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How best to help kids lose weight
Illustrative case
A 10-year-old boy comes in with his mother for a well-child check-up. His BMI is 40 kg/m2—above the 99th percentile for his age and up from 37 a year ago. His blood pressure is 120/84 mm Hg. What treatment, if any, should you offer for his obesity?
Childhood obesity is a global epidemic. In the United States, 19.6% of children ages 6 through 11 and 18.1% of 12- to 19-year-olds are obese, a 3-fold increase in the last 30 years.3 Without intervention, most obese adolescents will become obese adults, threatening to reverse the progress in slowing cardiovascular morbidity and mortality that has occurred over the past few decades.3
Obese kids get adult diseases
Obesity is a risk factor for a variety of chronic conditions, including cardiovascular disease, cerebrovascular disease, and arthritis. Severe obesity is also associated with higher mortality rates.4 Unfortunately, these comorbidities are not limited to adulthood.
“Adult” diseases, such as obstructive sleep apnea, dyslipidemia, and type 2 diabetes, are increasingly seen in children and adolescents.1 Nutritional deficits such as vitamin D and iron deficiency are often seen in obese children, as well.5 There are also psychological ramifications of childhood obesity, including social isolation and depression.6
The USPSTF recently upgraded its recommendation regarding obesity screening in children ages 6 and older from I (insufficient evidence) to B (a positive grade based on high or moderate certainty of the benefit of the intervention), citing new evidence in favor of screening and treating or referring children when appropriate.2 The systematic review we report on here, which formed the basis for the USPSTF’s upgrade, focused on management options for children identified as overweight or obese.
STUDY SUMMARY: Intense, comprehensive efforts pay off
This systematic review1 included studies of children ages 4 to 18 years who were overweight (defined as a body mass index [BMI] in the 85th to 94th percentile for age and sex) or obese (either a BMI at or above the 95th percentile for age and sex or a BMI >30 kg/m2). The researchers found 25 trials—15 of behavioral interventions alone and 10 that combined behavioral and pharmacologic interventions—that met their criteria: The studies focused on weight loss and/or maintenance, reported outcomes ≥6 months from baseline, and were conducted (or feasible) in a primary care setting.
Behavioral interventions were categorized by treatment intensity (as measured by hours of contact, which ranged from <10 hours to >75) and comprehensiveness (including nutritional counseling, physical activity counseling or participation, and counseling on behavioral management techniques). Weight outcomes were categorized as short-term (6-12 months since treatment initiation) or maintenance (≥12 months after the end of active treatment).
The 15 behavioral intervention trials included 1258 children ages 4 to 18 years, most of whom were obese. Most trials were small and reported high retention rates. All had beneficial effects on weight in the intervention group compared with the controls, but not all changes were statistically significant. Higher intensity and more comprehensive programs had better outcomes.
The largest effects were in 3 moderate- to high-intensity, comprehensive weight management programs with ≥26 hours of contact. These 3 trials demonstrated a difference in BMI of 1.9 to 3.3 in the intervention groups at 12 months compared with the controls. (A 3.3 difference in BMI is equal to approximately 13 lb in an 8-year-old and 17 lb in a 12-year-old.)
Four behavioral intervention studies reported outcomes ≥12 months after completing the intervention (range 15-48 months). Three of the 4 reported continued beneficial effects on weight after the active treatment period, but the effects were markedly attenuated.
The only adverse effect reported in the trials of behavioral interventions was the injury rate among children in an exercise program, but it was minimal: One fracture was reported, vs no injuries for the controls. No differences were reported in height, eating disorders, or depression. However, fewer than half of the behavioral intervention trials reported on adverse effects.
Weight loss drugs have modest effects
Ten trials combining pharmacologic and behavioral interventions involved a total of 1294 obese adolescents ages 12 to 19. All evaluated short-term weight loss effects of either sibutramine (10-15 mg/d) or orlistat (120 mg tid). Trials ranged from 3 to 12 months. Participants in both the control and intervention groups received behavioral counseling.
The trials all favored the treatment groups, although not all of the results were statistically significant. Trials of longer duration (12 months) had more favorable results than those lasting 6 months.
The largest sibutramine trial (n=498) reported a mean BMI reduction of 2.9 in the treatment group, compared with a reduction of 0.3 in the control group (P<.001). This corresponds to an average weight loss of 14 lb in the intervention group, vs 4.2 lb in the control group, after 12 months.
The largest orlistat trial (n=539) reported a mean BMI reduction in the treatment group of 0.6, vs 0.3 in the control group (P<.001)—an average weight loss of 4.2 lb in the intervention group, compared with 2.1 lb among the controls after 12 months. None of the trials evaluated weight change after cessation of the study drug, and none compared orlistat with sibutramine.
Adverse effects in the sibutramine-treated patients were primarily cardiovascular and gastrointestinal. Cardiovascular effects included tachycardia and increases in systolic and diastolic blood pressure. The differences between the intervention and control groups were small, and no differences were observed in discontinuation rates caused by adverse events. Nor were differences reported in growth and maturation between the intervention and control groups.
Adverse effects in the orlistat-treated patients were also low and similar in the intervention and control groups. Gastrointestinal effects were common. The number needed to harm (NNH) for fatty or oily stools was 2,4 and the NNH for fecal incontinence was 12.5
WHAT'S NEW: Clinicians treating obese kids have cause for optimism
Although the trials included in this review were heterogeneous and many were small, this systematic review provides evidence that intensive, comprehensive behavioral weight loss interventions for obese children can be effective up to 12 months after the conclusion of the program. Family physicians should consider referring obese children and adolescents to such programs—or finding ways to provide supportive strategies themselves.
Sibutramine and orlistat may be helpful in the context of comprehensive, intensive behavioral interventions, although there is no follow-up data to demonstrate long-term safety and weight maintenance after the medication is stopped.
CAVEATS: Little is known about long-term safety of the drugs
There have been few randomized trials of pharmacologic interventions in adolescents and none evaluating weight maintenance after 12 months (or discontinuation of treatment), or assessing long-term safety of the medication.
Sibutramine is not approved by the US Food and Drug Administration (FDA) for use in children or adolescents.7 Orlistat is currently approved only for individuals over the age of 12.8
In January 2010, an additional contraindication was added to the sibutramine drug label, stating that it is not to be used in patients with a history of cardiovascular disease.9 And the FDA is currently investigating a rare association between orlistat and liver injury, although no conclusions have been released.10 Children and adolescents are particularly vulnerable to long-term side effects, given their relatively young age at the time of drug initiation, so we urge caution with the use of these drugs in this patient population.
