Multicenter assessment of ultrasound of the spermatic cord in children with acute scrotum

The impact of ultrasound on testicular loss in cases of testicular torsion in children

PURPOSE

Ultrasound as a diagnostic tool in suspicion of testicular torsion is still highly debated. In this investigation, we aimed to evaluate whether time spent on scrotal ultrasonography had a negative impact on testicular loss.

METHODS

Patients' records containing a scrotal ultrasound and/or surgical procedure codes for testicular interventions on suspicion of testicular torsion were examined. Patients aged 0-15 years admitted during 2015-2019 at Copenhagen University Hospital, Rigshospitalet were included.

RESULTS

In total, 1566 patients underwent an ultrasound and 142 of these proceeded to surgery while 13 patients proceeded directly to surgery without an ultrasound. The rate of testicular loss with a preceding ultrasound was 23% versus 42% without (p = 0.18). Four cases of testicular torsion were misdiagnosed by ultrasound resulting in a sensitivity of 95.4% and specificity of 95.6%. The mean diagnostic delay from ultrasound examination was 55 ± 39 min, and the mean time from ultrasound to surgery was at 169 ± 76 min versus 171 ± 72 min without ultrasound.

CONCLUSION

In a clinical setting, ultrasound provided a reliable tool for the diagnosis of testicular torsion and did not seem to increase the orchiectomy rate.

[Ultrasound imaging of the testes in children and adolescents]

BACKGROUND

Ultrasound, the imaging method of choice to evaluate abnormalities of the testes and the scrotum, provides accurate anatomic details and allows the assessment of perfusion using color Doppler and power Doppler. Ultrasound represents a rapid and reliable procedure which in most cases leads to a conclusive diagnosis.

DIFFERENTIAL DIAGNOSIS

The three most common conditions in the clinical picture of acute scrotum are testicular torsion, torsion of the testicular appendages and inflammatory changes of the testis and the epididymis (epididymo-orchitis). Especially in the case of testicular torsion, rapid diagnosis is essential since time is an important factor to initiate organ-preserving therapy.

EQUIPMENT TECHNOLOGY

High-frequency linear array transducer (at least 10 MHz), which allows detection of slow flow rates, is recommended.

Functional Imaging of Testicular Torsion

This article discusses the current clinical role and scope of functional radionuclide imaging using testicular perfusion scintigraphy with 99mTc-pertechnetate in patients presenting with an acute hemiscrotum for an early and reliable diagnosis of testicular torsion. The technique of testicular perfusion scintigraphy is described, and the characteristic findings are detailed with examples. The imaging characteristics of the various phases of testicular torsion and its differentiation from epididymitis and/or epididymo-orchitis and the other related conditions presenting as an acute hemiscrotum are detailed. In some cases, further evaluation by SPECT imaging increases the clarity and accuracy of diagnosis and, on occasion, hybrid SPECT/CT in selected complicated cases improves the diagnostic yield of the perfusion scintigraphy. Ultrasonographic and color Doppler findings are described concurrently with the scintigraphic findings. The several case examples presented demonstrate the additional clinical benefit of complementing functional and structural imaging for improving the sensitivity, specificity and accuracy of testicular imaging in the diagnosis.

The diagnosis and treatment of testicular torsion in children with non-scrotal initial symptoms

Objective

To explore the clinical characteristics of testicular torsion in children with non-scrotal initial symptoms who were misdiagnosed.

Methods

A retrospective analysis of 73 cases children with testicular torsion and non-scrotal symptoms who were admitted to our department from October 2013 to December 2021 was performed. Patients were divided into misdiagnosis (27 cases) and clear diagnosis at first visit (46 cases) groups. Clinical data, including age at surgery, clinical presentation, physical examination, number of visits (≥2 times), affected side, time from initial symptoms to surgery, and surgical outcomes, were collected. The TWIST (Testicular Workup for Ischemia and Suspected Torsion) score was calculated and analyzed.

Results

Statistically significant differences between the misdiagnosis and clear diagnosis groups were seen in the time from initial symptoms to surgery, the number of visits, the degree of testicular torsion, and the rate of orchiectomy (P < 0.05). There were no statistically significant differences (P > 0.05) in age, affected side, TWIST score, guardian, direction of testicular torsion, intra-vaginal or extra-vaginal torsion, and Arda classification. Postoperative follow-up was 6-40 months. Of the 36 patients who required an orchiopexy, 1 had testicular atrophy at six months and 2 were lost to follow-up. The contralateral testis of the 37 children who underwent orchiectomies developed normally without torsion.

Conclusions

The clinical manifestations of testicular torsion in children are diverse and can easily lead to misdiagnosis. Guardians should be aware of this pathology and seek timely medical attention. When the initial diagnosis and treatment of testicular torsion is difficult, the TWIST score during the physical examination may be useful, especially for patients with intermediate-to-high risk scores. Color Doppler ultrasound can assist in making the diagnosis, but when testicular torsion is highly suspected, routine ultrasound is not necessary as it may lead to delayed surgical treatment.

Outcomes of Surgical Exploration of Acute Scrotal Pain Raising Suspicion of Testicular Torsion

Background and objective Testicular torsion (TT) is a surgical emergency, affecting approximately one in every 4000 males under the age of 25 years annually in the United States. In this study, we aimed to determine the outcomes of emergency scrotal surgical exploration of cases that raised suspicion of TT presenting to Salmaniya Medical Complex (SMC), Bahrain's largest secondary and tertiary care center. Methods This was a retrospective cohort study. The data were collected from the hospital's electronic medical record software (I-SEHA). The data included patient age, Doppler ultrasound (DUS) findings prior to any surgical procedure, type of surgical procedure, and the surgical findings of that procedure. Results Of the 198 patients who underwent scrotal exploration, 141 had presented with signs and symptoms suggestive of TT. The mean age of the patients was 22.3 ±9.3 years. Doppler imaging was performed preoperatively on 135 out of 141 (95.7%) patients. After scrotal exploration, 91.4% of the patients were found to have TT. The proportion of patients with salvageable testis was 78.7%. Conclusions The study found that surgical exploration remains the definitive method in the management of acute scrotum in TT patients. Our findings are in line with those from other similar studies and meta-analyses.

High risk and low prevalence diseases: Testicular torsion

INTRODUCTION

Testicular torsion is a serious condition that carries with it a high rate of morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of testicular torsion, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Testicular torsion is a urological emergency that occurs with rotation of the testicle along its supporting ligaments leading to obstruction of vascular flow. A key risk factor is the presence of a bell-clapper deformity. The most common population affected includes children in a bimodal distribution with the most cases occurring in the first year of life and between 12 and 18 years, although cases do occur in adults. Acute, severe, unilateral scrotal pain is the most common presenting symptom. Nausea and vomiting are common, but the presence or absence of a cremasteric reflex is not a reliable indicator of disease. The TWIST score may assist with clinical decision making in patients presenting with acute testicular pain but should not be used in isolation. If torsion is suspected or confirmed, consultation with the urology specialist should not be delayed, as outcomes are time sensitive. Ultrasound can be used for diagnosis, but a normal ultrasound examination cannot exclude the diagnosis. Treatment includes emergent urology consultation for surgical exploration and detorsion, as well as symptomatic therapy in the ED. Manual detorsion can be attempted in the ED while awaiting transfer or consultation.

