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Cremasteric Reflex

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1. The cremasteric reflex and its muscle - a paragon of ongoing scientific discussion. A systematic review. (PubMed)

The cremasteric reflex and its muscle - a paragon of ongoing scientific discussion. A systematic review. The technique of triggering the cremasteric reflex and its respective signaling pathway is not described uniformly throughout the literature. As this reflex is a useful sign in diagnosing testicular torsion, orchitis, varicocele, and undescended testis, it seems desirable to identify and define the correct mechanism. Our aim was to investigate how the cremasteric reflex and its signaling (...) pathway are described in the current literature and how the variability of the innervation of the inguinal region could affect the frequency of this reflex. Thirty-five original articles and 18 current textbooks were included after searching PubMed (MEDLINE) and Scopus for the terms "cremaster muscle," "cremasteric reflex," and "genitofemoral nerve" and after applying all exclusion criteria. This systematic review was performed according to the PRISMA Statement Rules. Eliciting the cremasteric reflex

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2017 Clinical anatomy (New York, N.Y.)

2. Cremasteric Reflex

Cremasteric Reflex Cremasteric Reflex Toggle navigation Brain Head & Neck Chest Endocrine Abdomen Musculoskeletal Skin Infectious Disease Hematology & Oncology Cohorts Diagnostics Emergency Findings Procedures Prevention & Management Pharmacy Resuscitation Trauma Emergency Procedures Ultrasound Cardiovascular Emergencies Lung Emergencies Infectious Disease Pediatrics Neurologic Emergencies Skin Exposure Miscellaneous Abuse Cancer Administration 4 Cremasteric Reflex Cremasteric Reflex Aka (...) : Cremasteric Reflex II. Indication Evaluation of III. Technique Examiner strokes or pinches medial thigh Stimulus usually causes cremasteric muscle contraction Observe for rise of the on same side (normal) IV. Interpretation Normal: Cremasteric Reflex present ( rises) Seen in Abnormal: Cremasteric Reflex absent (no rise) Suggests Also absent in 50% of boys under age 30 months Do not use this test under age 30 months V. Efficacy for : 99% Assumes age over 30 months VI. References Images: Related links

2018 FP Notebook

3. Cremasteric Reflex

Cremasteric Reflex Cremasteric Reflex Toggle navigation Brain Head & Neck Chest Endocrine Abdomen Musculoskeletal Skin Infectious Disease Hematology & Oncology Cohorts Diagnostics Emergency Findings Procedures Prevention & Management Pharmacy Resuscitation Trauma Emergency Procedures Ultrasound Cardiovascular Emergencies Lung Emergencies Infectious Disease Pediatrics Neurologic Emergencies Skin Exposure Miscellaneous Abuse Cancer Administration 4 Cremasteric Reflex Cremasteric Reflex Aka (...) : Cremasteric Reflex II. Indication Evaluation of III. Technique Examiner strokes or pinches medial thigh Stimulus usually causes cremasteric muscle contraction Observe for rise of the on same side (normal) IV. Interpretation Normal: Cremasteric Reflex present ( rises) Seen in Abnormal: Cremasteric Reflex absent (no rise) Suggests Also absent in 50% of boys under age 30 months Do not use this test under age 30 months V. Efficacy for : 99% Assumes age over 30 months VI. References Images: Related links

2015 FP Notebook

4. Testicular torsion

testicle horizontal lie absent cremasteric reflex nausea and vomiting abdominal pain fever urinary frequency age under 25 years neonate bell clapper deformity trauma/exercise intermittent testicular pain undescended testicle cold weather Diagnostic investigations grey-scale ultrasound power Doppler ultrasound colour Doppler ultrasound spectral Doppler urinalysis FBC CRP scintigraphy Treatment algorithm ACUTE Contributors Authors Professor of Surgery Department of Surgery UC San Diego School of Medicine

2018 BMJ Best Practice

5. Paediatric Urology

: 44. 45. Kaefer, M., et al. The incidence of intersexuality in children with cryptorchidism and hypospadias: stratification based on gonadal palpability and meatal position. J Urol, 1999. 162: 1003. 46. Kollin, C., et al. Cryptorchidism: a clinical perspective. Pediatr Endocrinol Rev, 2014. 11 Suppl 2: 240. 47. Caesar, R.E., et al. The incidence of the cremasteric reflex in normal boys. J Urol, 1994. 152: 779. 48. Barthold, J.S., et al. The epidemiology of congenital cryptorchidism, testicular (...) epididymitis in boys: evidence of a post-infectious etiology. J Urol, 2004. 171: 391. 151. Yerkes, E.B., et al. Management of perinatal torsion: today, tomorrow or never? J Urol, 2005. 174: 1579. 152. Boettcher, M., et al. Clinical and sonographic features predict testicular torsion in children: a prospective study. BJU Int, 2013. 112: 1201. 153. Nelson, C.P., et al. The cremasteric reflex: a useful but imperfect sign in testicular torsion. J Pediatr Surg, 2003. 38: 1248. 154. Mushtaq, I., et al

