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Ooi SY, Tan TSE. Acute left testicular pain in a child. BMJ 2024; 385:e077516. [PMID: 38663917 DOI: 10.1136/bmj-2023-077516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Affiliation(s)
- Shin Yin Ooi
- Department of Diagnostic and Interventional Imaging, KK Women's and Children's Hospital, Singapore
| | - Timothy Shao Ern Tan
- Department of Diagnostic and Interventional Imaging, KK Women's and Children's Hospital, Singapore
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2
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Lacy A, Smith A, Koyfman A, Long B. High risk and low prevalence diseases: Testicular torsion. Am J Emerg Med 2023; 66:98-104. [PMID: 36738571 DOI: 10.1016/j.ajem.2023.01.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 01/17/2023] [Accepted: 01/20/2023] [Indexed: 01/27/2023] Open
Abstract
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.
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Affiliation(s)
- Aaron Lacy
- Department of Emergency Medicine, Washington University School of Medicine, St Louis, MS, USA.
| | - Amanda Smith
- Department of Emergency Medicine, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN, USA.
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam, Houston, TX, USA.
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Alzahrani MA, Alasmari MM, Altokhais MI, Alkeraithe FW, Alghamdi TA, Aldaham AS, Hakami AH, Alomair S, Hakami BO. Is There a Relationship Between Waking Up from Sleep and the Onset of Testicular Torsion? Res Rep Urol 2023; 15:91-98. [PMID: 36855423 PMCID: PMC9968432 DOI: 10.2147/rru.s404073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023] Open
Abstract
Testicular torsion is a serious urologic emergency that can present with unusual or atypical history and examination. Classical pain from testicular torsion is of sudden onset, significantly severe, and is accompanied by nausea and vomiting. However, in some patients, the initial scrotal pain appears to considerably subside within the next few hours. In others, testicular torsion tends to occur while sleeping, and many patients recount a history of being woken up from sleep by intense pain. Furthermore, some patients in this subset can resume normal activities and even sleep through the night with little or no discomfort, without a perceived need for pain medications. Other patients initially experience mild pain, which worsens over time. Consequently, these patients are less likely to be evaluated immediately. In view of these atypical cases, the question remains unanswered regarding sleep as a predisposing factor for testicular torsion. This narrative review focuses on exploring the association between sleep and testicular torsion.
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Affiliation(s)
- Meshari A Alzahrani
- Department of Urology, College of Medicine, Majmaah University, Al-Majmaah, Saudi Arabia,Correspondence: Meshari A Alzahrani, Department of Urology, College of Medicine, Majmaah University, Al-Majmaah, 11952, Saudi Arabia, Tel +966569990693, Fax +966164042500, Email
| | | | - Moataz I Altokhais
- Department of Urology, King Khalid University Hospital, Riyadh, Saudi Arabia
| | | | - Talal A Alghamdi
- Department of Urology, King Fahad Medical City, Riyadh, Saudi Arabia
| | | | - Alwaleed H Hakami
- College of Medicine and Surgery, Jazan University, Jazan, Saudi Arabia
| | - Saud Alomair
- College of Medicine, Majmaah University, Al-Majmaah, Saudi Arabia
| | - Basel O Hakami
- Department of Urology, King Faisal Medical City for Southern Region (KFMC), Abha, Saudi Arabia
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Zvizdic Z, Aganovic A, Milisic E, Jonuzi A, Zvizdic D, Vranic S. The Role of Demographic and Clinical Characteristics in Distinguishing Testicular Torsion from Torsion of the Appendix Testis: A Single-center Retrospective Study. Prague Med Rep 2023; 124:255-264. [PMID: 37736949 DOI: 10.14712/23362936.2023.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023] Open
Abstract
The acute scrotum (AS) in the pediatric population is a medical emergency. AS is usually caused by testicular torsion (TT) and torsion of the appendix testis (TAT). The current study explored which demographic and clinical characteristics can help distinguish between TT and TAT. We analyzed all children ≤16 years who underwent surgical exploration for AS. The patients were divided into Group 1/TT and Group 2/TAT. Ninety patients were included in the study (24 with TT and 66 with TAT). The peak incidence of TT was significantly higher than in the TAT group (p<0.001). Scrotal pain was more prevalent in the TAT group (p=0.02), whereas systemic signs (nausea/vomiting and abdominal pain) affected more frequently the TT patients (p=0.003 and p<0.001, respectively). The duration of symptoms was significantly longer in the TAT group (p<0.001). The duration of symptoms in the TT cohort significantly impacted the testicular salvage (p=0.008). Color Doppler ultrasound (CDUS) findings of absent/decreased testicular blood flow in the affected testis strongly favored the diagnosis of TT (p<0.001). The older age, shorter duration of symptoms, systemic signs, and CDUS findings can help distinguish between the two most common acute scrotum causes.
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Affiliation(s)
- Zlatan Zvizdic
- Clinic of Pediatric Surgery, University Clinical Center Sarajevo, Sarajevo, Bosnia and Herzegovina
| | | | - Emir Milisic
- Clinic of Pediatric Surgery, University Clinical Center Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Asmir Jonuzi
- Clinic of Pediatric Surgery, University Clinical Center Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Denisa Zvizdic
- Eye Clinic, University Clinical Center Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Semir Vranic
- College of Medicine, QU Health, Qatar University, Doha, Qatar.
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5
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Comparison of demographic and clinical characteristics in distinguishing testicular torsion from torsion of the appendix testis: A single-center retrospective study. Asian J Urol 2022. [DOI: 10.1016/j.ajur.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Hassell J, Kitteringham L, Hall NJ. The role of ultrasound in detecting renal tract abnormalities following a single episode of epididymitis. J Pediatr Surg 2022; 57:275-277. [PMID: 34823844 DOI: 10.1016/j.jpedsurg.2021.10.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/23/2021] [Indexed: 11/17/2022]
Abstract
AIM The aim of the study was to establish the utility of ultrasound scan in detecting renal tract abnormalities following a single episode of epididymitis. METHODS A single-centre retrospective review of all boys diagnosed with epididymitis between October 2012 and 2017 including review of follow up imaging and clinical course was completed. Primary outcome was new diagnosis of renal tract abnormality by ultrasound. MAIN RESULTS Eighty-four boys with a first diagnosis of epididymitis were identified. Sixty-four cases (76%) were diagnosed at scrotal exploration, the remaining twenty clinically. Median age was 7.30 years (range 0.08-15.83 years), and five had a positive urine culture at presentation. Forty-eight boys (57%) had a follow-up ultrasound scan (at median 4.57 weeks [range 1-31 weeks]). Only two renal tract abnormalities were identified by ultrasound scan, both in boys aged < 6 months, and neither was clinically relevant. Recurrent epididymitis occurred in 4 cases at median 26 days after initial presentation, of whom 3 had been followed up by ultrasound after initial presentation, all of which were normal. Further investigation revealed posterior urethral valves in 1 boy (age 6.5 months at initial presentation). CONCLUSION Following a single episode of epididymitis, ultrasound was not helpful at detecting clinically relevant renal tract abnormalities, and furthermore did not identify the only patient with a clinically relevant abnormality. Based on these data, we propose follow-up imaging only in boys ≤ 6 months of age with a positive urine culture or a recurrent episode with consideration given to micturating cystogram even if ultrasound normal. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Jack Hassell
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - Lara Kitteringham
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - Nigel J Hall
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK; University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, UK.