CHALLENGES TO IMPLEMENTATION: Intensive approach may be hard to reproduce
Implementation of high-intensity comprehensive interventions for obese children faces a number of roadblocks, including limited availability of programs, cost, and reimbursement. Most of the intensive interventions in these trials took place in specialty centers rather than in primary care offices. Replicating them could require a referral—or significant resources within the primary care setting itself. Yet many, if not most, insurance policies still do not cover such extensive lifestyle interventions. (For information on weight loss interventions for adults, see “Weight loss strategies that really work”).
None of these trials reported on cost or cost effectiveness. Despite the considerable cost of a comprehensive obesity management program, however, a successful weight-maintenance model could be a worthwhile investment in long-term health.
Lastly, the results of this trial should not negate the importance of obesity prevention efforts by parents, who are in the best position to reverse the childhood obesity epidemic.11
Acknowledgement
The PURLs Surveillance System is supported in part by Grant Number UL1RR024999; awarded by the National Center for Research Resources; the grant is a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.
Click here to view PURL METHODOLOGY
1. Whitlock E, O’Connor E, Williams S, et al. Effectiveness of weight management interventions in children: a targeted systematic review for the USPSTF. Pediatrics. 2010;125:e396-e418.
2. US Preventive Services Task Force. Screening for obesity in children and adolescents: recommendation statement. http://www.ahrq.gov/clinic/uspstf10/childobes/chobesrs.htm. Accessed April 11, 2010.
3. Daniels SR, Arnett DK, Eckel RH, et al. Overweight in children and adolescents: pathophysiology, consequences, prevention, and treatment. Circulation. 2005;111:1999-2012.
4. Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and trends in obesity among US adults, 1999-2008. JAMA. 2010;303:235-241.
5. Han JC, Lawlor DA, Kimm SY. Childhood obesity. Lancet. 2010;375:1737-1748.
6. Strauss RS, Pollack HA. Social marginalization of overweight children. Arch Pediatr Adolesc Med. 2003;157:746-752.
7. US Food and Drug Administration. Meridia approval history. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020632s032lbl.pdf. Accessed June 16, 2010.
8. US Food and Drug Administration. Xenical approval letter. Available at: www.accessdata.fda.gov/drugsatfda_docs/appletter/2003/20766se5-018ltr.pdf. Accessed June 16, 2010.
9. US Food and Drug Administration. Early communication about an ongoing safety review of Meridia (sibutramine hydrochlo-ride). Available at: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationfor
PatientsandProviders/ucm180076.htm. Accessed March 29, 2010.
10. US Food and Drug Administration. Early communication about an ongoing safety review of orlistat. Available at: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm180076.htm. Accessed April 11, 2010.
11. Gruber KJ, Haldeman LA. Using the family to combat childhood and adult obesity. Prev Chronic Dis. 2009;6:A106.-
Illustrative case
A 10-year-old boy comes in with his mother for a well-child check-up. His BMI is 40 kg/m2—above the 99th percentile for his age and up from 37 a year ago. His blood pressure is 120/84 mm Hg. What treatment, if any, should you offer for his obesity?
Childhood obesity is a global epidemic. In the United States, 19.6% of children ages 6 through 11 and 18.1% of 12- to 19-year-olds are obese, a 3-fold increase in the last 30 years.3 Without intervention, most obese adolescents will become obese adults, threatening to reverse the progress in slowing cardiovascular morbidity and mortality that has occurred over the past few decades.3
Obese kids get adult diseases
Obesity is a risk factor for a variety of chronic conditions, including cardiovascular disease, cerebrovascular disease, and arthritis. Severe obesity is also associated with higher mortality rates.4 Unfortunately, these comorbidities are not limited to adulthood.
“Adult” diseases, such as obstructive sleep apnea, dyslipidemia, and type 2 diabetes, are increasingly seen in children and adolescents.1 Nutritional deficits such as vitamin D and iron deficiency are often seen in obese children, as well.5 There are also psychological ramifications of childhood obesity, including social isolation and depression.6
The USPSTF recently upgraded its recommendation regarding obesity screening in children ages 6 and older from I (insufficient evidence) to B (a positive grade based on high or moderate certainty of the benefit of the intervention), citing new evidence in favor of screening and treating or referring children when appropriate.2 The systematic review we report on here, which formed the basis for the USPSTF’s upgrade, focused on management options for children identified as overweight or obese.
STUDY SUMMARY: Intense, comprehensive efforts pay off
This systematic review1 included studies of children ages 4 to 18 years who were overweight (defined as a body mass index [BMI] in the 85th to 94th percentile for age and sex) or obese (either a BMI at or above the 95th percentile for age and sex or a BMI >30 kg/m2). The researchers found 25 trials—15 of behavioral interventions alone and 10 that combined behavioral and pharmacologic interventions—that met their criteria: The studies focused on weight loss and/or maintenance, reported outcomes ≥6 months from baseline, and were conducted (or feasible) in a primary care setting.
Behavioral interventions were categorized by treatment intensity (as measured by hours of contact, which ranged from <10 hours to >75) and comprehensiveness (including nutritional counseling, physical activity counseling or participation, and counseling on behavioral management techniques). Weight outcomes were categorized as short-term (6-12 months since treatment initiation) or maintenance (≥12 months after the end of active treatment).
The 15 behavioral intervention trials included 1258 children ages 4 to 18 years, most of whom were obese. Most trials were small and reported high retention rates. All had beneficial effects on weight in the intervention group compared with the controls, but not all changes were statistically significant. Higher intensity and more comprehensive programs had better outcomes.
The largest effects were in 3 moderate- to high-intensity, comprehensive weight management programs with ≥26 hours of contact. These 3 trials demonstrated a difference in BMI of 1.9 to 3.3 in the intervention groups at 12 months compared with the controls. (A 3.3 difference in BMI is equal to approximately 13 lb in an 8-year-old and 17 lb in a 12-year-old.)
Four behavioral intervention studies reported outcomes ≥12 months after completing the intervention (range 15-48 months). Three of the 4 reported continued beneficial effects on weight after the active treatment period, but the effects were markedly attenuated.
The only adverse effect reported in the trials of behavioral interventions was the injury rate among children in an exercise program, but it was minimal: One fracture was reported, vs no injuries for the controls. No differences were reported in height, eating disorders, or depression. However, fewer than half of the behavioral intervention trials reported on adverse effects.
Weight loss drugs have modest effects
Ten trials combining pharmacologic and behavioral interventions involved a total of 1294 obese adolescents ages 12 to 19. All evaluated short-term weight loss effects of either sibutramine (10-15 mg/d) or orlistat (120 mg tid). Trials ranged from 3 to 12 months. Participants in both the control and intervention groups received behavioral counseling.
