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Abu-Baih RH, Abu-Baih DH, Abdel-Hafez SMN, Fathy M. Activation of SIRT1/Nrf2/HO-1 and Beclin-1/AMPK/mTOR autophagy pathways by eprosartan ameliorates testicular dysfunction induced by testicular torsion in rats. Sci Rep 2024; 14:12566. [PMID: 38822026 PMCID: PMC11143266 DOI: 10.1038/s41598-024-62740-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 05/21/2024] [Indexed: 06/02/2024] Open
Abstract
Testicular torsion carries the ominous prospect of inducing acute scrotal distress and the perilous consequence of testicular atrophy, necessitating immediate surgical intervention to reinstate vital testicular perfusion, notwithstanding the paradoxical detrimental impact of reperfusion. Although no drugs have secured approval for this urgent circumstance, antioxidants emerge as promising candidates. This study aspires to illustrate the influence of eprosartan, an AT1R antagonist, on testicular torsion in rats. Wistar albino rats were meticulously separated into five groups, (n = 6): sham group, eprosartan group, testicular torsion-detorsion (T/D) group, and two groups of T/D treated with two oral doses of eprosartan (30 or 60 mg/kg). Serum testosterone, sperm analysis and histopathological examination were done to evaluate spermatogenesis. Oxidative stress markers were assessed. Bax, BCL-2, SIRT1, Nrf2, HO-1 besides cleaved caspase-3 testicular contents were estimated using ELISA or qRT-PCR. As autophagy markers, SQSTM-1/p62, Beclin-1, mTOR and AMPK were investigated. Our findings highlight that eprosartan effectively improved serum testosterone levels, testicular weight, and sperm count/motility/viability, while mitigating histological irregularities and sperm abnormalities induced by T/D. This recovery in testicular function was underpinned by the activation of the cytoprotective SIRT1/Nrf2/HO-1 axis, which curtailed testicular oxidative stress, indicated by lowering the MDA content and increasing GSH content. In terms of apoptosis, eprosartan effectively countered apoptotic processes by decreasing cleaved caspase-3 content, suppressing Bax and stimulating Bcl-2 gene expression. Simultaneously, it reactivated impaired autophagy by increasing Beclin-1 expression, decreasing the expression of SQSTM-1/p62 and modulate the phosphorylation of AMPK and mTOR proteins. Eprosartan hold promise for managing testicular dysfunction arising from testicular torsion exerting antioxidant, pro-autophagic and anti-apoptotic effect via the activation of SIRT1/Nrf2/HO-1 as well as Beclin-1/AMPK/mTOR pathways.
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Affiliation(s)
- Rania H Abu-Baih
- Faculty of Pharmacy, Drug Information Center, Minia University, Minia, 61519, Egypt
| | - Dalia H Abu-Baih
- Department of Biochemistry and Molecular Biology, Faculty of Pharmacy, Deraya University, Minia, 61111, Egypt
- Deraya Center for Scientific Research, Deraya University, Minia, 61111, Egypt
| | | | - Moustafa Fathy
- Department of Biochemistry, Faculty of Pharmacy, Minia University, Minia, 61519, Egypt.
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Barkai E, Dekalo S, Yossepowitch O, Ben-Chaim J, Bar-Yosef Y, Beri A, Mano R. Complete Blood Count Markers and C-Reactive Protein as Predictors of Testicular Viability in the Event of Testicular Torsion in Adults. Urol Int 2023; 107:801-806. [PMID: 37423214 PMCID: PMC10614481 DOI: 10.1159/000531145] [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: 02/06/2023] [Accepted: 05/15/2023] [Indexed: 07/11/2023]
Abstract
INTRODUCTION The association between blood markers and testicular viability after testicular torsion (TT) is not well known. We evaluated the role of complete blood count markers and C-reactive protein (CRP) in predicting testicular viability after TT. METHODS Fifty men, ≥18 years of age, operated for TT between the years 2015-2020 were enrolled. Blood markers including neutrophil-, lymphocyte-, and platelet count, and CRP were obtained. Neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) were calculated. The study outcome was testicular salvage. RESULTS Median age was 23 years (interquartile range [IQR]: 21, 31). Median duration of torsion was 10 h (IQR: 6, 42). Sonographic texture of the testis was homogenous in 27 (56%) patients and heterogenous in 21 (44%). During scrotal exploration, 36 patients (72%) underwent orchiopexy and 14 (28%) underwent orchiectomy. Patients who underwent orchiopexy were younger (22 years vs. 31 years, p = 0.009), had a shorter duration of torsion (median 8 h vs. 48 h, p < 0.001), and a homogenous texture on scrotal ultrasound (76.5 vs. 7.1%, p < 0.001). Median NLR, PLR, and CRP were higher among patients who underwent orchiectomy; however, these differences did not reach statistical significance. Patients with heterogenous echotexture were significantly more likely to undergo orchiectomy (odds ratio = 42, 95% confidence interval: 7, 831, adjusted p value = 0.009). CONCLUSIONS We found no association between blood-based biomarkers and testicular viability after TT; however, testicular echotexture significantly predicted outcome.
