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Herek D, Çakmak V, Çomut E, Herek Ö. The value of multimodal ultrasonography in the evaluation of late presenting testicular torsion in a rat experimental model. Br J Radiol 2024; 97:377-385. [PMID: 38302083 DOI: 10.1093/bjr/tqad059] [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] [Received: 07/25/2023] [Revised: 10/15/2023] [Accepted: 11/07/2023] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVE To evaluate the value of multimodal ultrasonography (US) in a rat experimental torsion model after 6 h of torsion with different degrees. METHODS Twenty-one male rats were divided into three groups. Left testes of the rats were twisted around their vascular pedicle 360 degrees in group 1, 720 degrees in group 2, and 1080 degrees in group 3 and intact right testes of the rats were accepted as control group. Grey-scale US, superb microvascular imaging (SMI), colour Doppler ultrasonography (CDUS), strain elastography (SE), and two-dimensional (2-D) shear wave elastography (SWE) examinations were applied 6 h after torsion procedure and testes were removed for pathological evaluation. RESULTS Short-axis dimensions and volumes of the torsion side were higher than control testes. Lengths of the testes in the 3rd torsion group were smaller than the testes in groups 1 and 2 (P < 0.002). SMI was better than CDUS in recognizing blood flow in testicular tissue. Strain ratios were higher in group 1 and decreased with the increasing torsion degree. Emean and standard deviation (SD) measurements increased in the torsion side. Pathologically the mean testicular damage scores were statistically significant between torsion and control testes in all groups. CONCLUSION Our results showed that short-axis and volume measurements, SMI, 2D-SWE, and SE are effective in the evaluation and diagnosis of testicular torsion (TT). ADVANCES IN KNOWLEDGE Evaluation of affected testis and intact testis with multiparametric US in late presenting TT cases is more reliable than being dependent on a single sonographic modality.
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Affiliation(s)
- Duygu Herek
- Pamukkale University Hospital, Department of Radiology, Denizli, 20160, Turkey
| | - Vefa Çakmak
- Pamukkale University Hospital, Department of Radiology, Denizli, 20160, Turkey
| | - Erdem Çomut
- Pamukkale University Hospital, Department of Pathology, Denizli, 20160, Turkey
| | - Özkan Herek
- Pamukkale University Hospital, Department of Paediatric Surgery, Denizli, 20160, Turkey
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Stewart S, Briggs KB, Fraser JA, Osuchukwu OO, Roberts C, Oyetunji TA, Alemayehu H. Testicular torsion disparities in the pediatric population. J Natl Med Assoc 2022; 114:558-563. [PMID: 36229235 DOI: 10.1016/j.jnma.2022.09.009] [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: 08/09/2022] [Revised: 09/07/2022] [Accepted: 09/17/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND There are disparate findings in the literature on the impact of race and insurance status on gonadal loss in testicular torsion. We sought to determine if race or levels of social vulnerability influence the rate of torsion or gonadal loss. METHODS Retrospective cross-sectional review between December 2017 and September 2019. Social vulnerability index was dichotomized using the 75th percentile. Primary outcome was the diagnosis of testicular torsion. RESULTS 515 patients were included. There was no difference in median age, torsion diagnosis, and orchiectomy rate between the two institutions. Black/African American patients were >3 times more likely than Caucasian patients to be diagnosed with TT when controlled for dichotomized SVI, insurance, and age (OR 3.39, 95% CI 1.74 - 6.61, p < 0.01). CONCLUSION Black/African American children have an increased risk of testicular torsion. Despite these patients having higher levels of social vulnerability, it was not associated.
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Affiliation(s)
- Shai Stewart
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, USA; School of Medicine, University of Missouri-Kansas City, 2411 Holmes St, Kansas City, MO 64108, USA.
| | - Kayla B Briggs
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - James A Fraser
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Obiyo O Osuchukwu
- Department of Surgery and Pediatrics, Children's and Women's Hospital, 1601 Center St, Ste 1E Mobile, AL 36604, USA
| | - Christopher Roberts
- College of Medicine, University of South Alabama, 5795 USA Drive North, CSAB 170 Mobile, AL 36688, USA
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, USA; School of Medicine, University of Missouri-Kansas City, 2411 Holmes St, Kansas City, MO 64108, USA
| | - Hanna Alemayehu
- Department of Surgery and Pediatrics, Children's and Women's Hospital, 1601 Center St, Ste 1E Mobile, AL 36604, USA
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Choi JB, Han KH, Lee Y, Ha US, Cho KJ, Kim JC, Koh JS. The incidence of testicular torsion and testicular salvage rate in Korea over 10 years: A nationwide population-based study. Investig Clin Urol 2022; 63:448-454. [PMID: 35670008 PMCID: PMC9262487 DOI: 10.4111/icu.20220122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/19/2022] [Accepted: 05/02/2022] [Indexed: 11/18/2022] Open
Abstract
PURPOSE We performed a nationwide epidemiological study of testicular torsion using the National Health Insurance System database for the entire male population of Korea. MATERIALS AND METHODS Age, sex, socioeconomic status, regional information, and diagnostic codes were retrieved from January 2009 to December 2019. To clearly identify the diagnosis of testicular torsion, patients who had not undergone orchiectomy or orchiopexy were excluded from the study. Multivariable logistic regression models were used to analyze the association between demographic characteristics and testicular loss. RESULTS The overall incidence of testicular torsion in males was 2.02 cases per 100,000 person-years and 6.99 cases per 100,000 person-years in males under 19 years of age. Testicular torsion most commonly occurred either in infancy or adolescence. The total testicular salvage rate was 75.22% and highest in children at 79.91%. The rate of orchiectomy was high in infancy and in the oldest patients. We determined that age distribution was related to the risk of testicular loss. CONCLUSIONS This study is the first nationwide epidemiological study of testicular torsion, which contains the entire Korean population. Although the testicular salvage rate in Korea was higher compared to other countries, it is necessary to educate males under 19 years of age on the seriousness of acute testicular pain to minimize the possibility of testicular loss.
