Acute testicular torsion in children: the role of sonography in the diagnostic workup

[Acute genital diseases]

Acute genital diseases can occur at any age and are characterized by complaints of various kinds of the external genitalia. Pain, swelling, and redness of the scrotum, adjacent groin region, and immediate surroundings are the leading symptoms, the severity of which may vary. In addition, peritonitic symptoms such as nausea, vomiting, and circulatory sensations may be present and are comparable to symptoms of an acute abdomen. The term "acute scrotum" encompasses various clinical entities, where scrotal symptoms are predominant and represent a urological emergency situation. Immediate and comprehensive diagnostics are necessary to ensure timely management in case of necessary surgical intervention.

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.

Acute Scrotum in Children: A Retrospective Study of Cases With Review of Literature

BACKGROUND

Testicular pain or swelling, often referred to as acute scrotum, can have a number of causes and presentations. Testicular torsion is an emergency condition requiring early diagnosis and surgery to salvage the involved testis in order to preserve testicular fertility. The study is aimed to know the incidence, aetiology, and management of acute scrotal conditions with a particular focus on testicular torsion. Epididymorchitis, trauma, and scrotal cellulitis are other causes of acute scrotum which are managed conservatively after proper investigations.

MATERIAL AND METHODS

 The authors retrospectively reviewed 10-year epidemiological data of all children age under 14 years admitted to the tertiary care hospital with the diagnosis of acute scrotum. Data were collected about the clinical history, physical examination, biochemical investigations, Doppler ultrasound, and management done.

RESULTS

 133 children aged between 0 days and 14 years (mean age, 7.5 years) were found to have acute scrotum out of which 67 (50.37%) patients had epididymitis, 54 (40.60%) patients presented with Torsion testis, three (2.25%) had torsion of testicular appendages, eight (6.01%) had scrotal cellulitis and one (0.75%) presented with a strangulated hernia. Due to late presentation, testis could be salvaged in only eight of the 54 patients with torsion testis. The testicular loss was seen more in bigger children and those with signs of infection in blood reports and colour Doppler showing no blood flow in the testis.

CONCLUSION

 The study results indicate that non-recognition of the severity of paediatric acute scrotum results in late presentation leading to testicular loss. Timely diagnosis will require sensitization of the parents, primary care providers, and paediatricians for this grave condition which leads to permanent testicular loss.

Real-world management of testicular torsion: Level of adherence to the EAU Pediatric Urology guidelines

BACKGROUND

Testicular torsion is the most frequent cause of irreversible ischemia to the testis. Despite guidelines being available, challenges remain in both diagnosis and management of the disease.

OBJECTIVE

This study aims to determine the adherence of urologists and residents in urology to the European Association of Urology (EAU) Pediatric Guideline on Testicular torsion.

STUDY DESIGN

Both Dutch and European urologists, and residents in urology filled in a survey on testicular torsion. Information on demographics, diagnostics, and treatment modalities was retrieved from the questionnaire based on the EAU Guideline on Paediatric Urology.

RESULTS

A total of 303 responders participated, of which 214 (71%) were from The Netherlands. Most (61%) responders treated three or more cases of testicular torsion in 2020. Ultrasound was used by 64%, followed by an attempt of manual detorsion by 38% (Summary Fig.). Importantly, 23% preferred not to perform emergency surgery after successful manual detorsion. A Winkelmann procedure was performed by 23%, without fixation of the test is using suture material. A large group of responders (30%) only fixed the contralateral testis by a proven testicular torsion.

DISCUSSION

A feasible adherence to the EAU Guideline on Paediatric Urology in treating testicular torsion was reported using this survey, although not all recommendations are implemented as proposed. The fact that outcomes of the different diagnostic and treatment modalities are lacking might be a limitation in interpreting the results of this survey.

CONCLUSION

Majority of the responders followed the EAU Guideline on Paediatric Urology in the diagnosis and treatment of testicular torsion. Ultrasound might contribute to diagnosing testicular torsion as long as this does not cause any delay for surgical exploration. Surprisingly, many urologists do not perform a surgical fixation of the testis after detorsion. Since a wide range of techniques and materials is used in case of surgical fixation, the guideline may provide in preferences for a unified policy among urologists.

[Conservative therapy after self-mutilation of the scrotum resulting in bilateral testicular underperfusion]

We report the case of a patient with massive penile and scrotal swelling due to use of a compression ring with auto-erotic intent and under the influence of addictive substances. Based on the patient history, the mechanical pressure on the scrotum was about 30 hours (h). The Doppler sonogram showed no central perfusion in either testicle. Conservative treatment with antibiotics and analgesics was initiated with a slight increase in inflammatory parameters and local edema and necrosis formation. Follow-up showed regression of swelling, healing of necrosis and improvement of laboratory parameters. Testosterone substitution therapy was necessary due to the bilateral testicular atrophy that developed.

A case of intra-vaginal intrauterine testicular torsion

Objectives

Intrauterine testicular torsion is extremely rare and the exact cause remains largely unknown. It is the result of an ischemic insult intrauterine, which presents as either extra-vaginal or intravaginal testicular torsion. Urgent surgical exploration and fixating the contralateral testis is key in the management of this condition.

