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Weigel Muñoz M, Cohen DJ, Da Ros VG, González SN, Rebagliati Cid A, Sulzyk V, Cuasnicu PS. Physiological and pathological aspects of epididymal sperm maturation. Mol Aspects Med 2024; 100:101321. [PMID: 39340983 DOI: 10.1016/j.mam.2024.101321] [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: 07/08/2024] [Revised: 09/10/2024] [Accepted: 09/19/2024] [Indexed: 09/30/2024]
Abstract
In mammals, sperm that leave the testes are nonfunctional and require a complex post-testicular maturation process to acquire their ability to recognize and fertilize the egg. The crucial maturation changes that provide sperm their fertilizing capability occur while passing through the epididymis. Due to the widespread use of assisted reproductive technologies to address male infertility, there has been a significant decrease in research focusing on the mechanisms underlying the maturation process over the past decades. Considering that up to 40% of male infertility is idiopathic and could be reflecting sperm maturation defects, the study of post-testicular sperm maturation will clearly contribute to a better understanding of the causes of male infertility and to the development of both new approaches to maturing sperm in vitro and safer male contraceptive methods. Based on this, the present review focuses on the physiopathology of the epididymis as well as on current approaches under investigation to improve research in sperm maturation and as potential therapeutic options for male infertility.
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Affiliation(s)
- Mariana Weigel Muñoz
- Instituto de Biología y Medicina Experimental (IBYME). Fundación IBYME. Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Ciudad Autónoma de Buenos Aires, Argentina.
| | - Débora J Cohen
- Instituto de Biología y Medicina Experimental (IBYME). Fundación IBYME. Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Ciudad Autónoma de Buenos Aires, Argentina.
| | - Vanina G Da Ros
- Instituto de Biología y Medicina Experimental (IBYME). Fundación IBYME. Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Ciudad Autónoma de Buenos Aires, Argentina.
| | - Soledad N González
- Instituto de Biología y Medicina Experimental (IBYME). Fundación IBYME. Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Ciudad Autónoma de Buenos Aires, Argentina.
| | - Abril Rebagliati Cid
- Instituto de Biología y Medicina Experimental (IBYME). Fundación IBYME. Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Ciudad Autónoma de Buenos Aires, Argentina.
| | - Valeria Sulzyk
- Instituto de Biología y Medicina Experimental (IBYME). Fundación IBYME. Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Ciudad Autónoma de Buenos Aires, Argentina.
| | - Patricia S Cuasnicu
- Instituto de Biología y Medicina Experimental (IBYME). Fundación IBYME. Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Ciudad Autónoma de Buenos Aires, Argentina.
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Sunar Yayla EN, Bakkaloğlu SA. Clinical features of paediatric immunoglobulin A vasculitis patients with scrotal involvement. Mod Rheumatol 2023; 33:1016-1020. [PMID: 36107741 DOI: 10.1093/mr/roac111] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/18/2022] [Accepted: 09/12/2022] [Indexed: 08/27/2023]
Abstract
OBJECTIVES Immunoglobulin (Ig) A vasculitis (IgAV), is the most common vasculitis of childhood, is a leucocytoclastic vasculitis that affects small vessels of the skin, gastrointestinal (GI) tract, joints, and kidneys. Scrotal involvement is relatively rare. In this study, we aimed to reveal the clinical and laboratory characteristics of patients with scrotal involvement in IgAV and its relationship with other clinical features of the disease. METHODS A total number of 301 male patients with a diagnosis of IgAV between January 2005 and 2022 were retrospectively analysed. The patients were divided into two groups as with and without scrotal involvement. The clinical and laboratory characteristics of the groups were compared. RESULTS Scrotal involvement was detected in 16.3% (49) of male IgAV patients. Scrotal involvement was unilateral in 51% of patients. While single acute scrotal attack was present in 93.9% of patients, only three patients had recurrent acute scrotal involvement. In patients with scrotal involvement, the age at diagnosis was younger (p = .007), and disease recurrence was higher (p = .003). Glucocorticoid use was more common in patients with scrotal involvement (p < .001). In multivariable analysis, a statistically significant relation between scrotal involvement and age at diagnosis (odds ratio = 0.85, 95% confidence interval 0.76-0.96, p = .006) was detected. CONCLUSIONS In IgAV patients with scrotal involvement, the age at diagnosis is lower, steroid use is more common, and recurrent disease is more frequent.