The trials all favored the treatment groups, although not all of the results were statistically significant. Trials of longer duration (12 months) had more favorable results than those lasting 6 months.
The largest sibutramine trial (n=498) reported a mean BMI reduction of 2.9 in the treatment group, compared with a reduction of 0.3 in the control group (P<.001). This corresponds to an average weight loss of 14 lb in the intervention group, vs 4.2 lb in the control group, after 12 months.
The largest orlistat trial (n=539) reported a mean BMI reduction in the treatment group of 0.6, vs 0.3 in the control group (P<.001)—an average weight loss of 4.2 lb in the intervention group, compared with 2.1 lb among the controls after 12 months. None of the trials evaluated weight change after cessation of the study drug, and none compared orlistat with sibutramine.
Adverse effects in the sibutramine-treated patients were primarily cardiovascular and gastrointestinal. Cardiovascular effects included tachycardia and increases in systolic and diastolic blood pressure. The differences between the intervention and control groups were small, and no differences were observed in discontinuation rates caused by adverse events. Nor were differences reported in growth and maturation between the intervention and control groups.
Adverse effects in the orlistat-treated patients were also low and similar in the intervention and control groups. Gastrointestinal effects were common. The number needed to harm (NNH) for fatty or oily stools was 2,4 and the NNH for fecal incontinence was 12.5
WHAT'S NEW: Clinicians treating obese kids have cause for optimism
Although the trials included in this review were heterogeneous and many were small, this systematic review provides evidence that intensive, comprehensive behavioral weight loss interventions for obese children can be effective up to 12 months after the conclusion of the program. Family physicians should consider referring obese children and adolescents to such programs—or finding ways to provide supportive strategies themselves.
Sibutramine and orlistat may be helpful in the context of comprehensive, intensive behavioral interventions, although there is no follow-up data to demonstrate long-term safety and weight maintenance after the medication is stopped.
CAVEATS: Little is known about long-term safety of the drugs
There have been few randomized trials of pharmacologic interventions in adolescents and none evaluating weight maintenance after 12 months (or discontinuation of treatment), or assessing long-term safety of the medication.
Sibutramine is not approved by the US Food and Drug Administration (FDA) for use in children or adolescents.7 Orlistat is currently approved only for individuals over the age of 12.8
In January 2010, an additional contraindication was added to the sibutramine drug label, stating that it is not to be used in patients with a history of cardiovascular disease.9 And the FDA is currently investigating a rare association between orlistat and liver injury, although no conclusions have been released.10 Children and adolescents are particularly vulnerable to long-term side effects, given their relatively young age at the time of drug initiation, so we urge caution with the use of these drugs in this patient population.
CHALLENGES TO IMPLEMENTATION: Intensive approach may be hard to reproduce
Implementation of high-intensity comprehensive interventions for obese children faces a number of roadblocks, including limited availability of programs, cost, and reimbursement. Most of the intensive interventions in these trials took place in specialty centers rather than in primary care offices. Replicating them could require a referral—or significant resources within the primary care setting itself. Yet many, if not most, insurance policies still do not cover such extensive lifestyle interventions. (For information on weight loss interventions for adults, see “Weight loss strategies that really work”).
None of these trials reported on cost or cost effectiveness. Despite the considerable cost of a comprehensive obesity management program, however, a successful weight-maintenance model could be a worthwhile investment in long-term health.
Lastly, the results of this trial should not negate the importance of obesity prevention efforts by parents, who are in the best position to reverse the childhood obesity epidemic.11
Acknowledgement
The PURLs Surveillance System is supported in part by Grant Number UL1RR024999; awarded by the National Center for Research Resources; the grant is a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.
Click here to view PURL METHODOLOGY
Illustrative case
A 10-year-old boy comes in with his mother for a well-child check-up. His BMI is 40 kg/m2—above the 99th percentile for his age and up from 37 a year ago. His blood pressure is 120/84 mm Hg. What treatment, if any, should you offer for his obesity?
Childhood obesity is a global epidemic. In the United States, 19.6% of children ages 6 through 11 and 18.1% of 12- to 19-year-olds are obese, a 3-fold increase in the last 30 years.3 Without intervention, most obese adolescents will become obese adults, threatening to reverse the progress in slowing cardiovascular morbidity and mortality that has occurred over the past few decades.3
Obese kids get adult diseases
Obesity is a risk factor for a variety of chronic conditions, including cardiovascular disease, cerebrovascular disease, and arthritis. Severe obesity is also associated with higher mortality rates.4 Unfortunately, these comorbidities are not limited to adulthood.
“Adult” diseases, such as obstructive sleep apnea, dyslipidemia, and type 2 diabetes, are increasingly seen in children and adolescents.1 Nutritional deficits such as vitamin D and iron deficiency are often seen in obese children, as well.5 There are also psychological ramifications of childhood obesity, including social isolation and depression.6
The USPSTF recently upgraded its recommendation regarding obesity screening in children ages 6 and older from I (insufficient evidence) to B (a positive grade based on high or moderate certainty of the benefit of the intervention), citing new evidence in favor of screening and treating or referring children when appropriate.2 The systematic review we report on here, which formed the basis for the USPSTF’s upgrade, focused on management options for children identified as overweight or obese.
STUDY SUMMARY: Intense, comprehensive efforts pay off
This systematic review1 included studies of children ages 4 to 18 years who were overweight (defined as a body mass index [BMI] in the 85th to 94th percentile for age and sex) or obese (either a BMI at or above the 95th percentile for age and sex or a BMI >30 kg/m2). The researchers found 25 trials—15 of behavioral interventions alone and 10 that combined behavioral and pharmacologic interventions—that met their criteria: The studies focused on weight loss and/or maintenance, reported outcomes ≥6 months from baseline, and were conducted (or feasible) in a primary care setting.
Behavioral interventions were categorized by treatment intensity (as measured by hours of contact, which ranged from <10 hours to >75) and comprehensiveness (including nutritional counseling, physical activity counseling or participation, and counseling on behavioral management techniques). Weight outcomes were categorized as short-term (6-12 months since treatment initiation) or maintenance (≥12 months after the end of active treatment).
The 15 behavioral intervention trials included 1258 children ages 4 to 18 years, most of whom were obese. Most trials were small and reported high retention rates. All had beneficial effects on weight in the intervention group compared with the controls, but not all changes were statistically significant. Higher intensity and more comprehensive programs had better outcomes.
