Testicular torsion: a 15-year single-centre clinical and histological analysis

Sex-based Disparities in the Management of Pediatric Gonadal Torsion

INTRODUCTION

In 2015, the U.S. News and World Report (USNWR) implemented a quality metric to expedite surgery for testicular torsion (TT), but not ovarian torsion (OT). This study examined OR timing among children with suspected TT and OT before and after this metric.

METHODS

A single-center retrospective cohort study of children (1-18yr) who underwent surgery for suspected gonadal torsion was performed. Time to OR (TTOR) from hospital presentation to surgery start was calculated. An interrupted time series analysis identified changes in TTOR for suspected TT versus OT after the 2015 USNWR quality metric.

RESULTS

Overall, 216 patients presented with TT and 120 with OT. Median TTOR for TT was 147 min (IQR:99-198) versus 462 min (IQR:308-606) for OT. Post-quality metric, children with TT experienced a 27.8 min decrease (95% CI:-51.7,-3.9, p = 0.05) in annual median TTOR. No significant decrease was observed for children with OT (p = 0.22). Children with history of a known ovarian mass (N = 62) experienced a shorter TTOR compared to those without (422 vs 499min; p = 0.04).

CONCLUSION

Implementation of a national quality metric for TT expedited surgical care for children with TT, but not children with OT. These findings highlight the need for equitable quality metrics for children presenting with suspected gonadal torsion.

LEVEL OF EVIDENCE

III.

TYPE OF STUDY

Retrospective Comparative Study, Observational Cohort Study.

Low-Grade Injury following Testicular Torsion: A Multicenter Study Confirming a Disturbing Possibility

INTRODUCTION

There is an ongoing debate whether to perform orchiectomy or orchidopexy following testicular torsion (TT) in cases where the testis seems non-viable. The main problem is lack of objective criteria defining testicular viability. The aim of this study was to investigate the grade of injury in orchiectomy specimens obtained from cases of TT and its association with clinical findings.

METHODS

This multicenter retrospective study involved double-blinded reassessment of the patient files and the pathological specimens using Mikuz classification to analyze the relation between clinical and pathological findings.

RESULTS

A total of 289 patient charts from 14 centers were reviewed and 228 were included in this study. Twenty (8.8%) patients had grade 1 injury which refers to reversible injury. The clinical findings of these 20 patients were compared to 208 patients with higher grades of injury. As expected, there was statistically significant difference regarding duration of symptoms (p < 0.001); however, range was wide in both groups (as long as 96 h for grade 1 and as short as 7 h for higher grades). There was no statistically significant difference in any other variable including age (median 14 for both, p = 0.531), symptoms (pain: 19/20 vs. 189/202, p = 0.801; swelling: 13/19 vs. 168/197, p = 0.094), absence of blood flow in Doppler US (15/19 vs. 164/197, p = 0.635), or degree of torsion (median 720° for both, p = 0.172).

CONCLUSION

Our study revealed necessity for better criteria to define viability of testis following TT. Histopathological injury appeared to be reversible even in some patients with more severe perioperative findings, late admission, or high degree of twisting. Our findings support the tendency for testicular fixation instead of orchiectomy as none of the clinical or perioperative findings could be attributed to high-grade injury.

Evaluation of testicular blood flow during testicular torsion surgery in children using the indocyanine green-guided near-infrared fluorescence imaging technique

Objective

This study investigates the feasibility of the indocyanine green-guided near-infrared fluorescence (ICG-NIRF) imaging technique in evaluating testicular blood flow during testicular torsion (TT) surgery in pediatric cases.

Methods

We retrospectively analyzed the eight pediatric patients with TT who underwent surgery in our hospital between February and July 2023. The intraoperative two-step method of ICG-NIRF imaging and testicular incision was used to evaluate the testicular blood flow, followed by a selection of different surgical methods. The removed testes were pathologically examined after surgery, and all patients were followed up 1 month after surgery to evaluate testicular blood flow using gray-scale ultrasound and color Doppler flow imaging (CDFI).

Results

Eight pediatric TT patients aged 1-16 years, with a median age of 11.5 years, were enrolled. Time from the onset ranged from 4 to 72 h (mean 26.13 ± 25.09 h). A total of eight testes were twisted, including four on the left side and four on the right side. The twisting direction of the testes was clockwise in four cases and counterclockwise in four cases. The rotation of torsion was 180°-1,080° (mean 472.5° ± 396°). There was no statistically significant difference in the imaging time between the four patients with testicular blood vessel imaging on both the torsional and normal sides (P > 0.05). The postoperative recovery was uneventful, with no complications during the follow-up period of 1 month. The postoperative histopathological results of three patients who underwent orchiectomy showed extensive hemorrhage, degeneration, and necrosis of the testicular tissue. Among the five patients who underwent orchiopexy, a gray-scale ultrasound and CDFI examinations showed uniform internal echo of the testes and normal blood flow signals in four patients. One patient with no testicular blood vessel imaging on the torsional side showed uneven internal echo of the testis and no blood flow signals.