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Affiliation(s)
- Emine Nur Sunar Yayla
- Department of Pediatrics, Division of Pediatric Rheumatology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Sevcan A Bakkaloğlu
- Department of Pediatrics, Division of Pediatric Rheumatology, Gazi University Faculty of Medicine, Ankara, Turkey
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3
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Maynard W, Shanmugathas N, Mundell A, Yassin M, Bertoncelli-Tanaka M, Morley R, Minhas S. Scrotal exploration for acute testicular pain: A contemporary UK series from a tertiary centre. JOURNAL OF CLINICAL UROLOGY 2022. [DOI: 10.1177/20514158221099390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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
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Affiliation(s)
- William Maynard
- ST4 Urology, North Central and East Thames deanery, London, UK
- Urology Department, Charing Cross Hospital, Fulham Palace Road, London
| | | | | | | | | | | | - Suks Minhas
- Imperial College Healthcare NHS Trust, London, UK
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4
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[CLINICAL AND IMAGING FINDINGS OF ACUTE EPIDIDYMITIS IN CHILDREN]. Nihon Hinyokika Gakkai Zasshi 2022; 113:22-27. [PMID: 36682808 DOI: 10.5980/jpnjurol.113.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
(Objective) The etiology of acute epididymitis in children remains poorly understood. Several studies have demonstrated that urine tests are negative in the majority of children with acute epididymitis, and the condition is self-limiting. The need for radiological evaluation of the urinary tract in children with acute epididymitis is still debatable. The aim of this study was to describe clinical and imaging findings in children with acute epididymitis. (Methods) We identified 47 children with acute epididymitis at our institute between 2017 and 2021.We retrospectively reviewed their clinical features and radiological and laboratory data. All children underwent ultrasonography of the kidney and urinary tract. (Results) Median patient age was 9 years (range, 6 months-16 years) and 60% of the cases occurred between the ages of 7 and 12 years. Thirteen children (28%) had a past history of genitourinary malformations. The common malformations were hypospadias in eight children and bladder dysfunction in three. Ultrasound revealed no new urinary tract abnormalities in the remaining 34 children. Urinalysis were performed in 27 children, nine of whom (33%) had pyuria. Urine culture was positive in two children. Of the nine children with genitourinary malformations, eight had pyuria. All 18 children without genitourinary malformations had a negative urinalysis except for one patient (p< 0.0001). (Conclusions) Acute epididymitis is a common cause of acute scrotum in pediatric patients. In this study, one-third of acute epididymitis cases presented pyuria, and about 30% had a past history of genitourinary malformations. The presence of pyuria was associated with a past history of genitourinary malformations. For children with no previous genitourinary malformations, routine use of ultrasound for the detection of urinary tract abnormalities is questionable due to the low yield.
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5
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Usmani S, Niyaz K. Gamma camera imaging of scrotal and penile diseases. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00217-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Muraliharan JS, Jacob TJK, Bollu BK, Graf N, Sebastian T, Thomas G. Surgical management of the acute paediatric scrotum: a three-year single centre experience. ANZ J Surg 2021; 91:2514-2517. [PMID: 34585831 DOI: 10.1111/ans.17231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acute scrotal pain is a common emergency presentation in paediatric surgery. Torsion of the testicular appendage (TTA) is the most common cause for pain, with testicular torsion (TT) being the sinister pathology to exclude. Outcomes are time dependent, and a delayed scrotal exploration could result in testicular loss. METHODS We performed a review on a large retrospective cohort of 449 surgical scrotal explorations at a large referral paediatric surgical centre over three years. RESULTS Only about a quarter of children with testicular pain presented within 4 h. TT is commonly associated with nausea and an abnormal lie. Two children with a classical 'blue dot' sign were later found to have a testicular torsion. 19% of all children with a TTA were also seen to have Bell clapper anomaly (BCA). Recurrent testicular pain was associated with 84.7% (p < 0.001) of BCA. Intra-operative diagnosis of TTA correlated with histopathology in 84.6% (p=0.021). The sensitivity of intraoperative diagnosis was 90.9% with a specificity of 75.3%. CONCLUSION Routine histopathology for a classic TTA may not be required especially in resource poor situations. All children presenting with recurrent episodes of testicular pain must be considered for surgical scrotal exploration. And in view of the incidence of BCA in this cohort, all scrotal explorations for acute scrotal pain should include an assessment for BCA.