The largest effects were in 3 moderate- to high-intensity, comprehensive weight management programs with ≥26 hours of contact. These 3 trials demonstrated a difference in BMI of 1.9 to 3.3 in the intervention groups at 12 months compared with the controls. (A 3.3 difference in BMI is equal to approximately 13 lb in an 8-year-old and 17 lb in a 12-year-old.)
Four behavioral intervention studies reported outcomes ≥12 months after completing the intervention (range 15-48 months). Three of the 4 reported continued beneficial effects on weight after the active treatment period, but the effects were markedly attenuated.
The only adverse effect reported in the trials of behavioral interventions was the injury rate among children in an exercise program, but it was minimal: One fracture was reported, vs no injuries for the controls. No differences were reported in height, eating disorders, or depression. However, fewer than half of the behavioral intervention trials reported on adverse effects.
Weight loss drugs have modest effects
Ten trials combining pharmacologic and behavioral interventions involved a total of 1294 obese adolescents ages 12 to 19. All evaluated short-term weight loss effects of either sibutramine (10-15 mg/d) or orlistat (120 mg tid). Trials ranged from 3 to 12 months. Participants in both the control and intervention groups received behavioral counseling.
The trials all favored the treatment groups, although not all of the results were statistically significant. Trials of longer duration (12 months) had more favorable results than those lasting 6 months.
The largest sibutramine trial (n=498) reported a mean BMI reduction of 2.9 in the treatment group, compared with a reduction of 0.3 in the control group (P<.001). This corresponds to an average weight loss of 14 lb in the intervention group, vs 4.2 lb in the control group, after 12 months.
The largest orlistat trial (n=539) reported a mean BMI reduction in the treatment group of 0.6, vs 0.3 in the control group (P<.001)—an average weight loss of 4.2 lb in the intervention group, compared with 2.1 lb among the controls after 12 months. None of the trials evaluated weight change after cessation of the study drug, and none compared orlistat with sibutramine.
Adverse effects in the sibutramine-treated patients were primarily cardiovascular and gastrointestinal. Cardiovascular effects included tachycardia and increases in systolic and diastolic blood pressure. The differences between the intervention and control groups were small, and no differences were observed in discontinuation rates caused by adverse events. Nor were differences reported in growth and maturation between the intervention and control groups.
Adverse effects in the orlistat-treated patients were also low and similar in the intervention and control groups. Gastrointestinal effects were common. The number needed to harm (NNH) for fatty or oily stools was 2,4 and the NNH for fecal incontinence was 12.5
WHAT'S NEW: Clinicians treating obese kids have cause for optimism
Although the trials included in this review were heterogeneous and many were small, this systematic review provides evidence that intensive, comprehensive behavioral weight loss interventions for obese children can be effective up to 12 months after the conclusion of the program. Family physicians should consider referring obese children and adolescents to such programs—or finding ways to provide supportive strategies themselves.
Sibutramine and orlistat may be helpful in the context of comprehensive, intensive behavioral interventions, although there is no follow-up data to demonstrate long-term safety and weight maintenance after the medication is stopped.
CAVEATS: Little is known about long-term safety of the drugs
There have been few randomized trials of pharmacologic interventions in adolescents and none evaluating weight maintenance after 12 months (or discontinuation of treatment), or assessing long-term safety of the medication.
Sibutramine is not approved by the US Food and Drug Administration (FDA) for use in children or adolescents.7 Orlistat is currently approved only for individuals over the age of 12.8
In January 2010, an additional contraindication was added to the sibutramine drug label, stating that it is not to be used in patients with a history of cardiovascular disease.9 And the FDA is currently investigating a rare association between orlistat and liver injury, although no conclusions have been released.10 Children and adolescents are particularly vulnerable to long-term side effects, given their relatively young age at the time of drug initiation, so we urge caution with the use of these drugs in this patient population.
CHALLENGES TO IMPLEMENTATION: Intensive approach may be hard to reproduce
Implementation of high-intensity comprehensive interventions for obese children faces a number of roadblocks, including limited availability of programs, cost, and reimbursement. Most of the intensive interventions in these trials took place in specialty centers rather than in primary care offices. Replicating them could require a referral—or significant resources within the primary care setting itself. Yet many, if not most, insurance policies still do not cover such extensive lifestyle interventions. (For information on weight loss interventions for adults, see “Weight loss strategies that really work”).
None of these trials reported on cost or cost effectiveness. Despite the considerable cost of a comprehensive obesity management program, however, a successful weight-maintenance model could be a worthwhile investment in long-term health.
Lastly, the results of this trial should not negate the importance of obesity prevention efforts by parents, who are in the best position to reverse the childhood obesity epidemic.11
Acknowledgement
The PURLs Surveillance System is supported in part by Grant Number UL1RR024999; awarded by the National Center for Research Resources; the grant is a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.
Click here to view PURL METHODOLOGY
1. Whitlock E, O’Connor E, Williams S, et al. Effectiveness of weight management interventions in children: a targeted systematic review for the USPSTF. Pediatrics. 2010;125:e396-e418.
2. US Preventive Services Task Force. Screening for obesity in children and adolescents: recommendation statement. http://www.ahrq.gov/clinic/uspstf10/childobes/chobesrs.htm. Accessed April 11, 2010.
3. Daniels SR, Arnett DK, Eckel RH, et al. Overweight in children and adolescents: pathophysiology, consequences, prevention, and treatment. Circulation. 2005;111:1999-2012.
4. Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and trends in obesity among US adults, 1999-2008. JAMA. 2010;303:235-241.
5. Han JC, Lawlor DA, Kimm SY. Childhood obesity. Lancet. 2010;375:1737-1748.
6. Strauss RS, Pollack HA. Social marginalization of overweight children. Arch Pediatr Adolesc Med. 2003;157:746-752.
7. US Food and Drug Administration. Meridia approval history. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020632s032lbl.pdf. Accessed June 16, 2010.
8. US Food and Drug Administration. Xenical approval letter. Available at: www.accessdata.fda.gov/drugsatfda_docs/appletter/2003/20766se5-018ltr.pdf. Accessed June 16, 2010.
9. US Food and Drug Administration. Early communication about an ongoing safety review of Meridia (sibutramine hydrochlo-ride). Available at: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationfor
PatientsandProviders/ucm180076.htm. Accessed March 29, 2010.
10. US Food and Drug Administration. Early communication about an ongoing safety review of orlistat. Available at: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm180076.htm. Accessed April 11, 2010.
11. Gruber KJ, Haldeman LA. Using the family to combat childhood and adult obesity. Prev Chronic Dis. 2009;6:A106.-
1. Whitlock E, O’Connor E, Williams S, et al. Effectiveness of weight management interventions in children: a targeted systematic review for the USPSTF. Pediatrics. 2010;125:e396-e418.
2. US Preventive Services Task Force. Screening for obesity in children and adolescents: recommendation statement. http://www.ahrq.gov/clinic/uspstf10/childobes/chobesrs.htm. Accessed April 11, 2010.
3. Daniels SR, Arnett DK, Eckel RH, et al. Overweight in children and adolescents: pathophysiology, consequences, prevention, and treatment. Circulation. 2005;111:1999-2012.
4. Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and trends in obesity among US adults, 1999-2008. JAMA. 2010;303:235-241.
5. Han JC, Lawlor DA, Kimm SY. Childhood obesity. Lancet. 2010;375:1737-1748.
6. Strauss RS, Pollack HA. Social marginalization of overweight children. Arch Pediatr Adolesc Med. 2003;157:746-752.
7. US Food and Drug Administration. Meridia approval history. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020632s032lbl.pdf. Accessed June 16, 2010.
8. US Food and Drug Administration. Xenical approval letter. Available at: www.accessdata.fda.gov/drugsatfda_docs/appletter/2003/20766se5-018ltr.pdf. Accessed June 16, 2010.
9. US Food and Drug Administration. Early communication about an ongoing safety review of Meridia (sibutramine hydrochlo-ride). Available at: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationfor
PatientsandProviders/ucm180076.htm. Accessed March 29, 2010.
10. US Food and Drug Administration. Early communication about an ongoing safety review of orlistat. Available at: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm180076.htm. Accessed April 11, 2010.
11. Gruber KJ, Haldeman LA. Using the family to combat childhood and adult obesity. Prev Chronic Dis. 2009;6:A106.-
Copyright © 2010 The Family Physicians Inquiries Network.
All rights reserved.
How should you further evaluate an adult with a testicular mass?
Perform a scrotal ultrasonography immediately to determine whether emergency surgery is necessary for patients with an exam or history that suggests testicular torsion or rupture (strength of recommendation [SOR]: B, based on cohort trials of patient oriented outcomes). In less urgent cases, ultrasound is also useful for verifying diagnoses made by physical exam, and to exclude conditions such as neoplasm, for which further workup is indicated (SOR: C, based on expert opinion).
In those cases in which ultrasound and clinical exam are inconclusive or conflicting, magnetic resonance imaging (MRI) can provide additional information to improve management and decrease unnecessary surgery (SOR: B, based on cohort trials of patient-oriented outcomes).
Acutely painful testicle? Involve a radiologist and urologist early on
Peter C. Smith, MD
Rose Family Medicine Residency, University of Colorado Health Sciences Center, Denver
One of the keys to managing testicular masses is to differentiate normal anatomical structures and benign peritesticular pathology (such as varicoceles and spermatoceles) from true testicular masses. Early in my career, after I counseled men to do testicular self-exams, they occasionally made return visits concerned about a mass. These were almost always the testicular appendix, the epididymis, or scrotal inclusion cysts. I now describe these findings as a routine part of my counseling. Given the devastating consequences of a missed or delayed diagnosis of torsion, infarction, and cancer, I always make 2 phone calls early on when a patient has an acutely painful testicle or a true testicular mass: I call the radiologist and the urologist. These 2 phone calls can substantially reduce the risk of diagnostic delay.
Evidence summary
A wide variety of conditions can cause scrotal masses (see TABLE 1 for a list of causes of acute scrotal swelling and TABLE 2 for causes of nonacute swelling).1,2 Many just require that you reassure the patient; however, some conditions do need diagnostic testing to determine appropriate treatment.
TABLE 1
Causes of acute scrotal swelling1,2
| CONDITION | CLINICAL PRESENTATION | PHYSICAL EXAM/CLINICAL COMMENTS |
|---|---|---|
| Epididymitis | • Severe swelling and pain | • Edema, tenderness, erythema • Positive urinalysis because it’s often associated with urinary tract infection or prostatitis • Can result in abscess formation |
| Testicular torsion | • Severe pain sudden in onset (except in neonates) | • Usually occurs in post-pubertal and neonatal age group • Often presents with an asymmetric high riding testis or transverse orientation of affected testis • Cremasteric reflex usually absent • Not relieved with elevation • Surgical emergency |
| Trauma | • Associated with wide spectrum of injuries | • May result in testicular rupture or torsion, which are surgical emergencies |
| Torsion of appendix testis | • Gradual onset of pain | • Usually pre-pubertal age group • Cremasteric reflex preserved • Tenderness often localized to anterosuperior testes • Surgery not required in majority of cases |
| Inguinal hernia | • Pain and swelling | • May hear bowel sounds on affected side |
TABLE 2
Causes of nonacute scrotal swelling1
| CONDITION | CLINICAL PRESENTATION | PHYSICAL EXAM/CLINICAL COMMENTS |
|---|---|---|
| Hydrocele | • Painless mass that may increase in size throughout the day | • Can be transilluminated • Reactive hydrocele may be associated with testicular neoplasm, epididymitis, orchitis, or torsion |
| Testicular cyst | • None | • Benign incidental finding • Nonpalpable |
| Varicocele | • Scrotal swelling secondary to dilation of spermatic veins • May present as infertility • May present with pain if intratesticular | • Usually left-sided • Described as a bag of worms superior to the testicle • Noticeable when standing or with Valsalva maneuver |
| Spermatocele | • If painful, relieved with elevation | • Often an incidental finding on exam • Freely mobile • Usually located in epididymal head |
| Epidermoid cyst | • Painless mass | • Found anywhere in epididymis • Often surgically removed because it may be difficult to differentiate from malignancy |
| Primary testicular tumor1,9 | • Solid mass • Classically painless but may produce testicular discomfort | • 10% present acutely with hemorrhage • Most common malignancy in males between ages 18 and 40 |
| Metastatic tumor | • Painless mass | • Possible primary cancers include leukemia lymphoma, melanoma, lung, prostate, kidney, GI tract |
Ultrasound is the best initial test
Testicular torsion and acute epididymoorchitis are the most common causes of an acute scrotum.3 Patients with an acute scrotum require an urgent ultrasound to exclude pathology that requires immediate surgery (TABLES 1 AND 2).1 Although clinical exam identifies almost all cases of torsion, a few cases are missed.4 In a study of 209 emergency scrotal explorations, clinical exam by general practitioners and surgeons correctly diagnosed only 92.5% and 94% of testicular torsion cases, respectively, compared with the surgical diagnosis.4
In another study, which used surgery as the diagnostic gold standard, color Doppler ultrasound had a sensitivity of 93.5% for the diagnosis of testicular torsion;5 this has led some to say the combination of both clinical exam and ultrasound should be used to determine the need for surgery.1 However, this combination has not been thoroughly evaluated by researchers, and the best evidence shows that physician exam is essentially the same as color Doppler ultrasound for diagnosing testicular torsion. If torsion cannot be reliably excluded, emergent surgical exploration is mandatory.4
For patients who have a nonacute scrotal mass, ultrasound is often indicated to distinguish intratesticular from extratesticular masses.1 Although testicular neoplasm is relatively rare, it is a concern for patients with non-painful masses. Fortunately, false-negative scrotal ultrasounds are rare. In a small study comparing clinical exam with ultrasound for diagnosis of testicular tumor, the negative predictive value of ultrasound was 100%.6
Although ultrasound has high sensitivity for detection of testicular neoplasm, it cannot differentiate benign from malignant tumors.2 Additionally, ultrasound sometimes fails to differentiate a neoplastic process from a complication of an infection such as an abscess. In those instances, a repeat ultrasound is suggested after antibiotic administration to ensure resolution of the mass.2
When ultrasound is inconclusive, MRI may be helpful
When clinical and ultrasound findings are inconclusive, MRI may help deter-mine a diagnosis. For example, MRI can help distinguish inflammation or abscess from neoplasm, thus preventing a patient from undergoing unnecessary surgical intervention.2,7 If testicular neoplasm cannot be excluded based on clinical and radiographic findings, surgery is indicated.1
Recommendations from others
Few current evidence-based recommendations exist on the approach to patients with scrotal masses. The National Collaborating Centre for Primary Care (UK) suggests an urgent ultrasound when a scrotal mass does not transilluminate or when the examiner cannot distinguish the body of the testis.8
1. Micallef M, Torreggiani WC, Hurley M, Dinsmore WW, Hogan B. The ultrasound investigation of scrotal swelling. Int J STD AIDS 2000;11:297-302.
2. Eyre RC. Evaluation of nonacute scrotal pathology in adults. In: Rose BD, ed. UpToDate [online database]. Version 14.1. Waltham, Mass: UpToDate; 2006.
3. Akin EA, Khati NJ, Hill MC. Ultrasound of the scrotum. Ultrasound Q 2004;20:181-200.
4. Watkin NA, Reiger NA, Moisey CU. Is the conservative management of the acute scrotum justified on clinical grounds? Br J Urol 1996;78:623-627.
5. Andipa E, Liberopoulos K, Asvestis C. Magnetic resonance imaging and ultrasound evaluation of penile and testicular masses. World J Urol 2004;22:382-391.
6. van Dijk R, Doesburg WH, Verbeek AL, van der Schouw YT, Debruyne FM, Rosenbusch G. Ultrasonography versus clinical examination in evaluation of testicular tumors. J Clin Ultrasound 1994;22:179-182.
7. Muglia V, Tucci S, Jr, Elias J, Jr, Trad CS, Bilbey J, Cooperberg PL. Magnetic resonance imaging of scrotal diseases: when it makes the difference. Urology 2002;59:419-423.
8. National Collaborating Centre for Primary Care Referral guidelines for suspected cancer. London: National Institute for Health and Clinical Excellence; June 2005. NICE Clinical Guideline 27. Available at www.nice.org.uk/page.aspx?o=261649. Accessed on August 29, 2007.
Perform a scrotal ultrasonography immediately to determine whether emergency surgery is necessary for patients with an exam or history that suggests testicular torsion or rupture (strength of recommendation [SOR]: B, based on cohort trials of patient oriented outcomes). In less urgent cases, ultrasound is also useful for verifying diagnoses made by physical exam, and to exclude conditions such as neoplasm, for which further workup is indicated (SOR: C, based on expert opinion).
In those cases in which ultrasound and clinical exam are inconclusive or conflicting, magnetic resonance imaging (MRI) can provide additional information to improve management and decrease unnecessary surgery (SOR: B, based on cohort trials of patient-oriented outcomes).
Acutely painful testicle? Involve a radiologist and urologist early on
Peter C. Smith, MD
Rose Family Medicine Residency, University of Colorado Health Sciences Center, Denver
One of the keys to managing testicular masses is to differentiate normal anatomical structures and benign peritesticular pathology (such as varicoceles and spermatoceles) from true testicular masses. Early in my career, after I counseled men to do testicular self-exams, they occasionally made return visits concerned about a mass. These were almost always the testicular appendix, the epididymis, or scrotal inclusion cysts. I now describe these findings as a routine part of my counseling. Given the devastating consequences of a missed or delayed diagnosis of torsion, infarction, and cancer, I always make 2 phone calls early on when a patient has an acutely painful testicle or a true testicular mass: I call the radiologist and the urologist. These 2 phone calls can substantially reduce the risk of diagnostic delay.
Evidence summary
A wide variety of conditions can cause scrotal masses (see TABLE 1 for a list of causes of acute scrotal swelling and TABLE 2 for causes of nonacute swelling).1,2 Many just require that you reassure the patient; however, some conditions do need diagnostic testing to determine appropriate treatment.