Case presentation

We present here the case of a two-day old neonate with in-born right scrotal swelling admitted at Children’s hospital. The patient was born at term via cesarean section at a private hospital. Upon arrival in the emergency department, he was well hydrated, pink at room temperature with good perfusion. Upon examination, the right testis was found to be enlarged, tense, non-tender visibly reddish with overlying skin excoriation. Trans-illumination was negative in right but positive in the contralateral testis. Both hernial orifices were normal. Doppler ultrasound of the inguinoscrotal area found the right testis to be enlarged (15.6*9.4 mm) and showed heterogeneous hypoechoic texture with prominent rete testis and no flow on color doppler analysis. An urgent scrotal exploration was undertaken. Intra-operatively there was frank necrotic right testis with intravaginal torsion of the testis and minimal hydrocele. A right orchidectomy and contralateral orchidopexy were performed.

Conclusions

Intrauterine testicular torsion should be treated as a surgical emergency. We advocate early recognition of intrauterine testicular torsion, alongside surgical exploration and simultaneous contralateral orchidopexy.

Validation of testicular workup for ischemia and suspected torsion score in patients with acute scrotum

INTRODUCTION

The Testicular Workup for Ischemia and Suspected Torsion (TWIST) score was created to help physicians in the clinical evaluation of acute scrotum in which testicular torsion (TT) is suspected. There have been only a few reports on validation of the TWIST score since the original study was published.

OBJECTIVES

To validate the TWIST score as a scoring system.

PATIENTS AND METHODS

We reviewed the records of 106 patients with acute scrotum in our prospectively maintained database. The patients were divided into two groups by the final diagnosis: testicular torsion (group TT) or non-testicular torsion (group NTT). We retrospectively calculated the TWIST score of the patients. Patients were divided into low (0-2), intermediate (3-4), or high (5-7) risk groups according to the total score.

RESULTS

Fifteen patients (14%) had TT. The median age at presentation was 13.3 years (range 1.6-16.2) in group TT and 10.4 years (range 0.25-18.9) in group NTT, respectively. The sensitivity of clinical and Color Doppler ultrasonography (CDUS) findings to diagnose TT was 100%, whereas the specificity was 93.4%. Positive predictive value (PPV) and negative predictive value (NPV) were 71.4% and 100%, respectively. According to the calculated TWIST score, 65, 23, and 18 patients belonged to low, intermediate, and high risk groups, respectively. TT was found in 1(1.3%), 3(13%), and 11 (61%) patients of low, intermediate, and high risk groups, respectively. The NPV of the TWIST score for the low risk group was 98.5%, whereas the PPV of the TWIST score for the high risk group was 61.1%. Among the four patients with TT in low risk and intermediate risk groups, three patients presented to our institutions within 6 h after the onset. The torsion was 180° in two of the three patients.

CONCLUSION

The TWIST score can be useful for clinical diagnosis of testicular torsion, but is inferior to clinical findings along with CDUS. We should consider the possibility that a TWIST score could be underestimated when patients present with acute scrotum immediately after onset or the affected testis is mildly twisted.

The diagnostic value of ultrasound in pediatric testicular torsion with preserved flow

BACKGROUND

Testicular torsion is the reduction of blood flow to the testis after spermatic cord torsion. For patients, the diagnosis of testicular torsion is controversial and complicated by the fact that ultrasound blood flow signals are not significantly reduced in comparison to the unaffected, healthy, testis, despite persistent symptoms on the affected side. Our study aims to investigate the diagnostic characteristics of high-resolution ultrasonography (US) in pediatric testicular torsion with the preserved flow to increase diagnostic accuracy.

METHODS

Seven pediatric patients aged 49 days to 15 years old, with the preserved blood flow, but surgically diagnosed as testicular torsion, from October 2017 to August 2019, were retrospectively included in the study. The imaging manifestations of high-frequency ultrasonography were evaluated.

RESULTS

All cases had preserved testicular blood flow, but the surgical findings showed various degrees of twist, from 90 to 540 degrees. Preoperative ultrasound showed spermatic cord distortion in all cases, and testicular long axis tilting in four cases (4/7 = 57.1%).

CONCLUSION

In some testicular torsion cases, Color Doppler may show normal or increased blood flow signals in the testis. We should further observe the morphology and position of the testes and epididymides, the echo of the testicular parenchyma, and, especially evaluate the "whirlpool sign" in the spermatic cord, to avoid missing testicular torsion with blood flow signals.