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Affiliation(s)
- Eyal Barkai
- Department of Urology, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel
- Department of Urology, Samson Assuta Ashdod University Hospital, Ashdod, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Snir Dekalo
- Department of Urology, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Ofer Yossepowitch
- Department of Urology, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Jacob Ben-Chaim
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
- Department of Pediatric Urology, Dana-Dwek Children’s Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel
| | - Yuval Bar-Yosef
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
- Department of Pediatric Urology, Dana-Dwek Children’s Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel
| | - Avi Beri
- Department of Urology, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Roy Mano
- Department of Urology, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
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Long-Term Follow-Up after Testicular Torsion: Prospective Evaluation of Endocrine and Exocrine Testicular Function, Fertility, Oxidative Stress and Erectile Function. J Clin Med 2022; 11:jcm11216507. [PMID: 36362741 PMCID: PMC9659157 DOI: 10.3390/jcm11216507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/24/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
Background: This study investigates endocrine and exocrine testicular function, oxidative stress (OS) in semen, and erectile function in patients who underwent surgery for suspected testicular torsion (TT). Methods: We evaluated 49 patients over a mean follow-up of 101 months: n = 25 patients treated with surgical exploration, n = 20 patients treated with detorsion, and n = 4 treated with orchiectomy. We performed semen analysis including Male infertility Oxidative System (MyOxSIS) analysis, physical examination, and evaluation of endocrine and erectile function. Results: OS, erectile function and spermiogram categories did not differ significantly between the groups. The interval from the onset of symptoms to surgery differed significantly between groups (p < 0.001). Preservation of the testes was associated with a higher round cell count (p = 0.002) and follicle stimulating hormone (FSH, p = 0.003). OS showed a significant positive correlation with the spermiogram category (0.337; p = 0.022). A negative correlation was observed between OS and age (p = 0.033), sperm concentration (p < 0.001) and total sperm count (p = 0.006). Conclusions: Endocrine, exocrine and erectile function are not significantly affected by TT in the long term. Orchiectomy results in elevated FSH and a lower round cell count compared to preservation of the testis.
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Bašković M, Krsnik D, Himelreich Perić M, Katušić Bojanac A, Sinčić N, Sonicki Z, Ježek D. Astaxanthin Relieves Testicular Ischemia-Reperfusion Injury—Immunohistochemical and Biochemical Analyses. J Clin Med 2022; 11:jcm11051284. [PMID: 35268375 PMCID: PMC8911179 DOI: 10.3390/jcm11051284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 12/10/2022] Open
Abstract
Testicular torsion potentially leads to acute scrotum and testicle loss, and requires prompt surgical intervention to restore testicular blood flow, despite the paradoxical negative effect of reperfusion. While no drug is yet approved for this condition, antioxidants are promising candidates. This study aimed to determine astaxanthin’s (ASX), a potent antioxidant, effect on rat testicular torsion−detorsion injury. Thirty-two prepubertal male Fischer rats were divided into four groups. Group 1 underwent sham surgery. In group 2, the right testis was twisted at 720° for 90 min. After 90 min of reperfusion, the testis was removed. ASX was administered intraperitoneally at the time of detorsion (group 3) and 45 min after detorsion (group 4). Quantification of caspase-3 positive cells and oxidative stress markers detection were determined immunohistochemically, while the malondialdehyde (MDA) value, superoxide dismutase (SOD), and glutathione peroxidase (GPx) activities were determined by colorimetric assays. The number of apoptotic caspase-3 positive cells and the MDA value were lower in group 4 compared to group 2. A significant increase in the SOD and GPx activity was observed in group 4 compared to groups 2 and 3. We conclude that ASX has a favorable effect on testicular ischemia-reperfusion injury in rats.
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Affiliation(s)
- Marko Bašković
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia; (D.K.); (M.H.P.); (A.K.B.); (N.S.); (Z.S.); (D.J.)
- Department of Pediatric Urology, Children’s Hospital Zagreb, Ulica Vjekoslava Klaića 16, 10000 Zagreb, Croatia
- Correspondence: ; Tel.: +385-1-3636-379
| | - Dajana Krsnik
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia; (D.K.); (M.H.P.); (A.K.B.); (N.S.); (Z.S.); (D.J.)
- Department of Biology, School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
| | - Marta Himelreich Perić
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia; (D.K.); (M.H.P.); (A.K.B.); (N.S.); (Z.S.); (D.J.)