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Wynn J, McCafferty J, Dodds L. Idiopathic fat necrosis of scrotum: an important differential of childhood scrotal pain. ANZ J Surg 2022; 92:2348-2349. [PMID: 35038365 DOI: 10.1111/ans.17471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 12/22/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Jessica Wynn
- Department of Urology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Jonathan McCafferty
- Department of Urology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Lachlan Dodds
- Department of Urology, Ballarat Health Services, Ballarat, Victoria, Australia
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Parenchymal echotexture changes as a predictor of viability in testicular torsion. Emerg Radiol 2022; 29:359-363. [PMID: 34994880 DOI: 10.1007/s10140-021-02014-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 12/27/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Preoperative test that can predict the salvageability of the torsed testis may add essential information to the surgeon managing testicular torsion (TT), this can assist with patients' and parents' expectations, particularly with nonviable testes. We aimed to examine if parenchymal echotexture changes in preoperative ultrasound can predict irreversible hemorrhagic necrosis. MATERIALS AND METHODS Preoperative ultrasound studies of 154 patients with TT were reviewed by 3 raters (2 radiologists and 1 urologist). The raters were asked to categorize the affected testicular parenchymal echotexture into one of the following categories: (1) normal (identical to the contra-lateral testis), (2) homogenous hypoechoic, or (3) focal heterogeneous echotexture. Testis non-viability was defined macroscopically during surgical exploration and correlated with the US results. Sensitivity, specificity, and positive and negative predicting values of the proposed diagnostic test were calculated. Cohen's kappa coefficient was used to determine inter-rater agreement. RESULTS A total of 54/154 patients had a nonviable testis. Mean of 59.5% cases was classified as category 1, 27.3% cases as category 2, and 13.2% cases as category 3. Testicular necrosis was 12%, 34%, and 92% in each category, respectively. Category 3 classified non-viability with a mean specificity of 99.3% and with a high inter-rater agreement level (Cohen's kappa coefficient of 0.830). Mean positive predictive value of 97% and mean negative predictive value of 74.3%. The mean sensitivity of this test however was low 39.7%. CONCLUSION Ultrasound finding of focal parenchymal echotexture heterogeneous changes is highly specific although not sensitive, for nonviable testis. The presence of this finding reassures non-viability in over 99%.
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9
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Tanaka K, Kato H, Nikai K, Mikami T, Okazaki T. Testicular appendage torsion in children. Pediatr Int 2022; 64:e15010. [PMID: 34597452 DOI: 10.1111/ped.15010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 08/10/2021] [Accepted: 08/18/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Testicular appendage torsion (TAT) is a medical emergency that presents as an acute scrotum, usually in children and preadolescents. In previous reports of TAT, most cases have been treated conservatively, but some necessitate surgical treatment. Our aim was to examine the incidence, clinical examination findings, etiology, and treatment of TAT. METHODS We retrospectively reviewed records of all patients with TAT (aged ≤15 years) treated at the Juntendo University Urayasu Hospital between January 2012 and September 2020. Surgical treatment was performed when a diagnosis of testicular torsion could not be completely ruled out or if pain recurred after conservative treatment. Patients with a hard scrotum or scrotal erythema were hospitalized for conservative treatment. Data regarding age, diagnosis, blood test results, and clinical findings were analyzed. RESULTS Among 101 boys with TAT, the median age was 10 years. The incidence of TAT varied significantly according to age and was highest among patients aged 8-11 years. Sixty-seven boys (66.3%) underwent inpatient surgical treatment, 10 boys (9.9%) received inpatient conservative treatment, and 24 boys (23.8%) received outpatient conservative treatment. The median duration of hospitalization was significantly shorter among those who underwent surgery (2.0 days) than among those who received inpatient conservative treatment group (3.5 days). CONCLUSIONS Operations were short, uncomplicated, and safe; they shortened the hospital stay; and they would certainly prevent recurrence of TAT and testicular torsion on one side. Furthermore, we recommended that TAT patients presenting with signs of severe inflammation, such as hard scrotum or scrotal erythema, receive early surgical treatment to minimize duration of hospitalization.
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Affiliation(s)
- Keiichiro Tanaka
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Urayasu-shi, Japan
| | - Haruki Kato
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Urayasu-shi, Japan
| | - Koki Nikai
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Urayasu-shi, Japan
| | - Takafumi Mikami
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Urayasu-shi, Japan
| | - Tadaharu Okazaki
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Urayasu-shi, Japan
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Bermingham HN, Popplewell MA, Naumann DN, Gulamhussein MA, Liaw F, Layton GR, Fernando H, Tucker O, Bowley D, Dilworth MP. Comparing the surgical management of acute paediatric scrotal pain between adult urologists and general surgeons in the UK: an observational study. Ann R Coll Surg Engl 2021; 104:373-379. [PMID: 34939856 DOI: 10.1308/rcsann.2021.0190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Acute scrotal pain is a common paediatric surgical emergency. Assessment and timely exploration are required to rule out testicular torsion (TT) and prevent unnecessary morbidity. METHODS A retrospective observational cohort study was carried out at two district general hospitals in the UK for boys aged ≤16 years presenting with acute scrotal pain between January 2014 and October 2017 managed by adult general surgery (AGS) at one hospital and adult urology (AU) at the other. RESULTS Some 565 patients were eligible for inclusion (n=364 AGS, n=201 AU). A higher proportion of patients underwent surgical exploration at AGS compared with AU (277/346 (80.1%) vs 96/201 (47.8%); p<0.001). Of those who underwent exploration, 101/373 (27.1%) had TT, of whom 25/101 (24.8%) underwent orchidectomy and 125/373 (33.5%) had torted testicular appendage. There was no statistically significant difference in rates of orchidectomy between AGS (19/68, 27.9%) and AU (6/33, 18.2%) with testicular salvage rates of 72.1% and 81.8%, respectively (p=0.334). Patients were twice as likely to be readmitted at AGS as at AU (28/346 (8.1%) vs 8/201 (4.0%); p=0.073). CONCLUSION Although intraoperative findings were similar between adult general surgeons and urologists, there were significant differences in surgical management, with a higher rate of surgical exploration by general surgeons. Testicular salvage and 30-day postoperative morbidity rates at both institutions were acceptable but the readmission rate was high at 6.6%. It is not known why there is a heterogeneity in management of acute scrotal pain between specialist centres, and further prospective investigations are warranted.
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Affiliation(s)
- H N Bermingham
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - M A Popplewell
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - D N Naumann
- University Hospitals Birmingham NHS Foundation Trust, UK
| | | | - F Liaw
- University Hospital of North Midlands NHS Trust, UK
| | - G R Layton
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - H Fernando
- University Hospital of North Midlands NHS Trust, UK
| | - O Tucker
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - D Bowley
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - M P Dilworth
- University Hospitals Birmingham NHS Foundation Trust, UK
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11
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Muraliharan JS, Jacob TJK, Bollu BK, Graf N, Sebastian T, Thomas G. Surgical management of the acute paediatric scrotum: a three-year single centre experience. ANZ J Surg 2021; 91:2514-2517. [PMID: 34585831 DOI: 10.1111/ans.17231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acute scrotal pain is a common emergency presentation in paediatric surgery. Torsion of the testicular appendage (TTA) is the most common cause for pain, with testicular torsion (TT) being the sinister pathology to exclude. Outcomes are time dependent, and a delayed scrotal exploration could result in testicular loss. METHODS We performed a review on a large retrospective cohort of 449 surgical scrotal explorations at a large referral paediatric surgical centre over three years. RESULTS Only about a quarter of children with testicular pain presented within 4 h. TT is commonly associated with nausea and an abnormal lie. Two children with a classical 'blue dot' sign were later found to have a testicular torsion. 19% of all children with a TTA were also seen to have Bell clapper anomaly (BCA). Recurrent testicular pain was associated with 84.7% (p < 0.001) of BCA. Intra-operative diagnosis of TTA correlated with histopathology in 84.6% (p=0.021). The sensitivity of intraoperative diagnosis was 90.9% with a specificity of 75.3%. CONCLUSION Routine histopathology for a classic TTA may not be required especially in resource poor situations. All children presenting with recurrent episodes of testicular pain must be considered for surgical scrotal exploration. And in view of the incidence of BCA in this cohort, all scrotal explorations for acute scrotal pain should include an assessment for BCA.
