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

Ultrasound for the Diagnosis of Testicular Torsion: A Systematic Review and Meta-analysis of Diagnostic Accuracy

BACKGROUND AND OBJECTIVE

Uncertainty regarding the diagnostic accuracy of ultrasound for testicular torsion (TT) and a lack of high-level evidence to inform international guidelines have led to significant global variation in its use. The objective of this study was to assess the diagnostic accuracy of ultrasound for TT.

METHODS

This systematic review was undertaken in accordance with the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy. A comprehensive electronic search strategy was applied up to January 4, 2024. Colour Doppler sonography (CDS) was the primary index test, with surgical scrotal exploration or clinical follow-up as the reference standard. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool was used to assess the risk of bias and applicability. Meta-analyses were performed using bivariate models.

KEY FINDINGS AND LIMITATIONS

Sixty-three studies met the inclusion criteria; 54 (85.7%) assessed CDS, and the others assessed spectral doppler sonography (n = 6), contrast enhanced ultrasound (n = 1), or an alternative combination of ultrasound technologies (n = 2). The summary sensitivity (95% confidence interval [CI]) and specificity (95% CI) of CDS for the diagnosis of TT were 95.3% (91.4-97.5) and 98.3% (96.2-99.3), respectively (42 studies, 4422 participants). Patient selection (related to the risk of bias and applicability concern) was identified as the domain of the greatest methodological concern on QUADAS-2 assessment.

CONCLUSIONS AND CLINICAL IMPLICATIONS

CDS has high diagnostic accuracy for TT. The ideal patient pathway for suspected TT should integrate timely access to ultrasound alongside clinical assessment, with careful patient counselling.

Development and Validation of an Ultrasound Imaging Algorithm for Structured Reporting in Testicular Pathology

Background/Objectives: Testicular ultrasound (US) imaging is a critical modality for diagnosing a variety of testicular pathologies, including malignancies. This study aimed to develop and validate a standardized diagnostic algorithm to enhance diagnostic accuracy and consistency in evaluating testicular lesions, particularly for distinguishing between benign and malignant conditions. Methods: The algorithm was applied retrospectively to 110 testicular imaging cases, including 90 abnormal and 20 normal cases, analyzed by three radiologists with varying experience levels. Key diagnostic features, including lesion morphology, vascularity, and echotexture, were evaluated to guide the differentiation process. Results: demonstrated high diagnostic accuracy, with sensitivity reaching 100% for detecting abnormal cases and specificity ranging between 80% and 95%. In distinguishing benign from malignant lesions, the algorithm achieved an area under the curve (AUC) of up to 0.917, with specificities exceeding 93%. Notably, strong inter-rater agreement was observed, underscoring the algorithm's reliability across different expertise levels. While the algorithm significantly improved standardization and diagnostic performance, some variability in sensitivity for less experienced evaluators highlights the need for further refinement. Conclusions: This study shows that the proposed diagnostic algorithm is an effective tool for testicular US, facilitating accurate and reproducible assessments, which are crucial for early detection and optimal management of testicular pathologies.

Hurdles to boys with acute scrotal pain being evaluated and treated in district general hospitals: we are not Getting It Right the First Time yet

INTRODUCTION

Testicular torsion is a time-critical emergency, though its incidence in the paediatric age group is relatively rare. Changes in training pathways have led to a decreasing number of adult general surgical and urological trainees being comfortable in performing an emergency scrotal exploration in children, resulting in children being transferred to regional units with the requisite expertise. This delay has been shown to increase the risk of orchidectomy. There is, therefore, an increased emphasis on the diagnostic evaluation of these children by emergency department staff.

METHODS

We explore how lack of experience and availability of appropriate investigations led to transfer of children presenting to a district general hospital in the North East of England.

RESULTS

Children with true testicular torsion in this cohort had an unacceptably high rate of needing an orchidectomy (∼67%) compared with the reported incidence of orchidectomy with testicular torsion (∼20%).