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Affiliation(s)
| | - Tarun John K Jacob
- Department of Paediatric Surgery, Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Department of Paediatric Surgery, Christian Medical College, Vellore, India
| | - Bapesh Krishna Bollu
- Department of Paediatric Surgery, Children's Hospital at Westmead, Sydney, New South Wales, Australia.,School of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Nicole Graf
- School of Medicine, University of Sydney, Sydney, New South Wales, Australia.,Department of Pathology, Children's Hospital Westmead, Sydney, New South Wales, Australia
| | - Tunny Sebastian
- Department of Paediatric Surgery, Christian Medical College, Vellore, India.,Department of Clinical Nutrition, College of Applied Medical Science, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Gordon Thomas
- Department of Paediatric Surgery, Children's Hospital at Westmead, Sydney, New South Wales, Australia.,School of Medicine, University of Sydney, Sydney, New South Wales, Australia
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Qamar AY, Hussain T, Rafique MK, Bang S, Tanga BM, Seong G, Fang X, Saadeldin IM, Cho J. The Role of Stem Cells and Their Derived Extracellular Vesicles in Restoring Female and Male Fertility. Cells 2021; 10:2460. [PMID: 34572109 PMCID: PMC8468931 DOI: 10.3390/cells10092460] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 09/10/2021] [Accepted: 09/14/2021] [Indexed: 12/21/2022] Open
Abstract
Infertility is a globally recognized issue caused by different reproductive disorders. To date, various therapeutic approaches to restore fertility have been attempted including etiology-specific medication, hormonal therapies, surgical excisions, and assisted reproductive technologies. Although these approaches produce results, however, fertility restoration is not achieved in all cases. Advances in using stem cell (SC) therapy hold a great promise for treating infertile patients due to their abilities to self-renew, differentiate, and produce different paracrine factors to regenerate the damaged or injured cells and replenish the affected germ cells. Furthermore, SCs secrete extracellular vesicles (EVs) containing biologically active molecules including nucleic acids, lipids, and proteins. EVs are involved in various physiological and pathological processes and show promising non-cellular therapeutic uses to combat infertility. Several studies have indicated that SCs and/or their derived EVs transplantation plays a crucial role in the regeneration of different segments of the reproductive system, oocyte production, and initiation of sperm production. However, available evidence triggers the need to testify the efficacy of SC transplantation or EVs injection in resolving the infertility issues of the human population. In this review, we highlight the recent literature covering the issues of infertility in females and males, with a special focus on the possible treatments by stem cells or their derived EVs.
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Affiliation(s)
- Ahmad Yar Qamar
- College of Veterinary Medicine, Chungnam National University, Daejeon 34134, Korea
- College of Veterinary and Animal Sciences, Jhang, Sub-Campus of University of Veterinary and Animal Sciences, Lahore 54000, Pakistan
| | - Tariq Hussain
- College of Veterinary and Animal Sciences, Jhang, Sub-Campus of University of Veterinary and Animal Sciences, Lahore 54000, Pakistan
| | - Muhammad Kamran Rafique
- College of Veterinary and Animal Sciences, Jhang, Sub-Campus of University of Veterinary and Animal Sciences, Lahore 54000, Pakistan
| | - Seonggyu Bang
- College of Veterinary Medicine, Chungnam National University, Daejeon 34134, Korea
| | - Bereket Molla Tanga
- College of Veterinary Medicine, Chungnam National University, Daejeon 34134, Korea
- Faculty of Veterinary Medicine, Hawassa University, Hawassa 05, Ethiopia
| | - Gyeonghwan Seong
- College of Veterinary Medicine, Chungnam National University, Daejeon 34134, Korea
| | - Xun Fang
- College of Veterinary Medicine, Chungnam National University, Daejeon 34134, Korea
| | - Islam M Saadeldin
- College of Veterinary Medicine, Chungnam National University, Daejeon 34134, Korea
| | - Jongki Cho
- College of Veterinary Medicine, Chungnam National University, Daejeon 34134, Korea
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Ihara T, Arino S, Nomura O. Movable discoloration in the scrotum with attendant pain. Emerg Med J 2021; 38:578-586. [PMID: 34449429 DOI: 10.1136/emermed-2020-210269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Takateru Ihara
- Division of Pediatric Emergency Medicine, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
| | - Satoshi Arino
- Division of Pediatric Emergency Medicine, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
| | - Osamu Nomura
- Department of Emergency and Disaster Medicine, Hirosaki University, Hirosaki, Japan
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Teurneau-Hermansson K, Zindovic I, Jakobsson J, Navntoft A, Nozohor Ekmark A, Salö M, Wagenius M. Doppler ultrasound improves diagnostic accuracy for testicular torsion. Scand J Urol 2021; 55:461-465. [PMID: 34369846 DOI: 10.1080/21681805.2021.1962404] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Doppler ultrasound can diagnose testicular torsion with high sensitivity and specificity but may delay surgical treatment. This study aims to assess whether the use of doppler ultrasound, in cases with intermediate clinical suspicion of testicular torsion, can improve diagnostic accuracy compared to clinical assessment alone. METHODS We implemented a new clinical algorithm where patients with intermediate suspicion of testicular torsion undergo doppler ultrasound within 60 min. This study compared the patients that presented within one year prior to the implementation (group 1) to the patients who presented within one year after the implementation (group 2). The primary outcome measure was failure to confirm testicular torsion upon surgical exploration (negative surgical exploration). Missed testicular torsion was one of the secondary endpoints. RESULTS 590 consecutive patients were included. 322 (55%) in group 1 and 268 (45%) in group 2. There were 9 (2.8%) testicular torsions in group 1 vs 9 (3.4%) in group 2 (p = 0.69) and 2 (0.6%) missed testicular torsions in group 1 vs 0 in group 2 (p = 0.50). Doppler ultrasound was performed in 65 patients (24.2%) in group 2 vs 0 in group 1 (p < 0.01). Negative surgical exploration was performed in 27 (8.4%) patients in group 1 vs 8 (3.0%) in group 2 (p < 0.01). CONCLUSION Doppler ultrasound assessment of patients at intermediate clinical risk of testicular torsion significantly reduced the frequency of negative surgical explorations without increased rate of missed testicular torsions.