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Affiliation(s)
| | - Tarun John K Jacob
- Department of Paediatric Surgery, Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Department of Paediatric Surgery, Christian Medical College, Vellore, India
| | - Bapesh Krishna Bollu
- Department of Paediatric Surgery, Children's Hospital at Westmead, Sydney, New South Wales, Australia.,School of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Nicole Graf
- School of Medicine, University of Sydney, Sydney, New South Wales, Australia.,Department of Pathology, Children's Hospital Westmead, Sydney, New South Wales, Australia
| | - Tunny Sebastian
- Department of Paediatric Surgery, Christian Medical College, Vellore, India.,Department of Clinical Nutrition, College of Applied Medical Science, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Gordon Thomas
- Department of Paediatric Surgery, Children's Hospital at Westmead, Sydney, New South Wales, Australia.,School of Medicine, University of Sydney, Sydney, New South Wales, Australia
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Nakayama A, Ide H, Osaka A, Inoue Y, Shimomura Y, Iwahata T, Kobori Y, Saito K, Soh S, Okada H. The Diagnostic Accuracy of Testicular Torsion by Doctors on Duty Using Sonographic Evaluation with Color Doppler. Am J Mens Health 2021; 14:1557988320953003. [PMID: 32993407 PMCID: PMC7533943 DOI: 10.1177/1557988320953003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Akinori Nakayama
- Department of Urology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Hisamitsu Ide
- Department of Urology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Akiyoshi Osaka
- Department of Urology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Yasuyuki Inoue
- Department of Urology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Yukihito Shimomura
- Department of Urology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Toshiyuki Iwahata
- Department of Urology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Yoshitomo Kobori
- Department of Urology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Kazutaka Saito
- Department of Urology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Shigehiro Soh
- Department of Urology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Hiroshi Okada
- Department of Urology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
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13
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Gopal M, O'Connor E, McDonald L, Goaman A, Radford A, Melling C, Henneyake S, Kumbhar V, Dagash H. Emergency scrotal exploration in children: Is it time for a change in mindset in the UK? J Pediatr Urol 2021; 17:190.e1-190.e7. [PMID: 33317943 DOI: 10.1016/j.jpurol.2020.11.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 11/18/2020] [Accepted: 11/21/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Acute scrotal pain is a common problem in children. Amongst the various causes, only testicular torsion (TT) needs urgent, and arguably any, surgical intervention. However TT accounts for only approximately 25% of cases. The diagnosis of TT is currently based mainly on history and clinical examination in the UK. OBJECTIVE We sought to find the incidence of finding TT during emergency scrotal exploration in four paediatric surgical centres in the UK. We also assessed the preoperative utilisation of clinical risk scores and Doppler ultrasound (DUS) to aid in the diagnosis. PATIENTS AND METHODS A retrospective review of 50 consecutive scrotal explorations done for acute scrotal pain at four tertiary pediatric surgical centres in 2019, including the preoperative utilisation of DUS, was analysed. Additionally an online survey was also sent out to consultant members of the British Association of Paediatric Urology to gauge their threshold for exploration, use of preoperative investigations and incidence of finding TT in their practice. RESULTS In the four UK centres reviewed, TT was found in 24.5% (SD = 8.54) of explorations. The overall utilisation of preoperative DUS was 10%. The online survey revealed a low threshold for exploration. However 72% of respondents recalled finding TT in <50% of explorations, with just over a third reporting finding TT in only 10% of explorations. There was low utilisation of preoperative DUS and clinical risk scores. DISCUSSION The incidence of finding TT during exploration in this cohort is the same as the incidence of TT in a population of children presenting with acute scrotal pain. We hypothesise that this is due to low accuracy of clinical assessment, low utilisation of preoperative clinical and radiological aids and the practice of exploring torted testicular appendages. Improving awareness and training in these modalities will increase diagnostic accuracy, limiting emergency scrotal explorations to those children with a higher risk of testicular torsion. A care pathway for children presenting with acute scrotal pain is suggested () CONCLUSIONS: There is a low incidence of finding testicular torsion during paediatric scrotal explorations in the UK. There is low preoperative utilisation of clinical risk scores and Doppler ultrasound, which if utilised, could improve diagnostic accuracy.
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Affiliation(s)
- Milan Gopal
- Great North Children's Hospital, Queen Victoria Road, Newcastle Upon Tyne, NE1 4LP, UK.
| | - Elizabeth O'Connor
- Great North Children's Hospital, Queen Victoria Road, Newcastle Upon Tyne, NE1 4LP, UK
| | - Leigh McDonald
- Great North Children's Hospital, Queen Victoria Road, Newcastle Upon Tyne, NE1 4LP, UK
| | - Amy Goaman
- Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, UK
| | - Anna Radford
- Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, UK
| | - Charlotte Melling
- Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Supul Henneyake
- Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Vikrant Kumbhar
- Leicester Royal Infirmary, Infirmary Square, Leicester, LE1 5WW, UK
| | - Haitham Dagash
- Leicester Royal Infirmary, Infirmary Square, Leicester, LE1 5WW, UK
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14
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Duration of symptoms is the only predictor of testicular salvage following testicular torsion in children: A case-control study. Am J Emerg Med 2020; 41:197-200. [PMID: 33221112 DOI: 10.1016/j.ajem.2020.11.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 11/11/2020] [Indexed: 11/20/2022] Open
Abstract
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.
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Syed MK, Al Faqeeh AA, Othman A, Hussein AA, Hussain S, Almas T, Alsufyani R, Alaeddin H, Syed S, Syed SK. The Spectrum of Testicular Pathologies Upon Scrotal Exploration for Acute Scrotum: A Retrospective Analysis. Cureus 2020; 12:e10984. [PMID: 33209540 PMCID: PMC7667721 DOI: 10.7759/cureus.10984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background The term acute scrotum encompasses a plethora of testicular pathologies that are detrimental to the survival and sustenance of testes. The aim of the present study is to determine the spectrum of these testicular pathologies upon scrotal exploration performed in the aftermath of acute scrotal pain in the pediatric population. Methods This multicenter retrospective cross-sectional study was conducted at the department of pediatric surgery at two hospitals. During the study period, the clinical characteristics of the 76 patients that underwent scrotal exploration for acute scrotum were assessed. These included age, duration of symptoms on presentation, and identification of the etiology underlying scrotal pain. The data obtained was eventually analyzed using the Statistical Package for the Social Sciences (SPSS) 23.0 software (IBM Corp., Armonk, NY). Results A total of 76 scrotal exploration procedures were performed. The involvement of the left side of the scrotum was more common than the right side. Most of the patients who presented were older than five years of age. A majority of the patients presented after 24 hours of the commencement of their symptoms. Of the included participants, 36 patients (47.47%) were found to have an underlying torsion of appendix testes that was appropriately managed. Testicular torsion was observed in 15 patients, out of which eight viable testes were salvaged with a subsequent orchidopexy while seven torsions required orchiectomy owing to their non-viability. Other findings included epididymo-orchitis and infected hydrocele. A total of 19 testes appeared completely normal upon scrotal exploration. Conclusion Scrotal exploration should be considered as part of the medical and surgical workup and in the management of acute scrotum, as it divulges the specific underlying testicular pathology. Prompt scrotal exploration can aid in ascertaining the underlying etiology and is, therefore, pivotal in the apt management of the underlying pathology.
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Affiliation(s)
| | | | - Alsayed Othman
- Pediatric Surgery, Al-Azhar University - Assuit Branch, Assuit, EGY
| | | | - Salman Hussain
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Talal Almas
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Reema Alsufyani
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Hasan Alaeddin
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Saifullah Syed
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Sabahat K Syed
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
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16
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Tanaka K, Ogasawara Y, Nikai K, Yamada S, Fujiwara K, Okazaki T. Acute scrotum and testicular torsion in children: a retrospective study in a single institution. J Pediatr Urol 2020; 16:55-60. [PMID: 31874735 DOI: 10.1016/j.jpurol.2019.11.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 11/20/2019] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Testicular torsion (TT), as per the reported incidences in children and preadolescents, is an emergency medical condition that requires prompt surgical treatment. In cases of TT, early and accurate diagnosis of acute scrotum (AS) is important to preserve testicular fertility. In this study, the authors aimed to determine the incidence, clinical examination, etiology, clinical predictors, and treatment of patients with AS and TT. MATERIAL AND METHODS The authors retrospectively reviewed all children (age, ≤15 years) with AS who visited their hospital between January 2012 and June 2019. Data on age and diagnosis, clinical findings, mode of treatment, and blood examination results were collected. RESULTS The authors examined 165 children aged between 0 days and 15 years (mean age, 9.4 years). Final diagnosis identified 72 patients with torsion of the appendix testis, 44 patients with epididymitis, and 38 patients with TT. Testes were salvaged in 23 of the 38 patients with TT (60.5%). Statistically significant variables revealed that the risk factors of TT were age (older than 12 years), white blood cell (WBC) count (>12,000 cells/mm3), and laterality (left side). The level of C-reactive protein (CRP), duration of symptoms, and degree of torsion were significantly higher in the non-salvageable testis group than in the salvageable testis group. Furthermore, the significant predictive factor for non-salvageable testis was the level of CRP >1.0 mg/dl. CONCLUSION The study results indicates that age, WBC count, and laterality are key factors to distinguish TT from AS. Salvageability largely depended on the duration of symptoms and the degree of TT. The salvage rate of the testis can be improved by educating pediatricians, parents, patients, and medical staff about the early diagnosis and treatment of torsion.