CONCLUSIONS

We offer potential solutions to the hurdles that have to be overcome to improve this service. This will align the service to the recently published Get It Right First Time report on the management of testicular torsion in children and young adults and is within the remit of Operational Delivery Networks.

Clinical characteristics and treatment analysis of neonatal testicular torsion

BACKGROUND

Neonatal testicular torsion is a rare but critical condition that requires prompt diagnosis and treatment. While early surgical intervention may offer some benefit, in many prenatal cases, preventing testicular loss remains challenging, even with timely intervention. Early recognition remains challenging due to subtle clinical presentations in newborns.

OBJECTIVE

This study aims to analyze the clinical characteristics, diagnostic methods, and treatment outcomes of neonatal testicular torsion, providing a reference for early diagnosis and intervention of the disease.

METHODS

A retrospective analysis was conducted on cases of neonatal testicular torsion admitted to Anhui Provincial Children's Hospital from August 2014 to June 2024. Information collected included the infants' age, at diagnosis onset time, clinical manifestations, diagnostic methods, surgical treatment, and postoperative follow-up results.

RESULTS

This study included 21 cases of neonatal testicular torsion. Among them, 1 case involved bilateral testicular torsion, and the remaining 20 cases involved unilateral torsion, with 11 cases on the right side and 9 on the left. The median age at diagnosis of the patients was 1 day (IQR: 1-3), and the median onset time was 24 h (IQR: 10-60). All patients underwent surgical exploration, revealing a median torsion angle of 720 degrees (IQR: 360-720). The average surgery duration was 57.9 min (SD: 25.9). In the case of bilateral testicular torsion, the blood supply was restored after detorsion, and the testicles were preserved. However, in the 20 cases of unilateral torsion, necrotic testicles were removed. Postoperative follow-up over an average period of 31.3 months (SD: 11.5) showed no atrophy in the preserved testicles, with good development of the contralateral testicles and no recurrence of torsion.

CONCLUSION

Neonatal testicular torsion is rare and urgent, often prenatally occurring with high testicular necrosis risk. Ultrasound is crucial for diagnosing cryptorchid testicular torsion. Clinical uncertainty requires prompt surgical exploration to save the testicle.

Genitourinary Ultrasound

Renal and genitourinary (GU) complaints are common reasons for presentation to the emergency department (ED). This article reviews the approach to renal, bladder, and testicular point-of-care ultrasound (POCUS) with specific discussions of commonly encountered ED pathology. It presents algorithms highlighting the clinical integration of renal and GU POCUS into the evaluation and management of these patients.

Manual detorsion in pediatric testicular torsion: A narrative review of the literature

Manual detorsion is infrequently performed in pediatric emergency medicine, particularly in centers with urology coverage. In no other emergency condition does an emergency physician not take immediate action to alleviate pain and damage, even if definitive care is close by. A small number of case reports exist in which pediatric emergency physicians have performed manual detorsion. This review the literature presents the case for routine manual detorsion prior to definitive orchiopexy.

Multimodal ultrasound diagnosis of epididymo-orchitis with secondary testicular infarction: A case report

We report a case of a 48-year-old man with testicular infarction caused by epididymo-orchitis (EO). Multimodal ultrasound showed extensive necrosis of the testis, and the patient underwent right orchiectomy. Postoperative pathology confirmed extensive necrosis of the testis. After 3 months of follow-up, the examination of scrotal ultrasound showed that the left testis and epididymis had no obvious abnormality.

Updates on the clinical integration of point-of-care ultrasound in pediatric emergency medicine

PURPOSE OF REVIEW

There is expanding evidence for point-of-care ultrasound (POCUS) use in pediatric emergency medicine - this review highlights the benefits and challenges in the clinical integration of high-yield POCUS applications. Specifically, it will delve into POCUS applications during resuscitations, controversies of Focused Assessment with Sonography for Trauma (FAST) in pediatric trauma, POCUS-guided procedures, and examples of clinical pathways where POCUS can expedite definitive care.