CONCLUSIONS

An understanding of testicular torsion can assist emergency clinicians in diagnosing and managing this disease.

Clinical risk factors for testicular torsion and a warning against falsely reassuring ultrasound scans: a 10-year single-centre experience

BACKGROUND

We sought to determine which demographic, clinical and ultrasonography characteristics are predictive of testicular torsion (TT) and to determine factors associated with time to treatment.

METHODS

We retrospectively reviewed all medical records of patients (0-17 years) with acute scrotal syndrome (ASS) who were treated in our hospital in Lithuania between 2011 and 2020. We extracted patients' demographic data, in-hospital time intervals, clinical, US and surgical findings. TT was determined at surgery or clinically after manual detorsion. Test characteristics of demographic, clinical and US findings for the diagnosis of TT versus other causes of ASS were determined. We performed a multivariate analysis to identify independent clinical predictors of torsion, and factors associated with surgical delay.

RESULTS

A search of medical records yielded 555 cases: 196 (35%) patients with TT and 359 (65%) patients with other ASS causes. Multivariate logistic regression analysis showed that age between 13 and 17 years (OR 8.39; 95% CI 5.12 to 13.76), duration of symptoms <7 hours (OR 3.41; 95% CI 2.03 to 5.72), palpated hard testis (OR 4.65; 95% CI 2.02 to 10.67), scrotal swelling (OR 2.37; 95% CI 1.31 to 4.30), nausea/vomiting (OR 4.37; 95% CI 2.03 to 9.43), abdominal pain (OR 2.38; 95% CI 1.27 to 4.45) were independent clinical predictors of TT. No testicular blood flow in Doppler US had a specificity of 98.2% and a positive predictive value of 94.6%. However, 75 (41.7%) patients with TT had normal testicular blood flow, yielding low sensitivity (58.3%) and negative predictive value of 81.3% for this US finding. In-hospital waiting time for surgery was longer in patients with TT with normal testicular blood flow by USS (195 min) compared with no blood flow (123 min), p<0.01. Higher orchiectomy rates were associated with longer duration of symptoms (p<0.001) and longer waiting time for USS (p=0.029) but not with false-negative US.

CONCLUSIONS

Pubertal age, symptoms duration of <7 hours, nausea/vomiting, palpated hard testis, abdominal pain and scrotal swelling are predictive factors for TT. Time lost between symptom onset and seeking medical care, and between arrival and US are associated with the need for orchiectomy. Preserved blood flow in USS does not rule out TT and may contribute to delays to surgery.

Diagnostic accuracy of point-of-care ultrasound for paediatric testicular torsion: a systematic review and meta-analysis

BACKGROUND

Previous studies have examined the utility of ultrasonography performed by radiologists for diagnosing paediatric testicular torsion. While point-of-care ultrasound (POCUS) is used in paediatric emergency medicine, its diagnostic accuracy is still unknown.

OBJECTIVES

The present systematic review and meta-analysis aimed to clarify the accuracy of POCUS in diagnosing testicular torsion in children.

METHODS

Following the Preferred Reporting Items for Systematic Review and Meta-analysis of Diagnostic Test Accuracy guidelines, a systematic review was performed using the indices of MEDLINE, EMBASE plus EMBASE classics, PubMed and the Cochrane database from inception to November 2020. Any study investigating the diagnostic accuracy of POCUS for paediatric testicular torsion was extracted. The primary outcome was the assessment of the diagnostic accuracy of POCUS for paediatric testicular torsion. The pooled sensitivity and specificity were calculated. Quality analysis was conducted using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2).

RESULTS

Four studies enrolling 784 patients in total were included. The pooled sensitivity, specificity, and positive and negative likelihood ratios of POCUS were 98.4% (95% CI: 88.5% to 99.8%), 97.2% (95% CI: 87.2% to 99.4%), 34.7 (95% CI: 7.4 to 164.4) and 0.017 (95% CI: 0.002 to 0.12), respectively. Risk-of-bias assessment using QUADAS-2 revealed that two of the studies had a high risk of bias in patient selection.

CONCLUSION

The present systematic review and meta-analysis showed that POCUS had high sensitivity and specificity for identifying testicular torsion in paediatric patients although the risk of bias was high in the studies analysed.

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

Testicular Torsion Appearance and Diagnosis on Computed Tomography of the Abdomen/Pelvis: Case Report

Introduction: Testicular torsion, or the twisting of the spermatic cord compromising blood flow to the testis, is a urologic emergency with the potential to cause infertility in male patients. The diagnosis may be clinical or confirmed using imaging, with ultrasound being the modality of choice. Case Report: We present a case of right lower quadrant pain with radiation to the groin and right scrotum in a young male. A computed tomography of the abdomen and pelvis was ordered to assess for appendicitis, which showed a “whirl” sign on the inferior periphery of the images near the scrotum. The finding was not appreciated during the emergency department visit and the patient was discharged home. He returned 48 hours later due to continued pain and was ultimately diagnosed with testicular torsion via ultrasound and surgical pathology. Conclusion: This is the first reported case to our knowledge identifying “whirl” sign for the diagnosis of testicular torsion. This finding was not appreciated by multiple clinicians during the initial patient presentation, highlighting the uncommon nature of the finding.

Advances in the antibiotic management of epididymitis

INTRODUCTION

Acute epididymitis is commonly encountered and typically presents acutely within a wide clinical spectrum. Most cases of acute epididymitis are caused by bacterial infection, most often by sexually transmitted organisms and urinary pathogens. Current treatment regimens remain empirical, although recent advances using modern diagnostic techniques support a change in the management paradigm.

AREAS COVERED

The choice of the initial antibiotic regimen is empirical and based on the most likely causative pathogen, whether sexually transmitted, enteric or other. Adherence of clinical practice remains short of available guidance, which may be improved by thorough clinical and microbiologic assessment, supported by a knowledge of the commonly associated pathogenic organisms, and the appropriate choice of tests required for their identification. Use of advanced microbiology techniques and studies of current practice provide new insights that have challenged traditional management paradigms. The authors discuss these points in and provide their expert perspectives on its treatment and future developments.

EXPERT OPINION

Relatively sparse direct trial data exists on antimicrobial treatments for acute epididymitis. Much of the presently available guidance is derived from previous guidance recommendations, knowledge of antimicrobial activities of specific agents, and treatment outcomes in uncomplicated infections. Identification of specific pathogens and prescribing accuracy is dependent on the extent to which cases are investigated and is therefore variable.

Impact of treatment delays on outcome of acute testicular torsion: a 15-year retrospective study

INTRODUCTION

Preservation of the testicle is directly associated with the duration of torsion. The aim in this retrospective study was to identify factors that influence pre-and in-hospital times and measure the extent to which these times affect testicle survival.

PATIENTS AND METHODS

A retrospective review of 116 patients who underwent exploration for testicular torsion between 2000 and 2015. Patients were divided into orchiectomy and salvaged testicle groups. Times in patient management and clinical features were compared with Mann-Whitney, chi-squared, and Fisher exact tests. Multivariate logistical regression was used to identify independent factors associated with orchiectomy.