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Affiliation(s)
| | - Igor Zindovic
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Jon Jakobsson
- Department of Urology, Helsingborg Hospital, Helsingborg, Sweden
| | - Anders Navntoft
- Department of Radiology, Helsingborg Hospital, Helsingborg, Sweden
| | - Ann Nozohor Ekmark
- Department of Pediatric Surgery, Skåne University Hospital, Lund, Sweden
| | - Martin Salö
- Department of Pediatric Surgery, Skåne University Hospital, Lund, Sweden
| | - Magnus Wagenius
- Department of Urology, Helsingborg Hospital, Helsingborg, Sweden
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10
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Revisiting testicular torsion scores in an Asian healthcare system. J Pediatr Urol 2020; 16:821.e1-821.e7. [PMID: 33077388 DOI: 10.1016/j.jpurol.2020.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 09/23/2020] [Accepted: 09/25/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Testicular pain is a common presentation amongst young boys. It is important to distinguish between testicular torsion and other testicular pathology as testicular viability is dependent on timely diagnosis and surgical intervention. OBJECTIVES The aim of this study was to evaluate the utility of the TWIST score in our population. Our second objective was to compare a new testicular torsion score (TT score) developed in a paediatric Asian population, with the TWIST score in risk stratification for testicular torsion. Duration of symptoms and delays after presentation were also correlated with testicular viability. METHODS This is a prospective cohort study of children admitted with testicular pain from January 2016 to December 2018 at a tertiary care hospital in Singapore. Relevant findings such as age, nausea/vomiting, testicular swelling/firmness, absence of cremasteric reflex and abnormal lie were collected. Univariate and multivariate logistic regression was performed to identify significant predictive factors of testicular torsion to generate TT score. RESULTS A total of 315 patients were involved in this study. Mean age of patients was 121.3 ± 44.2 months. There were 43 patients with testicular torsion. No patients with a TT score of ≤1 were found to have testicular torsion. In contrast, 10 patients with a TWIST score of ≤2 were found to have testicular torsion. Of the patients with testicular torsion, 16 had a TWIST score of ≥5 and 22 had a TT score of ≥6. In this study, the area under the curve was 0.87 for the TWIST score and 0.93 for the TT score. CONCLUSION In conclusion, the TT score is a reliable score for excluding testicular torsion in an Asian patient population with a sensitivity and negative predictive value of 100% at a cut-off value of ≤1. Both TWIST and TT score performed equally well in early presenters (<6 h) Further prospective validation studies are needed to evaluate the utility of the TT score. Delay in presentation to hospital is the most important determinant of outcome.
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11
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Abstract
Coronavirus disease 2019 (COVID-19) symptoms in children are incompletely described. We present the first case of orchiepididymitis associated with COVID-19 in a boy and discuss pathways of testicular involvement by SARS-CoV2 virus. This case underlines the need for further study of the clinical presentation of pediatric COVID-19 and the potential association with nonrespiratory symptoms.
