Clinical evaluation of testicular torsion presenting with acute abdominal pain in young males

Patient Query in Adolescent Testicular Torsion Cases: "Was it Necessary to Mention My Scrotal Pain?"

Objective This study investigates the reasons for the failure to diagnose testicular torsion (TT) in different healthcare facilities (HCFs) and by various physicians. Method We retrospectively analyzed all male patients who underwent TT surgery within the adolescent age group between 2015 and 2023. Healthy adolescent patients who initially presented or were referred to an HCF and were subsequently diagnosed at our hospital for TT surgery were analyzed, focusing on why they were not diagnosed earlier. Results A total of 11 patients aged 10 to 17 who were surgically confirmed to have TT at our hospital between 2015 and 2023 were analyzed retrospectively. These patients had been admitted to various public and private HCFs due to the sudden onset of symptoms such as abdominal pain, vomiting, fainting, sweating, and walking difficulties during and after working hours. Four patients had previously been admitted to one HCF, while seven had been admitted two to six times to an HCF. All patients were healthy, and all but one had received age-appropriate education. However, only two of them had reported experiencing scrotal pain. Laboratory tests and/or radiological examinations were conducted on eight patients, and nine patients received medical treatment and/or prescriptions. None of the patients were initially diagnosed with acute scrotum. Conclusion Despite having unrestricted and free access to well-equipped HCFs, the early diagnosis and treatment of TT are not ensured. Factors contributing to this delay include patients' concealment of, or failure to fully disclose, scrotal complaints, as well as physicians' incomplete history taking and genital examinations. The physician's male gender was not found to contribute to an earlier diagnosis of TT. A mandatory genital examination should be included in the emergency assessment protocol for male patients.

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

Objective

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

Methods

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

Results

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

Conclusions

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

The Role of Demographic and Clinical Characteristics in Distinguishing Testicular Torsion from Torsion of the Appendix Testis: A Single-center Retrospective Study

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.

[Management of testicular torsion by a general surgeon isolated in Africa]

The onset of sudden and intense scrotal pain exposes to several problems when it occurs in a young man in Africa. Among the possible etiologies, testicular torsion is the surgical emergency to rule out, because beyond 6 hours of evolution the functional prognosis of the testicle is concerned. The septic evolution towards a purulent melting, in case of exceeded torsion, is also possible. Of slightly lower incidence than in Western countries, lack of awareness of this pathology by local health actors, the precariousness or health isolation of certain populations in certain under-medicalized regions, contribute to diagnostic and therapeutic delays. This often leads to a pejorative development, loss of the testicle being directly correlated with the delay in treatment. Testicular torsion has thus been identified as one of the main causes of male infertility in Africa. However, clinical diagnosis and surgical treatment require few resources and remain accessible in an environment with low resources or in precarious conditions. Indeed, despite the contribution of ultrasound in certain situations, the clinical picture is at the center of the diagnosis and therapeutic decision making. At the slightest doubt, surgical exploration is necessary. The multi-tunic anatomy of the testicle facilitates its surgical fixation in the event of conservation, ideally by triangulation of single-strand non-absorbable thread. Simultaneous fixation of the contralateral testicle is currently the subject of debate in the literature. In Africa, the benefit/risk balance, taking into account in particular the difficulty of subsequent access to care, justifies, from our point of view, performing contralateral orchidopexy at the same time. Depending on the appearance of the testicle and, to a lesser extent, the duration of the evolution of the symptoms, orchidectomy may be necessary. This article describes the clinical picture of spermatic cord torsion and the orchidopexy technique.

Diagnosis and treatment of cryptorchid testicular torsion in children: A 12-year retrospective study

PURPOSE

To investigate the clinical characteristics, treatment, and prognosis of cryptorchid testicular torsion in children.

METHODS

The clinical data of 25 children who received treatment for cryptorchid testicular torsion between January 2010 and December 2021 were retrospectively reviewed. The median age of the patients was 64.5 months (range: 2 months to 15 years). All patients had unilateral torsion, and the duration of symptoms ranged from 3 to 192 h.

RESULTS

Among the 25 patients, five underwent orchidopexy, while the remaining 20 underwent orchiectomy. After 6 months to 8 years of follow up, the 20 patients who had undergone orchiectomy had a well-developed testis on the healthy side. Four of the five patients who had undergone orchidopexy of the affected testis had well-developed testes bilaterally, while one experienced testicular atrophy.

CONCLUSION

Cryptorchid testicular torsion is a rare urological emergency that displays a delayed presentation and is often misdiagnosed. Clinicians need to carefully review the patient's medical history and ultrasound findings and perform a thorough physical examination to make a correct diagnosis. Active testicular exploration is required for patients suspected to have cryptorchid testicular torsion, and the decision to perform orchidopexy or orchiectomy depends on the intraoperative situation.

