A comparison of clinical outcomes of acute testicular torsion between prepubertal and postpubertal males

A nomogram for predicting risk factors of testicular salvage after testicular torsion in children

OBJECTIVES

This study aimed to establish a nomogram for predicting the probability of testicular salvage after testicular torsion in children.

METHODS

We retrospectively collected data of children with testicular torsion who were treated at Shenzhen Children's Hospital between September 2005 and August 2022. Of the training cohort, 113 patients who underwent orchiectomy and five with testicular atrophy after orchiopexy were included in the failed testicular salvage group. Additionally, 37 patients who underwent orchiopexy without postoperative testicular atrophy were included in the successful testicular salvage group. The predictive factors affecting testicular salvage were determined using univariate and multivariate logistic regression analyses; a nomogram was constructed. The nomogram was verified using data from the validation group.

RESULTS

Using multivariate logistic regression analysis, the independent risk factors of testicular salvage after testicular torsion were symptom duration (p = 0.034), intratesticular blood flow (p = 0.003), spermatic cord torsion degree (p = 0.037), and monocyte count (odds ratio: 0.012, p = 0.036). A nomogram was established based on these four risk factors. In the training cohort, the area under the receiver operating characteristic curve was 0.969. The area under the receiver operating characteristic curve of the verification cohort was 0.965, indicating good discrimination ability of the nomogram. Increased symptom duration without intratesticular blood flow increased the monocyte count and spermatic cord torsion degree and decreased the success rate of testicular salvage.

CONCLUSION

This prediction model could obtain the corresponding probability of testicular salvage according to the clinical characteristics of different patients with testicular torsion, providing reference for clinicians and parents.

Point-of-Care Ultrasound for the Diagnosis of Pediatric Testicular Torsion: A Retrospective Case Series Analysis

OBJECTIVES

Acute testicular torsion is a surgical emergency that warrants prompt treatment. The diagnosis is typically confirmed by ultrasonography interpreted by a radiologist (RADUS); however, in this study, we describe the clinical course of 23 patients for whom point-of-care ultrasound (POCUS) was performed by pediatric emergency medicine physicians during the initial assessment for testicular torsion in the pediatric emergency department (PED).

METHODS

A retrospective case series analysis of patients aged 0 to 18 years who were diagnosed with acute testicular torsion after undergoing scrotal POCUS through our PED.

RESULTS

Between June 2015 and December 2020, 155 boys received an International Classification of Diseases-9 code of Torsion of Testis after presenting to our PED. Seventy-three patients were imaged preoperatively, of which 50 (68.5%) were diagnosed via RADUS alone. Twenty-three patients (31.5%) underwent POCUS (median age 14.1 years [interquartile range {IQR}: 11.4-15.9 years]), of which 14 (60.9%) were imaged by POCUS alone, whereas the remaining 9 patients (39.1%) underwent POCUS before RADUS. Thirteen of the 23 patients (56.5%) who underwent POCUS had intraoperative findings consistent with acute testicular torsion, whereas another 3 patients (13.0%) required manual detorsion in the PED before orchiopexy. Six patients required orchiectomy. All patients for which POCUS findings were suggestive of acute testicular torsion were correctly classified.The median length of stay from time to admission to orchiopexy for those who received RADUS only versus POCUS only was 184 minutes (IQR: 136-255), and 121 minutes (IQR: 80-202), respectively ( P = 0.036). Among the patients who experienced POCUS, the median length of stay for those who underwent RADUS in addition to POCUS compared with those who underwent POCUS alone was 202 minutes (IQR: 136-338.4) ( P = 0.031).

CONCLUSIONS

Point-of-care ultrasound performed by pediatric emergency medicine physicians can be used to expedite surgical management and streamline the management of pediatric patients suspected of acute testicular torsion.

Atypical symptoms of testicular torsion in a 7-year-old child: A case report

RATIONALE

Testicular torsion accounting for 25% of acute scrotal disease, is an acute surgical condition. Atypical presentations of testicular torsion may lead delay diagnosis.

PATIENT CONCERNS

A 7-year-old boy was admitted to the pediatric emergency department with continuous and progressive left scrotal pain for 2 days, associated symptoms and signs included left scrotal swelling and erythema. The pain started 4 days ago as left lower abdominal pain which then migrated to the left scrotum.

