Management of the acute scrotum in children

A Systematic Review of Testicle Survival Time After a Torsion Event

BACKGROUND

The time window for possible salvage and survival of a torsed testicle is commonly thought to be 6 to 8 hours. However, survival of torsed testicles with or without subsequent atrophy is known to occur outside that critical time window. In this article, we performed a systematic review of the English literature to provide a more accurate understanding of reported time frames of testicle survival after a torsion event.

OBJECTIVES

The primary research question was to determine the relationship between time to treatment and the rate of survival for testicles of male patients presenting with testicular torsion (TT).

METHODS

A systematic review of the literature was performed and structured according to PRISMA guidelines. An exhaustive library search was performed after search strategies were developed for multiple databases that included PubMed, Cochrane library, Ovid MEDLINE, Web of Science, and ProQuest Theses and Dissertations. Two different searches were developed including "testicular torsion" and TT with the search term "time" added. Articles specifically reporting TT case series, testicle outcomes, and time to surgical or manual treatment were selected for review. In addition to and preceding the systematic review, an exhaustive manual search of the literature was also performed by the authors. As a result of these searches, a total of 30 studies with data considered relevant to the research question were included. The information extracted from the articles was tabulated with regard to time intervals to treatment and survival outcome.

RESULTS

The systematic review process and protocol are reported in this article. A total of 30 studies were found that reported case series of TT patients and their outcomes as well as time to treatment reported in useful time frames. From these reports, a total of 2116 TT patients were culled, and their outcomes and time to treatment are reported. Because the time to treatment was reported variously in different case series, the 3 most common formats for reporting time to treatment and outcome were used. When overlap between the tables existed, the data were tallied and reported cumulatively. When reported in 6-hour intervals (1,283 patients), survival at 0 to 6 hours was 97.2%; 7 to 12 hours, 79.3%; 13 to 18 hours, 61.3%; 19 to 24 hours, 42.5%; 25 to 48 hours, 24.4%; and greater than 48 hours, 7.4%. Moreover, we reported cumulative survival data based on reporting for all 3 groups of patients. Testicular salvage in the first 12 hours is 90.4%, from 13 to 24 hours survival is 54.0%, and beyond 24 hours survival is 18.1%. Testicle survival after TT was significant beyond the commonly held 6 to 8 hour time frame and even after more than 24 hours of ischemia.

CONCLUSIONS

Survival of the testicle irrespective of subsequent atrophy, decreased spermatogenesis or impaired endocrine function after TT can be much longer than the 6 to 8 hours that is commonly taught. Our systematic review of the literature demonstrates that survival percentages are significant even past 24 hours of torsion. This information should encourage aggressive management of patients presenting with TT pain that has been ongoing for many hours.

Evaluation of Adult Acute Scrotum in the Emergency Room: Clinical Characteristics, Diagnosis, Management, and Costs

OBJECTIVE

To evaluate the clinic characteristics, diagnosis, management, and costs of the adult acute scrotum in the emergency room (ER). Acute scrotum is a syndrome characterized by intense, acute scrotal pain that may be accompanied by other symptoms. It is usual in children and commonly found as well in adults, with different causal pathologies between these groups.

METHODS

Between November 2013 and September 2014, 669 cases of adult acute scrotum who presented to our ER were prospectively analyzed. Patients under 15 years of age were excluded. Patient age, reason for consultation, investigations performed, final diagnosis, management, and costs were evaluated. For the statistical analysis, the Mann-Whitney, Kruskal-Wallis U, and chi-square tests were used.

RESULTS

A total of 669 cases of acute scrotum were analyzed. The mean age at presentation was 40.2 ± 17.3 years. The most presented diagnoses were orchiepididymitis (28.7%), epididymitis (28.4%), symptoms of uncertain etiology (25.1%), and orchitis (10.3%). Diagnostic tests were carried out in 57.8% of cases. Most cases were treated as outpatients (94.2%), with 5.83% admitted and 1% undergoing surgical treatment. Overall, 13.3% of patients represented to the ER. Abnormal results in blood and urine tests were more common among older patients and infectious pathologies. The average cost generated by an acute scrotum ER consult was 195.03€.