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Affiliation(s)
- Jin Bong Choi
- Department of Urology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyu Hun Han
- Department of Urology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yunhee Lee
- Department of Urology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - U-Syn Ha
- Department of Urology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kang Jun Cho
- Department of Urology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joon Chul Kim
- Department of Urology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jun Sung Koh
- Department of Urology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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van Welie M, Qu LG, Adam A, Lawrentschuk N, Laher AE. Recurrent testicular torsion post orchidopexy - an occult emergency: a systematic review. ANZ J Surg 2022; 92:2043-2052. [PMID: 35257473 PMCID: PMC9543734 DOI: 10.1111/ans.17592] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/15/2022] [Accepted: 02/22/2022] [Indexed: 12/29/2022]
Abstract
Background Recurrent Testicular Torsion (RTT) is a rarely reported event after previous testicular torsion (TT) repair. Both conditions have similar signs and symptoms. Various techniques have been attempted to reduce the incidence of retorsion. This review assesses the presentation, diagnosis, risk factors, management and outcomes associated with RTT. Methods After PROSPERO Registration (CRD42021258997), a systematic search of PubMed, Google Scholar, Embase, Scopus, Web of Science, Cochrane Database of Systematic Reviews, Global Index Medicus and Cumulative Index to Nursing and Allied Health Literature (CIANHL) was performed using specific search terms. Study metadata including patient demographics, orchidopexy techniques, RTT rates and RTT timing were extracted. Results Twenty‐six articles, comprising 12 case series and 14 case reports, with a total of 46 patients were included. Overall, the median (IQR) age of the pooled cohort was 18 (15–26) years, the median (IQR) time to presentation was 6 (3–36) hours from the onset of testicular pain. The most common presenting features were testicular pain (100%), testicular swelling (60.9%) and a high riding testicle (34.8%). The left testicle was most commonly affected (63.0%), RTT was on the ipsilateral side in relation to the primary episode of TT in 52.2% of cases, the median (IQR) interval between torsion and retorsion events was 4 (1.3–10.0) years, non‐absorbable sutures were the most common suture material used during orchidopexy after RTT (88.9%). Conclusion RTT is a rare presentation to the Emergency Department. Even with a prior history of TT, RTT should be considered in patients presenting with classic symptoms.
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Affiliation(s)
- Mikayla van Welie
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Liang G Qu
- Department of Urology, Olivia Newton John Cancer Research Institute, Austin Health, Heidelberg, Victoria, Australia
| | - Ahmed Adam
- Division of Urology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nathan Lawrentschuk
- Department of Urology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Abdullah E Laher
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Sintim-Damoa A, Cohen HL. Pearls and Pitfalls of Pediatric Scrotal Imaging. Semin Ultrasound CT MR 2022; 43:115-129. [PMID: 35164905 DOI: 10.1053/j.sult.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Ultrasonography (US) is the primary imaging modality for the evaluation of pediatric scrotal disease. The ability to obtain exceptional anatomical detail and testicular perfusion information without ionizing radiation makes it the essential tool for evaluating scrotal pain and palpable masses. Challenges arise in both the performance and interpretation of scrotal US in the child. Optimizing imaging parameters and recognizing key differentiating US features help minimize misinterpretations that can lead to poor patient outcomes. Key pearls and pitfalls in pediatric scrotal ultrasound methods and diagnoses are reviewed. Knowledge of what is normal for the various ages of childhood from neonate through adolescence is necessary for accurate US analysis. Imaging evaluation of key causes of the acute painful scrotum including testicular appendage torsion, epididymitis, and testicular torsion are discussed. Sonographic features for the diagnosis of benign and malignant scrotal masses, microlithiasis, and cryptorchidism are reviewed.
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Affiliation(s)
- Akosua Sintim-Damoa
- Department of Radiology, LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Harris L Cohen
- Department of Radiology, LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN.
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6
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Clinical Features and Misdiagnosis Analysis of Testicular Torsion in 313 Children. Indian J Surg 2022. [DOI: 10.1007/s12262-021-03185-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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7
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Shields LBE, Daniels MW, Peppas DS, Rosenberg E. Testicular Torsion in Patients With Intellectual and Developmental Disabilities. Glob Pediatr Health 2021; 8:2333794X211059119. [PMID: 34869797 PMCID: PMC8637397 DOI: 10.1177/2333794x211059119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 10/23/2021] [Indexed: 11/17/2022] Open
Abstract
Patients with intellectual/developmental disabilities are at risk of delayed diagnosis of testicular torsion due to their inability to effectively communicate their symptoms. We identified males ages 1 to 18 years with testicular torsion between January 1, 2015 and December 31, 2020, focusing on patients with intellectual and/or developmental disabilities. Of the 140 patients with testicular torsion, 5 (3.6%) patients exhibited intellectual/developmental disabilities with an inability to effectively verbalize testicular/groin/scrotal pain. The patients with intellectual/developmental disabilities underwent more orchiectomies (5/5, 100%, P = .009) and had a longer duration of symptoms (median = 48 hours, P = .047) compared to those without intellectual/developmental disabilities (51/135, 38% and median = 9 hours, respectively) (51/134, 38%) (P = .038). Parents and other caregivers of males with intellectual/developmental disabilities who are unable to adequately verbalize their testicular/groin/scrotal pain should be cognizant of the signs and symptoms associated with testicular torsion, perform a genitalia examination, and seek an immediate evaluation to diagnose and treat this urgent condition.
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8
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Aquila I, Abenavoli L, Sacco MA, Ricci P. The limits of diagnosis of testicular torsion in the child: Medicolegal implications in clinical practice. Clin Case Rep 2021; 9:e05180. [PMID: 34938556 PMCID: PMC8659548 DOI: 10.1002/ccr3.5180] [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: 09/21/2021] [Revised: 11/07/2021] [Accepted: 11/22/2021] [Indexed: 11/05/2022] Open
Abstract
Testicular torsion is a pediatric urological emergency. We report a case of testicular torsion that occurred in a 10-year-old child. The case shows that it is a disease with risk of medicolegal litigation. We demonstrate the role of proper triage, and we analyze the limits and critical points for diagnosing it.
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Affiliation(s)
- Isabella Aquila
- Institute of Legal MedicineDepartment of Medical and Surgical SciencesUniversity “Magna Graecia” of CatanzaroCatanzaroItaly
| | - Ludovico Abenavoli
- Department of Health SciencesUniversity “Magna Graecia” of CatanzaroCatanzaroItaly
| | - Matteo Antonio Sacco
- Institute of Legal MedicineDepartment of Medical and Surgical SciencesUniversity “Magna Graecia” of CatanzaroCatanzaroItaly
| | - Pietrantonio Ricci
- Institute of Legal MedicineDepartment of Medical and Surgical SciencesUniversity “Magna Graecia” of CatanzaroCatanzaroItaly
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9
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Boissier R, Long JA, Chiron P, Savoie PH. [Non-infectious emergencies of the lower urinary tract and genitals]. Prog Urol 2021; 31:1022-1038. [PMID: 34814986 DOI: 10.1016/j.purol.2021.08.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/02/2021] [Accepted: 08/07/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The objective of this narrative review was to report the most relevant data on the contemporary management of the main non-infectious emergencies of the lower urinary tract and genital organs. METHODS A narrative synthesis of the articles (French, English) available on the Pubmed database was carried out in June 2021. A request to the health surveillance network for emergencies and deaths (SurSaUD®, Santé Publique France) revealed original data on the epidemiology of non-infectious lower urinary tract and genital organs emergencies. RESULTS Non-infectious emergencies of the low urinary tract and genital organs represent a large panel of traumatic and non-traumatic situations, which constitute the 3rd reasons in urology for a consultation at the emergency department after, infectious disease (1st) and non-traumatic/non-infectious emergencies of the upper urinary tract (2nd). Hematuria is the 3rd urological reason for men for a consultation at the emergency department. Globally, pelvic trauma and genital traumatism mainly concern men. These emergencies rarely affect the prognosis but can be integrated into more complete situations which are likely to impact their treatment, particularly in multiple traumas. CONCLUSIONS In this article we report the epidemiology and the principles of management of non-infectious emergencies of the lower urinary tract and genital organs.