Sonography in Childhood and Adolescence for General Radiologists - More Possibilities Than Expected

Sonography is the most common imaging modality in childhood and adolescence. The rapid availability, absence of X-rays, bedside applicability, e. g., in intensive care units, the lack of need for sedation, and last but not least the very good ultrasound conditions in the vast majority of cases are the main advantages of sonography. Due to the spectrum of patients, from premature infants to adolescents, a great variety of questions arise for the examiner. This requires knowledge of the various disease patterns in the different age groups. Proper handling of the young patients as well as their parents is essential in order to make the examination conditions as optimal as possible. Due to the smaller body size compared to adults, sonographic examinations of the abdomen and thorax in children and adolescents are usually possible with very good image quality. In the majority of cases, a definitive diagnosis is made by sonography without additional cross-sectional imaging, which is more common in adults. Due to the acoustic windows provided by the still open fontanelles, excellent image quality of the central nervous system is usually possible in the first year of life. In most cases, complex MRI examinations are not necessary. Due to the partly still missing ossification of the bony structures, further acoustic windows are available, which allow an examination of, e. g., the spinal canal. Ultrasound also plays a major role in the examination of soft tissues and the musculoskeletal system in childhood and adolescence, not only in hip ultrasound. The aim of this article is to show this very broad spectrum for colleagues working predominantly in adult radiology, to highlight some representative examples and to present the respective clinical features in childhood and adolescence. KEY POINTS::   · Ultrasound is the most important initial imaging modality in children and adolescents.. · Often, no further cross-sectional imaging is necessary.. · The most important area of application is the abdomen and pelvis.. · Furthermore, there are additional special applications such as CNS in neonates and infants, thorax, musculoskeletal system.. CITATION FORMAT: · Schaal MC, Moritz JD, Mentzel H et al. Sonography in Childhood and Adolescence for General Radiologists - More Possibilities Than Expected.... Fortschr Röntgenstr 2021; DOI: 10.1055/a-1681-2136.

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.

A systematic review on the utility of ultrasonography in the diagnosis of testicular torsion in acute scrotum patients

INTRODUCTION

Ultrasound is a valuable tool in establishing the cause of acute scrotum pain. However, its role in testicular torsion (TT) detection remains controversial. This review aims integrate pre-existing data to assess the value of B-mode and colour Doppler ultrasound (CDS) features combined in the detection of TT in acute scrotum pain patients of all ages.

METHODS

A search through electronic databases, grey literature and hand searching using specific search terms was conducted to identify relevant literature. Search results were subjected to a three-step selection process to ensure the inclusion criteria of this review were met. Statistical data pertaining to the accuracy, sensitivity, and specificity of the B-mode, CDS and combined B-mode CDS features were extracted. These results subsequently underwent a narrative analysis.

RESULTS

Five studies met the inclusion criteria. A variety of B-mode features were identified. Most studies showed that reliance on CDS alone can be prone to false-negative results. The combination of B-mode and CDS features were found to increase the overall sensitivity of ultrasound towards TT (up to 100% in 3 studies). All studies recommended correlation with clinical examination findings. Several limitations in methodology of the included studies were noted: small sample populations and lack of information on the experience of ultrasound practitioners. This highlighted the need for a primary study with a larger sample population to validate the findings of this review.

CONCLUSION

The combination of B-mode and CDS ultrasound is a useful and reliable triage tool in the detection of TT, particularly in equivocal or low suspicion cases but its findings should always be adjunct with clinical examination. Nevertheless, it is noted that appropriate service level agreements, pathways, and training are key factors in ensuring effectiveness of the process.

IMPLICATIONS FOR PRACTICE

Dedicated training and appropriate departmental protocol are key in ensuring accurate diagnosis across all levels of practice.

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.

The BAL-Score Almost Perfectly Predicts Testicular Torsion in Children: A Two-Center Cohort Study

Introduction: Testicular torsion (TT) is a common emergency that warrants immediate exploration to prevent infertility or testicular loss. To improve diagnostic reliability, various scoring systems have been published. The aim of this study was to evaluate and validate different testicular torsion scores in a large cohort of children with acute scrotum. Methods: Retrospective analysis of all male children that were admitted for acute scrotum at the Pediatric Surgery Department of the Altonaer Kinderkrankenhaus and University medical Center Hamburg-Eppendorf from 01/2013 to 03/2019. Two testicular torsion scores (Boettcher Alert Score, Testicular Workup for Ischemia and Suspected Torsion Score) were applied to all data sets. Furthermore, an artificial intelligence (AI)-based score was developed and compared to the two current scores. Results: In total, 460 boys were included in the study. Of those, 48 (10.4%) had TT. Children with TT suffered most often from short duration of pain, nausea and vomiting, high riding testicle and absent cremasteric reflex. The BALS and the AI-based score had excellent predictive values and all patients with TT would have been detected. Conclusion: The BAL and the AI score show excellent predictive capabilities and may be used to identify all cases of TT in a pediatric population. The scores are easy to apply. As the BALS was slightly better, we advocate to use this score but to validate our findings in prospective multicenter studies.

Clinical state of the paediatric acute scrotum in south-eastern Victoria

BACKGROUND

Acute scrotal pain is a common paediatric surgical presentation. Delays in treatment can result in testicular loss from torsion. It is unclear where delays occur. We aimed to investigate presentations with an acute scrotum to identify any potential areas of delay.

METHODS

We conducted a prospective study (April 2017-November 2018) of paediatric patients (<18 years) presenting with acute scrotal pain. Data collected included: patient demographics, history/examination findings, mode of presentation, clinical timeline details and outcomes.