RESULTS

The median prehospital time of 48 h (15.4-138 h) in the orchiectomy group was longer than the 2.4 h (1.6 h-5.2h) in the salvaged group. Patients examined by a general practitioner (GP) prior to presenting at hospital had a median prehospital time of 48 h, compared to 3 h for patients not examined before presentation at hospital. In-hospital times between admission and operation room, as well as times between ultrasonography and operation room, were also longer in the orchiectomy group. Previous GP consultation (OR = 27.26, 95% CI 2.32-320.59, p = .009), prehospital time (OR = 1.04, 95% CI 1.01-1.07, p = .003) and nausea (OR = 9.25, 95% IC 1.33-64.52, p = .025) were independent predictive factors associated with orchiectomy.

CONCLUSION

Prehospital time was a determining factor in orchiectomy. For each extra hour of prehospital delay, the risk of orchiectomy increased by 4%. The rate of orchiectomy was higher among patients who first consulted a GP.

Pearls and Pitfalls of Pediatric Scrotal Imaging

Ultrasonography (US) is the primary imaging modality for the evaluation of pediatric scrotal disease. The ability to obtain exceptional anatomical detail and testicular perfusion information without ionizing radiation makes it the essential tool for evaluating scrotal pain and palpable masses. Challenges arise in both the performance and interpretation of scrotal US in the child. Optimizing imaging parameters and recognizing key differentiating US features help minimize misinterpretations that can lead to poor patient outcomes. Key pearls and pitfalls in pediatric scrotal ultrasound methods and diagnoses are reviewed. Knowledge of what is normal for the various ages of childhood from neonate through adolescence is necessary for accurate US analysis. Imaging evaluation of key causes of the acute painful scrotum including testicular appendage torsion, epididymitis, and testicular torsion are discussed. Sonographic features for the diagnosis of benign and malignant scrotal masses, microlithiasis, and cryptorchidism are reviewed.

Testicular Pain Pathway in Children: Investigating Where Missed Torsion Occurs Most Often

OBJECTIVES

Acute scrotal pain in children is a common presenting complaint in hospital, and it is imperative that cases of testicular torsion are identified and managed promptly. We aim to identify the most influential points in the pathway in determining whether patients are managed in the appropriate time frame, so these areas can be targeted to improve salvage rates.

METHODS

Using quality improvement principles, the pediatric scrotal pain pathway was mapped out, commencing with initial symptom onset and ending with definitive surgical management. We retrospectively reviewed data on all patients between 0 and 18 years of age attending the emergency department at Whipps Cross University Hospital with acute scrotal pain between October 2010 and October 2013.

RESULTS

Over the 3-year period, 238 patients 18 years or younger presented to casualty with scrotal pain. Of the patients assessed initially by an emergency department physician, 52.8% (n = 67) were discharged without referral. To our knowledge, none of these patients presented later with a missed torsion. Torsion was diagnosed in 23.2% of the patients operated on (n = 22), of which 5 required orchidectomy, comprising 2.1% of all patients presenting with scrotal pain. In this group, 4 were due to late presentation by the patient.

CONCLUSIONS

We demonstrate the value of different stages of the pathway, as more than half of patients seen in A&E were correctly discharged without referral. In the context of our study, late presentation to hospital appears to be the most significant factor leading to orchidectomy. To target this issue, awareness among both children and parents must be improved.

Nomogram predicting testicular torsion in Japanese patients with acute scrotal pain using physical examination findings and environmental conditions: Development and prospective external validation

OBJECTIVES

To develop a prediction tool based on physical findings and environmental conditions without utilizing color Doppler ultrasonography to guide non-urologists and patients' families in determining the testicular torsion possibility among patients with acute scrotal pain.

METHODS

Overall, 110 consecutive patients aged ≤30 years with acute scrotal pain at Saitama Medical Center between 2012 and 2014 were retrospectively evaluated. Physical examination results, including scrotal inspection, palpation and gait observation, and environmental conditions at pain onset (time range and ambient temperature) were collected. Multivariate analysis identified significant and independent risk factors for testicular torsion, and a nomogram predicting testicular torsion was constructed. The model underwent prospective validation in an independent set of 123 consecutive patients admitted with acute scrotal pain to our institution between 2015 and 2017.

RESULTS

Testicular torsion diagnosis rates were 27% (30/110) and 26% (32/123) in the training and validation cohorts, respectively. Logistic regression analysis showed four risk factors for developing testicular torsion: abnormal testicular position, walking difficulty, midnight to early morning onset and ambient temperature <15°C at pain onset. The constructed nomogram showed that the areas under the receiver operating characteristic curves were 0.92 and 0.84 for the training and validation cohorts, respectively. The calibration plot showed an acceptable fitness between the predicted probability and the observed rate of testicular torsion.

CONCLUSIONS

A novel nomogram was developed solely based on physical findings and environmental conditions to predict testicular torsion in Japanese patients with acute scrotal pain.

The Diagnostic Accuracy of Testicular Torsion by Doctors on Duty Using Sonographic Evaluation with Color Doppler

As testicular torsion is a medical emergency, it requires quick diagnosis and treatment. Color Doppler ultrasound (CDUS) is useful for the diagnosis of testicular torsion. An accurate diagnosis can be difficult when CDUS indicates the preservation of blood flow in the testis. We examined the accuracy of testicular torsion diagnosis in patients with acute scrotum made by doctors on duty using CDUS. The subjects included 26 patients who visited our department between January 2016 and June 2018 presenting with acute scrotal pain. Patients were placed into one of three groups based on testicular blood flow evaluated by CDUS. The first group had no testicular blood flow, the second had diminished blood flow, and the last group had normal or increased blood flow. Patients were also diagnosed through scrotal exploration. Finally, patients were further divided into two groups identified by CDUS frequency utilized during diagnosis (12 MHz groups and ≤8 MHz groups), and the diagnostic accuracy of the two groups was compared. Characterizing torsion by either the absence of or diminished, testicular blood flow in the CDUS evaluation, the sensitivity and specificity of the CDUS performed by doctors on duty accounted for 69.2% and 53.8%, respectively. No improvement in diagnostic accuracy was evident despite the usage of a 12-MHz ultrasonic transducer. In this study, the sensitivity of CDUS performed by doctors on duty was about 70%, suggesting that scrotal exploration should be performed promptly even if testicular blood flow is observed and testicular torsion is suspected from medical history and body findings.

United Kingdom British association for sexual health and HIV national guideline for the management of epididymo-orchitis, 2020

The British Association for Sexual Health and HIV (BASHH) UK guideline for the management of epididymo-orchitis has been updated in 2020. It offers advice on diagnostic tests, treatment and health promotion principles in the effective management of epididymo-orchitis. Empirical treatment should be started in patients with objective swelling and tenderness on testicular examination. First-line empirical treatment for sexually acquired epididymo-orchitis has changed to ceftriaxone 1g intramuscularly and doxycycline. Higher dose of ceftriaxone in line with the BASHH 2018 gonorrhoea guideline ensures effective treatment of strains with reduced susceptibility. Ofloxacin or doxycycline is recommended in patients with epididymo-orchitis probably due to non-gonococcal organisms (e.g. negative microscopy for gram-negative intracellular diplococci or no risk factors for gonorrhoea identified). Where Mycoplasma genitalium is tested and identified, treatment should include an appropriate antibiotic (e.g. moxifloxacin). If enteric pathogens are a likely cause (e.g. older patient, not sexually active, recent instrumentation, men who practice insertive anal intercourse, men with known abnormalities of the urinary tract or a positive urine dipstick for leucocytes and nitrites), ofloxacin and levofloxacin are recommended. A clinical care pathway has been produced to simplify the management of epididymo-orchitis. A patient information leaflet has been developed.