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13
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Wu WJ, Gitlin JS. The Male Genital System. Pediatr Rev 2020; 41:101-111. [PMID: 32123021 DOI: 10.1542/pir.2017-0316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Wayland J Wu
- Smith Institute for Urology, Zucker School of Medicine, Lake Success, NY
| | - Jordan S Gitlin
- Cohen Children's Medical Center, Division of Pediatric Urology, Zucker School of Medicine, New Hyde Park, NY
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14
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Grimsby GM, Schlomer BJ, Menon VS, Ostrov L, Keays M, Sheth KR, Villanueva C, Granberg C, Dajusta D, Hill M, Sanchez E, Harrison CB, Jacobs MA, Burgu B, Hennes H, Baker LA. Prospective Evaluation of Predictors of Testis Atrophy After Surgery for Testis Torsion in Children. Urology 2018; 116:150-155. [PMID: 29572055 DOI: 10.1016/j.urology.2018.03.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 02/25/2018] [Accepted: 03/05/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To prospectively correlate pain duration, red scrotal skin, ultrasound appearance of testis, and intraoperative testis color to future testis atrophy after acute testicular torsion. METHODS Patients 2 months-18 years old with unilateral acute scrotum were consecutively enrolled in a National Institutes of Health transcutaneous near-infrared spectroscopy study, with a subgroup analysis of the true torsion group. Presence or absence of red scrotal skin, pain duration, testicular heterogeneity on preoperative ultrasound, and intraoperative testis color based on a novel visual chart 5 minutes after detorsion were recorded. All testes underwent orchiopexy regardless of appearance. Percent volume difference between normal and torsed testicles on follow-up ultrasound was compared between patients with and without risk factors. RESULTS Thirty of 56 patients who had surgical detorsion underwent scrotal ultrasound at a mean of 117 days after surgery. A color of black or hemorrhagic 5 minutes after detorsion, pain duration >12 hours, and heterogeneous parenchyma on preoperative ultrasound were associated with significant testis volume loss in follow-up compared with normal testis. All patients with a black or hemorrhagic testis had >80% volume loss. Erythematous scrotal skin was not significantly associated with smaller affected testis volume in follow-up. CONCLUSION Based on the high atrophy rate, orchiectomy can be considered for testes that are black or hemorrhagic 5 minutes after detorsion. Pain duration >12 hours and parenchymal heterogeneity on preoperative ultrasound were also associated with testis atrophy. Red scrotal skin was not a reliable predictor of atrophy and should not delay exploration.
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Affiliation(s)
- Gwen M Grimsby
- Division of Pediatric Urology, Phoenix Children's Hospital, Phoenix, AZ
| | - Bruce J Schlomer
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Division of Pediatric Urology, Children's Health, Dallas, TX
| | - Vani S Menon
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Division of Pediatric Urology, Children's Health, Dallas, TX
| | - Lauren Ostrov
- Division of Pediatric Urology, Children's Health, Dallas, TX
| | - Melise Keays
- Division of Pediatric Urology, Children's Hospital of East Ontario, Ottawa, Ontario, Canada
| | - Kunj R Sheth
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Carlos Villanueva
- Division of Pediatric Urology, Children's Hospital & Medical Center, Omaha, NE
| | | | - Daniel Dajusta
- Division of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH
| | - Martinez Hill
- Division of Pediatric Urology, Children's Health, Dallas, TX
| | - Emma Sanchez
- Division of Pediatric Urology, Children's Health, Dallas, TX
| | - Clanton B Harrison
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Division of Pediatric Urology, Children's Health, Dallas, TX
| | - Micah A Jacobs
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Division of Pediatric Urology, Children's Health, Dallas, TX
| | - Berk Burgu
- Department of Urology, Ankara Üniversitesi Tıp Fakültesi, Ankara, Turkey
| | - Halim Hennes
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Division of Pediatric Urology, Children's Health, Dallas, TX
| | - Linda A Baker
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Division of Pediatric Urology, Children's Health, Dallas, TX.
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Abstract
Urologic emergencies can involve the kidneys, ureters, bladder, urethra, penis, scrotum, or testicles. History and physical examination are essential to diagnosis, whereas imaging is increasingly used to confirm diagnoses. Acute urinary retention should be relieved with Foley placement. Penile emergencies include paraphimosis, which can be treated by foreskin reduction, whereas penile fracture and priapism require urologic intervention. Fournier gangrene and testicular torsion are scrotal emergencies requiring emergent surgery. Nephrolithiasis, although painful, is not an emergency unless there is concern for concomitant urinary tract infection, both ureters are obstructed by stones, or there is an obstructing stone in a solitary kidney.
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Affiliation(s)
- Adarsh S Manjunath
- Department of Urology, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue 16-703, Chicago, IL 60611, USA
| | - Matthias D Hofer
- Department of Urology, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue 16-703, Chicago, IL 60611, USA.
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16
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Frohlich LC, Paydar-Darian N, Cilento BG, Lee LK. Prospective Validation of Clinical Score for Males Presenting With an Acute Scrotum. Acad Emerg Med 2017; 24:1474-1482. [PMID: 28833896 DOI: 10.1111/acem.13295] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 07/25/2017] [Accepted: 08/12/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective was to validate the Testicular Workup for Ischemia and Suspected Torsion (TWIST) score among pediatric emergency medicine providers for the evaluation of pediatric males presenting with testicular pain and swelling (acute scrotum). METHODS We conducted a prospective cohort study of males 3 months to 18 years old presenting with an acute scrotum. History and physical examination findings, including components of the TWIST score (hard testicle, absent cremasteric reflex, nausea/vomiting, and high riding testicle) as well as diagnostic results (ultrasound, urine, sexually transmitted infection testing) were recorded. Testicular torsion was confirmed by surgical exploration. Frequencies of patient characteristics, TWIST components, and tests were calculated. We performed the kappa statistic for inter-rater reliability and calculated the test characteristics and receiver operator characteristics curves for the TWIST score (range = 0-7). RESULTS During the study period 258 males were enrolled in the study; 19 (7.4%) had testicular torsion. The mean (±SD) age was 9.8 (±0.3) years. The high-risk TWIST score of 7 had 100% specificity (95% confidence interval [CI] = 98%-100%) with 100% positive predictive value (95% CI = 40%-100%) for testicular torsion. The area under the curve was 0.82. The kappa statistic for the overall TWIST score was fair at 0.39. CONCLUSIONS In this prospective validation of the TWIST score among pediatric emergency providers, the high-risk score demonstrated strong test characteristics for testicular torsion. The TWIST score could be used as part of a standardized approach for evaluation of the pediatric acute scrotum to provide more efficient and effective care.