CONCLUSION

Infectious pathologies are the most common causes of acute scrotum at ER. Abnormal blood and urine tests are unusual and are more common in older patients and infectious pathologies.

Evaluation of acute scrotum in our consecutive operated cases: a one-center study

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.

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Torsion of the testicle: it is time to stop tossing the dice

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.

Perfusion CT evaluation in experimentally induced testicular torsion

INTRODUCTION

In this study, we define the characteristics of perfusion computed tomography (CT) in an experimental model of testicular torsion.

METHODS

Twenty male Sprague-Dawley rats were included for the study. Torsion was applied to 10 rats and perfusion CT was performed in the first hour to evaluate the following perfusion parameters: blood flow (BF), blood volume (BV) and time to peak (TTP) values. Detorsion was done for the same rats, and perfusion CT was repeated 2 hours later to evaluate reperfusion. Ten rats were left as part of the control group.

RESULTS

There is significant statistical correlation between the BF and BV values in the torsion and control groups (p = 0.001 and p = 0.001, respectively). There is no statistical correlation of the TTP parameters between the groups. No correlation was found between torsion and detorsion perfusion parameters.

CONCLUSION

Perfusion CT can demonstrate the testicular perfusion insult in an experimental model of torsion. Perfusion CT may be an alternative method for diagnosis of torsion in indeterminate cases. Following detorsion an interval of 2 hours is not sufficient for demonstrating luxury perfusion of the testis.

Clinical predictors for testicular torsion as seen in the pediatric ED

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.

Feasibility of Using Near-Infrared Spectroscopy to Diagnose Testicular Torsion: An Experimental Study in Sheep

STUDY OBJECTIVE

To assess whether near-infrared spectroscopy can detect testicular hypoxia in a sheep model of testicular torsion within 6 hours of experimental torsion.

METHODS

This was a randomized, controlled, nonblinded study. Trans-scrotal, near-infrared, spectroscopy-derived testicular tissue saturation of oxygen values were obtained from the posterior hemiscrota of 6 anesthetized sheep at baseline and every 15 minutes for 6 hours after either experimental-side, 720-degree, unilateral, medial testicular torsion and orchidopexy or control-side sham procedure with orchidopexy and then for 75 minutes after reduction of torsion and pexy. Color Doppler ultrasonography was performed every 30 minutes to confirm loss of vascular flow on the experimental side, return of flow after torsion reduction, and preserved flow on the control side.

RESULTS

Near infrared spectroscopy detected a prompt, sustained reduction in testicular tissue saturation of oxygen after experimental torsion. Further, it documented a rapid return of these values to pretorsion levels after reduction of torsion. Experimental-side testicular tissue saturation of oxygen fell from a median value of 59% (interquartile range [IQR] 57% to 69%) at baseline to 14% (IQR 11% to 29%) at 2.5 hours of torsion, and postreduction values were approximately 70%. Control-side testicular tissue saturation of oxygen values increased from a median value of 67% (IQR 59% to 68%) at baseline to 77% (IQR 77% to 94%) at 2.5 hours and remained at approximately 80% for the entire protocol. The difference in median testicular tissue saturation of oxygen between experimental and control sides, using the Friedman test, was found to be significant (P=.017).

CONCLUSION

This study demonstrates the feasibility, in a sheep model, of using near-infrared spectroscopy for the noninvasive diagnosis of testicular torsion and for quantification of reperfusion after torsion reduction. The applicability of these findings, from an animal model using complete torsion, to the clinical setting remains to be established.

Management of acute scrotum in children--the impact of Doppler ultrasound

BACKGROUND

Investigation of the value of scrotal Doppler ultrasound (DUS) in the diagnosis of acute scrotum and its impact on the treatment strategy was undertaken.

METHOD

Seventy-nine children (mean age, 9.2 years) with acute scrotum were prospectively studied. The protocol included history, clinical examination, scrotal DUS, and standard laboratory analysis. Depending on scrotal DUS findings, the children were treated either nonoperatively (normal or increased testicular blood flow) or surgically (reduced or absent testicular blood flow). A follow-up investigation 6 weeks after discharge included a scrotal DUS.

