Case 17: Smoking Made It Bigger

It’s almost seven p.m. and I’m handed the chart of a man in his sixties. “Can you see this one first,” the nurse says, “he needs an ultrasound.” I skim the triage note, which is often like reading the blurb at the back of the DVD. If it says “pain all over for eight months,” it’s not likely to be a Hot New Rental.  Frank Martin* has been sent from a walk-in clinic with a ‘swollen scrotum’. I walk fast and I’m ready to talk even faster. The ultrasound technician will be leaving in an hour. Depending on how back-logged she is, I may already be cut off. But if Mr. Martin has torsion – a twisting of the testicle that can cause blood loss and tissue death within hours, I’ll make a call and plead with her to do the scan before she leaves.

As I approach the room, I see him, and I relax. There’s no way he has torsion, and no matter what he has, the ultrasound can probably wait. When organs lose blood supply, it’s not just painful, it’s excruciating; it’s the buckling chest-clutch of a heart-attack; it’s the unrelenting stab of an ischemic gut. Frank is in no distress.  His reading glasses pinch the tip of his nose, as he smiles, and reads the newspaper. He sees me and he laughs. I already know, before he speaks, that we’re going to get along well.

“Funniest thing,” he says, looking around and lowering his voice. He points to his mid-section. “It’s blown up like a balloon. Full of fluid. The doctor at the walk-in took one look and sent me over here.” It happened two days ago, while Frank was having a bowel movement. “I was pushing hard, and suddenly there was a pop and I felt a twinge down there.” He denied pain. “By yesterday, it had tripled in size. You’ve gotta see it.” The doctor he’d seen at the walk-in told him he’d likely broken a vessel from pushing so hard, and that blood had pooled in his scrotum.

I ask him a few more questions. He has an enlarged prostate, and had been a long-time smoker until recently. He’d run into some trouble with his lungs and his breathing, but other than that, he’s been healthy, and looks great for his age.

I pull the drape. “So let’s see it.”

Seconds later, his pants are down. The swelling is odd. Scrotal swelling isn’t uncommon. Patients who retain fluid often have large, swollen scrota (I had to look this up – “what is the pleural form of ‘scrotum’). The fluid settles in the skin’s tissues, and thins it, giving it a silky grey appearance. But Frank’s scrotum isn’t the problem. The swelling is almost exclusively in his foreskin. In fact, it looks like he has a third testicle sitting on top of the other two. I put on gloves and start poking around. The surface is bumpy, unlike the smooth sheen of fluid-filled tissues. “Did the doctor at the walk-in examine you?”

“Yeah, he took one look at it and sent me here.”

“But did he touch it?”

Frank thinks about it. He can’t remember.

I palpate harder, and suddenly, the diagnosis is made. “Did you feel that?” I ask.

“Feel what.”

I scribble on the chart and pull out a pink sheet. “You need a chest x-ray,” I say, as he hops off the table and pulls up his pants.

“No ultrasound?”

“No ultrasound.”

Twenty minutes later, I’m looking at a picture of his lungs on a monitor. “Such a weird case,” I tell my assistant, pointing to the tissue just beside his rib cage. “Check it out. I’ve never seen anything like this before. I’ve never even heard of it.”

Certainly I’d seen a pneumothorax before – I’ve probably seen one a month for the last fifteen years. This happens when air leaks out of the lung into the space between a person’s lung and chest wall. Sometimes, the air puts pressure on the deflating lung and the lung collapses. Patients are often heavy smokers (whose habit has weakened their lung lining) or tall, thin teenagers (whose body shape simply makes them susceptible to this problem).

When I pushed on Frank’s foreskin, it crackled and popped, as if Rice Krispies were tucked inside. This is a tell-tale sign for subcutaneous emphysema – air in the tissues of the skin. Subcutaneous emphysema is also not uncommon. What’s uncommon, is that Frank had no lung symptoms – no chest pain, no shortness of breath, and that air had tracked down directly into his penis, of all places. Usually with a collapsed lung, air tracks into the tissue surrounding the chest, and tracks up into the neck. I explain this to Frank, and he’s fascinated. Shortly after, his pants are back down, as I photograph the curious finding, while he asks me to send him a copy if I ever write about it.

Later that day, a tube is placed between Frank’s ribs, into his chest. A gush of trapped air escapes, and within a few days, his penis returns to its normal size.

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