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Affiliation(s)
- R Boissier
- Aix-Marseille Université, Service de Chirurgie urologique et de Transplantation rénale, CHU La Conception, APHM, Marseille, France.
| | - J A Long
- Service d'urologie et de la transplantation rénale, CHU Grenoble, France; TIMC-IMAG CNRS 5525, France
| | - P Chiron
- Service d'urologie, Hôpital D'instruction des Armées BEGIN, Saint Mandé, France
| | - P-H Savoie
- Service d'urologie, Hôpital d'Instruction des Armées Sainte Anne, BP 600, 83800 Toulon cedex 09, France
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10
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Management of testicular torsion in the ER: lessons learned from medical professional liability claims. Actas Urol Esp 2021; 45:391-397. [PMID: 34088439 DOI: 10.1016/j.acuroe.2021.04.001] [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: 12/10/2020] [Accepted: 01/04/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate emergency care for testicular torsion (TT) in medical professional liability (MPL) claims. METHODS Claims related to TT from 2000 to 2018 were located. The assistance provided and the association with MPL were analyzed. RESULTS Eighty complaints were identified, testicular pain was reported in 83.75% of first consultations, with a mean evolution time of 15.5 h. The mean time to diagnosis was 7.98 days. The first consultation was at the hospital in 75.1% of cases, but an ultrasound was performed only in 7.5%. When TT diagnosis was performed, 97.3% had undergone ancillary tests. The MPL was significantly associated with non-criminal proceedings and with less than 6 h of symptoms' evolution, and, within this subgroup, without undergoing an ultrasound scan. CONCLUSIONS Late consultations, wrong diagnosis and late diagnosis are claimed. When MPL are claimed by means of non-criminal law, the existence of responsibility is frequently considered, even more in those cases when the consultation took place before 6 h of evolution with no ancillary tests having been performed.
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11
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Management of testicular torsion in the ER: Lessons learned from medical professional liability claims. Actas Urol Esp 2021. [PMID: 33581908 DOI: 10.1016/j.acuro.2021.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate emergency care for testicular torsion in medical professional liability claims. METHOD Claims related to testicular torsion from 2000 to 2018 were located. The assistance provided and the association with medical professional liability were analyzed. RESULTS Eighty complaints were identified, testicular pain was reported in 83.75% of first consultations, with a mean evolution time of 15.5h. The mean time to diagnosis was 7.98 days. The first consultation was at the hospital in 75.1% of cases, but an ultrasound was performed only in 7.5%. When testicular torsion diagnosis was performed, 97.3% had undergone ancillary tests. The medical professional liability was significantly associated with non-criminal proceedings and with less than 6h of symptoms' evolution, and, within this subgroup, without undergoing an ultrasound scan. CONCLUSIONS Late consultations, wrong diagnosis and late diagnosis are claimed. When medical professional liability are claimed by means of non-criminal law, the existence of responsibility is frequently considered, even more in those cases when the consultation took place before 6h of evolution with no ancillary tests having been performed.
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Delaying Urgent Exploration in Neonatal Testicular Torsion May Have Significant Consequences for the Contralateral Testis: A Critical Literature Review. Urology 2020; 153:277-284. [PMID: 33373706 DOI: 10.1016/j.urology.2020.10.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 10/06/2020] [Accepted: 10/13/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the optimal management strategy for boys with neonatal testicular torsion (NTT) in the first 30 days of life, and to stratify outcomes for prenatal, postnatal, unilateral, synchronous, and asynchronous events METHODS: All articles including case reports published between 1946 and 2020 in Embase/Scopus/Medline/Pubmed and Web of Science that had a defined diagnosis of NTT within the first 30 days of life were reviewed. Data and outcomes were analyzed individually, and together as pooled data, using a random effect model. RESULTS There was a total of 152 studies representing 1336 patients. Outcome data was available on 974 patients (1121 testes). NTT was unilateral in 829 cases, synchronous bilateral in 80 cases, and asynchronous in 66 cases. There were a total of 1107 orchiectomies, and 229 salvage orchiopexies. A total of 2.5% synchronous NTT underwent successful salvage. A total of 95.7% of prenatal unilateral torsions underwent orchiectomy, compared with 92% postnatal torsions. 11.8% of all NTT events were asynchronous with a median time to second torsion of 1 day (Range 1-8). The contralateral orchiectomy rate in this group was 31.8%, with a 40% atrophy rate following orchiopexy. The number needed to treat to avoid bilateral orchiectomy was 1.6, and the number needed to treat to avoid solitary atrophy was 2.6. CONCLUSION NTT is an important condition carrying a significant risk for testicular loss and endocrine insufficiency. Given the potential catastrophic risk of asynchronous extravaginal torsion, we recommend urgent, safe, surgical intervention with both unilateral and bilateral NTT.
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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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14
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Laher A, Ragavan S, Mehta P, Adam A. Testicular Torsion in the Emergency Room: A Review of Detection and Management Strategies. Open Access Emerg Med 2020; 12:237-246. [PMID: 33116959 PMCID: PMC7567548 DOI: 10.2147/oaem.s236767] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 09/21/2020] [Indexed: 11/23/2022] Open
Abstract
Testicular torsion is a challenging and time-sensitive diagnosis that is encountered frequently in daily practice, especially in the emergency room. A thorough history, the presence of a painful and swollen testis and testicular ultrasonography plays a vital role in the prompt diagnosis of testicular torsion. Prompt diagnosis is essential to prevent complications of testicular torsion which include testicular infarction, necrosis, and sub/infertility. This can be challenging as there are various other conditions that may mimic the presentation of testicular torsion. Since testicular torsion is an extremely time-sensitive diagnosis, it may also be a subject of many medicolegal challenges. This review article serves as a guide for clinicians involved with the diagnosis and management of testicular torsion. We review and discuss detection and management strategies based on their validity, statistical significance, and effectiveness in enabling prompt diagnosis and management of testicular torsion. Medicolegal implications of testicular torsion are also highlighted.