Conclusion

ICG-NIRF imaging is a feasible method to evaluate testicular blood flow during TT surgery. Testicular blood vessel imaging within 5 minutes after ICG injection might be the basis for testicular retention during TT surgery.

Assessing timeline delays associated with utilization of ultrasound diagnostics in paediatric acute scrotum, pre and per COVID-19 pandemic

INTRODUCTION

Acute scrotum is a common presentation in the pediatric population and can indicate serious conditions such as testicular torsion, in which quick diagnosis and treatment is crucial for increasing the chances of a favorable outcome. During the COVID-19 pandemic, even patients with serious conditions, had delayed presentations and in-hospital management, resulting in worse outcomes.

OBJECTIVE

The aim of the study was to evaluate the safety of ultrasound in diagnosing pediatric acute scrotum and to identify delays from onset of symptoms until surgical exploration. Additionally, we wanted to gauge the impact of COVID-19 pandemic on delay and outcome.

METHODS

Medical records of patients aged 1-16 years seen with acute scrotum at the authors' University Hospital from 2017 to 2020 were reviewed, and 438 patients in 467 individual visits were included. Information on demographics, symptoms, ultrasound results, outcome, and time courses were retrieved and analyzed with regards to outcome and the presence COVID-19.

RESULTS

We did not find the use of ultrasound to increase the risk of orchiectomy (OR 2.259 (0.387-13.195)), however patients undergoing ultrasound had a significantly longer pre-hospital ischemia time, and therefore an increased orchiectomy rate. Delay between referral and presentation was the greatest predictor of orchiectomy in testicular torsion (OR 1.031 (1.003-1.060)), while in-hospital delay did not increase the risk of orchiectomy (OR 0.998 (0.992-1.004)). Time courses and outcome did not significantly differ before- and during the COVID-19 pandemic.

DISCUSSION

The primary contributor to ischemic time in testicular torsion was pre-hospital delay, and neither in-hospital delay nor the delay incurred by use of ultrasound affected the outcome. This might be explained by timely in-hospital management and ultrasound only being used selectively in patients with a lower clinical suspicion of testicular torsion and in those with prolonged symptom duration. During the COVID-19 pandemic, pre- and in-hospital delay as well as outcome did not differ significantly from pre-pandemic measures, which indicates that parents felt safe approaching the healthcare system, and resources were sufficient to handle this patient group in spite of an ongoing pandemic. The current study is limited by its retrospective design, and relatively small group of testicular torsion patients.

CONCLUSION

We found ultrasound to be safe in diagnosing pediatric acute scrotum. Furthermore, it can be inferred that measures aimed at reducing pre-hospital delay could potentially increase the salvage rate in testicular torsion. We did not find COVID-19 to affect either outcome or time to treatment in testicular torsion.

Successful salvage of torsion testis by means of intraoperative indocyanine green fluorescence imaging

Background

Testicular torsion (TT) is common surgical emergency that requires early diagnosis and immediate intervention within 6 h since its onset to salvage the testis. However, the decision was made only by the surgeon’s experience whether it has to be resected or not. Recently, indocyanine green (ICG) has become an excellent tool to identify biliary and vascular anatomy, and assess perfusion abnormalities in tissues. In this case report, we successfully salvaged the twisted testis, since the testicular blood perfusion was confirmed by means of intraoperative ICG (IICG) fluorescence imaging.

Case presentation

A 14-year-old healthy male patient presented due to acute left testicular pain. The patient was diagnosed with TT and had immediate surgery. Macroscopically, the testis had stagnant blood flow and appeared to be dark colored. After manual detorsion, the testis remained cyanotic and with macroscopically poor blood flow. ICG angiography was performed under near-infrared light by laparoscopic camera to assess the perfusion of the affected testicle. An excellent ICG signal appeared after 45 s in the testis, and decision was made to be preserved. Therefore, left orchidopexy was performed to complete the operation. The patient had a good postoperative course and was discharged the day after surgery. Six months later, the testis did not show any shrinkage, and both sides of the testis showed the same size without any consequences.

Conclusion

The blood flow in the testis was visually confirmed during the IICG fluorescence method. ICG fluorescence imaging may become an effective alternative to evaluate whether a testis can be preserved following TT.