DIAGNOSES

Physical examination showed left scrotum skin redness, swelling, local heat, tenderness, high-riding testis, absence of the left side cremasteric reflex and a negative Prehn's sign. Subsequent point of care ultrasound of scrotum revealed increased volume of the left testicle, inhomogeneous hypo-echoic left testis, and no detectable flow in the left testis. Left testicular torsion was diagnosed.

INTERVENTIONS

Surgical examination confirmed testicular torsion showing 720° counterclockwise rotation of the spermatic cord with ischemic changes in the left testis and epididymis.

OUTCOMES

The patient was stabilized and discharged after left orchiectomy, right orchiopexy and antibiotic therapy.

LESSONS

Symptoms of testicular torsion may be atypical, especially in prepubertal age. Detailed history, physical examination, point of care ultrasound usage and timely urologist consultation and intervention are important for prompt rescue to prevent testicular loss, testicular atrophy, and eventual impairment of fertility.

Differences in Clinical Characteristics Between Prepubescent and Postpubescent Males With Testicular Torsion

Testicular torsion represents a pediatric surgical emergency. In this 6-year study with 140 patients, prepubescent (<13 years) and postpubescent (≥13 years) males with testicular torsion were identified. Prepubescent boys had a longer symptom duration (P = .016) and underwent more orchiectomies (P = .005) compared with postpubescent boys. The risk of orchiectomy decreased by 15% per 1-year increase in age (P = .002). Boys who underwent an orchiectomy had a longer symptom duration (P < .001), were younger (P = .002), had scrotal swelling (P = .001), scrotal erythema (P < .001), higher degrees of torsion (P = .036), and more left-sided surgeries (P = .014) compared with those who had an orchiopexy. Postpubescent boys were 63% less likely to receive an orchiectomy versus an orchiopexy compared with prepubescent boys. Pediatricians should be cognizant of the age discrepancies between prepubescent and postpubescent males with testicular torsion and educate parents about the importance of urgent evaluation in the Emergency Department to reduce the likelihood of an orchiectomy.

Scrotal exploration for acute testicular pain: A contemporary UK series from a tertiary centre

Objectives:

The objective of this study was to assess the evaluation and operative outcomes of patients attending a single urology centre with acute testicular pain (ATP) who underwent scrotal exploration. We sought to determine adherence to the Royal College of Surgeons England (RCS) commissioning guide on testicular torsion, clinical and radiological features predictive of torsion, time-dependent salvage rates and surgical technique in a contemporary cohort.

Patients and Methods:

A single-centre retrospective review was carried out from 2015 to 2020. All patients presenting with acute testicular pain undergoing surgical exploration were included.

Results:

140 patients were identified, median age 16 years, 40 had testicular torsion (TT) (30%) where nausea (positive predictive value (PPV) 51.7%, p = 0.009) and abnormal testis lie (PPV 50%, p = 0.008) were more frequent. TT was the most common diagnosis if presenting <4 hours (44%), and in patients 13–16 years (62%). Time-to-surgery from the assessment was <3 hours in 109 of 128 (85.2%). The overall salvage rate was 74.4%, with salvage rates of 100% at 6 hours from the onset of pain. Viable tissue was seen on histology in 30% of orchidectomies, up to 25 hours from the onset of pain.

Discussion:

Surgical exploration <6 hours from the onset of pain is the threshold for salvage in TT. Clinical findings should be combined with patient age and time to presentation to aid diagnosis. Patients between 13 and 16 years are at the highest risk of TT and frequently present early following the onset of pain. Given the heterogenicity of surgical management and the highest risk of TT to the paediatric population, speciality organisations should produce definitive guidance on the management of TT.

Level of evidence:

OCEBM Level 3 evidence

The limits of diagnosis of testicular torsion in the child: Medicolegal implications in clinical practice

Testicular torsion is a pediatric urological emergency. We report a case of testicular torsion that occurred in a 10-year-old child. The case shows that it is a disease with risk of medicolegal litigation. We demonstrate the role of proper triage, and we analyze the limits and critical points for diagnosing it.

Abdominal Pain in the Emergency Department: Missed Diagnoses

Abdominal pain is the most common chief complaint in the Emergency Department. Abdominal pain is caused by a variety of gastrointestinal and nongastrointestinal disorders. Some frequently missed conditions include biliary pathology, appendicitis, diverticulitis, and urogenital pathology. The Emergency Medicine clinician must consider all aspects of the patient's presentation including history, physical examination, laboratory testing, and imaging. If no diagnosis is identified, close reassessment of pain, vital signs, and physical examination are necessary to ensure safe discharge. Strict verbal and written return precautions should be provided to the patient.