RECENT FINDINGS

POCUS can enhance diagnostic accuracy and aid in management of pediatric patients in shock and help identify reversible causes during cardiac arrest. The use of the FAST in pediatric blunt abdominal trauma remains nuanced - its proper use requires an integration with clinical findings and an appreciation of its limitations. POCUS has been shown to enhance safety and efficacy of procedures such as nerve blocks, incision & drainage, and intravenous access. Integrating POCUS into pathways for conditions such as intussusception and testicular torsion expedites downstream care.

SUMMARY

POCUS enhances diagnostic efficiency and management in pediatric patients arriving at the ED with undifferentiated shock, cardiac arrest, or trauma. Additionally, POCUS improves procedural success and safety, and is integral to clinical pathways for expediting definitive care for various pediatric emergencies. Future research should continue to focus on the impact of POCUS on patient outcomes, ensuring user competency, and the expansion of POCUS into diverse settings.

The impact of health care on outcomes of suspected testicular torsion: results from the GRAND study

BACKGROUND

Suspicion of testicular torsion represents a urological emergency, necessitating immediate surgery. Comprehensive data on the current trends and perioperative outcomes regarding surgical exploration are sparse. Therefore, we utilized nationwide data on the prevalence and results of this surgery, aiming to provide evidence on this matter.

METHODS

We assessed the GeRmAn Nationwide inpatient Data (GRAND) from 2005 to 2021, provided by the Research Data Center of the Federal Bureau of Statistics. We performed multiple regression analyses to evaluate the perioperative outcomes (length of hospital stay, transfusion, and surgical wound infection) after surgical exploration due to suspected testicular torsion based on both the outcome of surgery (orchiectomy, detorsion with preservation of the testicle, and no testicular torsion) and on the department of operation (urological versus non-urological).

RESULTS

A total of 81,899 males underwent surgical exploration due to suspected testicular torsion in Germany from 2005 to 2021. Of them, 11,725 (14%) underwent orchiectomy, 30,765 (38%) detorsion with preservation of the testicle and subsequent orchidopexy, and 39,409 (48%) presented no testicular torsion. Orchiectomy was significantly associated with longer length of hospital stay (day difference of 1.4 days, 95%CI: 1.3-1.4, p < 0.001), higher odds of transfusion (1.8, 95% CI: 1.2-2.6, p = 0.002) and surgical wound infections (1.8, 95%CI: 1.4-2.3, p < 0.001) compared to no testicular torsion. The proportion of patients undergoing orchiectomy was significantly lower in urological departments (14%) versus non-urological departments (16%) and the proportion of patients undergoing preservation of testicle after detorsion was significantly higher in urological departments (38%) versus non-urological departments (37%), p < 0.001. Patients undergoing treatment in a urological department were discharged earlier and presented lower odds of transfusion and surgical wound infection (p < 0.001) compared to patients undergoing treatment in a non-urological department.

CONCLUSIONS

Nearly half of patients who underwent surgery for suspected testicular torsion did not have intraoperatively the condition confirmed. Patients treated in urological departments had significantly better perioperative outcomes compared to those treated in non-urological departments. Therefore, we advise to refer patients to urological treatment as early as possible.

Paediatric testicular torsion in low- and middle-income countries: an OxPLORE scoping study

BACKGROUND

Literature on paediatric surgical conditions in low- and middle-income countries (LMICs) remains limited. As a common emergency, timely treatment of testicular torsion acts as a benchmark of adequate emergency service delivery in paediatric surgery. This scoping study aims to synthesise all existing literature on paediatric testicular torsion in LMICs.

METHODS

A database search was conducted by the OxPLORE global paediatric surgery research group to identify studies containing the terms 'testicular torsion' or 'acute scrotum' originating from LMICs. A thematic analysis was applied to the results of the search and the quality of evidence was appraised for all included articles.

RESULTS

This review included 17 studies with 1798 patients. All studies originated from middle-income countries and the majority (76%) had sample sizes smaller than 100 patients. All studies were appraised as providing less than adequate evidence. Included studies identified long delays to treatment and highlighted ongoing debates on the value of scoring systems and Doppler ultrasonography in diagnosing torsion. Major heterogeneity in surgical approaches to treatment of testicular torsion in children was also observed.