Scrotal exploration for acute testicular pain: A contemporary UK series from a tertiary centre

Objectives:

The objective of this study was to assess the evaluation and operative outcomes of patients attending a single urology centre with acute testicular pain (ATP) who underwent scrotal exploration. We sought to determine adherence to the Royal College of Surgeons England (RCS) commissioning guide on testicular torsion, clinical and radiological features predictive of torsion, time-dependent salvage rates and surgical technique in a contemporary cohort.

Patients and Methods:

A single-centre retrospective review was carried out from 2015 to 2020. All patients presenting with acute testicular pain undergoing surgical exploration were included.

Results:

140 patients were identified, median age 16 years, 40 had testicular torsion (TT) (30%) where nausea (positive predictive value (PPV) 51.7%, p = 0.009) and abnormal testis lie (PPV 50%, p = 0.008) were more frequent. TT was the most common diagnosis if presenting <4 hours (44%), and in patients 13–16 years (62%). Time-to-surgery from the assessment was <3 hours in 109 of 128 (85.2%). The overall salvage rate was 74.4%, with salvage rates of 100% at 6 hours from the onset of pain. Viable tissue was seen on histology in 30% of orchidectomies, up to 25 hours from the onset of pain.

Discussion:

Surgical exploration <6 hours from the onset of pain is the threshold for salvage in TT. Clinical findings should be combined with patient age and time to presentation to aid diagnosis. Patients between 13 and 16 years are at the highest risk of TT and frequently present early following the onset of pain. Given the heterogenicity of surgical management and the highest risk of TT to the paediatric population, speciality organisations should produce definitive guidance on the management of TT.

Level of evidence:

OCEBM Level 3 evidence

Testicular torsion - symptomatology and outcomes of 101 scrotal explorations

Objective:

The objective was to study the symptomatology of testicular torsion of patients operated in our hospital and their operative results in relation to the duration of symptoms.

Materials and Methods:

Data of all patients operated for acute scrotum at all ages over a 14 months’ time were collected from hospital records. Symptomatology and operative results were studied.

Results:

Out of 101 consecutive scrotal explorations done in this time, 63.4% of all scrotal explorations were testicular torsion (n = 64). 22.8% were appendage torsion (n = 23) and 13.9% were epididymo-orchitis (n = 14). The peak age of testicular torsion was in the 11–15 years range and the left side is more common (65.6%). Symptoms of scrotal pain (92.2%), abdominal pain (18.8%), nausea/vomiting (18.8%), fever (9.4%), and urinary symptoms (3.1%) were seen in decreasing order of frequency. Among acute scrotum patients who had symptoms of nausea/vomiting or abdominal pain, testicular torsion was found to be significantly higher compared to those who did not have these symptoms (χ² = 0.044, P < 0.05). In all cases presented within 6 h of symptom onset, testicles were saved and salvage rates reduced with delay in presentation. The testicular salvage rates were 28.1% (18 out of 64 torsions). Patients below 18 years had more chance of going for orchiectomy than others (75% vs 66.7%). Patients who presented after 24 h had a statistically significantly lower salvage rate of 7.7% compared to those who presented within 24 h duration, 52.2%(χ² = 0.001, P < 0.05). Those with orchiopexy had a median duration of symptom of 6.5 h and the same for orchiectomy patients were 72 h. Our median symptom duration for testicular torsion was 36 h and it is higher than many other countries.

Conclusions:

Delay in presentation to the health-care facility is the major cause of poor salvage rates in the state and its improvement requires public health interventions and health education.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Access to emergency paediatric surgery for testicular torsion or intestinal volvulus in New Zealand: A system perspective

AIM

The risk of organ loss is increased in children with testicular torsion or intestinal volvulus if surgical management is not expedient. The current retrospective study aims to review the time-course from first symptom to 'knife to skin' in these conditions, to determine where delays occur and facilitate a systems approach to better manage these children.

METHODS

One hundred consecutive paediatric cases of scrotal exploration for presumed testicular torsion, and 100 neonatal cases presenting with possible malrotation/volvulus were analysed to evaluate the exact time-course of events from admission to surgery.

RESULTS

(i) Scrotal exploration: the median time from onset of symptoms to presentation was 12 h (interquartile range (IQR): 5-48 h). In children over 5 years of age, 36% (33/93) were transferred from an external district service area. (ii) Malrotation/volvulus: the median duration of symptoms prior to arrival/assessment was 12 h (IQR: 4-24 h). The median cumulative in-hospital time was over 6 h (368 min, IQR: 247-634 min).