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Affiliation(s)
- Lillian C. Frohlich
- Bioverativ, Waltham MA
- Division of Emergency Medicine; Boston Children's Hospital; Boston MA
| | | | | | - Lois K. Lee
- Division of Emergency Medicine; Boston Children's Hospital; Boston MA
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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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18
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Fujita N, Tambo M, Okegawa T, Higashihara E, Nutahara K. Distinguishing testicular torsion from torsion of the appendix testis by clinical features and signs in patients with acute scrotum. Res Rep Urol 2017; 9:169-174. [PMID: 28920055 PMCID: PMC5587186 DOI: 10.2147/rru.s140361] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | - Eiji Higashihara
- Department of Autosomal Dominant Polycystic Kidney Disease (ADPKD) Research, Kyorin University School of Medicine, Mitaka, Tokyo
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Demirbas A, Demir DO, Ersoy E, Kabar M, Ozcan S, Karagoz MA, Demirbas O, Doluoglu OG. Should manual detorsion be a routine part of treatment in testicular torsion? BMC Urol 2017; 17:84. [PMID: 28915866 PMCID: PMC5602835 DOI: 10.1186/s12894-017-0276-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 09/05/2017] [Indexed: 11/17/2022] Open
Abstract
Background It was aimed to investigate the efficiency and reliability of the manual detorsion (MD) procedure in patients diagnosed with testicular torsion (TT). Methods A retrospective analysis was made of the data of 57 patients diagnosed with TT, comprising 20 patients with successful MD (Group I), 28 patients who underwent emergency orchiopexy (Group II), and 9 patients applied with orchiectomy (Group III). The groups were compared in respect of age, and duration of pain. The success rate of MD, the time of testicular fixation (TF), any problems encountered in follow-up, and follow-up times were analyzed in Group I. Data were analyzed with P-P pilot, Mann-Whitney U, Kruskal Wallis and Chi-square tests. A value of p < 0.05 was considered statistically significant. Results MD was successful and detorsion could be achieved in 20 of 26 patients. The groups were similar in respect of age (p = 0.217). The median duration of pain was 3 (1–8), 4 (1–72), and 48 (12–144) hours in Groups I, II, and III, respectively, and determined as similar in Groups I and II (p = 0.257), although a statistically significant difference was determined between the 3 groups (p < 0.001). TF was applied to Group I after median 10 (0–45) days, and no parenchymal disorder was determined in the median follow-up period of 21.5 (2–40) months. Conclusion MD that can be easily and immediately performed after the diagnosis of TT decreases ischemia time. This seems to be an efficient and reliable procedure when applied together with elective orchiopexy, as a part of the treatment. Electronic supplementary material The online version of this article (10.1186/s12894-017-0276-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Arif Demirbas
- Department of Urology, Ankara Training and Research Hospital, 06340, Sukriye, Altındağ Ankara, Turkey.