Management of testicular torsion in the ER: lessons learned from medical professional liability claims

OBJECTIVE

To evaluate emergency care for testicular torsion (TT) in medical professional liability (MPL) claims.

METHODS

Claims related to TT from 2000 to 2018 were located. The assistance provided and the association with MPL were analyzed.

RESULTS

Eighty complaints were identified, testicular pain was reported in 83.75% of first consultations, with a mean evolution time of 15.5 h. The mean time to diagnosis was 7.98 days. The first consultation was at the hospital in 75.1% of cases, but an ultrasound was performed only in 7.5%. When TT diagnosis was performed, 97.3% had undergone ancillary tests. The MPL was significantly associated with non-criminal proceedings and with less than 6 h of symptoms' evolution, and, within this subgroup, without undergoing an ultrasound scan.

CONCLUSIONS

Late consultations, wrong diagnosis and late diagnosis are claimed. When MPL are claimed by means of non-criminal law, the existence of responsibility is frequently considered, even more in those cases when the consultation took place before 6 h of evolution with no ancillary tests having been performed.

A multicenter review of undescended testis torsion: A plea for early management

INTRODUCTION

Torsion of an undescended testis (UT) is a surgical emergency, difficult to diagnose, whose prognosis depends on a quick management.

AIM OF THE STUDY

To evaluate the management and outcome of these patients.

STUDY DESIGN

We retrospectively analyzed all cases of UT torsion operated in nine French hospitals between 1997 and 2017. We divided patients in two groups: patients referred less than 6 h after the onset of symptoms (group A) or more than 6 h (group B).

MAIN RESULTS

We collected 60 cases (17 in group A and 43 in group B). Median age was 2.2 years [IQR = 0.7-7.8] (2.3 y in group A and 2 y in group B, p = 0.76). Eleven patients (10 in group B) had neurological disorders (p = 0.15). The main reason for absence of UT treatment was the absence of surgical consultation in a normal delay (n = 44, 73%). Symptoms were pain (n = 58, 97%), inguinal mass (n = 55, 92%) and vomiting (n = 16, 27%). An inguinal mass with no palpable testis in the ipsilateral hemiscrotum was seen in 55 patients (92%). An ultrasound scan performed in 27 patients led to the diagnosis in 16 patients (59%). At surgery, an orchiectomy was performed in 4 patients (23%) of group A and 24 patients (56%) of group B (p = 0.04). After a median follow-up of 11 months [IQR = 4-23], 11 patients of group A (65%) and 7 patients of group B (16%) had a clinically normal testis (p = 0.03). The salvage rate among patients with conservative treatment was 85% for group A and 37% for group B (p = 0.01).

DISCUSSION

Our study reveals that although UT torsion is an emergency, 72% of patients are referred more than 6 h after the onset of symptoms. We mostly found classic clinical presentation of UT torsion: a painful inguinal mass with an empty ipsilateral scrotum. Ultrasound was performed in half cases, and even if the result was not significant, it still seemed to be associated with a higher rate of orchiectomy especially in group B because of the delay in care. However, when ultrasound was realized early, it led to diagnosis in all cases. This dilemma poses the problem of the role of imaging in diagnostic management.

CONCLUSIONS

Early clinical diagnosis in front of a painful inguinal mass with an empty scrotum is essential to improve the salvage rate of testis in UT torsion. Early management of UT should have avoided 68% of testis loss.

The Use of Doppler Ultrasound for Suspected Testicular Torsion: Lessons Learned from a 15-Year Multicentre Retrospective Study of 2922 Patients

BACKGROUND

Use of Doppler ultrasonography (DUS) for patients with suspected testicular torsion (TT) is highly controversial and remains debated, as it can delay surgery and its performance may vary.

OBJECTIVE

To assess the role, impact, safety, and performance of DUS in the management of patients with suspected TT before scrotal exploration.

DESIGN, SETTING, AND PARTICIPANTS

The TORSAFUF cohort retrospectively included patients older than 12 yr who underwent surgery for suspected TT in 14 academic hospitals between 2005 and 2019. Perioperative data and surgical and DUS reports were collected.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Clinical factors influencing DUS utilisation were analysed using multivariate logistic regression. The orchidectomy rate and delay to surgery were compared by group with and without DUS receipt using one-to-one propensity score (PS) matching to assess imaging safety. For the group with preoperative imaging, DUS performance was evaluated using a contingency table.

RESULTS AND LIMITATIONS

Overall, 2922 patients were included, of whom 956 (32.7%) underwent DUS before surgery. DUS was more likely to be performed in older patients (odds ratio [OR] 1.1, 95% confidence interval [CI] 1.1-1.2), those who experienced progressive onset of pain (OR 1.5, 95% CI 1.1-2), and patients who presented at the emergency department more than 6 h after their first scrotal symptoms (OR 2.3, 95% CI 1.9-2.8). After PS matching, DUS receipt was not significantly associated with orchidectomy but the delay to surgery was 1 h longer. DUS demonstrated strong sensitivity of 85.2% (95% CI 82.1-88.3%) and specificity of 52.7% (95% CI 48.8-56.6%). The performance was better for younger patients and for those with time since onset of pain of >6 h.

CONCLUSIONS

In this large retrospective study, DUS before surgery was safe, feasible, and useful in selected cases with suspected TT, but it should not delay or replace surgery in cases with a strong clinical suspicion.

PATIENT SUMMARY

We analysed the performance and safety of an ultrasound scan of the scrotum before surgery for patients with a suspected twisted testicle (TT). This scan before surgery was not associated with a higher risk of negative outcomes but was only moderate in accurately diagnosing TT. Surgery to correct TT should not be delayed.

A retrospective multicentric analysis on testicular torsion: is there still something to learn?

INTRODUCTION AND AIM

Speedy diagnosis are mandatory in testicular torsion, nevertheless some cases of irreversible ischemia still occur. In this study we analysed the results of patients undergoing surgical exploration for acute scrotum.

MATERIALS AND METHODS

A multicentric retrospective clinical evaluation was carried out on patients who underwent urgent scrotal exploration at 12 different departments in North-Eastern Italy. Data included complete anagraphic information, clinical presentation, numeric pain rating scale, previous testicular surgery, Doppler serial ultrasonography (US) evaluation and concordance with surgical findings, testicular mobility, surgical treatment, staged or concurrent treatment of the contralateral gonad. Statistical analysis was conducted both for descriptive and inferential statistics with SPSS v26.

RESULTS

Three hundred and sixty-eight cases were collected between January 2010 and June 2019. The time between symptom onset and ER access time was within 6 h in majority of patients. However, 17.4% of subject presented after more than 12 h. In patients undergoing US, this showed signs of ischemia in 237 patients (77.2%) and normal vascularisation in 70 (22.8%) of whom 26 had signs of testicular torsion at surgical exploration. Overall, the US data were concordant with the surgical findings in 254 cases (82.7%). A significant association was found between time-to-evaluation and time-to-treatment and the need for orchiectomy (p < 0.01).

CONCLUSION

Testicular torsion management is still challenging in terms of time-saving decision making. Scrotal US is helpful, but even in the contemporary its sensitivity is low era in a non-neglectable number of cases, therefore surgical exploration is warranted in acute scrotum when torsion cannot be ruled out, even when US shows vascularisation.