CONCLUSIONS

Time to presentation contributes significantly to testicular ischaemic time. This delay to timely surgical intervention is multi-factorial, and must be addressed at a public health level. Support and training in the management of testicular torsion should be provided to all adult surgeons/trainees that may care for these children. In general, this condition is best managed at the presenting hospital whenever appropriate expertise is available. Novel pathways that streamline care may improve efficiency at an institutional level. Addressing issues of access to specialised neonatal surgery is more vexed on account of the tyranny of distance, and the pre-requisite level of surgical expertise required.

Patient transfer influences the prognosis of pediatric patients operated for testicular torsion: a single-center experience

BACKGROUND

Testicular torsion (TT) remains an emerging issue for pediatric patients. This study's objective was to determine risk factors of TT outcomes in the Chinese pediatric cohort from a single center.

METHODS

We performed a retrospective cohort study of patients who met the inclusion criteria in our center from 2013 to 2018. Clinical demographics, and TT-related data, including laterality, torsion degree, torsion direction, position to the cavity of tunica vaginalis, enorchia, and outcomes, were reviewed and extracted from medical charts and databases. Statistical analysis was conducted to compare and figure out the risk factors of TT outcomes.

RESULTS

A total of 84 pediatric patients were enrolled in this study. Among these variables, age, duration of symptoms, and the patient transfer were significantly associated with the outcomes of TT (P<0.005). Patients transferred from other medical facilities underwent more orchiectomy than those without transfer (univariate analysis, P<0.0001; multivariate analysis, P=0.001). No difference was found in other variables between patients with or without transfer (P>0.05). Moreover, transferred patients tended to show worse testicular function.

CONCLUSIONS

We have reported that age, duration of symptoms, and patient transfer were three significant risk factors in this cohort. Patients with transfer tended to suffer from more orchiectomy and worse prognosis of TT.

Effects of platelet-rich plasma on spermatogenesis and hormone production in an experimental testicular torsion model

BACKGROUND

Platelet-rich plasma is a biological instrument rich in growth factors and cytokines.

OBJECTIVES

The aim of this study was to investigate the effect of platelet-rich plasma on spermatogenesis and hormone production in an experimental testicular torsion model.

MATERIALS AND METHODS

The rats were randomly divided into three groups, including six rats in each group as follows: the first group as the sham group; the second group as the ischemia/reperfusion + Saline group and the third group as the ischemia/reperfusion + platelet-rich plasma group. The left testicles of the ischemia/reperfusion + Saline and ischemia/reperfusion + platelet-rich plasma group were kept in four-hour torsion. Then, the left testicles of ischemia/reperfusion + Saline and ischemia/reperfusion + platelet-rich plasma groups were detorsioned, and intra-testicular 1 cc saline (ischemia/reperfusion + Saline) and 1 cc platelet-rich plasma (ischemia/reperfusion + platelet-rich plasma) were injected. At one month, blood samples were taken from all groups for hormonal evaluation and left orchiectomy was performed.

RESULTS

The mean follicle-stimulating hormone level of ischemia/reperfusion + Saline group was significantly higher than ischemia/reperfusion + platelet-rich plasma group (7.78 ± 0.23 vs 6.18 ± 0.28 nmol/l, respectively, P = .004). The mean LH level of ischemia/reperfusion + platelet-rich plasma group was significantly lower than ischemia/reperfusion + Saline group (3.63 ± 0.28 vs 5.68 ± 0.21 nmol/l, respectively, P = .004). The mean total testosterone level of ischemia/reperfusion + platelet-rich plasma group was significantly higher than ischemia/reperfusion + Saline group (8.05 ± 0.24 vs 5.78 ± 0.23 nmol/l, respectively, P = .004). The mean Johnsen scores of ischemia/reperfusion + platelet-rich plasma group were significantly higher than ischemia/reperfusion + Saline group (5.85 ± 0.58 vs 3.93 ± 0.65, respectively, P = .004). The mean Johnsen score of the sham group was significantly higher than ischemia/reperfusion + platelet-rich plasma and ischemia/reperfusion + Saline groups (P = .003 and P = .003, respectively).

DISCUSSION AND CONCLUSION

The platelet-rich plasma has beneficial effects on spermatogenesis and reproductive hormone production in testicular torsion. It is easily accessible and applicable. In the future, intra-testicular platelet-rich plasma injection may be used in testicular torsion after detorsion. However, further experimental and large-scale prospective clinical studies are needed to establish a definitive conclusion on this topic.