RESULTS

A total of 107 acute scrotum presentations were identified: 58 (54.2%) testicular appendage torsion, 23 (21.5%) testicular torsion, 6 (5.6%) epididymo-orchidits and 20 (18.7%) other diagnoses. Median age at presentation was 11 years (4 months-16 years). Fifty-seven (53.3%) underwent emergency surgery, of whom 23 (40.4%) had testicular torsion, with 2 requiring orchidectomy. Median time from onset of symptoms to seeking medical opinion was 5.5 (0-135) h. Once assessed by a medical professional, the route to paediatric surgical review via general practitioner (GP) and local emergency department (ED) to paediatric ED was 4.84 (1.67-24.5) h; via GP to paediatric ED was 2.58 (0.75-25.5) h; via local ED to paediatric ED was 2.25 (1-7.75) h; and directly to paediatric ED was 0.45 (0-1.42) h.

CONCLUSION

Delays in assessment and treatment of acute scrotal pain occur from the time parents are aware of symptoms to seeking medical opinion. Education to increase awareness may reduce time delays. GPs should refer patients directly to a paediatric ED. Local EDs should manage paediatric cases as per the local surgeons' skill base.

The applied value of medical history, physical examination, colour-Doppler ultrasonography and testis scintigraphy in the differential diagnosis of acute scrotum

Acute scrotum, especially testicular torsion, is a common surgical emergency. A delay in diagnosis or management may lead to permanent testicular ischaemic damage. Thus, it is particularly important to differentiate testicular torsion from other acute scrotum conditions as soon as possible. Our study has retrospectively investigated 358 patients with acute scrotum admitted to our hospital from the year 2007 to 2016. We have collected a thorough history and clinical data and drew the conclusion by comparing clinical features of different acute scrotum cases, medical history, imaging and surgical findings. Therefore, we propose an innovative "Testicular Torsion (TT) Green Channel" concept. Through the combination of a comprehensive medical history, physical examination and auxiliary colour-Doppler ultrasonography, the diagnosis of testicular torsion is definite in most circumstances. Testis scintigraphy is a novel and complementary diagnostic modality that can reduce the negative exploration rate in ambiguous and certain cases. The TT Green Channel is a new concept in the management of testicular torsion.

Evaluation of Testicular Workup for Ischemia and Suspected Torsion score in patients presenting with acute scrotum

Background

Testicular torsion is one of the causes of acute scrotum and it requires timely evaluation and surgical treatment. Color Doppler is considered investigation of choice, but it may delay treatment, as, many times, it may not be available for emergency situations. Barbosa et al. created Testicular Workup for Ischemia and Suspected Torsion (TWIST) score based on clinical parameters for clinical diagnosis of testicular torsion. We have evaluated this score in our population.

Materials and Methods

We retrospectively calculated TWIST score in patients of acute scrotum admitted to tertiary teaching institute. Patients without complete TWIST score were excluded from the study. The scoring system consisted of testicular swelling (2 points), hard testicle (2), absent cremasteric reflex (1), nausea/vomiting (1), and high-riding testis (1). Statistical analysis was done to evaluate the validity of scores.

Results

A total of 118 patients were included in the study, out of which 45 (38%) patients had testicular torsion. The mean age of patients was 16.6 years in testicular torsion patients and 15.2 years in other patients. Cutoff for low-risk and high-risk patients was two and five, respectively. Fifty percent, 26.2%, and 23.8% of patients were present in low-, intermediate-, and high-risk groups. Negative predictive value of TWIST score for low-risk patients was 96.61% while positive predictive value for high-risk patients was 92.86%.

Conclusions

TWIST score has high predictive value and can be used for clinical diagnosis of testicular torsion. It can decrease the need of color Doppler in about 50% of cases and can prevent delay in treatment.

Ultrasonographic findings in the epididymis of pediatric patients with testicular torsion

INTRODUCTION

Although grayscale ultrasound and color Doppler ultrasound characteristics of the torsed testis are well established in the literature, less is known about its anatomic partner: the epididymis.

OBJECTIVE

The purpose of this study was to describe the ultrasound characteristics of the epididymis in pediatric patients with testicular torsion, and to describe their potential role as prognostic criteria for testicular salvage outcomes.

STUDY DESIGN

During a retrospective review of 217 pediatric patients with acute testicular torsion during 2009-2016, morphological features of the epididymis from scrotal ultrasounds (size, parenchymal characteristics, and vascular flow of both epididymis heads), as well as patient demographics, time duration, surgical outcomes, histopathology results, and follow-up periods were analyzed.

RESULTS

Mean epididymis size and twisting degree were significantly higher in the torsed testes than in the contralateral epididymis (P < 0.001) (Summary table). Cystic structures in the epididymis were identified: a higher number of cysts was associated with testicular non-viability (P = 0.025) and higher twisting degree (P = 0.017). Histopathologic examination showed that these spaces were infiltrated connective tissue most likely formed by venous congestion and vessel rupture.