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Affiliation(s)
- Abdullah Laher
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shavania Ragavan
- Division of Urology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Puja Mehta
- Division of Urology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ahmed Adam
- Division of Urology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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15
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Greear GM, Romano MF, Katz MH, Munarriz R, Rague JT. Testicular torsion: epidemiological risk factors for orchiectomy in pediatric and adult patients. Int J Impot Res 2020; 33:184-190. [PMID: 32683416 DOI: 10.1038/s41443-020-0331-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/17/2020] [Accepted: 07/09/2020] [Indexed: 11/09/2022]
Abstract
Testicular torsion is a known cause of morbidity in pediatric patients, but the burden in the adult population is poorly understood. We sought to determine the incidence of testicular torsion and risk factors for orchiectomy in a population encompassing all ages. A cohort analysis of 1625 males undergoing surgery for torsion was performed using the 2011 and 2012 Healthcare Cost and Utilization Project Nationwide Emergency Departments Sample. Patient and hospital factors were examined for association with orchiectomy vs. testicular salvage. The estimated yearly incidence of testicular torsion was 5.9 per 100,000 males ages 1-17 years and 1.3 per 100,000 males ≥18 years. Among those undergoing surgical intervention, orchiectomy was performed in 33.6%. The risk of orchiectomy was highest in patients 1-11 years of age and patients over 50 years of age (46.0% and 69.7% of patients, respectively). Orchiectomy was also associated with public insurance (Medicaid/Medicare) or self-pay as primary payer. While testicular torsion is less common in the adult population, the rate of orchiectomy is high. Those with disadvantaged payer status are also at increased risk for testicular loss.
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Affiliation(s)
- Garrick M Greear
- Department of Urology, University of California San Diego, 200 West Arbor Drive, MC 7897, San Diego, CA, 92103, USA
| | - Michael F Romano
- Boston University School of Medicine, 72 E. Concord St, Boston, MA, 02118, USA
| | - Mark H Katz
- Department of Urology, Boston Medical Center, 725 Albany St., Suite 3B, Boston, MA, 02118, USA
| | - Ricardo Munarriz
- Department of Urology, Boston Medical Center, 725 Albany St., Suite 3B, Boston, MA, 02118, USA
| | - James T Rague
- Department of Urology, Boston Medical Center, 725 Albany St., Suite 3B, Boston, MA, 02118, USA.
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16
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Krishnaraju VS, Malik D, Kumar R, Bora GS, Mittal BR, Bhattacharya A. Incremental Role of 18FDG PET/CT in Assessment of Testicular Viability. Nucl Med Mol Imaging 2018; 52:377-379. [PMID: 30344786 DOI: 10.1007/s13139-018-0531-z] [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: 04/24/2018] [Revised: 06/05/2018] [Accepted: 06/11/2018] [Indexed: 11/28/2022] Open
Abstract
Testicular torsion is a common differential diagnosis of acute scrotal pain along with acute epididymo-orchitis, which may lead to testicular non-viability. Doppler ultrasound and testicular scintigraphy are two routinely used modalities for the assessment of testicular viability. However, in some cases, these investigations may prove inadequate in differentiating between the two entities with widely differing management. Here, we present a case of a 52-year-old male with questionable viability of testis, who was investigated initially using testicular scintigraphy and was further subjected to a regional 18F-FDG PET/CT scan, in view of inconclusive findings with the conventional modalities.
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Affiliation(s)
- Venkata Subramanian Krishnaraju
- 1Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector -12, Chandigarh, 160012 India
| | - Dharmender Malik
- 1Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector -12, Chandigarh, 160012 India
| | - Rajender Kumar
- 1Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector -12, Chandigarh, 160012 India
| | - Giridhar S Bora
- 2Department of Urology, Postgraduate Institute of Medical Education and Research (PGIMER), Sector -12, Chandigarh, 160012 India
| | - Bhagwant Rai Mittal
- 1Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector -12, Chandigarh, 160012 India
| | - Anish Bhattacharya
- 1Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector -12, Chandigarh, 160012 India
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Osumah TS, Jimbo M, Granberg CF, Gargollo PC. Frontiers in pediatric testicular torsion: An integrated review of prevailing trends and management outcomes. J Pediatr Urol 2018; 14:394-401. [PMID: 30087037 DOI: 10.1016/j.jpurol.2018.07.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 07/13/2018] [Indexed: 12/12/2022]
Abstract
Testicular torsion remains the most frequent cause of testicular ischemia, especially in adolescents and young adults. Timely diagnosis and intervention are keys to saving the affected testicle. This review presents current trends in the diagnosis and treatment of torsion, potential pitfalls and consequent outcomes. Additionally, other salient issues surrounding testicular torsion are also discussed, including: pathogenesis of injury, legal ramifications, fertility outcomes, novel management techniques, and recent advances in diagnostic technology.
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Affiliation(s)
- T S Osumah
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | - M Jimbo
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | - C F Granberg
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | - P C Gargollo
- Department of Urology, Mayo Clinic, Rochester, MN, USA.
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Arevalo MK, Sheth KR, Menon VS, Ostrov L, Hennes H, Singla N, Koral K, Schlomer BJ, Baker LA. Straight to the Operating Room: An Emergent Surgery Track for Acute Testicular Torsion Transfers. J Pediatr 2018; 192:178-183. [PMID: 29246339 PMCID: PMC5737783 DOI: 10.1016/j.jpeds.2017.09.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 07/19/2017] [Accepted: 09/07/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the effect of implementing an emergency surgery track for testicular torsion transfers. We hypothesized that transferring children from other facilities diagnosed with torsion straight to the operating room (STOR) would decrease ischemia time, lower costs, and reduce testicular loss. STUDY DESIGN Demographics, arrival to incision time, hospital cost in dollars, and testicular outcome (determined by testicular ultrasound) at follow-up were retrospectively compared in all patients transferred to our tertiary care children's hospital with a diagnosis of testicular torsion from 2012 to 2016. Clinical data for STOR and non-STOR patients were compared by Wilcoxon rank-sum, 2-tailed t test, or Fisher exact test as appropriate. RESULTS Sixty-eight patients met inclusion criteria: 35 STOR and 33 non-STOR. Children taken STOR had a shorter median arrival to incision time (STOR: 54 minutes vs non-STOR: 94 minutes, P < .0001) and lower median total hospital costs (STOR: $3882 vs non-STOR: $4419, P < .0001). However, only 46.8% of STOR patients and 48.4% of non-STOR patients achieved surgery within 6 hours of symptom onset. Testicular salvage rates in STOR and non-STOR patients were not significantly different (STOR: 68.4% vs non-STOR: 36.8%, P = .1), but follow-up was poor. CONCLUSIONS STOR decreased arrival to incision time and hospital cost but did not affect testicular loss. The bulk of ischemia time in torsion transfers occurred before arrival at our tertiary care center. Further interventions addressing delays in diagnosis and transfer are needed to truly improve testicular salvage rates in these patients.