RESULTS

In 66 children (84%), the result of DUS determined the management; 26 children with hyperperfusion (epididymitis and orchitis), 18 children with appendix testis torsion (ATT), and 9 children with normal perfusion (edema and hematoma) were treated nonoperatively. The follow-up examination revealed no testicular atrophy and confirmed the primary diagnosis. Ten children without testicular perfusion and suspected torsion and 3 children with orchitis and pyocele were surgically explored, and again, the initial DUS diagnosis was verified. In the remaining 13 patients (16%), the result of the ultrasound examination was unclear. Of these, 6 children were noncompliant and refused to undergo ultrasonography. Another 4 children were explored because of persistence of symptoms. In 3 additional patients, a testicular tumor was suspected. All these 13 children underwent surgical exploration, revealing inflammation (epididymitis) in 6 children and acute ATT in 4 children, whereas the suspected tumor emerged as postacute ATT in 3 boys.

CONCLUSION

In 84% of children with acute scrotal pain, the DUS was able to differentiate between surgical emergencies and other etiologies. In 16% of our pediatric patients, the DUS remained unclear, thereby necessitating surgical exploration.

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

Acute testicular torsion in children is an emergency and has to be diagnosed urgently. Doppler sonography is increasingly used in imaging the acute scrotum. Nevertheless, in uncertain cases, surgical exploration is required. In this study, we attempted to define the role of Doppler sonography in the diagnostic workup of the acutely painful scrotum. All patients admitted between 1999 and 2005 with acute scrotal pain were included. After clinical assessment, patients were imaged by Doppler sonography with a ''high-end'' instrument. In cases of absent arterial perfusion of the testis in Doppler sonography, surgical exploration was carried out. Patients with unaffected perfusion were followed clinically by ultrasound for up to 2 years. Sixty-one infants and children aged 1 day to 17 years (median: 7.9 years) were included. In 14 cases, sonography demonstrated absent central perfusion, with abnormal parenchymal echogenicity in six. Absence of venous blood flow together with reduction of central arterial perfusion was found in one infant. In these 15 patients, surgical exploration confirmed testicular torsion. Among the other 46 patients, we found four cases with increased testicular perfusion and 27 with increased perfusion of the epididymis. In one infant, a testicular tumour was found sonographically, and orchiectomy confirmed diagnosis of a teratoma. Follow-up examinations of the conservatively treated patients showed good clinical outcome with physiologic central perfusion as well as normal echogenic pattern of both testes. No case of testicular torsion was missed. By means of Doppler sonography, an unequivocal statement regarding testicular perfusion was possible in all cases. The initial Doppler diagnosis was confirmed by operative evaluation and follow-up ultrasound. Testicular torsion can therefore be excluded by correctly performed ultrasound with modern equipment.

The acute scrotum: a review of 40 cases

OBJECTIVE

To determine the relative importance of clinical presentation, laboratory studies, and ultrasonography in the diagnosis of acute scrotum, and to suggest an effective method of management.

SUBJECTS AND METHODS

Forty patients who were hospitalized between January 2002 and December 2002 for acute scrotum were studied with respect to history, physical examination, blood tests, urine analysis including culture, and scrotal ultrasonography with color Doppler study.

RESULTS

Epididymitis (n = 24) was the commonest cause of acute scrotum followed by testicular torsion (n = 11), torsion of testicular appendages (n = 4), and idiopathic scrotal edema (n = 1). Both mean age (40.7 vs. 13.8 years), and average duration of pain at presentation (4.5 days vs. 19.1 h) were higher in patients with epididymitis than in torsion. Onset was usually insidious in epididymitis, sudden in testicular torsion, and variable in torsion of testicular appendages. The majority (87.5%) of patients with epididymitis were managed conservatively. The testis was salvaged in 81.8% of patients with testicular torsion. The accuracy of ultrasonography was only 72.7% in testicular torsion, but was good in epididymitis.

CONCLUSION

Our results show that a careful clinical evaluation, by an experienced examiner, provides the correct diagnosis in acute scrotum rather than ultrasonography. It is of utmost importance to exclude testicular torsion in those who are younger than 16 years and whose pain duration is less than 24 h.