- Department of Biology, School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
| | - Ana Katušić Bojanac
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia; (D.K.); (M.H.P.); (A.K.B.); (N.S.); (Z.S.); (D.J.)
- Department of Biology, School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
| | - Nino Sinčić
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia; (D.K.); (M.H.P.); (A.K.B.); (N.S.); (Z.S.); (D.J.)
- Department of Biology, School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
| | - Zdenko Sonicki
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia; (D.K.); (M.H.P.); (A.K.B.); (N.S.); (Z.S.); (D.J.)
- Department of Medical Statistics, Epidemiology and Medical Informatics, School of Public Health Andrija Štampar, School of Medicine, University of Zagreb, Johna Davidsona Rockfellera 4, 10000 Zagreb, Croatia
| | - Davor Ježek
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia; (D.K.); (M.H.P.); (A.K.B.); (N.S.); (Z.S.); (D.J.)
- Department of Histology and Embryology, School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
- Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Kišpatićeva 12, 10000 Zagreb, Croatia
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Bašković M, Bojanac AK, Sinčić N, Perić MH, Krsnik D, Ježek D. The effect of astaxanthin on testicular torsion-detorsion injury in rats - Detailed morphometric evaluation of histological sections. J Pediatr Urol 2021; 17:439.e1-439.e12. [PMID: 33839034 DOI: 10.1016/j.jpurol.2021.03.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 03/11/2021] [Accepted: 03/20/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Testicular torsion is one of the conditions of the acute scrotum that requires immediate surgical intervention. If not recognized at time, it can result of ischemic injuries and testicular loss. Restoration of blood flow is essential to save ischemic tissue, but reperfusion itself paradoxically causes further damage. Seaweed and sponges are considered to be the richest source of bioactive compounds that have antioxidant activity. The antioxidant activity of astaxanthin is 10 times higher than zeaxanthin, lutein, canthaxanthin, β-carotene and 100 times higher than α-tocopherol. Since to date there is no drug given to patients with torsion-detorsion testicular injury, we have investigated the effect of this powerful antioxidant. OBJECTIVE The aim of this study was to determine the effect of astaxanthin (ASX) on testicular torsion-detorsion injury in rats. MATERIALS AND METHODS Thirty-two male Fischer prepubertal rats were divided into 4 groups of 8 individuals. Group 1 underwent sham surgery to determine basal values for histological evaluation. In group 2 (torsion-detorsion group), right testis was twisted at 720° for 90 min. After 90min of reperfusion, the testis was removed. Astaxanthin was administered intraperitoneally at the time of detorsion (group 3) and 45 min after detorsion (group 4) in the treatment groups. Using software ImageJ®, histological morphometric values were measured. RESULTS MSTD (mean seminiferous tubule diameter) values increase statistically significantly in ASX groups compared to T/D group. MSLD (mean seminiferous lumen diameter) value was statistically significantly lower in the ASX group 3 compared to the T/D group. Epithelial height was statistically significantly higher in ASX groups compared to the T/D group. Tubular area is statistically significantly higher in ASX group 4, while the luminal area is statistically significantly lower in the ASX group 3 compared to the T/D group. Johnsen score was statistically significantly higher in the ASX groups compared to the T/D group. DISCUSSION This is the first scientific paper to study the effects of a single powerful antioxidant on all morphometric parameters. In previous scientific papers, scientists have mainly measured MSTD and the Johnsen score. CONCLUSION By measuring all histological morphometric parameters (mean seminiferous tubule diameter, mean seminiferous lumen diameter, epithelial height, tubular area, luminal area, Johnsen score) it can be concluded that astaxanthin has a favorable effect comparing the treated groups to untreated group.
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Affiliation(s)
- Marko Bašković
- Department of Pediatric Urology, Children's Hospital Zagreb, Klaićeva 16, Zagreb, 10000, Croatia.