Pediatric Trauma-Induced Testicular Torsion: A Surgical Emergency

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Clinical Characteristics of Testicular Torsion and Identification of Predictors of Testicular Salvage in Children: A Retrospective Study in a Single Institution

PURPOSE

Testicular torsion (TT) is a serious surgical emergency. Prompt diagnosis and treatment of TT are essential to improve the incidence of salvaged testes. The aim of this study was to evaluate the historical features, physical examination findings, laboratory tests, and ultrasound examinations in children with TT, as well as to identify the predictors of testicular salvage in children.

MATERIALS AND METHODS

We retrospectively reviewed the records of 136 males who presented with TT to our institution. Clinical findings, physical examinations, laboratory data, color Doppler ultrasound findings, operating results, and the results of follow-up were collected and analyzed. Patients with neonatal torsion, negative scrotal exploration, or testicular appendix torsion were excluded. A multivariable logistic regression model was used to identify predictors of testicular salvage. Receiver operator characteristics analyses were performed to determine the probability of a non-salvageable torsed testis based on time and degree of twisting.

RESULTS

A total of 136 children with TT were identified. Patients were aged from 1 to 16 years, with a mean age of 9.7 years (median, 12; range, 1-16 years). The peak incidences of TT were found between ages of 12 and 14 years. Acute TT is significantly more common in the winter. Testicular salvage occurred in 49 (36%) cases. Of the 49 cases of testicular salvage, 5 patients developed subsequent testicular atrophy. Cutoff values of 13.5 h and 530 degrees of torsion would provide sensitivities of 96 and 61%, with specificity of 80 and 70%, respectively. Multivariate analysis showed that time to surgery and degree of testicular twist were correlated with the risk of a non-salvageable testis.

CONCLUSIONS

Testicular salvage can be predicted by the duration of symptoms along with degree of twisting. Early scrotal exploration based on careful physical examination decreases the risk of misdiagnosis of spermatic cord torsion. A certain percentage of children with TT presenting with lower abdominal pain should have their testicles checked to make sure that they do not have torsion, especially those visitors in cold season.

Testicular Workup for Ischemia and Suspected Torsion in Pediatric Patients and Resource Utilization

BACKGROUND

Testicular torsion (TT) is a pediatric emergency requiring prompt diagnosis and management. The Testicular Workup for Ischemia and Suspected Torsion (TWIST) scores patients on clinical symptoms and can predict TT. This study aimed to determine if the application of TWIST to children with acute scrotal pain could decrease the use of Doppler ultrasonography (DUS) and emergency department (ED) length of stay and ischemic time.

MATERIALS AND METHODS

A retrospective cohort study applying TWIST to patients who presented to a pediatric ED with acute testicular pain from December 2017 to June 2019 was performed. Demographics, TWIST score, diagnosis, DUS, consults, and time to the operation were recorded. Patients were stratified into low (LR), intermediate (IR), and high (HR) risk groups for TT based on TWIST score. Descriptive and comparative analyses were performed.

RESULTS

Seventy-seven patients were included in the study and had a mean age of 9.24 y ±5.24. All 9 HR patients (TWIST = 5-7) had TT, and none of the 57 LR patients (TWIST = 0-2) had TT. Use of TWIST could have reduced the number of DUS needed to diagnose TT from 69 to 11 (75.3% reduction in DUS).

CONCLUSIONS

TWIST accurately predicts torsion in HR groups and excludes torsion in LR groups. Application of TWIST to HR patients may eliminate the need for DUS and decrease ischemic time and cost of care. Application of TWIST in LR patients may likewise eliminate the need for DUS and decrease ED length of stay and cost of care.

Data and data illustrations supporting the analysis of transcripts from interviews exploring the views and experiences of young men and their parents/guardians regarding testicular health

Evidence shows young men have poor outcomes from testicular torsion directly attributable to delay in presentation to hospital [1]. Only a third to a half of adolescents present within 6 h with testicular pain, [2,3] There is poor understanding of why adolescents delay in presenting with testicular pain. The authors started without an a-priori hypothesis and designed a thematic qualitative research protocol to explore the phenomena is a naturalistic setting [4,5] . Sixteen young men (11–19 years) and their parents or guardians underwent semi-structured interviews, directed by a topic guide which evolved with subsequent interview findings. Young men were recruited from out of school clubs to minimise the bias associated with schools or hospital recruitment, and were naïve to testicular disease. Verbatim transcriptions were coded, categories and themes formed and final concepts derived utilising a framework methodology. The figure included shows the initial topic guide. The data tables presented show the emergent themes and the final code book. The authors have utilised the analysis to explore the factors impeding young men in presenting early to hospital with testicular pain [6]. The authors feel the data tables and raw data will be of interest to other researchers interested in adolescent health, health access, public health, linguistics and healthcare qualitative methodology.