DISCUSSION

Scrotal ultrasound can provide information on testicular morphology and viability, as well as morphological changes in the epididymis over time in pediatric patients with testicular torsion. These findings may provide potential prognostic information regarding testicular viability, as a higher number of cystic spaces in the epididymis was associated with a higher rate of testicular non-viability and a higher twisting degree. In addition, the epididymis size (volume) can change during the time course of the ischemic state.

CONCLUSIONS

This was the first study to describe and analyze epididymis ultrasound findings in pediatric patients with testicular torsion and to correlate them with testicular salvage outcomes. Further prospective studies are needed to determine the role of epididymis ultrasound findings as a potential pre-operative prognostic tool.

Perspectives in Pediatric Pathology, Chapter 19. Testicular Torsion, Testicular Appendix Torsion, and Other Forms of Testicular Infarction

Among the most frequent specimens at the pediatric surgical pathology bench, orchiectomy performed after testicular torsion deserves significant attention. Multiple implications, including fertility, legal complications, possibility of occult lesion, and others, need to be considered. Furthermore, torsion of testicular and other appendices represents common urological emergencies frequently encountered in surgical pathology. Here we present a review of testicular torsion and infarction, including theories about their pathogenesis and the appropriate handling by the diagnostic pathologist.

Ultrasonography of pediatric urogenital emergencies: review of classic and new techniques

Urogenital emergencies are fairly common in the pediatric population, and a timely and correct diagnosis is necessary to avoid possible future infertility. In this field, ultrasonography is essential, as it has the advantages of being radiation-free and readily accessible. In particular, a high-frequency transducer allows precise evaluation of the morphology and vascularity of the scrotum, which is on the surface of the body. Beyond conventional techniques, new advanced imaging techniques have been developed, including elastography and contrast-enhanced ultrasonography. However, several pitfalls remain in the diagnosis of urogenital diseases using ultrasonography. Thus, accurate knowledge and sufficient experience with the technique are essential for making a correct diagnosis. This review provides an overview of pediatric urogenital emergency pathologies and recent ultrasonography techniques.

Ultrasound assessment of perinatal testicular torsion

OBJECTIVE:

The goal of this study was to elucidate the different sonographic features of prenatal and postnatal testicular torsion (TT) using high-frequency colour Doppler ultrasound (HCDU) in an effort to increase diagnostic accuracy.

METHODS:

29 patients (average age, 7.5 days) with perinatal TT were divided into patients with postnatal (acute) TT vs patients with prenatal (chronic) TT and their clinical characteristics, imaging features on HCDU and surgical pathology results were retrospectively analyzed.

RESULTS:

Significant differences were observed between prenatal and postnatal TT cases with regard to testicular size (p = 0.01) and echogenicity (p = 0.007). All 17 prenatal cases had non-homogeneous testicular parenchymal echo patterns compared with only 9 (64.3%) postnatal TT cases. Five postnatal TT cases presented with homogeneous echo patterns compared with none of the prenatal TT cases. Testicular blood supply was absent in 25 (80.7%) of 31 testes on colour Doppler flow imaging, with the majority occurring in the prenatal TT cases [i.e. 16 (94.1%) cases]. 1 affected testis out of a total 17 testes from 16 patients with prenatal TT was salvaged, with a salvage rate of 1/17 or 0.06%. 7 affected testes out of a total 16 testes from 13 patients with postnatal neonatal TT were salvaged, with a salvage rate of 7/16 or 43.8%.

CONCLUSION:

In neonates with acute scrotal symptoms, the possibility of perinatal TT should be considered and HCDU examination should be performed in a timely manner. HCDU examination could aid in testicular salvage by prompting quick surgical intervention.

ADVANCES IN KNOWLEDGE:

This study underlined the clinical contribution of HCDU in evaluating postnatal (acute) vs prenatal (chronic) TT. The sonographic features of postnatal TT with salvageable testes were compared with prenatal torsion and the relative salvage rates in both cases were discussed.

A Minimally Invasive Method in Diagnosing Testicular Torsion: The Initial Experience of Scrotoscope

PURPOSE

To introduce scrotoscopy in the diagnosis of testicular torsion and evaluate its value in clinical application.

PATIENTS AND METHODS

From February 2010 to June 2013, 14 patients, aged 12 to 24 years, were included into this study due to acute onset of scrotal pain. On Doppler ultrasound imaging, the blood flow decreased in seven cases (including two "no flow" cases) and remained normal in the other seven. Following anesthesia, a 10F pediatric cystoscope employed as scrotoscope was inserted into the cavity of tunica vaginalis of the testis with continued saline washing to exam the testis and epididymis.

RESULTS

The scrotoscope had a diagnostic accuracy of 100% (100% specificity and 100% sensitivity), and the color Doppler ultrasound had 77.8% specificity. Five cases were diagnosed with testicular torsion, among which four were corrected and one underwent orchiectomy. No complications were observed in these patients. Nine patients with epididymitis were given oral antibiotics, and the blood flow of the testis was normal in the testis-preserving patient.

CONCLUSIONS

Our study showed that scrotoscopy could serve as a minimally invasive, safe, and effective approach in the early diagnosis of testicular torsion.

Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score

PURPOSE

The TWIST (Testicular Workup for Ischemia and Suspected Torsion) score uses urological history and physical examination to assess risk of testis torsion. Parameters include testis swelling (2 points), hard testis (2), absent cremasteric reflex (1), nausea/vomiting (1) and high riding testis (1). While TWIST has been validated when scored by urologists, its diagnostic accuracy among nonurological providers is unknown. We assessed the usefulness of the TWIST score when determined by nonurological nonphysician providers, mirroring emergency room evaluation of acute scrotal pain.

MATERIALS AND METHODS

Children with unilateral acute scrotum were prospectively enrolled in a National Institutes of Health clinical trial. After undergoing basic history and physical examination training, emergency medical technicians calculated TWIST score and determined Tanner stage per pictorial diagram. Clinical torsion was confirmed by surgical exploration. All data were captured into REDCap™ and ROC curves were used to evaluate the diagnostic usefulness of TWIST.

RESULTS

Of 128 patients (mean age 11.3 years) 44 (13.0 years) had torsion. TWIST score cutoff values of 0 and 6 derived from ROC analysis identified 31 high, 57 intermediate and 40 low risk cases (positive predictive value 93.5%, negative predictive value 100%).

CONCLUSIONS

TWIST score assessed by nonurologists, such as emergency medical technicians, is accurate. Low risk patients do not require ultrasound to rule out torsion. High risk patients can proceed directly to surgery, with more than 50% avoiding ultrasound. In the future emergency medical technicians and/or emergency room triage personnel may be able to calculate TWIST score to guide radiological evaluation and immediate surgical intervention at initial assessment long before urological consultation.

[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.

[Imaging of acute abdomen in childhood and adolescence]

Acute abdominal pain in childhood is a frequent reason for a medical consultation. The main diseases that lead to the clinical situation of acute abdomen show a significant age dependency. It is reasonable to group such ailments into three age categories: (1) the neonatal and infant period, (2) toddlerhood to kindergarten and (3) school age children. The task of the pediatric radiological examination is the differential diagnostic correlation of symptoms to the respective diseases. In children ultrasound is the appropriate method of choice.

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.

Small part ultrasound in childhood and adolescence

Small-part sonography refers to the display of small, near-surface structures using high-frequency linear array transducers. Traditional applications for small part ultrasound imaging include visualization and differential diagnostic evaluation in unclear superficial bodily structures with solid, liquid and mixed texture, as well as similar structures in nearly superficial organs such as the thyroid glands and the testes. Furthermore indications in the head and neck regions are the assessment of the outer CSF spaces in infants, the sonography of the orbit, the sonography of the walls of the large neck vessels, the visualization of superficially situated lymph nodes and neoplasms. Clinical evidence concludes that sonography, having of all imaging modalities the highest spatial resolution in the millimeter- and micrometer range (100-1000μm), can be considered the best suited technique for examining superficial pathological formations and near-surface organs. In addition, it delivers important information about characteristic, often pathognomonic tissue architecture in pathological processes.

The incidence rate and characteristics in patients with testicular torsion: a nationwide, population-based study

AIM

To determine the incidence rate and characteristics in patients with testicular torsion in Taiwan using a nationwide insurance database.

METHODS

This study utilizes a subset of national health insurance research database, which contains the data of all paid medical benefit claims over the period 1997-2010 for in 1 000 000 beneficiaries in 2005. We analysed claims data for all male subjects younger than 25 years with the diagnosis of testicular torsion.

RESULTS

A total of 86 subjects younger than 25 years with the diagnosis of testicular torsion were included. Among them, 22 (25.6%) underwent orchiectomies and 64 (74.4%) underwent orchiopexies. The estimated incidence of testicular torsion was 3.5 per 100 000 person-years. There are two peaks in the age-specific incidence rates: the first in boys aged 10-14 years (at 7.7 per 100 000 person-years) and the second in male infants aged <1 year (at 7.6 per 100 000 person-years). There was significant difference between orchiectomy and orchiopexy groups in the Insurance fee (p = 0.032).

CONCLUSION

The incidence of testicular torsion in Taiwan was similar with previous report in the United States. It is important to improve the medical access to achieve better outcomes of testicular torsion.

Testicular torsion and weather conditions: analysis of 21,289 cases in Brazil

PURPOSE

The hypothesis of association between testicular torsion and hyperactive cremasteric reflex, worsened by cold weather, has not been proved. Thirteen studies in the literature evaluated this issue, with inconclusive results. The aim of the present study was to evaluate the seasonality of testicular torsion in a large subset of patients surgically treated in Brazil, and additionally to estimate the incidence of testicular torsion.

MATERIALS AND METHODS

Brazilian Public Health System Database was assessed from 1992-2010 to evaluate hospital admissions associated with treatment of testicular torsion. Average monthly temperature between 1992-2010 was calculated for each region.

