss, sound generators (e.g. child who has increased problems in a quiet environment could listen to music while studying), and counseling. Counseling can validate the problem, discuss the natural history, identify aggravating and mitigating factors and help develop coping skills to address the tinnitus.

Questions for Further Discussion
1. What are indications for an audiogram?
2. How common is congenital hearing loss?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Tinnitus

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Savastano M, Marioni G, de Filippis C. Tinnitus in children without hearing impairment. Int J Pediatr Otorhinolaryngol. 2009 Dec;73 Suppl 1:S13-5.

Shetye A, Kennedy V. Tinnitus in children: an uncommon symptom? Arch Dis Child. 2010 Aug;95(8):645-8.

Sanchez TG, Oliveira JC, Kii MA, Freire K, Cota J, Moraes FV. Tinnitus in adolescents: the start of the vulnerability of the auditory pathways. Codas. 2015 Jan-Feb;27(1):5-12.

Aarhus L, Engdahl B, Tambs K, Kvestad E, Hoffman HJ. Association Between Childhood Hearing Disorders and Tinnitus in Adulthood. JAMA Otolaryngol Head Neck Surg. 2015 Nov;141(11):983-9.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital