The use of Doppler ultrasound in the clinical management of acute testicular pain

Evaluating Acute Testicular Pain Using Point-of-Care Hand-Held Doppler in the Emergency Department: A Prospective Pilot Study

Introduction Testicular pain is one of the common conditions in patients visiting the emergency department. The causes of acute testicular pain vary from non-urgent inflammatory conditions like epididymo-orchitis to testicular torsion which is a surgical emergency. Early diagnosis of testicular torsion with early initiation of appropriate surgical intervention helps in salvaging the testes. There is a need for a simple, rapid bedside diagnostic tool for the evaluation and triaging of subjects with acute testicular pain in the emergency department. The aim of this study is to determine whether hand-held Doppler (HHD) examination by the emergency department (ED) physician can safely rule out testicular torsion in a case of acute testicular pain. Materials and Methods A prospective pilot study was conducted in the emergency department of Alkhor Hospital, Hamad Medical Corporation, Qatar. The subjects between 18 to 50 years of age who presented to the ED with testicular pain were included. Subjects with recent trauma to the scrotum, or recent genitourinary surgery and those who had pain for more than 48 hours were excluded. Point-of-care HHD was done by a single ED physician who was blinded for the Doppler study results done by the radiologist. The results of the HHD performed by the ED physician and Doppler study performed by the radiologist were compared and analyzed. Results  Forty-five patients were included in the study. The mean age was 28 years and the mean duration of pain was 20 hours. HHD ruled out testicular torsion in 44 subjects with a specificity of 97.8%. In one subject, HHD was reported as torsion testis which was ruled out by the radiologist. The radiologist Doppler ruled out torsion in all 45 subjects. Conclusion The diagnostic performance of HHD by the ED physicians was almost equal to that of radiologists in ruling out testicular torsion. HHD can be used as a first-line triaging tool by the ED physician to rule out torsion of testis in patients presenting with acute testicular pain. We conclude that patients with testicular pain with a negative HHD for torsion testis can be safely discharged from the emergency department.

The effect of astaxanthin on testicular torsion-detorsion injury in rats - Detailed morphometric evaluation of histological sections

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.

Suspected testicular torsion in children: diagnostic dilemma and recommendation for a lower threshold for initiation of surgical exploration

Purpose

Testicular torsion (TT) represents a clinical challenge that needs emergency surgical assessment. It is common to have negative scrotal exploration due to confounding symptoms and signs which makes it sometimes difficult to differentiate from similar surgical emergencies that do not warrant surgery. At the same time, several occasions of misdiagnoses or late interventions occur with devastating effects. We aim at delineating the significance of the different clinical, laboratory, and radiological variables in the detection of TT.

Methods

We retrospectively reviewed the charts of 52 patients who were surgically explored with a preoperative working diagnosis of suspected TT in our center over the period from 2011 to 2015. All the patients were examined by pediatric surgeons in the emergency room and had undergone ultrasound imaging of the testes. The ultrasound images were retrospectively reviewed by a pediatric radiologist who was blinded to the intraoperative findings. Univariate and multivariate and logistic regression analyses were performed.

Results

Of the studied group of patients, the majority (84.6%) had TT upon surgical exploration. The most frequently presented symptom was pain (80.8%), and only a minority (11.5%) presented with vomiting. Radiological findings with the highest sensitivity were heterogeneous echogenicity in favor of TT and enlarged epididymis indicating that TT is unlikely. However, the predictability of TT by any of the assessed clinical and imaging factors was statistically insignificant.

Conclusion

It is important to gather all relevant data from clinical, laboratory, and imaging sources when assessing pediatric patients with suspected TT given the inaccuracy of each single one of them if used alone. Keeping this in mind, Doppler ultrasound has a significant role to aid in the accuracy of the diagnosis and hence the appropriate decision-making thereafter. However, we found no single clinical or imaging sign that is sensitive enough to prove or rule out TT. Therefore, surgical exploration should take place in a timely manner. Moreover, further research is necessary to construct scoring systems where different predictors collectively have higher reliability.