2019 European Association of Urology

6. Exam Series: Guide to the Back Exam

Sensory Reflexes L1 Groin Cremasteric L2 Hip flexion and hip adduction Anterior medial thigh L3 Hip flexion and knee extension Anterior medial thigh Knee L4 Knee extension, (quadriceps – squat and rise), foot inversion and dorsiflexion Lateral aspect of the thigh to the anterior and medial leg Knee L5 Foot dorsiflexion (walking on heels), foot inversion 1 st dorsal webspace S1 Foot plantar flexion (walking on toes), foot eversion Lateral foot Achilles S2 Toe plantar flexion Plantar foot S3, S4 Bowel

2018 CandiEM

7. CRACKCast E174 – Genitourinary and Renal Tract Disorders

cephalosporin). urologist should be urgently consulted for a scrotal or testicular abscess. [7] Describe the diagnosis and management of testicular torsion. Key points: Can occur at any age – most commonly 12-18 yrs Time sensitive dx! 10% salvage rate at 24 hrs! Diagnosis: Hx: acute constant scrotal pain, swelling, high riding testicle, with nausea and vomiting. acute scrotal pain and swelling, an elevated testicle and, typically, absence of the cremasteric reflex. This reflex can be demonstrated by lightly (...) stroking the skin of the inner thigh downward from the hip toward the knee. The cremaster muscle on the ipsilateral side rapidly contracts and elevates the testicle.Although absent in the vast majority of cases, the presence of the cremasteric reflex does not preclude testicular torsion. Abnormal (high-riding and transverse) epididymal and testicular position may also be noted , with left-sided torsions slightly more common than right. Pain is typically constant, and the patient may have a history

2018 CandiEM

8. CRACKCast E099 – Urological Disorders

Schistosomiasis Urinary symptoms, with sudden obstruction of the bladder outlet Usually need surgical removal after U/S or CT dx Acute Scrotal Pain – Rosens in Perspective Know your anatomy Know that the left testi normally sits lower than the right They normally sit in the vertical axis “The epididymis is located posterolateral to the testis and is normally nontender and soft. The cremasteric reflex is elicited by stroking or pinching the inner aspect of the thigh; more than 0.5 cm of elevation (...) after the onset of pain Often N/V or abdominal pain 10% may have no stated scrotal pain Physical: Absent cremasteric reflex favours testicular torsion (but its presence can’t rule out torsion) Tender, firm testicle Shortening of the spermatic cord Transverse lying position, with the epididymis off the posterior axis ***these findings may be absent after 24 hrs of sxt*** U/S: ask for color doppler duplex ultrasound of both testicles and spermatic cords Findings of TT: Enlarged, hypoechoic testicle

2017 CandiEM

9. CRACKCast E047 – Genitourinary Trauma

in sterile, saline moistened gauze in a plastic bag, then in a second bag of ice. The bleeding stump – direct pressure Local reshaping Blunt scrotal trauma Tough tunica albuginea surrounds the testicles and cremasteric reflex 85% of injuries happen during sporting events (kicks, falls, strikes) Testicular rupture: happens in 40% of blunt scrotal trauma who come to ER Symptoms Pain, faintness, N/V, urinary retention Physical assessment is of limited helpfulness Need imaging with ultrasound: 95% sensitive (...) to arteriolar vasoconstriction, aldosterone release. (net increase of blood pressure and blood volume) Epidemiology Renal injury – most commonly injured structure in the GU tract. Blunt trauma from MVCs/falls/direct blows to the flank account for 90% of injuries High energy injury damages all the structures that coalesce at the UPJ Penetrating trauma – often leads to nephrectomy Renal vein injuries → much more common than renal artery injury (if artery injured they have reflexive protective vasospasm) Veins