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Affiliation(s)
| | - Kunj R Sheth
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Vani S Menon
- Children’s Health, Dallas, TX,University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Halim Hennes
- Children’s Health, Dallas, TX,University of Texas Southwestern Medical Center, Dallas, TX
| | - Nirmish Singla
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Korgun Koral
- Children’s Health, Dallas, TX,University of Texas Southwestern Medical Center, Dallas, TX
| | - Bruce J Schlomer
- Children’s Health, Dallas, TX,University of Texas Southwestern Medical Center, Dallas, TX
| | - Linda A Baker
- Children’s Health, Dallas, TX,University of Texas Southwestern Medical Center, Dallas, TX
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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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20
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Comparison of superb micro-vascular imaging (SMI) and conventional Doppler imaging techniques for evaluating testicular blood flow. J Med Ultrason (2001) 2017; 45:443-452. [DOI: 10.1007/s10396-017-0847-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 11/06/2017] [Indexed: 10/18/2022]
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21
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Factors Associated with Delayed Presentation and Misdiagnosis of Testicular Torsion: A Case-Control Study. J Pediatr 2017; 186:200-204. [PMID: 28427778 DOI: 10.1016/j.jpeds.2017.03.037] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 02/15/2017] [Accepted: 03/13/2017] [Indexed: 11/20/2022]
Abstract
We identified factors associated with delay in presentation and misdiagnosis of testicular torsion. Compared with acute cases, delayed presentations were more likely to report isolated abdominal pain, developmental disorders, and history of recent genital trauma. Failure to perform a genitourinary examination or scrotal imaging was associated with misdiagnosis.
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Schlomer BJ, Keays MA, Grimsby GM, Granberg CF, DaJusta DG, Menon VS, Ostrov L, Sheth KR, Hill M, Sanchez EJ, Harrison CB, Jacobs MA, Huang R, Burgu B, Hennes H, Baker LA. Transscrotal Near Infrared Spectroscopy as a Diagnostic Test for Testis Torsion in Pediatric Acute Scrotum: A Prospective Comparison to Gold Standard Diagnostic Test Study. J Urol 2017; 198:694-701. [PMID: 28392394 DOI: 10.1016/j.juro.2017.03.134] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE A rapid test for testicular torsion in children may obviate the delay for testicular ultrasound. In this study we assessed testicular tissue percent oxygen saturation (%StO2) measured by transscrotal near infrared spectroscopy as a diagnostic test for pediatric testicular torsion. MATERIALS AND METHODS This was a prospective comparison to a gold standard diagnostic test study that evaluated near infrared spectroscopy %StO2 readings to diagnose testicular torsion. The gold standard for torsion diagnosis was standard clinical care. From 2013 to 2015 males with acute scrotum for more than 1 month and who were less than 18 years old were recruited. Near infrared spectroscopy %StO2 readings were obtained for affected and unaffected testes. Near infrared spectroscopy Δ%StO2 was calculated as unaffected minus affected reading. The utility of near infrared spectroscopy Δ%StO2 to diagnose testis torsion was described with ROC curves. RESULTS Of 154 eligible patients 121 had near infrared spectroscopy readings. Median near infrared spectroscopy Δ%StO2 in the 36 patients with torsion was 2.0 (IQR -4.2 to 9.8) vs -1.7 (IQR -8.7 to 2.0) in the 85 without torsion (p=0.004). AUC for near infrared spectroscopy as a diagnostic test was 0.66 (95% CI 0.55-0.78). Near infrared spectroscopy Δ%StO2 of 20 or greater had a positive predictive value of 100% and a sensitivity of 22.2%. Tanner stage 3-5 cases without scrotal edema or with pain for 12 hours or less had an AUC of 0.91 (95% CI 0.86-1.0) and 0.80 (95% CI 0.62-0.99), respectively. CONCLUSIONS In all children near infrared spectroscopy readings had limited utility in diagnosing torsion. However, in Tanner 3-5 cases without scrotal edema or with pain 12 hours or less, near infrared spectroscopy discriminated well between torsion and nontorsion.
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Affiliation(s)
- Bruce J Schlomer
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas.
| | | | | | | | | | - Vani S Menon
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas
| | | | - Kunj R Sheth
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Clanton B Harrison
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas
| | - Micah A Jacobs
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas
| | | | - Berk Burgu
- Ankara Üniversitesi Tıp Fakültesi, Ankara, Turkey
| | - Halim Hennes
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas
| | - Linda A Baker
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas
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Missed Torsion of the Spermatic Cord: A Common yet Underreported Event. Urology 2017; 102:202-206. [DOI: 10.1016/j.urology.2016.12.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 12/14/2016] [Accepted: 12/20/2016] [Indexed: 11/24/2022]
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Gaither TW, Copp HL. State appellant cases for testicular torsion: Case review from 1985 to 2015. J Pediatr Urol 2016; 12:291.e1-291.e5. [PMID: 27140000 PMCID: PMC5073043 DOI: 10.1016/j.jpurol.2016.03.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 03/23/2016] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Testicular torsion is one of the most common diagnoses involved in lawsuits in the pediatric patient. Missed diagnosis and diagnostic delays put patients at risk for testicular loss and have resulted in malpractice litigation. Using a national database, we sought to describe testicular torsion malpractice cases tried at the state and federal level and investigate factors associated with successful defense by the provider. METHOD We reviewed the Lexis Nexis academic legal database. We searched all cases using the terms "testicular torsion" and "medical malpractice" from 1985 to 2015. From this search, we compiled various medical and legal aspects of the case including the outcome of the trial. We performed multivariate logistic regression to determine which factors were associated with successful defense at the state level. RESULTS Fifty-three malpractice cases of testicular torsion were included. State appeals were in favor of providers in 26 (50%) of cases. The average time between initial presentation of the patient and the state verdict decision was 5 years. Emergency room (ER) physicians were the most common provider sued (35%). Approximately half of the patients (26, 51%) first presented to the ER, and atypical presentations were common, as 16 (31%) presented with abdominal pain only. The proportion of patients with false-negative ultrasounds was 16 of 25 (64%). If the patient first presented to the ER, the doctor was less likely to have a successful defense (OR = 0.23; 95% CI 0.06-0.79]). Most verdicts (8/9, 89%) were in favor of urologists. One urologist lost at the state level because of delayed time to the operating room. CONCLUSIONS Atypical clinical presentations and false-negative ultrasound findings are common in testicular torsion malpractice litigation at the state and federal level. Providers who used ultrasound were not more likely to win the state appeal, and providers whose patients presented to the ER were less likely to have a successful defense. Although 50% of providers won the state appeal, the time from initial patient presentation and final state verdict decision was substantial.