Acute scrotum and testicular torsion in children: a retrospective study in a single institution

INTRODUCTION

Testicular torsion (TT), as per the reported incidences in children and preadolescents, is an emergency medical condition that requires prompt surgical treatment. In cases of TT, early and accurate diagnosis of acute scrotum (AS) is important to preserve testicular fertility. In this study, the authors aimed to determine the incidence, clinical examination, etiology, clinical predictors, and treatment of patients with AS and TT.

MATERIAL AND METHODS

The authors retrospectively reviewed all children (age, ≤15 years) with AS who visited their hospital between January 2012 and June 2019. Data on age and diagnosis, clinical findings, mode of treatment, and blood examination results were collected.

RESULTS

The authors examined 165 children aged between 0 days and 15 years (mean age, 9.4 years). Final diagnosis identified 72 patients with torsion of the appendix testis, 44 patients with epididymitis, and 38 patients with TT. Testes were salvaged in 23 of the 38 patients with TT (60.5%). Statistically significant variables revealed that the risk factors of TT were age (older than 12 years), white blood cell (WBC) count (>12,000 cells/mm³), and laterality (left side). The level of C-reactive protein (CRP), duration of symptoms, and degree of torsion were significantly higher in the non-salvageable testis group than in the salvageable testis group. Furthermore, the significant predictive factor for non-salvageable testis was the level of CRP >1.0 mg/dl.

CONCLUSION

The study results indicates that age, WBC count, and laterality are key factors to distinguish TT from AS. Salvageability largely depended on the duration of symptoms and the degree of TT. The salvage rate of the testis can be improved by educating pediatricians, parents, patients, and medical staff about the early diagnosis and treatment of torsion.

Accuracy of point-of-care ultrasound by pediatric emergency physicians for testicular torsion

INTRODUCTION

Acute scrotum is a common presentation to the pediatric emergency department, and ultrasound is frequently used to narrow the differential diagnosis. Point-of-care ultrasound (POCUS) is increasingly used by urologists and emergency physicians and could potentially be used to detect pediatric testicular torsion.

OBJECTIVES

This study aimed to determine the accuracy of POCUS by pediatric emergency physicians in diagnosing testicular torsion and the agreement between point-of-care ultrasound and final diagnosis for other causes of acute scrotum.

STUDY DESIGN

A chart review of patients presenting to the study emergency department who received POCUS by a pediatric emergency physician, as well as radiology department ultrasound and/or surgery, was performed. Charts were reviewed for POCUS diagnoses, final diagnoses, and imaging time metrics.

RESULTS

A total of 120 patients met study criteria, with 12 cases of testicular torsion. The diagnostic accuracy of POCUS for testicular torsion is described in the summary table. For all causes of acute scrotum, point-of-care ultrasound agreed with final diagnosis in 70% (95% confidence interval [CI] 62-78%) of cases, and more experienced point-of-care ultrasound users displayed higher agreement with final diagnosis. Point-of-care ultrasound results were generated a median of 73 min (Q1 = 51, Q3 = 112) before radiology department ultrasound results.

DISCUSSION

Scrotal POCUS performed by pediatric emergency physicians appears to be an accurate tool to detect testicular torsion in children with acute scrotum and saves time compared with radiology ultrasound. The study results may not be generalizable to hospitals without a multidisciplinary POCUS system for quality assurance and image sharing. Future work on POCUS for acute scrotum should investigate its impact on patient outcomes, cost-effectiveness, and family satisfaction.

CONCLUSION

Point-of-care ultrasound by pediatric emergency physicians is accurate for detecting testicular torsion in children with acute scrotum and could expedite diagnosis of this time-sensitive condition.

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

Objective

To evaluate the features of testicular torsion presenting with acute abdominal pain and to raise awareness of testicular torsion with specific symptoms.

Methods

From October 2005 to June 2016, nine patients with testicular torsion who presented with isolated acute abdominal pain rather than scrotal pain as their primary symptom were retrospectively reviewed. Data, including the age of patients, season at admission, initial medical history, external genital examination, emergency ultrasound findings, operative findings, duration of abdominal pain, complications, and follow-up results, were collected.