| | - Ana Katušić Bojanac
- Department of Medical Biology, University of Zagreb, School of Medicine, Šalata 3, Zagreb, 10000, Croatia
| | - Nino Sinčić
- Department of Medical Biology, University of Zagreb, School of Medicine, Šalata 3, Zagreb, 10000, Croatia
| | - Marta Himelreich Perić
- Department of Medical Biology, University of Zagreb, School of Medicine, Šalata 3, Zagreb, 10000, Croatia
| | - Dajana Krsnik
- Department of Medical Biology, University of Zagreb, School of Medicine, Šalata 3, Zagreb, 10000, Croatia
| | - Davor Ježek
- Department of Histology and Embriology, University of Zagreb, School of Medicine, Šalata 3, Zagreb, 10000, Croatia
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Persily JB, Vijay V, Najari BB. How do we counsel men with obstructive azoospermia due to CF mutations?-a review of treatment options and outcomes. Transl Androl Urol 2021; 10:1467-1478. [PMID: 33850781 PMCID: PMC8039579 DOI: 10.21037/tau-19-681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Obstructive azoospermia (OA) is a rare cause of male infertility, with Congenital Bilateral Absence of The Vas Deferens (CBAVD) being a major cause. A wealth of literature has established an irrefutable link between CFTR mutations and CBAVD, with CBAVD affecting almost all men with cystic fibrosis (CF) disease and a significant portion of men that are CFTR mutation carriers. In the past two decades, assisted reproductive technologies have made the prospect of fathering children a viable possibility in this subset of men, using a combination of sperm extraction techniques and intracystoplasmic sperm injection (ICSI). In order to assess techniques for sperm retrieval, as well as reproductive outcomes, a systemic search of the MEDLINE database was conducted for all articles pertaining to management options for CBAVD, and also all reports describing outcomes of these procedures in the CBAVD population. Both epididymal and testicular sperm extraction (TESE) are viable options for men with CBAVD, and though rigorous data are lacking, live birth rates range from 8% to 50% in most small retrospective series and subset analyses. In addition, there does not appear to be significant differences in the rate of live birth or complications and miscarriages between the various techniques, though further investigation into other factors that limit reproductive potential of men with CFTR mutations and CBAVD is warranted.
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Affiliation(s)
- Jesse B Persily
- Department of Urology, New York University Langone School of Medicine, New York, NY, USA
| | - Varun Vijay
- Department of Urology, New York University Langone School of Medicine, New York, NY, USA
| | - Bobby B Najari
- Department of Urology, New York University Langone School of Medicine, New York, NY, USA.,Department of Population Health, New York University Langone School of Medicine, New York, NY, USA
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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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Tatekawa Y. A case of peeping testis moving from the inguinal position into the abdomen. J Surg Case Rep 2020; 2020:rjaa027. [PMID: 32161639 PMCID: PMC7059888 DOI: 10.1093/jscr/rjaa027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 02/06/2020] [Indexed: 11/12/2022] Open
Abstract
We report herein a 14-month-old boy with a left-sided peeping testis. At the age of 1 month, the left testis was palpated between the inguinal canal and the scrotum. When he was 6 months old, ultrasonography showed the left testis in the inguinal canal. At the age of 13 months, the left testis was not palpable. At the age of 14 months, he underwent surgery for a planned inguinal orchidopexy with a preoperative diagnosis of an undescended testis. When the inguinal canal was opened, a patent processus vaginalis was observed and the testis was found inside the abdominal cavity. The patent processus vaginalis was closed, a dartos pouch was created and the testis was guided into the pouch and fixed to its wall. We describe a case of a peeping testis moving from the inguinal position into the abdomen.
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Affiliation(s)
- Yukihiro Tatekawa
- Department of Pediatric Surgery, Saku Central Hospital Advanced Care Center, Nagano, Japan
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Zhu J, Song Y, Chen G, Hu R, Ou N, Zhang W, Liang Z, Liu X. Predictive value of haematologic parameters in diagnosis of testicular torsion: Evidence from a systematic review and meta‐analysis. Andrologia 2019; 52:e13490. [PMID: 31782182 DOI: 10.1111/and.13490] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/22/2019] [Accepted: 10/31/2019] [Indexed: 12/29/2022] Open
Affiliation(s)
- Jun Zhu
- Department of Urology Tianjin Medical University General Hospital Tianjin China
| | - Yuxuan Song
- Department of Urology Tianjin Medical University General Hospital Tianjin China
| | - Guangyuan Chen
- The Second Clinical Medical School Nanchang University Nanchang China
| | - Rui Hu
- Department of Urology Tianjin Medical University General Hospital Tianjin China
| | - Ningjing Ou
- Department of Urology Tianjin Medical University General Hospital Tianjin China
| | - Wei Zhang
- Department of Urology Tianjin Medical University General Hospital Tianjin China
| | - Zhen Liang
- Department of Urology Tianjin Medical University General Hospital Tianjin China
| | - Xiaoqiang Liu
- Department of Urology Tianjin Medical University General Hospital Tianjin China
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Almaramhy HH. Surgical practice among pediatric surgeons and pediatric urologists in the Kingdom of Saudi Arabia for the management of suspected testicular torsion. Saudi Med J 2018; 39:1232-1237. [PMID: 30520506 PMCID: PMC6344661 DOI: 10.15537/smj.2018.12.22958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives: To review and compare clinical practice and experience among pediatric surgeons (PS) and pediatric urologists (PU) for the management of testicular torsion (TT) in the Kingdom of Saudi Arabia (KSA). Methods: This was a cross-sectional study conducted between August 2016 and November 2017, among all PU and PS involved in the management of suspected TT in KSA. A questionnaire was distributed to participants through the Survs.com platform, and direct email when requested by participant. Results: Most PU (12/20, 60%) utilized ultrasound with Doppler before exploration, while 29 (74.4%) PS performed immediate exploration without imaging, representing a statistically significant difference (p=0.03). When the explored testis was dusky (not frank gangrenous), 27 PS (69.2%) performed fixation, 6 (15.4%) followed the second look policy, and 6 (15.4%) performed orchiectomy. With respect to PU, 6 (30%) performed fixation, 8 (40%) followed the second look policy, and 6 (30%) performed orchiectomy. The differences between the 2 specialties were statistically significant (p=0.02). Most consultants in both specialties performed fixation of the contralateral testis during the same operation. Also, there is a variation in practice when there is other pathology than TT. Conclusion: There were significant variations between the 2 specialties in the management of TT. National guidelines are needed to provide homogenous clinical practice and training of trainees.