TABLE 1
Causes of acute scrotal swelling1,2
| CONDITION | CLINICAL PRESENTATION | PHYSICAL EXAM/CLINICAL COMMENTS |
|---|---|---|
| Epididymitis | • Severe swelling and pain | • Edema, tenderness, erythema • Positive urinalysis because it’s often associated with urinary tract infection or prostatitis • Can result in abscess formation |
| Testicular torsion | • Severe pain sudden in onset (except in neonates) | • Usually occurs in post-pubertal and neonatal age group • Often presents with an asymmetric high riding testis or transverse orientation of affected testis • Cremasteric reflex usually absent • Not relieved with elevation • Surgical emergency |
| Trauma | • Associated with wide spectrum of injuries | • May result in testicular rupture or torsion, which are surgical emergencies |
| Torsion of appendix testis | • Gradual onset of pain | • Usually pre-pubertal age group • Cremasteric reflex preserved • Tenderness often localized to anterosuperior testes • Surgery not required in majority of cases |
| Inguinal hernia | • Pain and swelling | • May hear bowel sounds on affected side |
TABLE 2
Causes of nonacute scrotal swelling1
| CONDITION | CLINICAL PRESENTATION | PHYSICAL EXAM/CLINICAL COMMENTS |
|---|---|---|
| Hydrocele | • Painless mass that may increase in size throughout the day | • Can be transilluminated • Reactive hydrocele may be associated with testicular neoplasm, epididymitis, orchitis, or torsion |
| Testicular cyst | • None | • Benign incidental finding • Nonpalpable |
| Varicocele | • Scrotal swelling secondary to dilation of spermatic veins • May present as infertility • May present with pain if intratesticular | • Usually left-sided • Described as a bag of worms superior to the testicle • Noticeable when standing or with Valsalva maneuver |
| Spermatocele | • If painful, relieved with elevation | • Often an incidental finding on exam • Freely mobile • Usually located in epididymal head |
| Epidermoid cyst | • Painless mass | • Found anywhere in epididymis • Often surgically removed because it may be difficult to differentiate from malignancy |
| Primary testicular tumor1,9 | • Solid mass • Classically painless but may produce testicular discomfort | • 10% present acutely with hemorrhage • Most common malignancy in males between ages 18 and 40 |
| Metastatic tumor | • Painless mass | • Possible primary cancers include leukemia lymphoma, melanoma, lung, prostate, kidney, GI tract |
Ultrasound is the best initial test
Testicular torsion and acute epididymoorchitis are the most common causes of an acute scrotum.3 Patients with an acute scrotum require an urgent ultrasound to exclude pathology that requires immediate surgery (TABLES 1 AND 2).1 Although clinical exam identifies almost all cases of torsion, a few cases are missed.4 In a study of 209 emergency scrotal explorations, clinical exam by general practitioners and surgeons correctly diagnosed only 92.5% and 94% of testicular torsion cases, respectively, compared with the surgical diagnosis.4
In another study, which used surgery as the diagnostic gold standard, color Doppler ultrasound had a sensitivity of 93.5% for the diagnosis of testicular torsion;5 this has led some to say the combination of both clinical exam and ultrasound should be used to determine the need for surgery.1 However, this combination has not been thoroughly evaluated by researchers, and the best evidence shows that physician exam is essentially the same as color Doppler ultrasound for diagnosing testicular torsion. If torsion cannot be reliably excluded, emergent surgical exploration is mandatory.4
For patients who have a nonacute scrotal mass, ultrasound is often indicated to distinguish intratesticular from extratesticular masses.1 Although testicular neoplasm is relatively rare, it is a concern for patients with non-painful masses. Fortunately, false-negative scrotal ultrasounds are rare. In a small study comparing clinical exam with ultrasound for diagnosis of testicular tumor, the negative predictive value of ultrasound was 100%.6
Although ultrasound has high sensitivity for detection of testicular neoplasm, it cannot differentiate benign from malignant tumors.2 Additionally, ultrasound sometimes fails to differentiate a neoplastic process from a complication of an infection such as an abscess. In those instances, a repeat ultrasound is suggested after antibiotic administration to ensure resolution of the mass.2
When ultrasound is inconclusive, MRI may be helpful
When clinical and ultrasound findings are inconclusive, MRI may help deter-mine a diagnosis. For example, MRI can help distinguish inflammation or abscess from neoplasm, thus preventing a patient from undergoing unnecessary surgical intervention.2,7 If testicular neoplasm cannot be excluded based on clinical and radiographic findings, surgery is indicated.1
Recommendations from others
Few current evidence-based recommendations exist on the approach to patients with scrotal masses. The National Collaborating Centre for Primary Care (UK) suggests an urgent ultrasound when a scrotal mass does not transilluminate or when the examiner cannot distinguish the body of the testis.8
Perform a scrotal ultrasonography immediately to determine whether emergency surgery is necessary for patients with an exam or history that suggests testicular torsion or rupture (strength of recommendation [SOR]: B, based on cohort trials of patient oriented outcomes). In less urgent cases, ultrasound is also useful for verifying diagnoses made by physical exam, and to exclude conditions such as neoplasm, for which further workup is indicated (SOR: C, based on expert opinion).
In those cases in which ultrasound and clinical exam are inconclusive or conflicting, magnetic resonance imaging (MRI) can provide additional information to improve management and decrease unnecessary surgery (SOR: B, based on cohort trials of patient-oriented outcomes).
Acutely painful testicle? Involve a radiologist and urologist early on
Peter C. Smith, MD
Rose Family Medicine Residency, University of Colorado Health Sciences Center, Denver
One of the keys to managing testicular masses is to differentiate normal anatomical structures and benign peritesticular pathology (such as varicoceles and spermatoceles) from true testicular masses. Early in my career, after I counseled men to do testicular self-exams, they occasionally made return visits concerned about a mass. These were almost always the testicular appendix, the epididymis, or scrotal inclusion cysts. I now describe these findings as a routine part of my counseling. Given the devastating consequences of a missed or delayed diagnosis of torsion, infarction, and cancer, I always make 2 phone calls early on when a patient has an acutely painful testicle or a true testicular mass: I call the radiologist and the urologist. These 2 phone calls can substantially reduce the risk of diagnostic delay.
Evidence summary
A wide variety of conditions can cause scrotal masses (see TABLE 1 for a list of causes of acute scrotal swelling and TABLE 2 for causes of nonacute swelling).1,2 Many just require that you reassure the patient; however, some conditions do need diagnostic testing to determine appropriate treatment.