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Affiliation(s)
- Keiichiro Tanaka
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, 2-1-1, Tomioka, Urayasu-shi, Chiba, 279-0021, Japan.
| | - Yuki Ogasawara
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, 2-1-1, Tomioka, Urayasu-shi, Chiba, 279-0021, Japan
| | - Koki Nikai
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, 2-1-1, Tomioka, Urayasu-shi, Chiba, 279-0021, Japan
| | - Shunsuke Yamada
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, 2-1-1, Tomioka, Urayasu-shi, Chiba, 279-0021, Japan
| | - Kentaro Fujiwara
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, 2-1-1, Tomioka, Urayasu-shi, Chiba, 279-0021, Japan
| | - Tadaharu Okazaki
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, 2-1-1, Tomioka, Urayasu-shi, Chiba, 279-0021, Japan
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17
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Abstract
A subset of testicular torsion patients report resolution of their initial severe pain that is followed by variable periods of hours to days of reduced or absent pain. Other patients report only mild pain that is described as gradual in onset. Because of delayed initial presentations or less than timely returns for secondary evaluation, these pain honeymoons may be partially responsible for poor clinical outcomes of the torsed spermatic cords and ischemic testicles.
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18
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Tan Tanny SP, Wijekoon N, Pacilli M, Nataraja RM. Clinical state of the paediatric acute scrotum in south-eastern Victoria. ANZ J Surg 2019; 89:1615-1619. [PMID: 31508881 DOI: 10.1111/ans.15399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 06/29/2019] [Accepted: 07/10/2019] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Sharman P Tan Tanny
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Naveen Wijekoon
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Maurizio Pacilli
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Ramesh M Nataraja
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
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19
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Davies SJ, Copping R, Kumar R. Idiopathic scrotal fat necrosis: an unusual cause of scrotal pain. BMJ Case Rep 2018; 2018:bcr-2017-224087. [PMID: 29666095 DOI: 10.1136/bcr-2017-224087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The clinical differential diagnosis of scrotal pain with a mass in a prepubertal boy is difficult. Often conditions such as testicular torsion and epididymo-orchitis are diagnosed. We present a rare cause of scrotal pain, idiopathic scrotal fat necrosis. This condition has a typical clinical presentation and ultrasound findings that have been described in a limited number of case reports. However, if it is diagnosed correctly and confirmed with ultrasound, we hope that people will be treated without surgical intervention. We present a case of scrotal wall necrosis and a literature review.
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Affiliation(s)
- Samuel John Davies
- Medicine, University of Sydney, Camperdown, New South Wales, Australia.,Paediatric Surgery, John Hunter Children's Hospital, New Lambton, Australia
| | - Ross Copping
- Radiology, John Hunter Hospital, New Lambton, New South Wales, Australia
| | - Rajendra Kumar
- Paediatric Surgery, John Hunter Children's Hospital, New Lambton, Australia
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20
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Abstract
Urologic emergencies can involve the kidneys, ureters, bladder, urethra, penis, scrotum, or testicles. History and physical examination are essential to diagnosis, whereas imaging is increasingly used to confirm diagnoses. Acute urinary retention should be relieved with Foley placement. Penile emergencies include paraphimosis, which can be treated by foreskin reduction, whereas penile fracture and priapism require urologic intervention. Fournier gangrene and testicular torsion are scrotal emergencies requiring emergent surgery. Nephrolithiasis, although painful, is not an emergency unless there is concern for concomitant urinary tract infection, both ureters are obstructed by stones, or there is an obstructing stone in a solitary kidney.
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Affiliation(s)
- Adarsh S Manjunath
- Department of Urology, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue 16-703, Chicago, IL 60611, USA
| | - Matthias D Hofer
- Department of Urology, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue 16-703, Chicago, IL 60611, USA.
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21
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Bandarkar AN, Blask AR. Testicular torsion with preserved flow: key sonographic features and value-added approach to diagnosis. Pediatr Radiol 2018; 48:735-744. [PMID: 29468365 PMCID: PMC5895684 DOI: 10.1007/s00247-018-4093-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/02/2018] [Accepted: 01/19/2018] [Indexed: 11/30/2022]
Abstract
Testicular sonography has contributed greatly to the preoperative diagnosis of testicular torsion in the pediatric patient and is the mainstay for evaluation of acute scrotal pain. Despite its high sensitivity and specificity, both false-negative and false-positive findings occur. Presence of documented Doppler flow within the testis might be a dissuading factor for surgical exploration with resultant testicular loss in the false-negative cases. Our goal is to illustrate key sonographic features in the spectrum of testicular torsion with preserved testicular flow, and to describe how to differentiate testicular torsion from epididymitis in order to avoid the under-diagnosis of testicular torsion. We simplify the anatomy of the bell clapper testis. We also describe our sonographic protocol for testicular torsion and share valuable tips from our approach to challenging cases.
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Affiliation(s)
- Anjum N. Bandarkar
- Department of Radiology, Mid-Atlantic Permanente Medical Group, 1890 Metro Center Drive, Reston, VA 20190 USA
| | - Anna R. Blask
- Department of Radiology, Children’s National Health System, Washington, DC USA
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22
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McBride CA, Patel B. Acutely painful scrotum: Tips, traps, tricks and truths. J Paediatr Child Health 2017; 53:1054-1059. [PMID: 29148188 DOI: 10.1111/jpc.13766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 09/28/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Craig A McBride
- Surgical Team: Infants, Toddlers, Children (STITCh), Lady Cilento Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia.,Discipline of Paediatrics and Child Health, School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Bhaveshkumar Patel
- Surgical Team: Infants, Toddlers, Children (STITCh), Lady Cilento Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia.,Discipline of Paediatrics and Child Health, School of Medicine, University of Queensland, Brisbane, Queensland, Australia
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23
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Demirbas A, Demir DO, Ersoy E, Kabar M, Ozcan S, Karagoz MA, Demirbas O, Doluoglu OG. Should manual detorsion be a routine part of treatment in testicular torsion? BMC Urol 2017; 17:84. [PMID: 28915866 PMCID: PMC5602835 DOI: 10.1186/s12894-017-0276-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 09/05/2017] [Indexed: 11/17/2022] Open
Abstract
Background It was aimed to investigate the efficiency and reliability of the manual detorsion (MD) procedure in patients diagnosed with testicular torsion (TT). Methods A retrospective analysis was made of the data of 57 patients diagnosed with TT, comprising 20 patients with successful MD (Group I), 28 patients who underwent emergency orchiopexy (Group II), and 9 patients applied with orchiectomy (Group III). The groups were compared in respect of age, and duration of pain. The success rate of MD, the time of testicular fixation (TF), any problems encountered in follow-up, and follow-up times were analyzed in Group I. Data were analyzed with P-P pilot, Mann-Whitney U, Kruskal Wallis and Chi-square tests. A value of p < 0.05 was considered statistically significant. Results MD was successful and detorsion could be achieved in 20 of 26 patients. The groups were similar in respect of age (p = 0.217). The median duration of pain was 3 (1–8), 4 (1–72), and 48 (12–144) hours in Groups I, II, and III, respectively, and determined as similar in Groups I and II (p = 0.257), although a statistically significant difference was determined between the 3 groups (p < 0.001). TF was applied to Group I after median 10 (0–45) days, and no parenchymal disorder was determined in the median follow-up period of 21.5 (2–40) months. Conclusion MD that can be easily and immediately performed after the diagnosis of TT decreases ischemia time. This seems to be an efficient and reliable procedure when applied together with elective orchiopexy, as a part of the treatment. Electronic supplementary material The online version of this article (10.1186/s12894-017-0276-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Arif Demirbas
- Department of Urology, Ankara Training and Research Hospital, 06340, Sukriye, Altındağ Ankara, Turkey.
| | - Demirhan Orsan Demir
- Department of Urology, Ankara Training and Research Hospital, 06340, Sukriye, Altındağ Ankara, Turkey
| | - Erim Ersoy
- Department of Urology, Ankara Training and Research Hospital, 06340, Sukriye, Altındağ Ankara, Turkey
| | - Mucahit Kabar
- Department of Urology, Ankara Training and Research Hospital, 06340, Sukriye, Altındağ Ankara, Turkey
| | - Serkan Ozcan
- Department of Urology, Ankara Training and Research Hospital, 06340, Sukriye, Altındağ Ankara, Turkey
| | - Mehmet Ali Karagoz
- Department of Urology, Ankara Training and Research Hospital, 06340, Sukriye, Altındağ Ankara, Turkey
| | - Ozgecan Demirbas
- Department of Pediatrics, Ankara Dr. Sami Ulus Women Health, Children's Training and Research Hospital, 06340, Ankara, Turkey
| | - Omer Gokhan Doluoglu
- Department of Urology, Ankara Training and Research Hospital, 06340, Sukriye, Altındağ Ankara, Turkey
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Dias AC, Alves JR, Buson H, Oliveira PGD. The Amount of spermatic cord rotation magnifies the timerelated orchidectomy risk in intravaginal testicular torsion. Int Braz J Urol 2017; 42:1210-1219. [PMID: 27619663 PMCID: PMC5117979 DOI: 10.1590/s1677-5538.ibju.2016.0166] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 05/23/2016] [Indexed: 12/02/2022] Open
Abstract
Purpose To investigate the roles of age, testicular rotation and time in the surgical outcome of intravaginal testicular torsion (iTT). Patients and Methods We retrieved the records of all iTT patients treated in our unit from January 2012 to January 2014. Explanatory variables were: age (years); presentation delay (PrD, time between symptoms and hospitalization); surgical delay (SurgD, time between hospitalization and surgery) and testicular rotation (rotation), with surgical outcome (orchidopexy, orchidectomy) as response variable. Differences in PrD, SurgD, age and rotation by surgical outcome were evaluated non-parametrically. Step-down logistic regression included age, PrD, SurgD and rotation as predictors. Statistical significance and confidence intervals (CI) were set at p<0.05 and 0.95. Odds ratios (OR) were computed from the model's coefficients. Results Complete variable information was available for 117 patients, and most (61, 52.1%) underwent orchidectomy. Ages were similar between orchidectomy and orchidopexy patients (median 15.8 vs. 16.0 years, p=0.78). In contrast, PrD (85.0 vs. 8.4 hours, p<0.001), SurgD (3.0 vs. 16.0 hours, p<0.001) were different between orchidectomy and orchidopexy patients. SurgD was similar with PrD<24 hours (4.0 vs. 2.8, p=0.1). Orchidectomy patients had greater rotation (3.0π vs. 2.0π radians, p<0.001). Logistic regression revealed that PrD (OR 0.94; 0.92–0.97; p<0.001) and rotation (OR 0.43; 0.27–0.70; p<0.001) were inversely associated with orchidopexy. Conclusion Testicular rotation exerts a multiplicative effect on PrD, so time should not be regarded as the sole predictor of surgical outcome in iTT.
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Affiliation(s)
| | - João Ricardo Alves
- Serviço de Urologia, Hospital de Base do Distrito Federal, Brasília, DF, Brasil
| | - Hélio Buson
- Serviço de Cirúrgica Pediátrica do Hospital de Base do Distrito Federal, Brasília, DF, Brasil
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Lala S, Price N, Upadhyay V. Re‐presentations and recurrent events following initial management of the acute paediatric scrotum: a 5‐year review. ANZ J Surg 2017; 89:E117-E121. [DOI: 10.1111/ans.13905] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 12/15/2016] [Accepted: 12/21/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Shareena Lala
- Department of Paediatric Surgery and UrologyStarship Children's Health Auckland New Zealand
| | - Neil Price
- Department of Paediatric Surgery and UrologyStarship Children's Health Auckland New Zealand
| | - Vipul Upadhyay
- Department of Paediatric Surgery and UrologyStarship Children's Health Auckland New Zealand
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26
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Mäkelä E, Lahdes-Vasama T, Rajakorpi H, Wikström S. A 19-Year Review of Paediatric Patients with Acute Scrotum. Scand J Surg 2016; 96:62-6. [PMID: 17461315 DOI: 10.1177/145749690709600112] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and Aims: The aim of the study was to compare incidence, symptoms and signs of spermatic cord torsion to those of other conditions causing acute scrotum. Material and Methods: Records of 388 consecutive boys under 17 years of age treated for acute scrotum at The Hospital for Children and Adolescents in Helsinki in 1977–1995 were reviewed. During the period studied all patients with acute scrotum underwent urgent surgery to ensure accurate diagnosis and treatment. The duration and characteristics of the symptoms, clinical findings prior to operation and the age of the patients were registered. Results: Scrotal explorations revealed 100 cases (26%) of spermatic cord torsion (SCT), 174 cases (45%) of torsion of the testicular appendage (AT), 38 cases (10%) of epididymitis (ED), 32 cases (8%) of incarcerated inquinal hernias and 44 (11%) other conditions. During the first year of life SCT was the most common cause of acute scrotum, another peak incidence being in adolescence. Almost half of the boys with AT were nine to 12 years of age (median 11). Except for infants, the patients' acute symptoms were pain (SCT 88%, AT 94%, ED 76%). Swelling in the hemiscrotum was found in 44% of SCT, in 39% of AT and in 88% of ED cases. Epididymitis was also accompanied by erythema (37%), but infrequently with fever (in 16%). Erythema was found also in AT (32%), but the “blue dot sign” was found positive in only 17 (10%) of the boys with AT. Three quarters of the boys who were operated on within six hours from onset of symptoms had testicle torsion. All testicles were saved when detorsion was performed within six hours, but salvage was possible in only half of the cases when symptoms had lasted more than six but less than 12 hours. Conclusions: The high probability of SCT among those admitted to an emergency department within six hours from the onset of the symptoms justifies immediate surgical exploration.
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Affiliation(s)
- E Mäkelä
- Department of Paediatric Surgery, Paediatric Research Centre, Tampere University Hospital, Tampere, Finland.
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27
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Hart J, Pastore G, Jones M, Barker A, Khosa J, Samnakay N. Chronic orchalgia after surgical exploration for acute scrotal pain in children. J Pediatr Urol 2016; 12:168.e1-6. [PMID: 26776747 DOI: 10.1016/j.jpurol.2015.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 11/27/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The aim was to review the pediatric cohort undergoing surgical exploration for acute scrotal pain at our institution and assess the entity of chronic orchalgia post exploration in this cohort. MATERIALS AND METHODS A retrospective review of all pediatric patients who underwent surgery for acute scrotal pain at a single institution between 1 January 2001 and 1 January 2012 was conducted. RESULTS A total of 1084 patients underwent scrotal exploration for acute scrotal pain where the underlying cause could not be clinically ascertained. Causes found at exploratory surgery are shown in the table. Forty-four children (4.1%) re-presented with another episode of acute scrotal pain and underwent re-exploration. A hundred of the 772 children with testicular appendage torsion at initial exploration had unilateral exploration only. Seven (7%) of these re-presented with contralateral appendage torsion. The complication rate of initial scrotal exploration was 5.6% and that of re-exploration was 6.8%. All complications were managed conservatively except for a painful reactive hydrocele that underwent the Jaboulay procedure. Fifteen (1.4%) children in this cohort developed chronic orchalgia. Thirteen (87%) of these had definite pathology found at initial exploration. One of 61 (2%) with postoperative complications (a reactive hydrocele) developed chronic orchalgia. Pediatric chronic pain specialists were consulted for all patients. In 10 of the 15 (67%), significant comorbidities included constipation, anxiety, somatization, hydrocele, dysfunctional voiding, and multiple joint pain. The Jaboulay procedure for reactive hydrocele and re-exploration to pex the testes due to suspected intermittent testicular torsion resolved chronic orchalgia in one patient each. DISCUSSION Pediatric chronic orchalgia post exploration is uncommon. It has a multifactorial etiology. Comorbidities are common. It is possible that some unexplored patients labeled as chronic orchalgia in the literature may have underlying correctable pathology. Surgically correctable pathology such as intermittent testicular torsion, metachronous testicular appendage torsion, and symptomatic hydrocele or varicocele should be excluded in children with chronic orchalgia. Chronic pain specialists should be consulted and associated comorbidities managed. Prior surgical exploration and testicular fixation in children with chronic orchalgia helped reassure patients and families that there was no underlying surgical cause for the pain and facilitated compliance with chronic pain management. CONCLUSIONS Pediatric chronic orchalgia has a multifactorial etiology and is uncommon after scrotal exploration surgery. Comorbidities are common and must be managed. Surgical exploration helps reassure patients that there is no correctable cause for the pain and facilitates engagement with chronic pain management.
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Affiliation(s)
- Jodi Hart
- University of Western Australia, Perth, Australia; Princess Margaret Hospital for Children, Perth, Australia
| | | | - Matthew Jones
- Princess Margaret Hospital for Children, Perth, Australia
| | - Andrew Barker
- Princess Margaret Hospital for Children, Perth, Australia
| | - Japinder Khosa
- Princess Margaret Hospital for Children, Perth, Australia
| | - Naeem Samnakay
- University of Western Australia, Perth, Australia; Princess Margaret Hospital for Children, Perth, Australia.
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28
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Epididymo-orchitis in an extremely preterm infant. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2016. [DOI: 10.1016/j.epsc.2016.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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29
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Fehér ÁM, Bajory Z. A review of main controversial aspects of acute testicular torsion. JOURNAL OF ACUTE DISEASE 2016. [DOI: 10.1016/j.joad.2015.06.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Yu Y, Zhang F, An Q, Wang L, Li C, Xu Z. Scrotal Exploration for Testicular Torsion and Testicular Appendage Torsion: Emergency and Reality. IRANIAN JOURNAL OF PEDIATRICS 2015. [PMID: 26199690 PMCID: PMC4505972 DOI: 10.5812/ijp.248] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Scrotal exploration is considered the procedure of choice for acute scrotum. OBJECTIVES We evaluated the importance of early diagnosis and testicular salvage on the therapeutic outcomes of patients with pediatric testicular torsion (TT) and testicular appendage torsion (TAT) in our geographic area. PATIENTS AND METHODS We performed a retrospective database analysis of patients who underwent emergency surgery for TT or TAT between January 1996 and June 2009. Patient history, physical examination findings, laboratory test results, color Doppler sonography (CDS) results, and surgical findings were reviewed. RESULTS A total of 65 cases were included in our analysis. Forty-two cases were followed up for at least 3 months. Testicular tenderness was identified as the major clinical manifestation of TT, while only a few patients with TAT presented with swelling. CDS was an important diagnostic modality. The orchiectomy rate was 71% in the TT group. CONCLUSIONS Cases of acute scrotum require attention in our area. Early diagnosis and scrotal exploration could salvage the testis or preserve normal function without the need for surgery.
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Affiliation(s)
- You Yu
- Department of Pediatric Surgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Feng Zhang
- Department of Radiation Oncology, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Qun An
- Department of Pediatric Surgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Long Wang
- Department of Pediatric Surgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Chao Li
- Department of Pediatric Surgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Zhilin Xu
- Department of Pediatric Surgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
- Corresponding author: Zhilin Xu, Department of Pediatric Surgery, First Affiliated Hospital of Harbin Medical University, Harbin 150001, China. Tel: +86-45185555139, Fax: +86-45153670428, E-mail:
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Gkentzis A, Lee L. The aetiology and current management of prepubertal epididymitis. Ann R Coll Surg Engl 2014; 96:181-3. [PMID: 24780779 PMCID: PMC4474044 DOI: 10.1308/003588414x13814021679311] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2013] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The aim of this study was to review the published evidence on the pathogenesis and management of acute epididymitis (AE) in prepubertal boys after the authors encountered an unexpectedly large number of such cases in their institution. METHODS Using MEDLINE(®), a literature search was performed for articles in English with the words "pre-pubertal" OR "boys" OR "p(a)ediatric" OR "children" AND "epididymitis" OR "epididymo-orchitis". RESULTS The literature suggests that it is rare to find a bacterial infection or anatomical anomaly as a cause for AE in this population. A postviral infectious phenomenon is the most likely explanation. The management should be supportive and antibiotics reserved for those with pyuria or positive cultures. Urodynamic studies and renal tract ultrasonography have been advocated for those with recurrent epididymitis. CONCLUSIONS AE in prepubertal boys is more common than believed previously. A careful history for recent viral illnesses should be included. Antibiotics, urinary tract imaging and functional studies should be used in selected cases.
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Goirand M, Berthaud R, Al Ikhtiar I, Lachtar M, Montoro J, Walter-Nicolet E. Orchi-épididymite néonatale : une affection rare révélatrice d’un sepsis secondaire à streptocoque du groupe B. Arch Pediatr 2014; 21:219-22. [DOI: 10.1016/j.arcped.2013.11.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 10/03/2013] [Accepted: 11/26/2013] [Indexed: 11/26/2022]
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Moslemi MK, Kamalimotlagh S. Evaluation of acute scrotum in our consecutive operated cases: a one-center study. Int J Gen Med 2014; 7:75-8. [PMID: 24470769 PMCID: PMC3896279 DOI: 10.2147/ijgm.s52413] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Purpose The purpose of the present study was to evaluate the clinical history, demographic data, surgical exploration findings, and final diagnoses in all young males presenting with acute scrotum to our center. Materials and methods This was a descriptive–retrospective study in which all consecutive cases of acute scrotum treated in our department from March 2008 to March 2012 were evaluated. Results A total of 116 cases were included in the study. Out of these cases, 100 cases underwent surgical exploration, and the remaining 16 cases were managed conservatively. Our eligible cases were divided into three groups: the testicular torsion (TT) group (68%); the torsion of the appendix testis (AT) group (20%); and the epididymo-orchitis (EO) group (9%). Testicular preservation was achieved in 39 cases of the TT group, while due to delayed referral, orchiectomy was performed in 29 cases. Thus, our testicular salvage rate was 57.5% and missed testicular torsion rate was 42.5%. Conclusion It was observed that our testicular salvage rate was lower than the expected figures published in the literature. This is may be attributed to different causes, including delayed referral or presentation of acute scrotum cases, inadequate knowledge of the general practitioners working in emergency departments, or poor knowledge of parents.
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Affiliation(s)
- Mohammad Kazem Moslemi
- Department of Urology, Kamkar Hospital, School of Medicine, Qom University of Medical Sciences, Qom, Iran
| | - Sharifeh Kamalimotlagh
- Department of Urology, Kamkar Hospital, School of Medicine, Qom University of Medical Sciences, Qom, Iran
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Shteynshlyuger A, Yu J. Familial testicular torsion: a meta analysis suggests inheritance. J Pediatr Urol 2013; 9:683-90. [PMID: 23017841 DOI: 10.1016/j.jpurol.2012.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 08/10/2012] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Familial occurrence of testicular torsion has been infrequently reported. To date, no systematic analysis has been published. We systematically analyzed the literature to elucidate the epidemiology, presentation, management, and whether the observed prevalence of testicular torsion in families is consistent with absence of inheritance and is randomly distributed. PATIENTS AND METHODS We searched electronic databases using keywords "testicular torsion", "spermatic cord torsion", "familial torsion" and "sibling torsion". Reports with genetically related first degree relatives were included in the analysis. Levene's nonparametric test was used to compare the variance of the age of presentation within families to that between different families to differentiate between familial predisposition and chance events. RESULTS Up to 10% of patients with testicular torsion have an affected first degree relative. We were able to reject the null hypothesis that the observed prevalence of testicular torsion is due to chance (p < 0.001). Family history is missed in at least 27% of affected families. There is a high incidence of bilateral testicular torsion in families (37%) and probands (17%) and a high concordance rate for bilaterality among monozygous twins. CONCLUSIONS Current evidence from clinical and animal studies suggests the presence of a genetically determined component in familiar testicular torsion. Increased awareness may lead to earlier clinical presentation and higher testicular salvage rates.