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Affiliation(s)
- Hamdi H Almaramhy
- Division of Pediatric Surgery, Department of Surgery, College of Medicine, Taibah University, Almadinah Al-munawarah, Kingdom of Saudi Arabia. E-mail.
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11
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Pearce I, Islam S, McIntyre IG, O'Flynn KJ. Suspected Testicular Torsion: A Survey of Clinical Practice in North West England. J R Soc Med 2017; 95:247-9. [PMID: 11983766 PMCID: PMC1279678 DOI: 10.1177/014107680209500508] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Several aspects of the management of suspected testicular torsion are controversial. A questionnaire was mailed to all 33 consultant urologists in the North West region of England to elicit their policies for routine clinical management. 29 of 33 questionnaires were returned (2 incomplete). As regards radiological investigation, 4 consultants always request ultrasound examination; the others do not favour routine imaging. When the diagnosis of testicular torsion is confirmed at operation, all consultants would perform bilateral testicular fixation, although with considerable variations in technique; most use Vicryl sutures (66%) and three-point fixation (57%). One-third would do an ipsilateral orchidopexy if there was no clear evidence of testicular torsion at operation. The variation revealed by this survey prompted an attempt to formulate a protocol for management. A review of the published work indicates that, in cases of proven testicular torsion, treatment should include bilateral fixation with delayed-absorption or nonabsorbable sutures; fixation should be at three points. When torsion is not found at operation, there is no evidence of benefit from orchidopexy.
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Affiliation(s)
- I Pearce
- Department of Urology, Hope Hospital, Stott Lane, Salford, Manchester M6 8WH, UK.
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12
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McBride CA, Patel B. Acutely painful scrotum: Tips, traps, tricks and truths. J Paediatr Child Health 2017; 53:1054-1059. [PMID: 29148188 DOI: 10.1111/jpc.13766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 09/28/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Craig A McBride
- Surgical Team: Infants, Toddlers, Children (STITCh), Lady Cilento Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia.,Discipline of Paediatrics and Child Health, School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Bhaveshkumar Patel
- Surgical Team: Infants, Toddlers, Children (STITCh), Lady Cilento Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia.,Discipline of Paediatrics and Child Health, School of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Rottenstreich M, Glick Y, Gofrit ON. The clinical findings in young adults with acute scrotal pain. Am J Emerg Med 2016; 34:1931-1933. [PMID: 27377834 DOI: 10.1016/j.ajem.2016.06.066] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 06/15/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Acute scrotal pain (ASP) is a common symptom of young adults. Testicular torsion is the most important diagnosis in these cases. It is a medical emergency in which the diagnosis must be made rapidly to prevent testicular loss. This requires a high index of clinical suspicion and prompt surgical intervention. This study was conducted to examine the spectrum of diagnoses in young man with ASP in a prehospital setting, the frequency of significant diagnoses, and their outcomes. METHODS The medical records of young adults in their obligatory military service presenting with ASP to primary care clinics from 2004 to 2014 were reviewed using the keywords: pain, testis, torsion, and orchialgia. Anamnestic data, physical findings, primary care physician decisions, and final outcomes were analyzed. RESULTS A total of 9922 medical visits were recorded. Idiopathic scrotal pain, varicocele, scrotal trauma, and genital tract infections were the most common diagnoses. In 3 visits (0.03%), testicular cancer was diagnosed. Testicular torsion was the etiology of ASP in only 12 (0.12%) visits, and 60% the testes were salvaged. The mean duration of symptoms in the salvaged group was 6.33 hours; and in the nonsalvaged group, 44 hours. CONCLUSIONS Testicular torsion is the etiology of ASP in only 0.12% of the visits to the primary care clinic. Patient delay before attending the primary care is responsible for most of the testes lost. Patient education in addition to high index of suspicion of primary care physicians is needed for salvage of more testicles.