CONCLUSIONS

Literature on paediatric testicular torsion in LMICs is scarce and heterogeneous. Prospective, multi-centre research on the management of this common paediatric surgical emergency is urgently required.

Contrast-enhanced ultrasound (CEUS) for the characterization of intra-scrotal lesions

Contrast-enhanced ultrasound (CEUS) has emerged as a promising imaging modality for the characterization of hepatic and renal lesions. However, there is a paucity of data describing the use of CEUS for the evaluation of intra-scrotal pathology. In the following review, we describe the clinical utility of CEUS for the characterization and differentiation of common and uncommon intra-scrotal conditions, including testicular torsion, infection, trauma, and benign and malignant intratesticular and extratesticular neoplasms. In addition, we outline key principles of CEUS and provide case examples from our institution.

Point-of-care ultrasonography for the diagnosis and manual detorsion of testicular torsion

Testicular torsion is a urological emergency caused by the loss of testicular tissue due to ischemic damage. Rapid diagnosis and urgent treatment play a crucial role in the management of testicular torsion. Manual detorsion can be performed at the bedside, thereby reducing the duration of ischemia. Recent studies have reported the use of point-of-care ultrasonography for diagnosing testicular torsion; however, no review article has focused on the ultrasonographic findings pertaining to manual detorsion. This review describes the diagnosis of testicular torsion and the ultrasonographic indications for manual detorsion. Spermatic cord twisting or the whirlpool sign, absence of or decreased blood flow within the affected testis, abnormal testicular axis, abnormal echogenicity, and enlargement of the affected testis and epididymis due to ischemia are the sonographic findings associated with testicular torsion. The following findings are considered indications for manual detorsion: direction of testicular torsion, i.e., inner or outer direction (ultrasonographic accuracy of 70%), and the degree of spermatic cord twist. The following sonographic findings are used to determine whether the treatment was successful: presence of the whirlpool sign and the degree and extent of perfusion of the affected testis. Misdiagnosis of the direction of manual detorsion, a high degree of spermatic cord twisting and insufficient detorsion, testicular compartment syndrome, and testicular necrosis were found to result in treatment failure. The success of manual detorsion is determined based on the symptoms and sonographic findings. Subsequent surgical exploration is recommended in all cases, regardless of the success of manual detorsion.

Implementing Point-of-Care Ultrasound for Acute Scrotal Pain in the Pediatric Emergency Department: Screening Testicular Torsion and Patient Flow Analysis

OBJECTIVES

Testicular torsion (TT) is a pediatric surgical emergency that requires prompt treatment. This study investigated the feasibility of point-of-care ultrasound (POCUS) for diagnosing TT in the pediatric emergency department (ED).

METHODS

We retrospectively reviewed the medical records of patients, aged 18 years or younger, who visited a university-affiliated hospital pediatric ED with acute scrotal pain without trauma history and underwent diagnostic ultrasounds between January 2010 and October 2022.

RESULTS

This study included 731 patients (median age: 9 years), Of these, 315 (43%) were in the POCUS-performed group: 188 in the POCUS-only group, and 127 in the POCUS-and-RADUS group. The other 416 patients (56.9%) were in the RADUS-only group. In total, 45 patients (6.2%) were diagnosed with TT (19 in the POCUS-performed group and 26 in the RADUS-only group). The sensitivity, specificity, and positive and negative predictive values of POCUS for diagnosing TT were 94.7%, 92.9%, 46.2%, and 99.6%, respectively. The median time to perform POCUS was shorter than RADUS (23 versus 61 minutes, P < .001). The POCUS-performed group had a shorter ED length of stay than the RADUS-only group (93 versus 170 minutes, P < .001). Among the patients diagnosed with TT, performing POCUS first did not significantly delay the ED process, including time to operation (250 versus 205 minutes, P = .142).

CONCLUSIONS

For patients with acute scrotal pain, evaluation performed by pediatric emergency physicians using POCUS performs well in screening TT, and can decrease length of stay in the ED.

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.