2016 CandiEM

10. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations from ESPGHAN and NASPGHAN

stenosis: ribbons stools, tight anal canal on rectal examination Abnormal anal position Sacral teratoma Sacral teratoma Sacral agenesis Sacral agenesis Spinal cord anomalies Spinal cord anomalies, trauma Weakness in legs, locomotor delay Weakness in legs, abnormal motility Pilonidal dimple covered by a tuft of hair Pilonidal dimple covered by a tuft of hair Gluteal cleft deviation Gluteal cleft deviation Absent anal and cremasteric re?ex Absent anal and cremasteric re?ex Decreased lower extremity tone (...) Severe abdominal distension Perianal ?stula Abnormal position of anus Absent anal or cremasteric re?ex Decreased lower extremity strength/tone/re?ex Tuft of hair on spine Sacral dimple Gluteal cleft deviation Extreme fear during anal inspection Anal scars HD¼Hirschsprung disease. (4) Based on expert opinion, if only 1 of the Rome III criteria is present and the diagnosis of functional constipation is uncertain, a digital examination of the anorectum is recommended. Voting: 7, 8, 8, 8, 9, 9, 9, 9 (5

2014 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition

11. Evaluation and Treatment of Cryptorchidism

with a vigorous cremasteric reflex), but that can be manually replaced in stable, dependent scrotal position and remain there without tension at least temporarily. An atrophic testis is one that suffers significant volume loss after prior inguinal or testicular surgery, or due to prolonged location in an extrascrotal position or primary developmental failure. Epidemiology Prevalence/incidence of congenital v. acquired cryptorchidism. Although delayed diagnosis or treatment of cryptorchidism beyond

2014 American Urological Association

12. Articles of the month (May 2018)

. This is a prospective observational study to validate the previously derived TWIST score for testicular torsion, and the quick answer is that the score isn’t good enough for clinical practice. The TWIST score is a 7 point score based on the history and physical: testicular swelling (2 points), hard testicle (2 points), absent cremasteric reflex (1 point), nausea or vomiting (1 point), and high riding testicle (1 point). They included a convenience sample of 258 males between the ages of 3 months and 18 years (...) scores, including a torsion in a patient with a score of 0. On the other hand, a score of 7 had a specificity of 100% (95% CI 98-100%) which might be valuable if you are trying to send the patient straight to the OR without imaging (but the sensitivity was only 21%). No aspect of the score was particularly good, meaning we can’t rely on testicular lie, cremasteric reflex, vomiting or any clinical data point to either rule in or rule out torsion. One important point: ultrasound was also not perfect

2018 First10EM

13. Prospective Validation of a Clinical Score for Males Presenting with an Acute Scrotum. (PubMed)

components of the TWIST score (hard testicle, absent cremasteric reflex, nausea/vomiting, and high riding testicle) as well as diagnostic results (ultrasound, urine, sexually transmitted infection testing) were recorded. Testicular torsion was confirmed by surgical exploration. Frequencies of patient characteristics, TWIST components, and tests were calculated. We performed the kappa statistic for inter-rater reliability and calculated the test characteristics and receiver operator characteristics curves

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2017 Academic Emergency Medicine

14. Undescended testes

. Retractile testes have descended into the scrotum, but come to lie in the groin because of a strong cremasteric reflex. Retractile testes do not need medical or surgical treatment, but require annual follow up because they may become ascending testes. Children with a suggestion of a disorder of sexual development (for example ambiguous genitalia or hypospadias) or bilateral undescended testes at birth should be urgently referred to a senior paediatrician within 24 hours (ideally within a tertiary (...) there by itself and will usually stay in the scrotum for a short time until the cremasteric reflex retracts it into the groin. If differentiation between undescended and retractile testis is difficult, refer to a paediatric surgeon or urologist for confirmation of the diagnosis. If the testis is not present in the scrotum or inguinal region, examine for an in the femoral, penile, and perineal regions. Check for ambiguity of the external genitalia, and for abnormalities such as hypospadias and any syndromic

2014 NICE Clinical Knowledge Summaries

15. Neurological History and Physical Examination (Overview)

of the frontal lobes (hence the term frontal-lobe release signs). Superficial reflexes These are segmental reflex responses that indicate the integrity of cutaneous innervation and the corresponding motor outflow. These include the corneal, conjunctival, abdominal, cremasteric, anal wink, and plantar (Babinski) reflexes. The corneal and conjunctival reflexes may be elicited by gently touching the appropriate structure with a sterile wisp of cotton. The normal response is bilateral winking. Absence (...) of such a response implies CN V paralysis. Blinking of only 1 eye suggests weakness of CN VII on the side that does not wink. The abdominal reflex can be elicited by drawing a line away from the umbilicus along the diagonals of the 4 abdominal quadrants. A normal reflex draws the umbilicus toward the direction of the line that is drawn. The cremasteric reflex is elicited by drawing a line along the medial thigh and watching the movement of the scrotum in the male. A normal reflex results in elevation