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Affiliation(s)
- Thomas W Gaither
- Department of Urology, University of California, San Francisco, CA, USA
| | - Hillary L Copp
- Department of Urology, University of California, San Francisco, CA, USA.
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Colaco M, Heavner M, Sunaryo P, Terlecki R. Malpractice Litigation and Testicular Torsion: A Legal Database Review. J Emerg Med 2015; 49:849-54. [PMID: 26409673 DOI: 10.1016/j.jemermed.2015.06.052] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 06/15/2015] [Accepted: 06/23/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The litigious nature of the American medical environment is a major concern for physicians, with an estimated annual cost of $10 billion. OBJECTIVE The purpose of this study is to identify causes of litigation in cases of testicular torsion and what factors contribute to verdicts or settlements resulting in indemnity payments. METHODS Publicly available jury verdict reports were retrieved from the Westlaw legal database (Thomson Reuters, New York, NY). In order to identify pertinent cases, we used the search terms "medical malpractice" and "testicular torsion" with date ranging from 2000 to 2013. Jury verdicts, depositions, and narrative summaries were evaluated for their medical basis, alleged malpractice, findings, and indemnity payment(s) (if any). RESULTS Fifty-two cases were identified that were relevant to this study. Fifty-one percent of relevant cases were found in favor of the defendant physician, with the remaining 49% involving an indemnity payment (13% of which were settled). The most commonly sued medical providers were emergency physicians (48% of defendants), with urologists being second most common and making up 23% of the defendant pool. Emergency physicians were significantly more likely to make indemnity payments than urologists. CONCLUSION Testicular torsion is a delicate condition and requires expertise in evaluation and treatment. When emergency physicians choose not to consult an urologist for possible torsion, they leave themselves open to litigation risk. When an urologist is involved in torsion litigation, they are rarely unsuccessful in their defense. Finally, ultrasound is no guarantee for success against litigation.
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Affiliation(s)
- Marc Colaco
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Matthew Heavner
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Peter Sunaryo
- Division of Urology, Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Ryan Terlecki
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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26
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Mohammed WM, Davis NF, O'Connor KM, Kiely EA. Re-evaluating the role of Doppler ultrasonography in patients presenting with scrotal pain. Ir J Med Sci 2015; 185:705-709. [PMID: 26248888 DOI: 10.1007/s11845-015-1349-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 07/25/2015] [Indexed: 11/28/2022]
Abstract
AIM To describe our experience of all patients presenting to a tertiary referral centre over a 5-year time period with acute scrotum and to investigate the role of Doppler ultrasonography (DUS) for investigating this group of patients. METHOD A retrospective analysis was performed on all patients presenting to the emergency department (ED) of a level 1 trauma centre with acute scrotum from 2009 to 2014 inclusive. Inclusion criteria included all patients who underwent an investigatory DUS and/or emergency scrotal exploration. Recorded patient demographics included age, presenting symptoms, duration of symptoms and relevant examination findings. RESULT Three-hundred and twelve patients were included with a mean age of 15 years (range 1 day-40 years). In total, 106 patients underwent immediate scrotal exploration, and testicular torsion (TT) was found in 30 % (n = 32/106). Two-hundred and twenty-two patients were initially investigated with DUS and 16 (7.2 %) proceeded to scrotal exploration. Of this sub-group, 2/16 presented with a history <24 h and exploration was negative for TT. In comparison, 14/16 presented with a history >24 h, and DUS findings were consistent with TT. No patients with a normal DUS represented to the ED after discharge. CONCLUSION DUS may prevent unnecessary scrotal exploration in patients presenting with acute scrotal pain and is useful for diagnosing TT in patients presenting with symptoms >24 h.
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Affiliation(s)
- W M Mohammed
- Department of Urology, Cork University Hospital, Co. Cork, Ireland
| | - N F Davis
- Department of Urology, Cork University Hospital, Co. Cork, Ireland.
| | - K M O'Connor
- Department of Urology, Cork University Hospital, Co. Cork, Ireland
| | - E A Kiely
- Department of Urology, Cork University Hospital, Co. Cork, Ireland
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Pogorelić Z, Mrklić I, Jurić I. Do not forget to include testicular torsion in differential diagnosis of lower acute abdominal pain in young males. J Pediatr Urol 2013; 9:1161-5. [PMID: 23743132 DOI: 10.1016/j.jpurol.2013.04.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 04/23/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Management and outcomes of pediatric patients with testicular torsion initially presenting as acute abdominal pain were evaluated. PATIENTS AND METHODS The case records of 84 children operated on for testicular torsion from January 1999 through May 2012 were retrospectively reviewed. Of the total number of operated patients, 9 presented with abdominal pain but without initial scrotal pain, and only they were included in the study. The diagnosis of testicular torsion was made clinically and confirmed by Doppler ultrasound and scrotal exploration. RESULTS The most common presenting symptoms were abdominal pain and vomiting. The patient's scrotum and testicles were not examined during the first evaluation in 6 cases, while in 3 cases the testicles were examined during the first physical examination. At surgery, 4 testes were salvaged, while 5 have been lost because of testicular necrosis. The mean duration of symptoms was 4 h in the group of salvaged testes and 39 h in the orchidectomy group. There were no major complications. CONCLUSION Testicular torsion should always be included in differential diagnosis when evaluating lower abdominal pain in young males. The external genital organs should be examined in every child or adolescent with acute abdominal pain.
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Affiliation(s)
- Zenon Pogorelić
- Department of Pediatric Surgery, Split University Hospital Centre and Split University School of Medicine, Spinčićeva 1, 21 000 Split, Croatia.