TABLE 1
Causes of acute scrotal swelling1,2
| CONDITION | CLINICAL PRESENTATION | PHYSICAL EXAM/CLINICAL COMMENTS |
|---|---|---|
| Epididymitis | • Severe swelling and pain | • Edema, tenderness, erythema • Positive urinalysis because it’s often associated with urinary tract infection or prostatitis • Can result in abscess formation |
| Testicular torsion | • Severe pain sudden in onset (except in neonates) | • Usually occurs in post-pubertal and neonatal age group • Often presents with an asymmetric high riding testis or transverse orientation of affected testis • Cremasteric reflex usually absent • Not relieved with elevation • Surgical emergency |
| Trauma | • Associated with wide spectrum of injuries | • May result in testicular rupture or torsion, which are surgical emergencies |
| Torsion of appendix testis | • Gradual onset of pain | • Usually pre-pubertal age group • Cremasteric reflex preserved • Tenderness often localized to anterosuperior testes • Surgery not required in majority of cases |
| Inguinal hernia | • Pain and swelling | • May hear bowel sounds on affected side |
TABLE 2
Causes of nonacute scrotal swelling1
| CONDITION | CLINICAL PRESENTATION | PHYSICAL EXAM/CLINICAL COMMENTS |
|---|---|---|
| Hydrocele | • Painless mass that may increase in size throughout the day | • Can be transilluminated • Reactive hydrocele may be associated with testicular neoplasm, epididymitis, orchitis, or torsion |
| Testicular cyst | • None | • Benign incidental finding • Nonpalpable |
| Varicocele | • Scrotal swelling secondary to dilation of spermatic veins • May present as infertility • May present with pain if intratesticular | • Usually left-sided • Described as a bag of worms superior to the testicle • Noticeable when standing or with Valsalva maneuver |
| Spermatocele | • If painful, relieved with elevation | • Often an incidental finding on exam • Freely mobile • Usually located in epididymal head |
| Epidermoid cyst | • Painless mass | • Found anywhere in epididymis • Often surgically removed because it may be difficult to differentiate from malignancy |
| Primary testicular tumor1,9 | • Solid mass • Classically painless but may produce testicular discomfort | • 10% present acutely with hemorrhage • Most common malignancy in males between ages 18 and 40 |
| Metastatic tumor | • Painless mass | • Possible primary cancers include leukemia lymphoma, melanoma, lung, prostate, kidney, GI tract |
Ultrasound is the best initial test
Testicular torsion and acute epididymoorchitis are the most common causes of an acute scrotum.3 Patients with an acute scrotum require an urgent ultrasound to exclude pathology that requires immediate surgery (TABLES 1 AND 2).1 Although clinical exam identifies almost all cases of torsion, a few cases are missed.4 In a study of 209 emergency scrotal explorations, clinical exam by general practitioners and surgeons correctly diagnosed only 92.5% and 94% of testicular torsion cases, respectively, compared with the surgical diagnosis.4
In another study, which used surgery as the diagnostic gold standard, color Doppler ultrasound had a sensitivity of 93.5% for the diagnosis of testicular torsion;5 this has led some to say the combination of both clinical exam and ultrasound should be used to determine the need for surgery.1 However, this combination has not been thoroughly evaluated by researchers, and the best evidence shows that physician exam is essentially the same as color Doppler ultrasound for diagnosing testicular torsion. If torsion cannot be reliably excluded, emergent surgical exploration is mandatory.4
For patients who have a nonacute scrotal mass, ultrasound is often indicated to distinguish intratesticular from extratesticular masses.1 Although testicular neoplasm is relatively rare, it is a concern for patients with non-painful masses. Fortunately, false-negative scrotal ultrasounds are rare. In a small study comparing clinical exam with ultrasound for diagnosis of testicular tumor, the negative predictive value of ultrasound was 100%.6
Although ultrasound has high sensitivity for detection of testicular neoplasm, it cannot differentiate benign from malignant tumors.2 Additionally, ultrasound sometimes fails to differentiate a neoplastic process from a complication of an infection such as an abscess. In those instances, a repeat ultrasound is suggested after antibiotic administration to ensure resolution of the mass.2
When ultrasound is inconclusive, MRI may be helpful
When clinical and ultrasound findings are inconclusive, MRI may help deter-mine a diagnosis. For example, MRI can help distinguish inflammation or abscess from neoplasm, thus preventing a patient from undergoing unnecessary surgical intervention.2,7 If testicular neoplasm cannot be excluded based on clinical and radiographic findings, surgery is indicated.1
Recommendations from others
Few current evidence-based recommendations exist on the approach to patients with scrotal masses. The National Collaborating Centre for Primary Care (UK) suggests an urgent ultrasound when a scrotal mass does not transilluminate or when the examiner cannot distinguish the body of the testis.8
1. Micallef M, Torreggiani WC, Hurley M, Dinsmore WW, Hogan B. The ultrasound investigation of scrotal swelling. Int J STD AIDS 2000;11:297-302.
2. Eyre RC. Evaluation of nonacute scrotal pathology in adults. In: Rose BD, ed. UpToDate [online database]. Version 14.1. Waltham, Mass: UpToDate; 2006.
3. Akin EA, Khati NJ, Hill MC. Ultrasound of the scrotum. Ultrasound Q 2004;20:181-200.
4. Watkin NA, Reiger NA, Moisey CU. Is the conservative management of the acute scrotum justified on clinical grounds? Br J Urol 1996;78:623-627.
5. Andipa E, Liberopoulos K, Asvestis C. Magnetic resonance imaging and ultrasound evaluation of penile and testicular masses. World J Urol 2004;22:382-391.
6. van Dijk R, Doesburg WH, Verbeek AL, van der Schouw YT, Debruyne FM, Rosenbusch G. Ultrasonography versus clinical examination in evaluation of testicular tumors. J Clin Ultrasound 1994;22:179-182.
7. Muglia V, Tucci S, Jr, Elias J, Jr, Trad CS, Bilbey J, Cooperberg PL. Magnetic resonance imaging of scrotal diseases: when it makes the difference. Urology 2002;59:419-423.
8. National Collaborating Centre for Primary Care Referral guidelines for suspected cancer. London: National Institute for Health and Clinical Excellence; June 2005. NICE Clinical Guideline 27. Available at www.nice.org.uk/page.aspx?o=261649. Accessed on August 29, 2007.
1. Micallef M, Torreggiani WC, Hurley M, Dinsmore WW, Hogan B. The ultrasound investigation of scrotal swelling. Int J STD AIDS 2000;11:297-302.
2. Eyre RC. Evaluation of nonacute scrotal pathology in adults. In: Rose BD, ed. UpToDate [online database]. Version 14.1. Waltham, Mass: UpToDate; 2006.
3. Akin EA, Khati NJ, Hill MC. Ultrasound of the scrotum. Ultrasound Q 2004;20:181-200.
4. Watkin NA, Reiger NA, Moisey CU. Is the conservative management of the acute scrotum justified on clinical grounds? Br J Urol 1996;78:623-627.
5. Andipa E, Liberopoulos K, Asvestis C. Magnetic resonance imaging and ultrasound evaluation of penile and testicular masses. World J Urol 2004;22:382-391.
6. van Dijk R, Doesburg WH, Verbeek AL, van der Schouw YT, Debruyne FM, Rosenbusch G. Ultrasonography versus clinical examination in evaluation of testicular tumors. J Clin Ultrasound 1994;22:179-182.
7. Muglia V, Tucci S, Jr, Elias J, Jr, Trad CS, Bilbey J, Cooperberg PL. Magnetic resonance imaging of scrotal diseases: when it makes the difference. Urology 2002;59:419-423.
8. National Collaborating Centre for Primary Care Referral guidelines for suspected cancer. London: National Institute for Health and Clinical Excellence; June 2005. NICE Clinical Guideline 27. Available at www.nice.org.uk/page.aspx?o=261649. Accessed on August 29, 2007.
Evidence-based answers from the Family Physicians Inquiries Network