Improving testicular examinations on paediatric patients in the emergency department: A quality improvement study to improve early diagnosis of testicular torsion

Objective

Male paediatric patients presenting with abdominal and/or testicular pain are common in the emergency department. As a time-sensitive diagnosis, the importance of early recognition, referral, and definitive management is critical. Missed or delayed diagnoses and management of testicular torsion can result in significant long-term sequelae including impaired fertility and psychological burden. In this quality improvement study, we utilised educational posters aiming to improve awareness of testicular torsion as a differential for abdominal pain and therefore, improve the quality of testicular examinations performed in the emergency department.

Methods

Observational pre- and post-intervention study was conducted at a tertiary hospital emergency department. A pre-interventional retrospective review of the electronic medical records was conducted. All male patients under 16-years-old presenting with “abdominal pain” or “testicular problem” were included. We assessed the rate of testicular examination and the quality of the examination based on four domains: Cremasteric reflex, lie, swelling, and hardness. Educational posters targeting both patients and clinicians were placed around the emergency department. Subsequent review of the electronic medical records post-intervention was performed assessing the same domains.

Results

A total of 235 presentations were analysed with 124 in the pre-intervention group and 111 in the post-intervention group. Overall rate of documented testicular examinations increased by 14% (p=0.032). The quality of testicular examinations also improved from an average of 0.85 domains documented to 2.29 post-intervention (p<0.001). Subgroup analysis found doctors in training had a greater improvement in both rate and quality of documented testicular examination.

Conclusion

Our study demonstrated the value of continuing education in promoting awareness of testicular torsion in the emergency department. We found a clear improvement in the quality of clinical documentation of a time-sensitive condition which may infer a decreased risk of missed and delayed diagnosis of testicular torsion.

Pediatric Trauma-Induced Testicular Torsion: A Surgical Emergency

OBJECTIVE

To evaluate the features of testicular torsion (TT) resulting from minor groin trauma and to raise the awareness of trauma-induced testicular torsion (TITT).

METHODS

This is a retrospective chart review of patients presenting with TT resulting from minor genital trauma that was performed from January 2010 to December 2018 at a single tertiary care institution. The demographic, clinical, and perioperative characteristics, as well as data on follow-up and complications, were analyzed.

RESULTS

Of the 155 patients treated for TT, 15 were included in this study. The average age of the patients was 10.3 years (range: 3.2-13.3 years). All patients experienced a direct scrotal trauma and subsequently presented with an ipsilateral scrotal or testicular pain secondary to the twisted testicle. Six patients were misdiagnosed as having scrotal inflammation or hematoma, and all were initially treated at local hospitals. The mean duration of symptoms before hospitalization was 138 h (range: 5-504 h). The mean degree of torsion was 390° (range: 180-720°). The testicular salvation rate, at 33%, was poor. No serious postoperative complications or recurrences of TT was observed.

CONCLUSIONS

TITT is a rare entity and still has delayed diagnosis. This may subsequently lead to a low testicular salvation rate. Emergency surgeons, especially in local hospitals, should be aware of the possibility of TT following testicular trauma in pediatric patients. Improving the parents' awareness regarding TT is also important.

Evaluation of parental sociocultural background and education level in response to pediatric testis torsion

INTRODUCTION

Acute scrotal pain (ASP) remains one of the most common male urologic emergencies in the pediatric age group. The most concerning outcome of testicular torsion (TT) is the need for orchiectomy, which has a negative impact on the child's development in general and on sexual development and psychology in particular. Time is the most important factor in the treatment of TT. Parental awareness of ASP indicating the possibility of TT is a significant factor in children's hospital admission time. Sociocultural background may be an indicator in parental awareness.

OBJECTIVE

This study sought to determine if parental sociocultural and education level is associated with delayed treatment for TT.

STUDY DESIGN

This retrospective study evaluated data for patients with scrotal or abdominal pain and TT at two hospitals in Konya, Turkey from 2012 to 2020. Study participants were the parents of the patients treated for TT. Participants were contacted by telephone and asked about their educational background. The study population was divided into 2 groups based on parent characteristics. Group 1 parents had an education level less than high school, had no health insurance, were in need of state aid, and had a low sociocultural background. Group 2 parents had an education level of at least high school or higher and had health insurance. Symptom duration (time between symptom onset and hospital admission) and surgical procedures for the patients were compared between the 2 parent groups.

RESULTS

Of the 140 patients who received a diagnosis of TT, 77 were in Group 1 and 63 in Group 2. Mean patient age was 12.7 ± 2.7 (5-16) years Median symptom duration was 7 (1-120) hours. Symptom duration was higher in Group 1, but no statistically significant differences were noted between groups (Group 1 duration was 8h vs. Group 2 duration of 6h; p = 0.331). Orchiectomy was performed for 62 (44.3%) patients and testicular-sparing surgery for 78 (55.7%). Orchiectomy rates between groups were statistically significant and higher in Group 1 with 41 (53.2%) versus 21 (33.3%) in Group 2.

CONCLUSION

Factors such as low sociocultural family background and low parental education level increase the risk of orchiectomy for their children. Awareness of the symptoms of TT may minimize the possibility of testicular loss.