Management of testicular torsion in the ER: Lessons learned from medical professional liability claims

OBJECTIVE

To evaluate emergency care for testicular torsion in medical professional liability claims.

METHOD

Claims related to testicular torsion from 2000 to 2018 were located. The assistance provided and the association with medical professional liability were analyzed.

RESULTS

Eighty complaints were identified, testicular pain was reported in 83.75% of first consultations, with a mean evolution time of 15.5h. The mean time to diagnosis was 7.98 days. The first consultation was at the hospital in 75.1% of cases, but an ultrasound was performed only in 7.5%. When testicular torsion diagnosis was performed, 97.3% had undergone ancillary tests. The medical professional liability was significantly associated with non-criminal proceedings and with less than 6h of symptoms' evolution, and, within this subgroup, without undergoing an ultrasound scan.

CONCLUSIONS

Late consultations, wrong diagnosis and late diagnosis are claimed. When medical professional liability are claimed by means of non-criminal law, the existence of responsibility is frequently considered, even more in those cases when the consultation took place before 6h of evolution with no ancillary tests having been performed.

Prenatally Diagnosed Testicular Torsion: A Rare Condition That Causes Dilemma in Management

Background

Prenatal testicular torsion (PTT) is exceedingly rare in intrauterine development, often diagnosed at the time of birth and very rarely diagnosed in utero during routine gestational ultrasound. As a result, incidence is unknown, and there exists no consensus regarding the pathophysiology of this phenomenon nor universally recognized algorithms and guidelines regarding its diagnosis and management. Case Presentation. We present the case of an antenatally diagnosed torsion and our subsequent management which included ipsilateral orchiectomy and prophylactic contralateral orchiopexy via a scrotal approach.

Conclusion

While controversy regarding surgical intervention in patients with unilateral PTT exists due to poor salvage rates-estimated to be less than 1%-the risk of anorchia is higher in affected patients due to limitations in the accuracy of detecting bilateral testicular involvement. Risk of misdiagnosis of bilaterality may lead to lasting sequelae such as infertility and devastating psychological consequences for affected patients, supporting the need for surgical exploration, as was performed in our case.

Establishment and internal validation of preoperative nomograms for predicting the possibility of testicular salvage in patients with testicular torsion

This study aimed to establish nomograms to preoperatively predict the possibility of testicular salvage (TS) in patients with testicular torsion. The clinical data of 204 patients with testicular torsion diagnosed at Xijing Hospital and Tangdu Hospital (Xi'an, China) between August 2008 and November 2019 were retrospectively analyzed. Univariate and multivariate logistic regression analyses were used to determine the independent predictors of TS. Based on multivariate regression coefficients, nomograms to predict possibility of TS were established. The predictive ability of the nomograms was internally validated by receiver operating characteristic (ROC) curves and calibration plots. The duration of symptoms ranged from 2 h to 1 month, with a median of 3.5 days. Thirty (14.7%) patients underwent surgical reduction and contralateral orchiopexy, while the remaining 174 (85.3%) underwent orchiectomy and contralateral orchiopexy. Finally, long symptom duration was an independent risk predictor for TS, while visible intratesticular blood flow and homogeneous testicular echotexture under color Doppler ultrasound were independent protective predictors. Internal validation showed that the nomograms, which were established by integrating these three predictive factors, had good discrimination ability in predicting the possibility of TS (areas under the ROC curves were 0.851 and 0.828, respectively). The calibration plots showed good agreement between the nomogram-predicted possibility of TS and the actual situation. In conclusion, this brief preoperative prediction tool will help clinicians to quickly determine the urgency of surgical exploration.

Duration of symptoms is the only predictor of testicular salvage following testicular torsion in children: A case-control study

OBJECTIVE

Testicular torsion (TT) is an emergency requiring a prompt diagnosis and surgery to avoid irreversible changes and a complete loss of testis. The present study aimed to identify potential factors that may be predict a testicular salvage after TT in pediatric patients.

METHODS

Consecutive medical records of all children ≤16 years old with surgically confirmed TT over a period of five years (2011-2016) were collected. Patients were divided into 2 groups according to testicular viability and the type of treatment: Orchidectomy and orchidopexy. The differences between the two groups and potential predictors of testicular salvage were analyzed.

RESULTS

Thirty-one boys with TT met the inclusion criteria and were included in the study. The mean age was 13.6 years (range, 10 days - 15.8 years). Testicular salvage was possible in 18 (58.1%) patients. The duration of symptoms and a lesser degree of torsion indicated a testicular salvage in children and adolescents with testicular torsion, but in multivariate analysis only duration of symptoms (time to surgical detorsion) was significantly associated with the risk of non-salvage. At follow-up, testicular atrophy affected 73.3% of the patients treated with orchidopexy.

CONCLUSION

Duration of symptoms is the only predictor of successful testicular salvage following testicular torsion in children. It is associated with a substantial risk of testicular loss and atrophy.

Validation of the TWIST score for testicular torsion in adults

PURPOSE

The TWIST (Testicular Work-up for Ischemia and Suspected Torsion) score was developed to allow for expedited diagnosis of testicular torsion (TT) in children based on clinical variables: edema (2 points), hard mass (2), absent cremasteric reflex (1), high-riding testis (1) and nausea/vomiting (1). We sought to validate the TWIST Score applied by non-expert physicians for the diagnosis of testicular torsion in an adult population.

METHODS

We prospectively analyzed all consecutive males presenting to a tertiary hospital with acute scrotum. Patients with previous scrotal pathology or trauma were excluded. Physical examination was performed by a general surgeon and variables of TWIST were recorded. All patients underwent Scrotal Doppler Ultrasound. Measures of accuracy of the TWIST score and ROC curves were generated to evaluate its performance in diagnosing TT in adults.

RESULTS

Of 68 patients, 34 had TT (50%). Median age was 24.9 years. According to the original cutoffs of TWIST, 23 patients had a score ≤ 2 among which none had TT. Fifteen patients had a score of 3-4, among which seven had TT. Thirty patients had a score ≥ 5, among which 27 had TT. All 18 patients with a score of 6 or greater had TT (100% PPV). ROC curve revealed an AUC of 0.95.

CONCLUSION

The TWIST Score is valid for the diagnosis of Testicular Torsion in adults, presenting a PPV of 90% for a cutoff of 5 points and 100% for six points. In all patients with a score of 2 or less, the disease could be safely excluded (100% NPV).

Complete testicular infarction secondary to epididymoorchitis and pyocele

Epididymoorchitis is a relatively common urologic condition involving the scrotum which presents with unilateral pain and swelling. It is typically treated with antibiotics but can progress to complications such as scrotal pyocele. Global testicular infarction is an exceedingly rare but devastating complication of epididymoorchitis. Grey scale and color Doppler ultrasound demonstrate testicular hypovascularity with subsequent hypoechoic changes of the testicular parenchyma. Scrotal MRI shows T2 hyperintense changes through the testicle with nonenhancement of the testicular parenchyma post contrast, consistent with infarction. The cause of global infarction in epididymitis is uncertain but may be due to mixed arterial and venous insufficiency. This case illustrates a 41-year-old male that developed acute left testicular pain. Initial ultrasound showed an enlarged left testicle with hyperemia. The patient's symptoms progressed and a scrotal MRI demonstrated a lack of left testicular enhancement consistent with global infarction, as well as an adjacent pyocele.