Distinguishing testicular torsion from torsion of the appendix testis by clinical features and signs in patients with acute scrotum

Purpose

Many physicians encounter confusion and difficulty in distinguishing testicular torsion (TT) from torsion of the appendix testis (TAT) in patients with acute scrotum because of the overlapping signs and symptoms. The objective of our study was to evaluate the clinical features and signs that can help distinguish TT from TAT.

Patients and methods

We performed a retrospective study of patients with surgically confirmed TT and TAT at our institute from January 1990 to December 2013. Clinical findings, physical examination findings, climatic conditions, laboratory data, and color Doppler ultrasound (CDUS) findings were compared between the TT and TAT groups.

Results

Seventy patients were included in this study (49 with TT and 21 with TAT). Patients with TT were significantly older than those with TAT (p < 0.001). The ambient temperature at onset was significantly lower in patients with TT than in patients with TAT (p = 0.038). Testicular swelling, high-riding testes, onset during sleep, high leukocyte counts, and high creatine phosphokinase levels were significantly more common in patients with TT than with TAT (p = 0.021, 0.032, 0.006, 0.003, and 0.043, respectively). Multivariate analysis showed that age and onset during sleep were significant independent factors for detection of TT. Eight patients (16.3%) underwent preoperative CDUS evaluation, and an absent or decreased blood signal in the involved testes was significantly correlated with the presence of TT (p = 0.018).

Conclusion

In clinical features, age and onset during sleep might be helpful to distinguish TT from TAT. When supported by findings, urgent surgical exploration is warranted in patients with suspected TT based on symptoms and CDUS features.

Cold weather is a predisposing factor for testicular torsion in a tropical country. A retrospective study

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.

Development and initial validation of a scoring system to diagnose testicular torsion in children

PURPOSE

Testicular torsion is a surgical emergency requiring prompt intervention. Although clinical diagnosis is recommended, scrotal ultrasound is frequently ordered, delaying treatment. We created a scoring system to diagnose testicular torsion, decreasing the indication for ultrasound.

MATERIALS AND METHODS

We prospectively evaluated 338 patients with acute scrotum, of whom 51 had testicular torsion. Physical examination was performed by a urologist, and all patients underwent scrotal ultrasound. Univariate analysis and logistic regression were performed, and a scoring system for risk stratification of torsion was created. Retrospective validation was performed with 2 independent data sets.

RESULTS

The scoring system consisted of testicular swelling (2 points), hard testicle (2), absent cremasteric reflex (1), nausea/vomiting (1) and high riding testis (1). Cutoffs for low and high risk were 2 and 5 points, respectively. Ultrasound would be indicated only for the intermediate risk group. In the prospective data set 69% of patients had low, 19% intermediate and 11.5% high risk. Negative and positive predictive values were 100% for cutoffs of 2 and 5, respectively (specificity 81%, sensitivity 76%). Retrospective validation in 1 data set showed 66% of patients at low, 16% intermediate and 17% high risk. Negative and positive predictive values for cutoffs of 2 and 5 were 100% (specificity 97%, sensitivity 54%). The second retrospective data set included only torsion cases, none of which was misdiagnosed by the scoring system.

CONCLUSIONS

This scoring system can potentially diagnose or rule out testicular torsion in 80% of cases, with high positive and negative predictive values for selected cutoffs. Ultrasound orders would be decreased to 20% of acute scrotum cases. Prospective validation of this scoring system is necessary.

Clinical Presentation of Acute Scrotum in Young Males

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.