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Affiliation(s)
- Alex Shteynshlyuger
- Phoenixville Urology Associates, 824 Main St Ste 203, Phoenixville, PA 19460, USA.
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Torsion of a benign cyst of the tunica vaginalis presenting as an acute scrotum: A case report and literature review. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2013. [DOI: 10.1016/j.epsc.2013.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
The current opinion on spermatic cord torsion is discussed in this review, with special attention to natural history, value of diagnostic tools, evidence for surgical management, outcome and management of atypical forms of torsion.
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Affiliation(s)
- Marcel Drlík
- Department of Urology, General Teaching Hospital and 1st Medical School of Charles University, Ke Karlovu 6, 128 08 Praha 2, Czech Republic.
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Altinkilic B, Pilatz A, Weidner W. Detection of Normal Intratesticular Perfusion Using Color Coded Duplex Sonography Obviates Need for Scrotal Exploration in Patients with Suspected Testicular Torsion. J Urol 2013; 189:1853-8. [DOI: 10.1016/j.juro.2012.11.166] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2012] [Indexed: 10/27/2022]
Affiliation(s)
- Bora Altinkilic
- Department of Urology, Pediatric Urology and Andrology, Justus Liebig University Giessen, Giessen, Germany
| | - Adrian Pilatz
- Department of Urology, Pediatric Urology and Andrology, Justus Liebig University Giessen, Giessen, Germany
| | - Wolfgang Weidner
- Department of Urology, Pediatric Urology and Andrology, Justus Liebig University Giessen, Giessen, Germany
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Shah MI, Chantal Caviness A, Mendez DR. Prospective pilot derivation of a decision tool for children at low risk for testicular torsion. Acad Emerg Med 2013; 20:271-8. [PMID: 23517259 DOI: 10.1111/acem.12086] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 09/11/2012] [Accepted: 09/12/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The purpose of this study was to derive a pilot clinical decision tool with 100% negative predictive value for testicular torsion based on prospectively collected data in children with acute scrotal pain. METHODS This was a prospective cohort study of a convenience sample of newborn to 21-year-old males evaluated for acute (72 hours or less) scrotal pain at an urban children's hospital emergency department (ED). A pediatric emergency medicine fellow or attending physician documented history and examination findings on a standardized data collection form. The study investigators used ultrasound (US), operative reports, or clinical follow-up to identify patients who had testicular torsion. Pearson's chi-square test and odds ratios (OR) were used to identify factors associated with the diagnosis of testicular torsion. The authors also used a recursive partitioning model to create a low-risk decision tool for testicular torsion. RESULTS Of the 450 eligible patients, 228 (51%) were enrolled, with a mean (± SD) age of 9.9 (± 4.1) years, including 21 (9.2%, 95% confidence interval [CI] = 5.8% to 13.7%) with testicular torsion. The derived clinical decision tool consisted of three variables: horizontal or inguinal testicular lie (OR = 18.17, 95% CI = 6.2 to 53.2), nausea or vomiting (OR = 5.63, 95% CI = 2.08 to 15.22), and age 11 to 21 years (OR = 3.9, 95% CI = 1.27 to 11.97). These variables had a sensitivity of 100% (95% CI = 98% to 100%) and negative predictive value of 100% (95% CI = 98% to 100%) for the diagnosis of testicular torsion. CONCLUSIONS Based on a decision tool derived with recursive partitioning, study patients with all of the following characteristics had no risk of testicular torsion: normal testicular lie, lack of nausea or vomiting, and age 0 to 10 years. Future research should focus on externally validating this tool to optimize emergent evaluation when testicular torsion is likely, while minimizing routine sonographic evaluation when patients are unlikely to have a serious condition requiring immediate management.
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Affiliation(s)
- Manish I. Shah
- Department of Pediatrics; Section of Emergency Medicine; Baylor College of Medicine; Houston TX
| | - A. Chantal Caviness
- Department of Pediatrics; Section of Emergency Medicine; Baylor College of Medicine; Houston TX
| | - Donna R. Mendez
- Department of Pediatrics; Section of Emergency Medicine; Baylor College of Medicine; Houston TX
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Alsbou I. Acute scrotum in children and the role of early exploration. ALEXANDRIA JOURNAL OF MEDICINE 2012. [DOI: 10.1016/j.ajme.2012.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Affiliation(s)
- Ibrahim Alsbou
- Queen Rania children hospital, King Hussein Medical center, Amman, Jordan
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Abstract
In this review, long-held myths and misperceptions about the evaluation and management of testicular torsion are discussed, and recommendations for the management of patients who present with acute scrotal pain are presented.
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Abstract
PURPOSE This study aimed to compare clinical manifestations, physical examination findings, laboratory, and radiographic dates in pediatric patients with different pathological diagnoses of acute scrotum as well as to accurately establish the true incidence of various pathological diagnoses of acute scrotum. METHODS The records of children hospitalized for acute scrotum from 1990 to 2008 were reviewed. RESULTS A total of 1228 cases were included in the study (103 with testicular torsion, 918 with torsion of the testicular appendix, 72 with tunica vaginalis inflammation, 46 with epididymitis and 89 with other pathological diagnoses). Duration of pain less than 6 hours, fever, vomiting, history of trauma or activities, absence of cremasteric reflex, and abnormal testicle direction were significantly associated with testicular torsion. Blue dot sign and tender nodule were found significantly associated with torsion of the testicular appendix. Ultrasound showed decreased or absent blood flow in 91.3% testicular torsion patients; enlarged epididymis was found in 91.1% and 91.3% patients with torsion of the testicular appendix and epididymitis, respectively; and scrotal wall edema and hydrocele were found significantly associated with tunica vaginalis inflammation. Our salvageability rate in testicular torsion was 30.1%. CONCLUSIONS Overlap existed between testicular torsion and other acute scrotum. The clinical manifestations, physical examination findings, laboratory, and radiographic data were helpful in distinguishing acute scrotum. Doppler ultrasound is an indispensable imaging modality for the clinical assessment of patients with acute scrotum; in the presence of a clinical suspicion of testicular torsion, even with an apparently normal-color Doppler ultrasound, surgical exploration is still indicated.
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Shteynshlyuger A, Freyle J. Familial testicular torsion in three consecutive generations of first-degree relatives. J Pediatr Urol 2011; 7:86-91. [PMID: 20971686 DOI: 10.1016/j.jpurol.2010.09.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Accepted: 09/29/2010] [Indexed: 11/24/2022]
Abstract
We report the first and largest family with testicular torsion in three consecutive generations affecting four first-degree relatives. The incidence of familial testicular torsion is under reported in the literature. We recommend eliciting family history in evaluation of acute scrotum, as a useful adjunct for clinical decision making. In families with a strong predisposition to testicular torsion, management should include family counseling about the significant risk of occurrence of this condition.
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Affiliation(s)
- Alex Shteynshlyuger
- Division of Urology, Washington University School of Medicine, Siteman Cancer Center, St. Louis, MO 63110, USA.
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Testicular torsion: sonomorphological appearance as a predictor for testicular viability and outcome in neonates and children. Pediatr Surg Int 2010; 26:281-6. [PMID: 19921212 DOI: 10.1007/s00383-009-2534-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/29/2009] [Indexed: 10/20/2022]
Abstract
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.
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Beni-Israel T, Goldman M, Bar Chaim S, Kozer E. Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med 2010; 28:786-9. [PMID: 20837255 DOI: 10.1016/j.ajem.2009.03.025] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2009] [Accepted: 03/31/2009] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The aim of the study was to identify clinical findings associated with increased likelihood of testicular torsion (TT) in children. DESIGN This study used a retrospective case series of children with acute scrotum presenting to a pediatric emergency department (ED). RESULTS Five hundred twenty-three ED visits were analyzed. Mean patient age was 10 years 9 months. Seventeen (3.25%) patients had TT. Pain duration of less than 24 hours (odds ratio [OR], 6.66; 95% confidence interval [CI], 1.54-33.33), nausea and/or vomiting (OR, 8.87; 95% CI, 2.6-30.1), abnormal cremasteric reflex (OR, 27.77; 95% CI, 7.5-100), abdominal pain (OR, 3.19; 95% CI, 1.15-8.89), and high position of the testis (OR, 58.8; 95% CI, 19.2-166.6) were associated with increased likelihood of torsion. CONCLUSIONS Testicular torsion is uncommon among pediatric patients presenting to the ED with acute scrotum. Pain duration of less than 24 hours, nausea or vomiting, high position of the testicle, and abnormal cremasteric reflex are associated with higher likelihood of torsion.