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Pilot Feasibility Study of Transscrotal Near Infrared Spectroscopy in the Evaluation of Adult Acute Scrotum. J Urol 2013; 190:124-9. [DOI: 10.1016/j.juro.2013.01.080] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2013] [Indexed: 11/21/2022]
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29
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Torsion du cordon spermatique chez l’enfant : impact du mode de consultation sur le délai de prise en charge et le taux d’orchidectomie. Arch Pediatr 2013; 20:364-8. [DOI: 10.1016/j.arcped.2013.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Revised: 11/20/2012] [Accepted: 01/08/2013] [Indexed: 11/22/2022]
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30
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Hadway P, Reynard JM. The six-hour rule for testis fixation in testicular torsion: is it history? JOURNAL OF CLINICAL UROLOGY 2013. [DOI: 10.1177/2051415812472676] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: To explore the historical and recent evidence behind the urological rule that operative management within six hours of pain onset in testicular torsion is necessary for organ salvage To use this information to guide those involved in related medico-legal cases Methods: Focused search of the PubMed database. Translation from German to English of the sentinel work of Hellner from 1933. Results: Hellner’s canine studies showed that complete ischaemia of the testis beyond six hours resulted in necrosis and then atrophy. He also showed that the degree of torsion was a key determinant of outcome with organ salvage possible at up to 24 hours when the twist was less than 3600. Recent clinical series support these findings and suggest a success rate of ≥98% when exploration is performed within six hours. Testicular salvage may be as good as 89% when surgery is delayed to 12 hours. Related medico-legal cases may consider whether the operative delay was causative in testicular loss, and where liability may lie for any such delay. Specific literature in this area is sparse. Conclusion: Hellner’s work explains the basis of the six hour rule and its application remains valid in today’s clinical practice. Surgical exploration is indicated out to 24 hours, however, given that testes can still be saved and that the degree of torsion cannot be gleaned pre-operatively. Medico-legally, we believe that an operative delay of up to 8 hours is probably safe when considering the causation of testicular loss, but more data are needed. Liability is more complex in that many factors can contribute to the delay and may be beyond the control of the doctor or hospital.
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Affiliation(s)
- Paul Hadway
- Department of Urology, Oxford University Hospitals, Churchill Hospital, Oxford, UK
| | - John M Reynard
- Department of Urology, Oxford University Hospitals, Churchill Hospital, Oxford, UK
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Aydogdu O, Burgu B, Gocun PU, Ozden E, Yaman O, Soygur T, Dursun A, Aydos K. Near Infrared Spectroscopy to Diagnose Experimental Testicular Torsion: Comparison With Doppler Ultrasound and Immunohistochemical Correlation of Tissue Oxygenation and Viability. J Urol 2012; 187:744-50. [DOI: 10.1016/j.juro.2011.09.145] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Indexed: 10/14/2022]
Affiliation(s)
- Ozgu Aydogdu
- Department of Urology, Bor State Hospital, Ankara, Turkey
| | - Berk Burgu
- Department of Urology, Nigde and Ankara University School of Medicine, Ankara, Turkey
| | - Pinar Uyar Gocun
- Department of Pathology, Gazi University School of Medicine, Ankara, Turkey
| | - Eriz Ozden
- Department of Urology, Nigde and Ankara University School of Medicine, Ankara, Turkey
| | - Onder Yaman
- Department of Urology, Nigde and Ankara University School of Medicine, Ankara, Turkey
| | - Tarkan Soygur
- Department of Urology, Nigde and Ankara University School of Medicine, Ankara, Turkey
| | - Ayse Dursun
- Department of Pathology, Gazi University School of Medicine, Ankara, Turkey
| | - Kaan Aydos
- Department of Urology, Nigde and Ankara University School of Medicine, Ankara, Turkey
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Davis JE. Genitourinary (GU) complaints can be quite distressing for the patient, parent, or caretaker (and even, at times, for the health care provider!). Introduction. Emerg Med Clin North Am 2011; 29:xv-xvi. [PMID: 21782068 DOI: 10.1016/j.emc.2011.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Adhikari S, Blaivas M. WITHDRAWN: Point-of-care emergency ultrasound evaluation of acute scrotal pain in the ED. Am J Emerg Med 2011:S0735-6757(11)00052-0. [PMID: 21450431 DOI: 10.1016/j.ajem.2011.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 01/15/2011] [Accepted: 01/16/2011] [Indexed: 11/24/2022] Open
Abstract
This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
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Affiliation(s)
- Srikar Adhikari
- Department of Emergency Medicine, University of Arizona Health Sciences Center, Tucson, AZ
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Bayne AP, Madden-Fuentes RJ, Jones EA, Cisek LJ, Gonzales ET, Reavis KM, Roth DR, Hsieh MH. Factors associated with delayed treatment of acute testicular torsion-do demographics or interhospital transfer matter? J Urol 2010; 184:1743-7. [PMID: 20728168 DOI: 10.1016/j.juro.2010.03.073] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2009] [Indexed: 11/27/2022]
Abstract
PURPOSE Testicular torsion is a true urological emergency. We determined whether a delay in treatment due to hospital transfer or socioeconomic factors would impact the orchiectomy rate in children with this condition. MATERIALS AND METHODS We retrospectively evaluated the records of boys seen at a single institution emergency department who proceeded to surgery for a diagnosis of acute testicular torsion from 2003 to 2008. Charts were reviewed for transfer status, symptom duration, race, insurance presence or absence and distance from the hospital. Orchiectomy specimens were evaluated for histological confirmation of nonviability. RESULTS We reviewed 97 records. The orchiectomy rate in patients who were vs were not transferred to the emergency department was 47.8% vs 68.9%, respectively (p = 0.07). Symptom duration was greater in the orchiectomy group with a mean difference of 47.9 hours (p <0.01). The mean transfer delay was 1 hour 15 minutes longer in the orchiectomy group (p = 0.01). Boys who underwent orchiectomy were 2.2 years younger than those who avoided orchiectomy (p = 0.01). Multivariate analysis showed that symptom duration and distance from the hospital were the strongest predictors of orchiectomy. CONCLUSIONS Data suggest that torsion is a time dependent event and factors that delay time to treatment lead to poorer outcomes. These factors include distance from the hospital and the time delay associated with hospital transfer.
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Affiliation(s)
- Aaron P Bayne
- Scott Department of Urology, Baylor College of Medicine, Houston, Texas, USA.