2014 eMedicine.com

16. Epididymitis (Overview)

of orchitis by 3-5 days Subclinical infections (30-40% of patients) Physical examination findings may fail to distinguish acute epididymitis from testicular torsion. Physical findings associated with acute epididymitis may include the following: Tenderness and induration occurring first in the epididymal tail and then spreading Elevation of the affected hemiscrotum Normal cremasteric reflex Erythema and mild scrotal cellulitis Reactive hydrocele (in patients with advanced epididymo-orchitis) Bacterial

2014 eMedicine.com

17. Ependymoma (Overview)

sign localizes lesions below T10 Abdominal skin reflexes usually are absent below the lesion Physical findings with lumbar ependymomas may include the following: These lesions are localized from the root level of sensory loss and motor weakness Nerve root compression: Radicular pain and weakness Lesions compressing only the first and second lumbar segments: Lost cremasteric reflexes, preserved abdominal reflexes, and increased knee and ankle jerks Lesions affecting the third and fourth lumbar (...) segments: If the roots of the cauda equina are not affected, weakness of the quadriceps, loss of the patellar reflexes, and hyperactive Achilles reflexes may be present; if they are affected, flaccid paralysis of the legs and loss of knee and ankle reflexes may occur Lesions affecting spinal cord and cauda equina concurrently: Spastic paralysis of one leg with increased ankle reflexes ipsilaterally may occur, as well as flaccid paralysis with loss of reflexes contralaterally Physical findings

2014 eMedicine.com

18. Urological Management in Neurological Disease (Diagnosis)

. The sacral roots may be stimulated magnetically or by placing needle electrodes in the foramina. Somatosensory evoked potentials may be obtained by stimulating the perineum or the bladder neck and recording cortically. Yilmaz et al have described a dartos reflex that is a sympathetically mediated scrotal reflex similar to the more commonly used cremasteric reflex. This evaluates the integrity of the T12-L2 sympathetics and the genitofemoral nerve. [ ] Previous Next: Bladder and Pelvic Floor Function (...) repetitive discharges are more common in the sphincters than in other striated muscles. Their presence has been associated with urinary retention in women [ ] and enuresis in children. [ ] Reflex responses Baseline electrical activity in the sphincters can be modified by a number of maneuvers. The Credé maneuver (ie, pressing on the bladder suprapubically), the Valsalva maneuver, and stimulation of perianal or perineal skin all can produce reflex activation of the sphincters. Manual stimulation

2014 eMedicine.com

19. Urological Management in Neurological Disease (Overview)

. The sacral roots may be stimulated magnetically or by placing needle electrodes in the foramina. Somatosensory evoked potentials may be obtained by stimulating the perineum or the bladder neck and recording cortically. Yilmaz et al have described a dartos reflex that is a sympathetically mediated scrotal reflex similar to the more commonly used cremasteric reflex. This evaluates the integrity of the T12-L2 sympathetics and the genitofemoral nerve. [ ] Previous Next: Bladder and Pelvic Floor Function (...) repetitive discharges are more common in the sphincters than in other striated muscles. Their presence has been associated with urinary retention in women [ ] and enuresis in children. [ ] Reflex responses Baseline electrical activity in the sphincters can be modified by a number of maneuvers. The Credé maneuver (ie, pressing on the bladder suprapubically), the Valsalva maneuver, and stimulation of perianal or perineal skin all can produce reflex activation of the sphincters. Manual stimulation

2014 eMedicine.com

20. Cryptorchidism (Diagnosis)

most are inguinal. Although not truly undescended, these testes may be suprascrotal secondary to an active cremasteric reflex. This reflex is usually weak in infants and most active in boys aged 5 years. These testes can be manipulated into the scrotum, where they remain without tension. This condition is considered a variant of normal; however, the risk of ascent may approach 50%. [ , ] Ascent probably represents an undescended testis that was almost in normal position. The distinction can (...) Next: Relevant Anatomy The undescended testis, when palpable, is usually found in the superficial inguinal pouch or in the inguinal canal under the external oblique aponeurosis. Care must be taken during dissection to avoid the ilioinguinal nerve near the spermatic cord. After dissection of the cremasteric fibers off the cord, the patent processus vaginalis, or hernia sac, may be located on the anteromedial surface of the cord. The intra-abdominal view of the anatomy is best seen in the image below

2014 eMedicine.com

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