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Affiliation(s)
- Tali Beni-Israel
- Pediatric Emergency Unit, Assaf Harofeh Medical Center, Sackler School of Medicine, Tel Aviv University, Zerifin 70300, Israel
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Marulaiah M, Gilhotra A, Moore L, Boucaut H, Goh DW. Testicular and Paratesticular Pathology in Children: a 12-Year Histopathological Review. World J Surg 2010; 34:969-74. [DOI: 10.1007/s00268-010-0459-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Reis LO. Fundamentos de la práctica diaria de la urología y la medicina basada en la evidencia. Actas Urol Esp 2009. [PMID: 20096173 DOI: 10.1016/s0210-4806(09)73180-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
This review describes the clinical, grey-scale and colour Doppler US findings of different conditions that may be the cause of an acute scrotum. The US appearances of testicular torsion, torsion of the appendix testis, epididymoorchitis, incarcerated hernia and idiopathic scrotal oedema are described. Some of the major studies regarding the sensitivity and specificity of US in the diagnosis of these diseases are reviewed. Grey-scale and colour Doppler US demonstrate high accuracy in the aetiological diagnosis of an acute scrotum and can differentiate between diseases that require immediate surgical intervention and those that can be treated conservatively.
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Affiliation(s)
- Matteo Baldisserotto
- Radiology Department, Hospital Sao Lucas da Pontificia, Universidade Católica do Rio Grando do Sul, Porto Alegre, RS, Brazil.
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Kaye JD, Shapiro EY, Levitt SB, Friedman SC, Gitlin J, Freyle J, Palmer LS. Parenchymal echo texture predicts testicular salvage after torsion: potential impact on the need for emergent exploration. J Urol 2008; 180:1733-6. [PMID: 18721947 DOI: 10.1016/j.juro.2008.03.104] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2007] [Indexed: 10/21/2022]
Abstract
PURPOSE In the setting of signs and symptoms of testicular torsion the absence of diastolic flow and/or color flow on Doppler ultrasound has traditionally prompted emergent scrotal exploration. This practice emanates largely from the difficulty on ultrasound of distinguishing salvageable torsed testes from those that are not salvageable. We identified ultrasound findings predictive of testicular viability or the lack thereof. MATERIALS AND METHODS We retrospectively reviewed the charts of all boys who underwent scrotal exploration for signs and symptoms of torsion during a 4-year period. In those who underwent preoperative Doppler ultrasound of the scrotum ultrasound findings were reviewed, as were the operative dictations. In patients who underwent orchiectomy the pathology reports were also reviewed. In patients in whom the torsed testis appeared viable and who underwent orchiopexy followup data were reviewed when available. Emergency room charts were also reviewed to ascertain, when documented, the duration of pain before presentation to the emergency room and the interval between ultrasound and operating room. RESULTS During this period 55 boys underwent exploration after preoperative scrotal Doppler ultrasound revealed absent diastolic flow and/or color flow Doppler in the symptomatic testis. Assessment of parenchymal echogenicity revealed heterogeneity in 37 testes (67%), of which none were deemed viable at exploration. Orchiectomy was performed in 34 of 37 cases. Pathological examination revealed necrosis in all 34 cases, a finding consistent with late torsion. The remaining 3 testes underwent orchiopexy by parental directive despite nonviability, as confirmed by biopsy and subsequent atrophy. Thus, heterogeneity on preoperative ultrasound was universally predictive of organ loss (chi-square p <0.001). Of the 18 symptomatic testes (33%) demonstrating homogeneity and isoechogenicity on ultrasound 16 (89%) were deemed viable at exploration. Boys in whom the torsed testicle was nonviable on exploration experienced an average of 27.5 hours of pain preoperatively (range 5 to 72), whereas boys in whom the torsed testis was salvaged experienced an average of 20.5 hours of pain (range 2 to 96) (p = 0.073). The nonviable group underwent surgery an average of 49 minutes after ultrasound, whereas the viable group underwent surgery 52 minutes after ultrasound (p = 0.92). None of the 55 patients experienced any surgical or anesthetic complications and no pathological condition was noted intraoperatively in the contralateral asymptomatic testis. CONCLUSIONS In the setting of Doppler proven testicular torsion heterogeneous parenchymal echo texture indicates late torsion and testicular nonviability. Therefore, the case may not require emergent scrotal exploration. On the other hand, homogeneous echo texture portends extremely well for testicular viability. Thus, such testes should be explored emergently.
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Affiliation(s)
- Jonathan D Kaye
- Division of Pediatric Urology, Schneider Children's Hospital, North Shore-Long Island Jewish Health System, Long Island, New York, USA
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Abstract
AIM Testicular torsion (TT) requires prompt diagnosis and treatment to avoid testicular loss. Most studies have focused on the ideal work up to rule TT out in cases of acute scrotum. We attempted here to define objective criteria to select between orchidopexy and orchidectomy in patients undergoing surgery for TT. PATIENTS AND METHODS Fifteen boys with a median age at presentation of 7.8 (range 6.4-12) years undergoing surgical treatment for TT underwent color-Doppler ultrasound (CDU) preoperatively, and a bleeding test intraoperatively. Duration of preoperative history, degree of torsion, CDU findings and degree of bleeding were analyzed. RESULTS Salvageability was independent of the degree of torsion. In patients with a history longer than 10h, no flow on CDU and no bleeding, after orchidectomy all the testicles were necrotic on pathology. When all these variables were negative, all the testicles did well during follow up. In the group of patients with no agreement among the analyzed variables, the outcome was unpredictable. Five out of six underwent orchidopexy, but in two cases the testicle atrophied (in spite of flow on CDU in one). CONCLUSIONS No predictive parameters were found for testicular salvageability. Taken as a whole, the parameters studied can be of help in treatment choice. In patients with no agreement among the parameters, orchidopexy seems the appropriate option, but parents should be informed of the risk of testicular atrophy during follow up.
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Murphy FL, Law H, Mushtaq I, Sebire NJ. Testicular and paratesticular pathology in infants and children: the histopathological experience of a tertiary paediatric unit over a 17 year period. Pediatr Surg Int 2007; 23:867-72. [PMID: 17639422 DOI: 10.1007/s00383-007-1959-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2007] [Indexed: 10/23/2022]
Abstract
To examine the pathological features of paediatric testicular and paratesticular lesions from a tertiary referral centre and describe their relative pathological frequency, highlighting relevant epidemiological and histopathological findings. A search was made of a computerised histopathology database covering the period from 1988 to 2004 inclusive to identify cases of testicular and paratesticular pathologies, and the clinical and histopathological features reviewed. Five hundred and fifty-one appropriate specimens underwent histological examination during the period. Three hundred and eleven (56%) presented with an impalpable testis with or without intersex disorder and 121 (22%) with a testicular/paratesticular mass. While metastatic leukaemic testicular involvement (N = 47) was the commonest tumour identified in this preselected series, at a peak of 8 years, primary testicular tumours such as yolk sac and teratoma were most commonly identified in infancy. Of 109 (20%) presenting with an acutely painful scrotum, the largest group (47%) represented torsion of the appendix testis. The vast majority of pathological samples arose from children less than 4 years of age in accordance with the predominance of cryptorchidism, 'vanished' testis, neonatal torsion and testicular tumours in this age group. The findings of this study demonstrate the spectrum of testicular pathology in childhood. Neoplasms represented >20% of the pathology, but the largest clinical group of pathological specimens in this patient population is associated with clinically impalpable or the palpably abnormal testis.
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Affiliation(s)
- F L Murphy
- Department of Paediatric Urology, Great Ormond Street Children's Hospital, Great Ormond Street, London WC1N 3JH, UK.
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