Estimating the time of onset of testicular torsion using ultrasonography in an experimental rat model

Purpose

We aimed to document the time of onset of ultrasonographic and histologic changes in the testes of a rat model following testicular torsion.

Methods

Twenty-five Sprague-Dawley rats were divided into four groups. All animals underwent preoperative Doppler ultrasonography. Groups 1, 2, and 3 underwent unilateral surgical torsion of the testis lasting for 72, 24, and 6 hours, respectively. Group 4 underwent a sham operation. The animals were followed with Doppler ultrasonography at 6, 24, 48, and 72 hours postoperatively. Histologic examinations were performed at the designated final time point for each group.

Results

After torsion, enlargement of the epididymal head and thickening of the spermatic cord over time were noted. Based on the ultrasonographic dimensions, the ratio of the epididymal volume increased with time following torsion (p=0.002). The torsed testes had an average weight gain of 0.27 g at 6 hours compared to the control testes, but an average weight loss of 0.22 g at 72 hours (P=0.006). Changes in testicular echotexture were noted as soon as 6 hours after torsion, but there was no consistent pattern of echotexture change thereafter. Histologically, viable tubules were seen 6 hours after torsion, while extensive hemorrhagic necrosis was found at 72 hours.

Conclusion

In evaluating testicular torsion, the enlargement ratio of the epididymis and thickening of the spermatic cord on Doppler ultrasonography may be useful for determining the urgency of immediate surgery. Changes in testicular echotexture may not be a reliable indicator of the time of onset.

Accuracy of point-of-care ultrasound by pediatric emergency physicians for testicular torsion

INTRODUCTION

Acute scrotum is a common presentation to the pediatric emergency department, and ultrasound is frequently used to narrow the differential diagnosis. Point-of-care ultrasound (POCUS) is increasingly used by urologists and emergency physicians and could potentially be used to detect pediatric testicular torsion.

OBJECTIVES

This study aimed to determine the accuracy of POCUS by pediatric emergency physicians in diagnosing testicular torsion and the agreement between point-of-care ultrasound and final diagnosis for other causes of acute scrotum.

STUDY DESIGN

A chart review of patients presenting to the study emergency department who received POCUS by a pediatric emergency physician, as well as radiology department ultrasound and/or surgery, was performed. Charts were reviewed for POCUS diagnoses, final diagnoses, and imaging time metrics.

RESULTS

A total of 120 patients met study criteria, with 12 cases of testicular torsion. The diagnostic accuracy of POCUS for testicular torsion is described in the summary table. For all causes of acute scrotum, point-of-care ultrasound agreed with final diagnosis in 70% (95% confidence interval [CI] 62-78%) of cases, and more experienced point-of-care ultrasound users displayed higher agreement with final diagnosis. Point-of-care ultrasound results were generated a median of 73 min (Q1 = 51, Q3 = 112) before radiology department ultrasound results.

DISCUSSION

Scrotal POCUS performed by pediatric emergency physicians appears to be an accurate tool to detect testicular torsion in children with acute scrotum and saves time compared with radiology ultrasound. The study results may not be generalizable to hospitals without a multidisciplinary POCUS system for quality assurance and image sharing. Future work on POCUS for acute scrotum should investigate its impact on patient outcomes, cost-effectiveness, and family satisfaction.

CONCLUSION

Point-of-care ultrasound by pediatric emergency physicians is accurate for detecting testicular torsion in children with acute scrotum and could expedite diagnosis of this time-sensitive condition.

Surgical practice among pediatric surgeons and pediatric urologists in the Kingdom of Saudi Arabia for the management of suspected testicular torsion

Objectives:

To review and compare clinical practice and experience among pediatric surgeons (PS) and pediatric urologists (PU) for the management of testicular torsion (TT) in the Kingdom of Saudi Arabia (KSA).

Methods:

This was a cross-sectional study conducted between August 2016 and November 2017, among all PU and PS involved in the management of suspected TT in KSA. A questionnaire was distributed to participants through the Survs.com platform, and direct email when requested by participant.

Results:

Most PU (12/20, 60%) utilized ultrasound with Doppler before exploration, while 29 (74.4%) PS performed immediate exploration without imaging, representing a statistically significant difference (p=0.03). When the explored testis was dusky (not frank gangrenous), 27 PS (69.2%) performed fixation, 6 (15.4%) followed the second look policy, and 6 (15.4%) performed orchiectomy. With respect to PU, 6 (30%) performed fixation, 8 (40%) followed the second look policy, and 6 (30%) performed orchiectomy. The differences between the 2 specialties were statistically significant (p=0.02). Most consultants in both specialties performed fixation of the contralateral testis during the same operation. Also, there is a variation in practice when there is other pathology than TT.

Conclusion:

There were significant variations between the 2 specialties in the management of TT. National guidelines are needed to provide homogenous clinical practice and training of trainees.

Bilateral Neonatal Testicular Torsion; Hidden Surgical Nightmare

Perinatal testicular torsion is a relatively rare event that remains unidentified in many situations and managed only after an avoidable delay of time. Its current management approaches include watchful observation, delayed contralateral orchiopexy, and emergent contralateral orchiopexy. On the other hand, bilateral torsion is now being more frequently reported. However, the assessment of the contralateral testis through physical examination and imaging can be inaccurate in cases of perinatal torsion. We report a case of prenatal testicular torsion with incidentally discovered metachronous contralateral extravaginal testicular torsion. Therefore, immediate surgical intervention is recommended both when uni- or bilateral testicular torsion is suspected. Whenever possible, affected testes should be preserved as some endocrine function may be retained.

Frontiers in pediatric testicular torsion: An integrated review of prevailing trends and management outcomes

Testicular torsion remains the most frequent cause of testicular ischemia, especially in adolescents and young adults. Timely diagnosis and intervention are keys to saving the affected testicle. This review presents current trends in the diagnosis and treatment of torsion, potential pitfalls and consequent outcomes. Additionally, other salient issues surrounding testicular torsion are also discussed, including: pathogenesis of injury, legal ramifications, fertility outcomes, novel management techniques, and recent advances in diagnostic technology.

[ACUTE SCROTUM IN THE PEDIATRIC EMERGENCY ROOM: A SINGLE CENTER RETROSPECTIVE STUDY]

(Objective) The objective of this study was to survey cases of acute scrotum examined at the pediatric emergency room (ER). (Subjects and methods) All patients examined for acute scrotum at the emergency outpatient unit between March 2010 and March 2014 were designated subjects of the study. Medical records were used to retrospectively investigate the final diagnoses including testicular torsion (TT), torsion of the testicular appendage, epididymitis, orchitis, incarcerated inguinal hernia, idiopathic scrotal edema, Schönlein-Henoch purpura, hydrocele, external trauma, as well as those with no confirmed diagnosis. (Results) A total of 257 patients presented with acute scrotum at the emergency outpatient unit. The patients had an average age of 6.7 years, with symptoms present on the right side in 120 cases (47%), left side in 108 cases (42%), and both sides in 29 cases (11%). Observing the frequency of each condition, TT was present in 33 cases (13%), torsion of the testicular appendage in eight cases (3%), epididymitis in 85 cases (33%), orchitis in four cases (2%), incarcerated inguinal hernia in 59 cases (23%), idiopathic scrotal edema in six cases (2%), Schönlein-Henoch purpura in nine cases (4%), hydrocele in 10 patients (4%), external trauma in 12 patients (5%), and unconfirmed diagnosis in 31 cases (12%). Average time between onset and presentation at the ER was 0.6 days for TT, with patients having previously been examined at other hospitals before coming to this institution in 12 cases (36%). Emergency urological surgery was performed in 31 cases (12%), with TT comprising 28 cases (90%), and orchiectomy performed in six cases (21%). (Conclusion) Of all patients examined for acute scrotum, epididymitis were high and TT in 13% at the pediatric ER. Average time for TT patients from symptom onset to ER presentation were longer, we must ensure that patients present at earliest possible opportunity requires educating the general population.