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Affiliation(s)
| | - Yuval Glick
- Medical Corps, Israeli Defense Forces, Tel Aviv, Israel
| | - Ofer Natan Gofrit
- Department of Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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Gomes DDO, Vidal RR, Foeppel BF, Faria DF, Saito M. Cold weather is a predisposing factor for testicular torsion in a tropical country. A retrospective study. SAO PAULO MED J 2015; 133:187-90. [PMID: 25271876 PMCID: PMC10876364 DOI: 10.1590/1516-3180.2013.7600007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 08/28/2013] [Accepted: 01/30/2014] [Indexed: 11/21/2022] Open
Abstract
CONTEXT AND OBJECTIVE Testicular torsion is a medical and urological emergency because it can lead to loss of the organ. The theory of seasonal testicular torsion occurrence is based on studies from institutions located in cold and temperate regions. The objective here was to determine whether cold weather is associated with higher incidence of testicular torsion in a tropical country, such as Brazil. DESIGN AND SETTING Retrospective study, conducted in a tertiary and teaching hospital. METHODS Patients with acute testicular torsion confirmed by surgery between April 2006 and March 2011 were studied. Information on weather conditions at the time of symptom onset was collected. RESULTS A total of 64 testicular torsion cases were identified. The months with the highest incidences of testicular torsion were June (16%), July (19%) and August (11%), which had the lowest mean temperatures, of 17.6 °C, 16.4 °C and 18.2 °C, respectively. Eleven percent of cases occurred during spring (October to December), 16% occurred in summer (January to March), 34% occurred in fall (April to June) and 39% occurred in winter (July to September). There was a significant association between the incidence of testicular torsion and the season (fall and winter), P < 0.001. CONCLUSIONS Testicular torsion follows a seasonal association even in a tropical country, and is more frequent in the colder months of the year, namely fall and winter, when almost three-quarters of the cases occurred. These observations add further evidence that cold weather has an etiologic role in testicular torsion occurrence.
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Affiliation(s)
| | - Rafael Rocha Vidal
- Department of Urology, Hospital Santa Marcelina, São Paulo, São Paulo, Brazil
| | | | - Danilo Fiorindo Faria
- Department of Pediatric Surgery, Hospital Santa Marcelina, São Paulo, São Paulo, Brazil
| | - Minori Saito
- Department of Urology, Hospital Santa Marcelina, São Paulo, São Paulo, Brazil
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A rare emergency: testicular torsion in the inguinal canal. BIOMED RESEARCH INTERNATIONAL 2015; 2015:320780. [PMID: 25654093 PMCID: PMC4310261 DOI: 10.1155/2015/320780] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 10/10/2014] [Accepted: 10/12/2014] [Indexed: 11/18/2022]
Abstract
Objectives. To report our experience and present the largest series of testicular torsion cases in the inguinal canal. Material and Methods. The clinical data of 13 patients with testicular torsion in the inguinal canal treated between 2005 and 2013 were reviewed. Recorded patient age, whether the testes were palpable or not, side of the affected testes, the presence of hernia, ischemia time, and operation outcomes were assessed. Results. Patient age ranged from 8 to 70 months (29.15 ± 20.22). Mean ischemia time was 16.5 ± 21.3 hours. Accompanying inguinal hernia was present in 92% of the cases (12/13). Four of the thirteen patients (30.8%) were treated by orchiectomy because the necrosis was present after prolonged ischemia time. Nine patients (69.2%) were treated by single session orchidopexy. Conclusion. Torsion of testes in the inguinal canal is a rare disease, but with rapid diagnosis, affected testes can be salvaged, but the key factor is to keep this condition in mind.
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Retrospective Review of Diagnosis and Treatment in Children Presenting to the Pediatric Department With Acute Scrotum. AJR Am J Roentgenol 2013; 200:W444-9. [DOI: 10.2214/ajr.12.10036] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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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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Cocuzza M, Alvarenga C, Pagani R. The epidemiology and etiology of azoospermia. Clinics (Sao Paulo) 2013; 68 Suppl 1:15-26. [PMID: 23503951 PMCID: PMC3583160 DOI: 10.6061/clinics/2013(sup01)03] [Citation(s) in RCA: 138] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 03/29/2012] [Indexed: 12/19/2022] Open
Abstract
The misconception that infertility is typically associated with the female is commonly faced in the management of infertile men. It is uncommon for a patient to present for an infertility evaluation with an abnormal semen analysis report before an extensive female partner workup has been performed. Additionally, a man is usually considered fertile based only on seminal parameters without a physical exam. This behavior may lead to a delay in both the exact diagnosis and in possible specific infertility treatment. Moreover, male factor infertility can result from an underlying medical condition that is often treatable but could possibly be life-threatening. The responsibility of male factor in couple's infertility has been exponentially rising in recent years due to a comprehensive evaluation of reproductive male function and improved diagnostic tools. Despite this improvement in diagnosis, azoospermia is always the most challenging topic associated with infertility treatment. Several conditions that interfere with spermatogenesis and reduce sperm production and quality can lead to azoospermia. Azoospermia may also occur because of a reproductive tract obstruction. Optimal management of patients with azoospermia requires a full understanding of the disease etiology. This review will discuss in detail the epidemiology and etiology of azoospermia. A thorough literature survey was performed using the Medline, EMBASE, BIOSIS, and Cochrane databases. We restricted the survey to clinical publications that were relevant to male infertility and azoospermia. Many of the recommendations included are not based on controlled studies.