| | - Demirhan Orsan Demir
- Department of Urology, Ankara Training and Research Hospital, 06340, Sukriye, Altındağ Ankara, Turkey
| | - Erim Ersoy
- Department of Urology, Ankara Training and Research Hospital, 06340, Sukriye, Altındağ Ankara, Turkey
| | - Mucahit Kabar
- Department of Urology, Ankara Training and Research Hospital, 06340, Sukriye, Altındağ Ankara, Turkey
| | - Serkan Ozcan
- Department of Urology, Ankara Training and Research Hospital, 06340, Sukriye, Altındağ Ankara, Turkey
| | - Mehmet Ali Karagoz
- Department of Urology, Ankara Training and Research Hospital, 06340, Sukriye, Altındağ Ankara, Turkey
| | - Ozgecan Demirbas
- Department of Pediatrics, Ankara Dr. Sami Ulus Women Health, Children's Training and Research Hospital, 06340, Ankara, Turkey
| | - Omer Gokhan Doluoglu
- Department of Urology, Ankara Training and Research Hospital, 06340, Sukriye, Altındağ Ankara, Turkey
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20
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Lee LK, Monuteaux MC, Hudgins JD, Porter JJ, Lipsett SC, Bourgeois F, Cilento BG, Neuman MI. Variation in the evaluation of testicular conditions across United States pediatric emergency departments. Am J Emerg Med 2017; 36:208-212. [PMID: 28774767 DOI: 10.1016/j.ajem.2017.07.078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/22/2017] [Accepted: 07/25/2017] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To explore the variation in diagnostic testing and management for males diagnosed with three testicular conditions (testicular torsion, appendix testis torsion, epididymitis/orchitis) using a large pediatric health care database. Diagnostic testing is frequently used in evaluation of the acute scrotum; however, there is likely variability in the use of these tests in the emergency department setting. METHODS We conducted a cross-sectional study of males with the diagnoses of testicular torsion, appendix testis torsion, and epididymitis/orchitis. We identified emergency department patients in the Pediatric Health Information Systems (PHIS) database from 2010 to 2015 using diagnostic and procedure codes from the International Classification of Diseases Codes 9 and 10. Frequencies of diagnoses by demographic characteristics and of procedures and diagnostic testing (ultrasound, urinalysis, urine culture and sexually transmitted infection testing) by age group were calculated. We analyzed testing trends over time. RESULTS We identified 17,000 males with the diagnoses of testicular torsion (21.7%), appendix testis torsion (17.9%), and epididymitis/orchitis (60.3%) from 2010 to 2015. There was substantial variation among hospitals in all categories of testing for each of the diagnoses. Overall, ultrasound utilization ranged from 33.1-100% and urinalysis testing ranged from 17.0-84.9% for all conditions. Only urine culture testing decreased over time for all three diagnoses (40.6% in 2010 to 31.5 in 2015). CONCLUSIONS There was wide variation in the use of diagnostic testing across pediatric hospitals for males with common testicular conditions. Development of evaluation guidelines for the acute scrotum could decrease variation in testing.
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Affiliation(s)
- Lois K Lee
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States.
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Joel D Hudgins
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States
| | - John J Porter
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Susan C Lipsett
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Florence Bourgeois
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Bartley G Cilento
- Department of Urology, Boston Children's Hospital, Boston, MA, United States
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States
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21
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Nistal M, Paniagua R, González-Peramato P, Reyes-Múgica M. Perspectives in Pediatric Pathology, Chapter 19. Testicular Torsion, Testicular Appendix Torsion, and Other Forms of Testicular Infarction. Pediatr Dev Pathol 2017; 19:345-359. [PMID: 25105275 DOI: 10.2350/14-06-1514-pb.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Among the most frequent specimens at the pediatric surgical pathology bench, orchiectomy performed after testicular torsion deserves significant attention. Multiple implications, including fertility, legal complications, possibility of occult lesion, and others, need to be considered. Furthermore, torsion of testicular and other appendices represents common urological emergencies frequently encountered in surgical pathology. Here we present a review of testicular torsion and infarction, including theories about their pathogenesis and the appropriate handling by the diagnostic pathologist.
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Affiliation(s)
- Manuel Nistal
- 1 Department of Pathology, Hospital La Paz, Universidad Autónoma de Madrid, Madrid 28029, Spain
| | - Ricardo Paniagua
- 2 Department of Cell Biology, Universidad de Alcala, Madrid, Spain
| | - Pilar González-Peramato
- 1 Department of Pathology, Hospital La Paz, Universidad Autónoma de Madrid, Madrid 28029, Spain
| | - Miguel Reyes-Múgica
- 3 Department of Pathology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA 15224, USA
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22
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Schlomer BJ, Keays MA, Grimsby GM, Granberg CF, DaJusta DG, Menon VS, Ostrov L, Sheth KR, Hill M, Sanchez EJ, Harrison CB, Jacobs MA, Huang R, Burgu B, Hennes H, Baker LA. Transscrotal Near Infrared Spectroscopy as a Diagnostic Test for Testis Torsion in Pediatric Acute Scrotum: A Prospective Comparison to Gold Standard Diagnostic Test Study. J Urol 2017; 198:694-701. [PMID: 28392394 DOI: 10.1016/j.juro.2017.03.134] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE A rapid test for testicular torsion in children may obviate the delay for testicular ultrasound. In this study we assessed testicular tissue percent oxygen saturation (%StO2) measured by transscrotal near infrared spectroscopy as a diagnostic test for pediatric testicular torsion. MATERIALS AND METHODS This was a prospective comparison to a gold standard diagnostic test study that evaluated near infrared spectroscopy %StO2 readings to diagnose testicular torsion. The gold standard for torsion diagnosis was standard clinical care. From 2013 to 2015 males with acute scrotum for more than 1 month and who were less than 18 years old were recruited. Near infrared spectroscopy %StO2 readings were obtained for affected and unaffected testes. Near infrared spectroscopy Δ%StO2 was calculated as unaffected minus affected reading. The utility of near infrared spectroscopy Δ%StO2 to diagnose testis torsion was described with ROC curves. RESULTS Of 154 eligible patients 121 had near infrared spectroscopy readings. Median near infrared spectroscopy Δ%StO2 in the 36 patients with torsion was 2.0 (IQR -4.2 to 9.8) vs -1.7 (IQR -8.7 to 2.0) in the 85 without torsion (p=0.004). AUC for near infrared spectroscopy as a diagnostic test was 0.66 (95% CI 0.55-0.78). Near infrared spectroscopy Δ%StO2 of 20 or greater had a positive predictive value of 100% and a sensitivity of 22.2%. Tanner stage 3-5 cases without scrotal edema or with pain for 12 hours or less had an AUC of 0.91 (95% CI 0.86-1.0) and 0.80 (95% CI 0.62-0.99), respectively. CONCLUSIONS In all children near infrared spectroscopy readings had limited utility in diagnosing torsion. However, in Tanner 3-5 cases without scrotal edema or with pain 12 hours or less, near infrared spectroscopy discriminated well between torsion and nontorsion.