Results

The average age of patients was 14 years (range 10–17 years). Seven patients whose genitals were not initially examined externally were misdiagnosed as having ordinary abdominal diseases. Surgical exploration revealed that all the involved testes necrotized, and orchidectomy was performed. In the other two patients, scrotal and testicular abnormalities were detected immediately on admission, and emergency surgical exploration determined that the involved testis remained vital, so orchiopexy was performed. The mean duration from symptom onset to diagnosis was 4 h (3–5 h) in the orchiopexy group and 37 h (18–72 h) in the orchidectomy group. Six patients were psychologically affected during postoperative follow-up. Neither recurrence of testicular torsion nor testicular atrophy was recorded.

Conclusion

Acute abdominal pain can be the initial and sole symptom of testicular torsion in young males. Physicians should pay close attention to the specific clinical presentation of testicular torsion.

Controversies in the management of neonatal testicular torsion: A meta-analysis

OBJECTIVE

This meta-analysis seeks to discern the optimal management strategy in neonatal testicular torsion (NTT).

METHODS

Reviewed all English-language articles published between 2005 and 2015 in Medline/Pubmed that had a defined diagnosis of NTT within the first thirty days of life, and discussed specific surgical and nonsurgical management. Exclusion criteria were non-English literature, case reports, case studies, and failure to clearly describe the management of NTT. Data from 9 studies were analyzed, individually and together as pooled data, using a random effect model with a random intercept to estimate the pooled proportions of interest. Results are presented with 95% confidence interval. All analyses were done in SAS 9.4®.

RESULTS

9 publications met criteria for this analysis with a total of 196 patients. Bilateral testicular torsions (n = 14) were less common as compared to right/left testicular torsion (n = 85/97). Asynchronous NTTs (n = 9) were more common than synchronous NTTs (n = 2). There was a higher incidence of NTT in neonates delivered by vaginal delivery (n = 110) as compared to those delivered by c-section (n = 25). Extravaginal torsion (n = 54) is far more common than intravaginal torsion (n = 2). Full-term neonates (n = 122) have a higher incidence of NTT as compared to preterm neonates (n = 9). A total of 15 testicles were salvaged. Of the salvaged testicles 2 were documented as prenatal, 10 postnatal and 3 were undocumented. A strategy of bilateral exploration allows for salvage of about 7% of ipsilateral testicles and prevent asynchronous torsion in about 4% of neonates.

CONCLUSIONS

Based on our population, between 8-12% of patients would benefit from bilateral exploration at the time of diagnosis. We recommend urgent bilateral exploration with orchiopexy of the contralateral testicle in order to avert anorchia.

TYPE OF STUDY

Systematic review.

LEVEL OF EVIDENCE

Level 5 meta-synthesis (Evidence from systematic reviews of qualitative and descriptive studies).

Bilateral Simultaneous Testicular Torsion in a Newborn: Report of a Case

INTRODUCTION

Testicular torsion is a urological emergency. If not recognized in time, this condition may result in ischaemic injury and loss of testis. Simultaneous bilateral neonatal testicular torsion is extremely rare and is usually misdiagnosed.

CASE REPORT

We report a case of a male newborn, who presented with bilateral scrotal swelling and redness of the scrotum. Doppler ultrasound supported the diagnosis of bilateral testicular torsion, with an absent blood flow signal on the right side and a weak signal on the left side. Testicular exploration through scrotal incision was performed and bilateral testicular torsion was found. Right testis was grossly gangrenous, and right orchiectomy was performed. Left testicle was dark but showed recovery after detorsion with some bleeding from incised tunica albugenia. Fixation of the left testicle was performed. At six month follow-up, the left testis showed signs of atrophy and hormonal assay showed very low testosterone and elevated LH and FSH, suggesting hypogonadism.

CONCLUSIONS

Management of neonatal testicular torsion is a matter of controversy. Testicular torsion results into acute ischemia and urgent surgical exploration is the key point of management. Although the possibility of salvaging the involved testicles is usually very low it is hard to justify a passive approach to a bilateral torsion resulting in such a devastating condition as anorchia.

Factors influencing rate of testicular salvage in acute testicular torsion at a tertiary pediatric center

Introduction

Studies have demonstrated that variables other than duration of symptoms can affect outcomes in children with acute testicular torsion. We examined demographic and logistical factors, including inter-hospital transfer, which may affect outcomes at a tertiary pediatric referral center.

Methods

We reviewed charts of all pediatric patients with acute testicular torsion during a five-year period. Data were collected regarding age, insurance type, socioeconomic status, duration of symptoms prior to presentation, transfer status, time of day, time to surgical exploration, and testicular salvage.