The ultrasonographic "whirlpool sign" in testicular torsion: valuable tool or waste of valuable time? A systematic review and meta-analysis

PURPOSE

A positive whirlpool sign (WS) is defined as the presence of a spiral-like pattern when the spermatic cord is assessed during ultrasonography (US), using standard, high-resolution ultrasonography (HRUS) and/or color Doppler sonography (CDS), in the presence of testicular torsion. The objective of this review was to assess the validity and accuracy of this sign by performing a comprehensive systematic literature review and meta-analysis.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a comprehensive literature search was performed (August, 2017), using the following databases: BMJ Best Practice, Cochrane Library, Embase, PubMed, Scopus, and Web of Science. Selected studies were further assessed for relevance and quality using the Oxford 2010 Critical Appraisal Skills Program (CASP).

RESULTS

Of the studies assessed, a total of 723 participants were included, with a mean of 72.3 (SD 71.9) participants. Of the participants, 226 (31.3%) were diagnosed with testicular torsion (TT). Meta-analysis of the studies that provided sufficient data resulted in a pooled sensitivity and specificity of the WS of 0.73 (95% CI, 0.65-0.79) and 0.99 (95% CI, 0.92-0.99), respectively. Removal of all neonates increased the pooled sensitivity to 0.92 (95% CI, 0.70-0.98) while the pooled specificity remained almost unchanged at 0.99 (95% CI, 0.95-1.00). The estimated summary effect of all studies with sufficient data was 4.34 (95% CI, 1.01-7.67; n = 394; p = 0.001). A large degree of heterogeneity was suggested by an I² statistic of 88.27% (95% CI, 68.60-98.68%). Removal of neonatal subjects increased the estimated summary effect to 5.32 (95% CI, 1.59-9.05; n = 375; p = 0.001).

CONCLUSION

The WS, when correctly diagnosed, may be viewed as a very definitive sign for TT in the pediatric and adult populations. However, its role in neonates is limited.

Distinguishing testicular torsion from torsion of the appendix testis by clinical features and signs in patients with acute scrotum

Purpose

Many physicians encounter confusion and difficulty in distinguishing testicular torsion (TT) from torsion of the appendix testis (TAT) in patients with acute scrotum because of the overlapping signs and symptoms. The objective of our study was to evaluate the clinical features and signs that can help distinguish TT from TAT.

Patients and methods

We performed a retrospective study of patients with surgically confirmed TT and TAT at our institute from January 1990 to December 2013. Clinical findings, physical examination findings, climatic conditions, laboratory data, and color Doppler ultrasound (CDUS) findings were compared between the TT and TAT groups.

Results

Seventy patients were included in this study (49 with TT and 21 with TAT). Patients with TT were significantly older than those with TAT (p < 0.001). The ambient temperature at onset was significantly lower in patients with TT than in patients with TAT (p = 0.038). Testicular swelling, high-riding testes, onset during sleep, high leukocyte counts, and high creatine phosphokinase levels were significantly more common in patients with TT than with TAT (p = 0.021, 0.032, 0.006, 0.003, and 0.043, respectively). Multivariate analysis showed that age and onset during sleep were significant independent factors for detection of TT. Eight patients (16.3%) underwent preoperative CDUS evaluation, and an absent or decreased blood signal in the involved testes was significantly correlated with the presence of TT (p = 0.018).

Conclusion

In clinical features, age and onset during sleep might be helpful to distinguish TT from TAT. When supported by findings, urgent surgical exploration is warranted in patients with suspected TT based on symptoms and CDUS features.

Pediatric scrotal ultrasound: review and update

In this pictorial essay the authors review the normal sonographic gray-scale and Doppler appearance of the pediatric scrotum with an emphasis on technique. The authors present an update on ultrasound diagnosis and outcomes in testicular torsion and differentiation from other acute scrotal processes, as well as sonographic imaging of testicular microlithiasis and uncommon or atypical scrotal masses including splenogonadal fusion, polyorchidism, meconium peritonitis and epidermoid cyst. Further, the authors discuss testicular neoplasms in the context of testicular microlithiasis.

State appellant cases for testicular torsion: Case review from 1985 to 2015

OBJECTIVE

Testicular torsion is one of the most common diagnoses involved in lawsuits in the pediatric patient. Missed diagnosis and diagnostic delays put patients at risk for testicular loss and have resulted in malpractice litigation. Using a national database, we sought to describe testicular torsion malpractice cases tried at the state and federal level and investigate factors associated with successful defense by the provider.

METHOD

We reviewed the Lexis Nexis academic legal database. We searched all cases using the terms "testicular torsion" and "medical malpractice" from 1985 to 2015. From this search, we compiled various medical and legal aspects of the case including the outcome of the trial. We performed multivariate logistic regression to determine which factors were associated with successful defense at the state level.

RESULTS

Fifty-three malpractice cases of testicular torsion were included. State appeals were in favor of providers in 26 (50%) of cases. The average time between initial presentation of the patient and the state verdict decision was 5 years. Emergency room (ER) physicians were the most common provider sued (35%). Approximately half of the patients (26, 51%) first presented to the ER, and atypical presentations were common, as 16 (31%) presented with abdominal pain only. The proportion of patients with false-negative ultrasounds was 16 of 25 (64%). If the patient first presented to the ER, the doctor was less likely to have a successful defense (OR = 0.23; 95% CI 0.06-0.79]). Most verdicts (8/9, 89%) were in favor of urologists. One urologist lost at the state level because of delayed time to the operating room.

CONCLUSIONS

Atypical clinical presentations and false-negative ultrasound findings are common in testicular torsion malpractice litigation at the state and federal level. Providers who used ultrasound were not more likely to win the state appeal, and providers whose patients presented to the ER were less likely to have a successful defense. Although 50% of providers won the state appeal, the time from initial patient presentation and final state verdict decision was substantial.

Sonography of pediatric blunt scrotal trauma: what the pediatric urologist wants to know

Pediatric blunt scrotal trauma is most often the consequence of sports injury and presents a diagnostic challenge because swelling and pain make a scrotal physical exam difficult. US with color flow and duplex Doppler is the first-line imaging modality with the goal of accurate and timely diagnosis of injury requiring surgery to preserve fertility and hormonal function. US imaging findings following blunt scrotal trauma include hydrocele, hematocele, testicular hematoma, testicular fracture, testicular rupture, compromised perfusion/testicular torsion and testicular dislocation. Importantly, several of these findings may coexist. Our goal is to present the pertinent intrascrotal anatomy, US imaging findings for each testicular injury, and contemporary management for each, with emphasis on what our pediatric urology colleagues need to know for optimal patient care.