RESULTS

We identified 21,289 hospital admissions for treatment of testicular torsion. There was a higher number of testicular torsions during colder months (p = 0.002). To estimate the incidence of testicular torsion, we have related our findings to data from the last Brazilian census (2010). In 2010, testicular torsion occurred in 1.4:100,000 men in Brazil.

CONCLUSIONS

Testicular torsion occurred at an annual incidence of approximately 1.4:100,000 men in Brazil in 2010. Seasonal variations do occur, with a significant increase of events during winter. Our findings support the theory of etiological role of cold weather to the occurrence of testicular torsion. Strategies to prevent these events can be based on these findings.

Scrotal exploration for acute scrotal pain: a 10-year experience in two tertiary referral paediatric units

OBJECTIVE

Acute scrotal pain is a common presentation to the paediatric emergency department. Testicular torsion is one of the most common causes of acute scrotal pain. Testicular torsion is a surgical emergency requiring immediate surgical exploration to prevent permanent testicular damage or loss. The aim of this study was to determine the surgical outcome of all scrotal explorations and to assess the use of colour Doppler ultrasound (CDUS) in the assessment of acute scrotal pain in two tertiary referral paediatric units.

MATERIAL AND METHODS

A retrospective review of a prospectively maintained database was carried out for all scrotal explorations between 1999 and 2010.

RESULTS

In total, 155 scrotal explorations were carried out for acute scrotal pain. The mean age was 9.1 years (range 0-15 years). The pathology in 46.5% (n = 72) was testicular torsion, 30.3% (n = 47) were torsion of a testicular appendage, 16.1% (n = 25) were epididymitis, 3.3% (n = 5) had no obvious pathology identified and other pathology accounted for 4%. There was a significant difference in age of presentation between those with testicular torsion and those with torsion of a testicular appendage (9 vs 10 years, p = 0.0074). CDUS was performed by a trained radiologist on 40 patients. Overall sensitivity, specificity, positive predictive value and negative predictive value for CDUS predicting testicular torsion were 96.9%, 88.9%, 96.9% and 89%, respectively. Overall, 36 patients (23%) with acute scrotal pain (50% of patients in the group with confirmed testicular torsion at exploration) required orchidectomy.

CONCLUSION

This study supports the practice of immediate surgical exploration with a clinical suspicion of testicular torsion in a paediatric population.

Ovarian torsion: diagnosis of inclusion mandates earlier intervention

PURPOSE

The treatment of ovarian torsion (OT) is often delayed because of diagnostic uncertainty and dependence on radiologic confirmation. In contrast, when testicular torsion (TT) is suspected, diagnosis and management are expedited despite lack of certainty, and operative exploration is not delayed by radiologic investigations. We compared the management of torsion in both sexes to define a better clinical pathway for suspected OT.

METHODS

A 2.5-year review of the Pediatric Health Information System database was performed to determine the incidence of TT and OT at large children's hospitals. A 10-year retrospective review of children (0-19 years) diagnosed with TT or OT at a single academic center was performed to identify differences in diagnosis and management and determine the impact on gonadal salvage rates.

RESULTS

The incidence of TT was comparable with OT in the Pediatric Health Information System database (0.03% vs 0.02%). A total of 158 patients with TT and 90 patients with OT were managed at our center with a median age of 12 years in both groups. Boys presented earlier after the onset of pain (36 vs 72 hours, P < .0001) and were imaged more quickly (0.77 vs 1.86 hours, P < .0001). Time to operating room (OR) was also shorter for TT (2.3 vs 6.3 hours, P < .0001). The salvage rate for TT was 30.3% vs 14.4% for OT (P < .01).

CONCLUSIONS

Girls with suspected OT waited 2.5 times as long for diagnostic imaging and 2.7 times as long to be taken to the operating room. In addition, the gonadal salvage rate was significantly worse for girls compared with boys with TT. More urgent intervention for OT, with liberal use of diagnostic laparoscopy and without reliance on a definitive diagnosis by imaging, should be considered in girls with lower abdominal pain.

The acute scrotum in childhood and adolescence

BACKGROUND

The acute scrotum in childhood or adolescence is a medical emergency. Inadequate evaluation and delays in diagnosis and treatment can result in irreversible harm, up to and including loss of a testis. Various diseases can produce this clinical picture. The testis is ischemic in only about 20% of cases.

METHODS

This review is based on a selective literature search, the existing clinical guideline, and the authors' experience.

RESULTS

The clinical approach to the acute scrotum must begin with a standardized, rapidly performed diagnostic evaluation. Dopper ultrasonography currently plays a central role. Its main use is to demonstrate the central arterial blood supply and venous drainage of the testis. The resistance index of the testicular vessels should also be determined.

CONCLUSION

Physical examination and properly performed Doppler ultrasonography enable adequate evaluation of the acute scrotum in childhood and adolescence. In the rare cases of diagnostic uncertainty, immediate surgical exposure of the testis remains the treatment of choice.