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Affiliation(s)
- Marcello Cocuzza
- Department of Urology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
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Sabbaghi MA, Bahrami AR, Feizzade B, Kalantar SM, Matin MM, Kalantari M, Aflatoonian A, Saeinasab M. Trial evaluation of bone marrow derived mesenchymal stem cells (MSCs) transplantation in revival of spermatogenesis in testicular torsion. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2012. [DOI: 10.1016/j.mefs.2012.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Liu CC, Huang SP, Chou YH, Li CC, Wu MT, Huang CH, Wu WJ. Clinical Presentation of Acute Scrotum in Young Males. Kaohsiung J Med Sci 2007; 23:281-6. [PMID: 17525012 DOI: 10.1016/s1607-551x(09)70410-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The purpose of this study was to assess the clinical presentation and ultrasonographic findings of acute scrotum in young males. A total of 87 patients (<or= 25 years old) with presentation of acute scrotum were retrospectively analyzed in Kaohsiung Medical University Hospital. The patients were divided into three groups according to their final diagnosis: 41 patients with testicular torsion (TT), eight patients with torsion of the testicular appendage (TTA), and 38 patients with epididymo-orchitis (EO). The mean ages of the TT group (14.0 +/- 5.7 years) and EO group (16.6 +/- 7.6 years) were higher than that of the TTA group (10.0 +/- 3.5 years) (p = 0.02). White blood cell count (> 10,000 cells/microL) was not found to be statistically different among groups. Pyuria was found in 10 (26%) patients with EO. Color Doppler ultrasound has high sensitivity (87.9%) and specificity (93.3%) rates to differentiate TT from other causes of acute scrotum. In cases with a lower risk of TT, we suggest that a technically adequate color Doppler ultrasound may be arranged to help differentiate diagnoses and prevent needless surgery. The importance of emergent management for acute scrotum should also be impressed upon the public through education to avoid delayed presentation to medical facilities.
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Affiliation(s)
- Chia-Chu Liu
- Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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Abstract
Testicular pain has a variety of etiologies, including torsion, inflammation, trauma, and cancer. Differentiation of these diseases is important for proper treatment and prevention of further complications. A most noteworthy cause of testicular pain may be testicular torsion, in which a delayed diagnosis could result in the loss of the testis. Sonography plays a major role in the diagnosis of testicular torsion. Both gray-scale and color Doppler sonography aid in deriving a specific diagnosis that will help the physician in managing the condition. A case of an elderly man with testicular discomfort and complex hydrocele is presented.
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Affiliation(s)
- Johan Ghazali
- British Columbia Institute of Technology, School of Health Sciences, Burnaby, British Columbia, Canada; Boucher Institute of Naturopathic Medicine, 320-435 Columbia Street, New Westminster, British Columbia, Canada V3L 5N8
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Tillett JW, Elmore J, Smith EA. Torsion of an indirect hernia sac within a hydrocele causing acute scrotum: case report and review of the literature. Pediatr Surg Int 2006; 22:1025-7. [PMID: 17013626 DOI: 10.1007/s00383-006-1708-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2006] [Indexed: 10/24/2022]
Abstract
We report a case of acute scrotum in a 2-year-old child caused by torsion of an indirect hernia sac within a hydrocele. This is an extremely rare cause of acute scrotal swelling and pain in the pediatric population, with this case representing only the eighth instance reported in the literature. Despite the scarcity with which this diagnosis has been encountered, clinicians should include torsion of an indirect hernia sac on the differential diagnosis for acute scrotum in a child.
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Affiliation(s)
- John W Tillett
- Department of Urology, Children's Hospital of Atlanta, Atlanta, GA, USA.
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Abstract
The entities described in this article represent processes that arise from, or can be mistaken for, common GU infections. It might be difficult to determine the point at which pyelonephritis develops into EPN or perinephric abscess. It might be equally challenging to distinguish scrotal cellulitis from Fournier's gangrene; however, as most EPs will acknowledge, the mere awareness of these entities in the appropriate clinical circumstances might be enough to prevent a "near-miss" of a surgical emergency.