[Scrotal ultrasound examinations in infants and toddlers]

BACKGROUND

Besides physical examination, ultrasonography is the most valuable diagnostic tool to assess the scrotum and testes in the case of an acute scrotum or scrotal pathology.

PROBLEMS

In infants and toddlers the examination can be challenging. Due to the limited patient compliance, the small testicular size (< 0.5 ml), and low blood flow velocity (< 3 cm/s), it can be difficult to achieve a proper flow curve when assessing blood flow.

CONCLUSION

The examiner's skills are as important as adequate equipment (i. e., linear ultrasound probe, 12-14 MHz) and optimal program settings (Doppler scale < 3 cm/s, gate 1 mm). However, if there is doubt, surgical exploration is unavoidable.

Sonographic appearances of the epididymis in boys with acute testicular torsion but preserved testicular blood flow on color Doppler

BACKGROUND

Little attention has been given to the sonographic appearances of the epididymis in testicular torsion.

OBJECTIVE

To describe the position and morphology of the epididymis in childhood acute testicular torsion when testicular flow is present on color Doppler sonography.

MATERIALS AND METHODS

We studied the sonographic findings in boys with clinically and surgically proven acute testicular torsion who were examined sonographically from May 2013 to May 2014 and who had preserved intratesticular flow on color Doppler sonography. We retrospectively evaluated the sonograms with emphasis on the epididymal findings.

RESULTS

In all nine boys with confirmed torsion but with preserved intratesticular flow on color Doppler sonography, the epididymal head had an unexpected configuration and size, and no close relationship with the upper pole of the testis. In five of these children the spermatic cord appeared twisted on the affected side. In the remaining four boys the spermatic cord appeared straight.

CONCLUSION

The position and morphology of the head of the epididymis were abnormal in all boys with acute testicular torsion but with preserved testicular flow.

Malpractice Litigation and Testicular Torsion: A Legal Database Review

BACKGROUND

The litigious nature of the American medical environment is a major concern for physicians, with an estimated annual cost of $10 billion.

OBJECTIVE

The purpose of this study is to identify causes of litigation in cases of testicular torsion and what factors contribute to verdicts or settlements resulting in indemnity payments.

METHODS

Publicly available jury verdict reports were retrieved from the Westlaw legal database (Thomson Reuters, New York, NY). In order to identify pertinent cases, we used the search terms "medical malpractice" and "testicular torsion" with date ranging from 2000 to 2013. Jury verdicts, depositions, and narrative summaries were evaluated for their medical basis, alleged malpractice, findings, and indemnity payment(s) (if any).

RESULTS

Fifty-two cases were identified that were relevant to this study. Fifty-one percent of relevant cases were found in favor of the defendant physician, with the remaining 49% involving an indemnity payment (13% of which were settled). The most commonly sued medical providers were emergency physicians (48% of defendants), with urologists being second most common and making up 23% of the defendant pool. Emergency physicians were significantly more likely to make indemnity payments than urologists.

CONCLUSION

Testicular torsion is a delicate condition and requires expertise in evaluation and treatment. When emergency physicians choose not to consult an urologist for possible torsion, they leave themselves open to litigation risk. When an urologist is involved in torsion litigation, they are rarely unsuccessful in their defense. Finally, ultrasound is no guarantee for success against litigation.

Outcomes of Second Look Exploration in Testicular Torsion of Children

Background:

Testicular torsion (TT), or twisting of the testicle resulting in a strangulation of the blood supply, occurs in men whose tissue surrounding the testicle is not well attached to the scrotum. It is important to emphasize that testicular torsion is a medical emergency.

Objectives:

The aim of this study is to evaluate the second look exploration and outcomes in TT.

Patients and Methods:

Seventy boys out of 124 patients underwent early exploration and 48 hours later second look exploration due to TT. All patients were checked with preoperative color-doppler ultrasonography (CDU) and intraoperative bleeding test. Data included age at admission, side of pathology, relation of TT with season of year, duration of preoperative history, degree of testicular torsion, CDU findings, and degree of bleeding; results of second look exploration, follow-up, and outcomes were analyzed.

Results:

Totally 70 patients were included in this study within five years, of which mean age was 28.6 ± 32.9 months (range 1 to 144), 48% of our patients had nausea and vomiting. Preoperative CDU showed absent/weak flow in 50 (71%) cases. Winter showed most frequently (44%) referred cases of testicular torsion. Orchidopexy was performed in 44 (63%) and orchidectomy in 26 (37%) cases after second look exploration. Mean follow-up duration was 3.1 ± 1.4 years. 4 (9%) cases in orchidopexy group developed testicular atrophy during follow-up, all four cases had a history of longer than 12 hours and grade II testicular bleeding test intra-operatively. Other orchidopexy patients salvaged. 26 patients, who were in grade III, underwent orchidectomy in second look exploration.

Conclusions:

TT requires emergency attention. The ischemia time of the testis is traditionally after 6 hours, and imaging or other diagnostic modality should not be a cause of delay. Early surgical exploration is modality of choice, and second look exploration after 48 hours can be more effective and salvageable in these patients.

A rare emergency: testicular torsion in the inguinal canal

Objectives. To report our experience and present the largest series of testicular torsion cases in the inguinal canal. Material and Methods. The clinical data of 13 patients with testicular torsion in the inguinal canal treated between 2005 and 2013 were reviewed. Recorded patient age, whether the testes were palpable or not, side of the affected testes, the presence of hernia, ischemia time, and operation outcomes were assessed. Results. Patient age ranged from 8 to 70 months (29.15 ± 20.22). Mean ischemia time was 16.5 ± 21.3 hours. Accompanying inguinal hernia was present in 92% of the cases (12/13). Four of the thirteen patients (30.8%) were treated by orchiectomy because the necrosis was present after prolonged ischemia time. Nine patients (69.2%) were treated by single session orchidopexy. Conclusion. Torsion of testes in the inguinal canal is a rare disease, but with rapid diagnosis, affected testes can be salvaged, but the key factor is to keep this condition in mind.

ESPR Uroradiology Taskforce--imaging recommendations in paediatric uroradiology, part VIII: retrograde urethrography, imaging disorder of sexual development and imaging childhood testicular torsion

Three new consensus-based recommendations of the European Society of Paediatric Radiology Uroradiology Taskforce and the European Society of Urogenital Radiology Paediatric Working Group on paediatric uroradiology are presented. One deals with indications and technique for retrograde urethrography, one with imaging in the work-up for disorders of sexual development and one with imaging workflow in suspected testicular torsion. The latter is subdivided to suggest a distinct algorithm to deal with testicular torsion in neonates. These proposals aim to outline effective imaging algorithms to optimise diagnostic accuracy and to harmonize diagnostic imaging among institutions and practitioners.

Contemporary review of testicular torsion: new concepts, emerging technologies and potential therapeutics

Testicular torsion is one of the few emergencies in pediatric urology which requires an accurate and timely diagnosis in order to avoid testis loss. It is not an uncommon event affecting a young male population. In fact, testicular torsion is more common than testicular tumors for this same age group, yet testicular torsion has not been given the public attention it deserves as a male health risk. In this review we highlight the new information published over the past four years regarding testicular torsion. We will discuss a variety of topics associated with torsion including: medical legal issues, etiology and genetics, imaging diagnostics, innovative surgical techniques, management controversies, fertility, and new drug therapies.