Sonographic Patterns of Testicular Torsion

The objective of this study was to determine the sonographic patterns of the testes in patients with testicular torsion. Clinical data of 46 patients with testicular torsion confirmed by surgical exploration or manual detorsion were reviewed, and sonographic patterns of testicular torsion were categorized according to the sonographic characteristics of the testes, and their relation to the pathologic changes were analyzed. The sonographic appearances of testicular torsion were categorized into six patterns, reflecting pathologic changes of testicular torsion. Sonography of testicular torsion has different patterns, and recognition of these patterns may help the examiner establish a diagnosis and subsequently manage the patient.

Acute appendicitis masquerading as acute scrotum: a case report

Acute appendicitis presents typically with periumbilical pain that in a few hours settles at the right lower quadrant of the abdomen. Atypical presentations are common but association with acute scrotum is an extreme rarity. A 30-year-old fisherman presented at a rural medical facility with a 2-day complaint of severe pain at the right hemiscrotum followed about 24 hours later with mild diffuse abdominal pain. There was associated mild fever and nausea but no vomiting. There were no urinary symptoms and no recent sexual exposure. Initial physical examination revealed mild generalized tenderness worse at the right lower quadrant but the scrotum was not remarkable, and cremasteric sign was negative. He was admitted as a case of acute abdomen for close observation. Abdominal and scrotal ultrasound scan were normal. By the second day of admission, pain became marked at the right lower abdomen with associated vomiting. There was also marked tenderness at the right lower quadrant with rebound. A diagnosis of acute appendicitis was thus made and appendicectomy done after proper workup. The abdominal and scrotal pain stopped after surgery and the patient was discharged on the seventh postoperative day. Patients with unusual abdominal and scrotal pain should be admitted and closely observed and evaluated to prevent unnecessary scrotal exploration or negative appendicectomy.

Outcomes of scrotal exploration for acute scrotal pain suspicious of testicular torsion: a consecutive case series of 173 patients

OBJECTIVE

• To determine the surgical outcome of all scrotal explorations performed on patients presenting with acute scrotal pain suspicious of testicular torsion.

PATIENTS AND METHODS

• Data was collected prospectively from a consecutive case series of patients of all ages who had scrotal exploration for acute testicular pain from 1998 to 2008. • The main outcome measures were pathology found during scrotal exploration, relationship between patient age and cause of scrotal pain, orchidectomy rate and the association between testicular torsion and cold weather.

RESULTS

• Data for 173 patients out of 179 was available for analysis. • The median age of the patients was 14 (0-92) years. 51% (n = 89) had testicular torsion, 24% (n = 42) had torsion of testicular appendages, 9% (n = 16) had epididymo-orchitis, and other pathology made up 5%. • No obvious pathology was seen in 10% (n = 17). • Patients with Torsion of Appendages were significantly younger than other patients with scrotal pain (P < 0.0001). • Age was not useful in discriminating between patients with Testicular Torsion from other patients with scrotal pain. 9% (n = 16) of all patients required an orchidectomy. • Frequency of Testicular Torsion was higher during the colder half of the year (n = 0.02).

CONCLUSIONS

• Testicular torsion was the most common finding at surgical exploration, followed by torsion of testicular appendages. • Age had limited value in diagnosing the cause of acute scrotal pain. • Testicular torsion was associated with cold weather. • Our findings support the practice of surgical exploration for acute scrotal pain suspicious of testicular torsion in patients of any age.

Testicular torsion after pediatric kidney transplantation

Kidney transplantation has become the treatment of choice for children with end-stage renal disease and offers recipients an excellent quality of life. Following kidney transplantation several types of medical and surgical complications can arise. In this report, a testicular torsion occurring on the sixth day after pediatric kidney transplantation is described. It remains unclear whether this unusual complication should be regarded as coincidental or as a direct consequence of the transplantation.

Testicular torsion: sonomorphological appearance as a predictor for testicular viability and outcome in neonates and children

INTRODUCTION

Testicular torsion in children is found both in neonates [perinatal testicular torsion (PTT), <30th day of life] and in older children [testicular torsion (TT)]. Prediction of testicular viability is essential for deciding whether to perform emergency exploration surgery. The aim of the present study, therefore, was to investigate the sonomorphological parameters as predictors for testicular viability.

MATERIALS AND METHODS

All our cases of sonographically diagnosed and surgically confirmed testicular torsion (n = 25) in a 7.5-year period were reviewed. We evaluated the overall group and two subgroups, PTT (n = 9) and TT (n = 16), and assessed the following sonomorphological parameters: normal echogenicity (homogeneous), diffuse hyper-/hypoechogenicity (homogeneous) and focal hyper-/hypoechogenicity (heterogeneous). These findings were correlated with the testicular recovery rate.

RESULTS

In both groups, we found the highest recovery rates in testes with normal, homogeneous echogenicity and a zero recovery rate in testes with heterogeneous echogenicity (p = 0.0117).

CONCLUSIONS

By using the sonomorpohological criteria presented here, testicular viability can be appraised in all age groups to help determine the prognosis for testicular outcome. In PTT, a nonperfused, homogeneously appearing testis represents the initial phase of torsion. Only for this type is there hope for salvage. In addition to the intraoperative appearance, a testis that is preoperatively heterogeneous in appearance can support the decision for orchiectomy.