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Merrot T, Chaumoitre K, Robert A, Alessandrini P, Panuel M. La bourse aiguë de l’enfant : corrélations radiocliniques. Prog Urol 2009; 19:176-85. [DOI: 10.1016/j.purol.2008.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2008] [Revised: 10/02/2008] [Accepted: 11/01/2008] [Indexed: 10/21/2022]
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38
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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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Kalfa N, Veyrac C, Lopez M, Lopez C, Maurel A, Kaselas C, Sibai S, Arena F, Vaos G, Bréaud J, Merrot T, Kalfa D, Khochman I, Mironescu A, Minaev S, Avérous M, Galifer RB. Multicenter assessment of ultrasound of the spermatic cord in children with acute scrotum. J Urol 2007; 177:297-301; discussion 301. [PMID: 17162068 DOI: 10.1016/j.juro.2006.08.128] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2006] [Indexed: 10/23/2022]
Abstract
PURPOSE Intravaginal or extravaginal spermatic cord torsion is a diagnostic challenge for the surgeon and radiologist. Color Doppler sonography can be inaccurate, leading to dangerous false-negative results. To date, no single reliable test has been able to provide 100% diagnostic accuracy. The direct visualization of the twisted cord during emergency high resolution ultrasonography has been proposed to avoid systematic and abusive surgical exploration. The aim of this multicenter study was to assess the validity and reproducibility of high resolution ultrasonography based management of acute scrotum in children. MATERIALS AND METHODS A total of 919 patients from 11 European university hospitals underwent color Doppler sonography and high resolution ultrasonography for acute scrotum between 1992 and 2005. The spermatic cord was studied along its complete length to detect a spiral twist. The surgical findings were correlated with the preoperative results. RESULTS A total of 208 patients had spermatic cord torsion proved at surgery. Intratesticular vascularization was absent in the affected testis in only 158 cases (76%). In contrast, high resolution ultrasonography detected the twist as a snail shell-shaped mass, measuring 7 to 33 mm, in 199 patients (96%). High resolution ultrasonography revealed a linear cord for all other causes of acute scrotum (711 patients) with a specificity of 99%. The radiologist training level was the best predictive factor of high resolution ultrasonography reliability (p <0.05). CONCLUSIONS High resolution ultrasonography based management of acute scrotum is reliable and reproducible. Thanks to its high sensitivity and specificity for the diagnosis of spermatic cord torsion, high resolution ultrasonography can significantly improve the management of acute scrotum in children.
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Affiliation(s)
- Nicolas Kalfa
- Department of Visceral Pediatric Surgery and Pediatric Urology, Lapeyronie Hospital, CHU Montpellier, France.
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Pepe P, Panella P, Pennisi M, Aragona F. Does color Doppler sonography improve the clinical assessment of patients with acute scrotum? Eur J Radiol 2006; 60:120-4. [PMID: 16730939 DOI: 10.1016/j.ejrad.2006.04.016] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2005] [Revised: 04/07/2006] [Accepted: 04/10/2006] [Indexed: 10/24/2022]
Abstract
INTRODUCTION AND OBJECTIVES Our experience concerning the use of color Doppler sonography (CDS) in the differential diagnosis of acute scrotum is reported. MATERIAL AND METHODS From July 2000 to July 2005, 155 patients (median 17.2 years) were admitted with a diagnosis of acute scrotum (unilateral in 150 cases, bilateral in 5). Along with a careful anamnesis and the physical exam, all patients underwent a CDS study of the scrotal content using a sonograph GE Logiq 500 with a multifrequency (7.5-10 MHz) linear probe Small Part. The following CDS parameters were evaluated: intensity of the color-power signal on the testicular parenchyma and on the epididymis; systolic peak velocity (SPV) and telediastolic velocity (TDV) in correspondence of the gonadal hilum. Ultrasound and flowmetry parameters registered on the painful testis were compared with those registered on the healthy controlateral testis. The reduction/absence versus the increase of color-power signal in the parenchyma and the reduction/absence versus the increase of SPV and TDV in the centripetal intratesticular arteries were considered presumptive of testicular torsion versus orchiepididymitis. RESULTS The results only refer to the 150 patients (300 testis) with acute monolateral scrotum. The clinical picture and the physical exam suggested a torsion of the spermatic cord in 40 cases, a spontaneous de-torsion in 5, an orchiepididymitis in 80, a blunt scrotal trauma in 15, a bulky epididymal cyst or a hydrocele in 4 and a testicular pain of unknown etiology in the remaining 6 cases. Standard US was pathological in 95 patients (63.3%); CDS was pathologic in 70 patients and in 42 of them suggested a testicular torsion. Fifty-three patients underwent surgical exploration: among 42 patients with a presumptive diagnosis of testicular torsion, the diagnosis was confirmed in 22 cases, no anomaly was found in 16 cases and in 4 patients a torsion of testicular appendix was found. The rupture of the tunica albuginea was present in six out of seven patients submitted to surgical exploration for previous blunt trauma and the sonographic diagnosis of hematocele was documented in all cases. The single false-negative diagnosis of testicular torsion in CDS occurred in an 18-month-old child. In presence of funicular torsion, the sensitivity and specificity of physical exam and CDS were 100% versus 95.7% and 86.5% versus 85.3%, respectively; sensitivity and specificity of SPV, TDV and color-Doppler signal on the testis were 100% and 94.8% versus 100% and 90.1% versus 95.7% and 90.8%. In the pre-operative assessment of scrotal trauma, the B-mode US showed a sensitivity and specificity of 100% and 90%, respectively; the color Doppler analysis has not supplied with additional elements for planning a surgical exploration. In presence of orchiepididymitis, the sensitivity and specificity of the physical exam in association to CDS was equal to 100%. In all patients with torsion of the testicular appendix, physical exam and CDS parameters were within normal limits. DISCUSSION AND CONCLUSIONS In our experience CDS is an indispensable imaging modality for the clinical assessment of patients with acute scrotum; however, the informations it can afford are operator-dependent and have to be supported by the history and physical exam of the patient. CDS findings constitute probably an important medico-legal support when the necessity of surgical exploration is excluded; anyway, in presence of a clinical suspicion of testicular torsion, even with an apparently normal CDS, the surgical exploration is recommended.
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Affiliation(s)
- Pietro Pepe
- Urology Unit, Cannizzaro Hospital, Catania, Italy.
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Shergill IS, Foley CL, Arya M, Bott SRJ, Mundy AR. Testicular torsion unravelled. HOSPITAL MEDICINE (LONDON, ENGLAND : 1998) 2002; 63:456-9. [PMID: 12212415 DOI: 10.12968/hosp.2002.63.8.1964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Testicular torsion is a true vascular emergency-prompt diagnosis and surgical management is critical. If treatment is not instigated within 4-6 hours of the onset of pain, irreversible testicular infarction may result, necessitating orchidectomy. This review presents the key features, management principles and medicolegal considerations of this serious condition.
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Affiliation(s)
- I S Shergill
- Institute of Urology and Nephrology, University College London, London W1P 7NN
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Affiliation(s)
- JAMES M. CUMMINGS
- From the Division of Urology, University of South Alabama College of Medicine, Mobile, Alabama
| | - JOHN A. BOULLIER
- From the Division of Urology, University of South Alabama College of Medicine, Mobile, Alabama
| | - DAVINDER SEKHON
- From the Division of Urology, University of South Alabama College of Medicine, Mobile, Alabama
| | - KELLEY BOSE
- From the Division of Urology, University of South Alabama College of Medicine, Mobile, Alabama
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