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Affiliation(s)
- Chi Lee
- Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
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Pearce I, Islam S, McIntyre IG, O'Flynn KJ. Suspected testicular torsion: a survey of clinical practice in North West England. J R Soc Med 2002. [PMID: 11983766 PMCID: PMC1279678 DOI: 10.1258/jrsm.95.5.247] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Several aspects of the management of suspected testicular torsion are controversial. A questionnaire was mailed to all 33 consultant urologists in the North West region of England to elicit their policies for routine clinical management. 29 of 33 questionnaires were returned (2 incomplete). As regards radiological investigation, 4 consultants always request ultrasound examination; the others do not favour routine imaging. When the diagnosis of testicular torsion is confirmed at operation, all consultants would perform bilateral testicular fixation, although with considerable variations in technique; most use Vicryl sutures (66%) and three-point fixation (57%). One-third would do an ipsilateral orchidopexy if there was no clear evidence of testicular torsion at operation. The variation revealed by this survey prompted an attempt to formulate a protocol for management. A review of the published work indicates that, in cases of proven testicular torsion, treatment should include bilateral fixation with delayed-absorption or non-absorbable sutures; fixation should be at three points. When torsion is not found at operation, there is no evidence of benefit from orchidopexy.
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Affiliation(s)
- I Pearce
- Department of Urology, Hope Hospital, Stott Lane, Salford, Manchester M6 8WH, UK.
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Abstract
Regardless of age, any presentation of an acute scrotum requires prompt triage and immediate evaluation. The potential for significant reduction in morbidity and mortality exists if timely diagnosis and treatment are provided. Often overlooked, an early scrotal examination in the emergency department may produce the most accurate information into the underlying pathologic process, be it systemic or localized to the scrotum. Although the immediately lethal conditions presenting as acute scrotal pain should be considered, the combined incidence and morbidity associated with testicular torsion make its exclusion paramount in acute scrotal presentations. Similarly, a painless scrotal mass must be assumed to be a testicular neoplasm until proven otherwise, with appropriate work-up and rapid urologic follow-up assured.
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Affiliation(s)
- D Marcozzi
- Brown University School of Medicine, Department of Emergency Medicine, Rhode Island Hospital, Providence, Rhode Island, USA
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Hegarty PK, Walsh E, Corcoran MO. Exploration of the acute scrotum: a retrospective analysis of 100 consecutive cases. Ir J Med Sci 2001; 170:181-2. [PMID: 12120970 DOI: 10.1007/bf03173885] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Acute scrotal pain is a common urological emergency. Urgent exploration is the standard means of management, as no investigation can confidently exclude torsion of testis from the differential diagnoses. In our department, all patients up to the age of 40 years, presenting with acute scrotal pain undergo emergency scrotal exploration. AIM This study assesses the outcome of such a policy in one unit. METHODS The notes of 100 consecutive males who underwent exploration of scrotum have been reviewed. RESULTS Testicular torsion was diagnosed in 33% of patients, with torsion of the appendix testis being the next most common entity. In the group with testicular torsion 12% required orchidectomy, and all had presented at least 24 hours after the onset of pain. The perioperative morbidity of scrotal exploration was very low. CONCLUSION These data justify the policy of emergency exploration for all cases of acute scrotal pain up to the age of 40 years.
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Affiliation(s)
- P K Hegarty
- Department of Urology, University College Hospital, Galway, Ireland.
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Abstract
Este artigo pretende fazer uma revisão geral do tema, com ênfase em conceitos atuais e/ou controversos no manejo das situações clínicas em questão, em especial conceitos ainda polêmicos quanto à fisiopatologia e ao manejo diagnóstico. Também é feita uma revisão extensa quanto aos aspectos clínicos e terapêuticos da torção de testículo neonatal e quanto aos aspectos de diagnóstico diferencial na síndrome do escroto agudo. São citadas informações estatísticas derivadas dos principais estudos clínicos publicados nos últimos 20 anos em literatura médica ocidental.
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Abstract
The diagnosis of acute scrotal pain can be difficult. The most common causes include torsion of a testicular appendage, epididymitis, and testicular torsion, which account for 85% to 90% of all cases. These entities may be clinically indistinguishable because characteristic symptoms and signs for each overlap, whereas pathognomonic features are uncommon. Diagnostic accuracy without delay is required to avoid the loss of testicular function in testicular torsion cases and to avoid unnecessary surgery in other cases. A thorough understanding of the key clinical features of each entity, coupled with an understanding of the appropriate use of perfusion imaging studies, will equip the emergency physician with the tools to accomplish this task.
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Affiliation(s)
- S W Burgher
- Department of Emergency Medicine, Naval Medical Center, Portsmouth, Virginia, USA.
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