Magnetic resonance imaging and ultrasound evaluation of penile and testicular masses

The purpose of this study is to present the role of ultrasonography and MRI in the investigation of testicular and penile masses, as well as to review the literature. This article is based on our experience with 230 patients who presented with acute or subacute scrotal pain or painless enlargement of the scrotum or penis. Gray scale and color Doppler ultrasonography (CDU) were applied in all cases. In 73 cases, the final diagnosis was established by surgery and in 157 cases by follow-up. MRI was performed in 48 cases. Ultrasonography was the initial imaging modality in all cases. It provided detailed anatomic information with high sensitivity and accuracy in cases of torsion, inflammation, varicocele and trauma. In cases of tumor, US showed the presence of the mass in all cases, while it additionally revealed certain characteristic features of tissue constitution and blood supply. In most cases, differentiation between various types of tumors or differentiation between malignant and benign lesions was impossible. MRI, besides the detailed anatomic imaging, also provided a certain degree of tissue specificity. MRI could help in the detection and staging of penile cancer and in the evaluation of testicular and scrotal masses, especially when a diagnostic dilemma occurred on ultrasonographic examination. Ultrasonography, combining gray scale and color techniques, is irreplaceable in the diagnostic work-up of scrotal and penile masses, while MRI can serve as a problem solving diagnostic modality.

The nontraumatic, acute scrotum

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.

An analysis of clinical outcomes using color doppler testicular ultrasound for testicular torsion

OBJECTIVES

To delineate the clinical outcomes of color Doppler ultrasound (US) in the equivocal torsion patient.

METHODS

From 1992 to 1997, 130 patients (<23 years old) from 2 institutions underwent US imaging using a 7.5-mHz linear transducer to evaluate an acute scrotum equivocal, or of low suspicion, for torsion. The US reports and hospital charts of these patients were retrospectively reviewed.

RESULTS

After clinical and radiologic evaluation, torsion was excluded in 110 patients without surgical exploration. In 3 patients, intermittent testicular torsion was diagnosed and in 17 patients, emergent exploration was performed for US diagnosis of testicular torsion. Twenty-five patients (22.7%) were subsequently lost to follow-up. Follow-up of 85 patients with US negative for torsion (mean length of follow-up = 466.9 days) revealed no testicular atrophy in 83. Two patients underwent delayed orchiectomy/contralateral orchiopexy for missed testicular torsion. Of 17 patients with US positive for torsion, 9 underwent orchiectomy for a necrotic torsed testis, 7 viable torsed testes were found, and 1 torsed appendix testis was found. Therefore, color Doppler US for the equivocal acute scrotum yielded a 1% false-positive rate, sensitivity of 88.9%, and specificity of 98.8%.

CONCLUSION

When faced with ruling out testicular torsion, it is necessary to integrate the multiple pieces of patient data, knowing that each piece of data may have inaccuracies. With this in mind, this analysis of outcomes verifies that color Doppler US is an excellent adjunctive study in the clinically real situation in which the clinical evaluation is equivocal or low suspicion.

Ultrasonographic diagnosis of testicular torsion by emergency physicians

Testicular torsion has an incidence of one case per 4,000 men/boys. Most frequently affected are pubescent boys. Average testicular salvage rate is only 50%, and infertility can result Testicular torsion remains problematic for emergency physicians (EPs) as clinical diagnosis can be difficult and other testicular pathology can present similarly. In many institutions there are delays in obtaining Doppler or Scintigraphy studies during off-hours. We report two cases of testicular torsion diagnosed by the treating EPs using power Doppler in the emergency department (ED). Rapid diagnosis of torsion led to successful salvage of the affected testicle in both cases. These represent the first cases for emergency screening ultrasound examinations (ESUEs) of testicular torsion in the literature. Rapid technological advances over the last decade have brought portable equipment with high-resolution capability to the bed-side for EPs, who should consider using it more frequently to evaluate testicular torsion.

Assessment of acute scrotal symptoms and findings. A clinician's dilemma

Diagnosis of testis torsion relies on the clinical wisdom of the examining physician, supplemented with timely imaging techniques by color Doppler examination or scintigraphy. A knowledge of the pathophysiology of acute scrotal conditions can help to eliminate diagnostic errors but the literature demonstrates that errors can occur even with sophisticated testing. Data from the literature suggests that manual detorsion of the testis can successfully relieve ischemia until surgical correction can eliminate the possibility of testis torsion. Surgical therapy has progressively improved and can save the germinal function of the testis.