Results

Our study included 114 patients. Testicular salvage was possible in 55.3% of patients. Thirty-one percent of patients included in the study were transferred from another facility. Inter-hospital transfer did not affect testicular salvage rate. Time to surgery and duration of pain were higher among patients who underwent orchiectomy versus orchidopexy. Patients older than eight years of age were more likely to undergo orchidopexy than those younger than eight (61.5% vs. 30.4%, p=0.01). Ethnicity, insurance type, or time of day did not affect the testicular salvage rates. On multivariate analysis, only duration of symptoms less than six hours predicted testicular salvage (OR 22.5, p<0.001).

Conclusion

Even though inter-hospital transfer delays definitive surgical management, it may not affect testicular salvage rates. Time to presentation is the most important factor in predicting outcomes in children with acute testicular torsion.

Testicular torsion in the inguinal canal in children

OBJECTIVE

To evaluate the management and outcomes of pediatric patients presenting with torsion of an undescended testis in the inguinal canal.

PATIENTS AND METHODS

The case records of 84 children operated on for testicular torsion were retrospectively reviewed. The medical records included initial medical history, physical examination, operative findings, and the results of follow-up. The diagnosis of torsion of undescended testis was made clinically and confirmed by a Doppler ultrasound and inguinal canal exploration.

RESULTS

Eight children were operated following torsion of undescended testis. In four cases the testicle was preserved and orchidopexy was performed, while in four cases orchidectomy was performed due to testicular gangrene. Mean duration of symptoms, at time of surgery, in the orchidopexy group was 6 h and in the orchidectomy group was 50 h. At follow-up atrophy of the testis was found in only one patient.

CONCLUSION

Torsion of an undescended testis is a relatively rare phenomenon that should be suspected, diagnosed and treated without delay. This study highlights the importance of examination of external genital organs. With improved recognition of this entity and earlier referrals of patients with undescended testes by primary care physicians, its occurrence might eventually be prevented.

Do not forget to include testicular torsion in differential diagnosis of lower acute abdominal pain in young males

BACKGROUND

Management and outcomes of pediatric patients with testicular torsion initially presenting as acute abdominal pain were evaluated.

PATIENTS AND METHODS

The case records of 84 children operated on for testicular torsion from January 1999 through May 2012 were retrospectively reviewed. Of the total number of operated patients, 9 presented with abdominal pain but without initial scrotal pain, and only they were included in the study. The diagnosis of testicular torsion was made clinically and confirmed by Doppler ultrasound and scrotal exploration.

RESULTS

The most common presenting symptoms were abdominal pain and vomiting. The patient's scrotum and testicles were not examined during the first evaluation in 6 cases, while in 3 cases the testicles were examined during the first physical examination. At surgery, 4 testes were salvaged, while 5 have been lost because of testicular necrosis. The mean duration of symptoms was 4 h in the group of salvaged testes and 39 h in the orchidectomy group. There were no major complications.

CONCLUSION

Testicular torsion should always be included in differential diagnosis when evaluating lower abdominal pain in young males. The external genital organs should be examined in every child or adolescent with acute abdominal pain.

Diurnal temperature change is associated with testicular torsion: a nationwide, population based study in Taiwan

PURPOSE

We investigated the association between climatic variables and testicular torsion in Taiwanese males.

MATERIALS AND METHODS

Using the Taiwan Longitudinal Health Insurance Database, we reviewed the files of patients who were diagnosed with testicular torsion and underwent orchiectomy or orchiopexy between January 1996 and December 2008. Children younger than 1 year were excluded from the study. Climatic data were provided by the Taiwan Central Weather Bureau and included ambient temperature, relative humidity, diurnal temperature change and barometric pressure. Patients with acute appendicitis who underwent appendectomy were chosen as the control group. Climatic variables in relation to testicular torsion were analyzed using the Mann-Whitney U test and chi-square test, and seasonal climatic variations using the Kruskal-Wallis H test. Relative risk was calculated to compare the incidence of testicular torsion for diurnal temperature changes.

RESULTS

A total of 65 patients with a mean age of 16.2 years presented with testicular torsion and were treated surgically. Four children younger than 1 year were excluded, and thus the study population consisted of 61 patients. The estimated incidence of testicular torsion was 2.58 per 100,000 person-years. There were no special climatic conditions on days of admission. However, 73.7% of the patients had testicular torsion when the diurnal temperature change was 6C or greater. Compared to the torsion rate for diurnal temperature changes less than 6C, the relative risk of testicular torsion at 6C or greater was 1.8 (p = 0.05). Average seasonal diurnal temperature change in the 2 days before hospitalization showed increases in all seasons except spring, which fluctuated.

CONCLUSIONS

Diurnal temperature change was associated with testicular torsion and may be an etiological climatic factor affecting this condition. This is the first known study to demonstrate an association between diurnal temperature change and testicular torsion.