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Affiliation(s)
- Bruce J Schlomer
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas.
| | | | | | | | | | - Vani S Menon
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas
| | | | - Kunj R Sheth
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Clanton B Harrison
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas
| | - Micah A Jacobs
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas
| | | | - Berk Burgu
- Ankara Üniversitesi Tıp Fakültesi, Ankara, Turkey
| | - Halim Hennes
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas
| | - Linda A Baker
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas
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23
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Mäkelä E, Lahdes-Vasama T, Rajakorpi H, Wikström S. A 19-Year Review of Paediatric Patients with Acute Scrotum. Scand J Surg 2016; 96:62-6. [PMID: 17461315 DOI: 10.1177/145749690709600112] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and Aims: The aim of the study was to compare incidence, symptoms and signs of spermatic cord torsion to those of other conditions causing acute scrotum. Material and Methods: Records of 388 consecutive boys under 17 years of age treated for acute scrotum at The Hospital for Children and Adolescents in Helsinki in 1977–1995 were reviewed. During the period studied all patients with acute scrotum underwent urgent surgery to ensure accurate diagnosis and treatment. The duration and characteristics of the symptoms, clinical findings prior to operation and the age of the patients were registered. Results: Scrotal explorations revealed 100 cases (26%) of spermatic cord torsion (SCT), 174 cases (45%) of torsion of the testicular appendage (AT), 38 cases (10%) of epididymitis (ED), 32 cases (8%) of incarcerated inquinal hernias and 44 (11%) other conditions. During the first year of life SCT was the most common cause of acute scrotum, another peak incidence being in adolescence. Almost half of the boys with AT were nine to 12 years of age (median 11). Except for infants, the patients' acute symptoms were pain (SCT 88%, AT 94%, ED 76%). Swelling in the hemiscrotum was found in 44% of SCT, in 39% of AT and in 88% of ED cases. Epididymitis was also accompanied by erythema (37%), but infrequently with fever (in 16%). Erythema was found also in AT (32%), but the “blue dot sign” was found positive in only 17 (10%) of the boys with AT. Three quarters of the boys who were operated on within six hours from onset of symptoms had testicle torsion. All testicles were saved when detorsion was performed within six hours, but salvage was possible in only half of the cases when symptoms had lasted more than six but less than 12 hours. Conclusions: The high probability of SCT among those admitted to an emergency department within six hours from the onset of the symptoms justifies immediate surgical exploration.
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Affiliation(s)
- E Mäkelä
- Department of Paediatric Surgery, Paediatric Research Centre, Tampere University Hospital, Tampere, Finland.
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24
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Sheth KR, Keays M, Grimsby GM, Granberg CF, Menon VS, DaJusta DG, Ostrov L, Hill M, Sanchez E, Kuppermann D, Harrison CB, Jacobs MA, Huang R, Burgu B, Hennes H, Schlomer BJ, Baker LA. Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score. J Urol 2016; 195:1870-6. [PMID: 26835833 DOI: 10.1016/j.juro.2016.01.101] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2016] [Indexed: 11/16/2022]
Abstract
PURPOSE The TWIST (Testicular Workup for Ischemia and Suspected Torsion) score uses urological history and physical examination to assess risk of testis torsion. Parameters include testis swelling (2 points), hard testis (2), absent cremasteric reflex (1), nausea/vomiting (1) and high riding testis (1). While TWIST has been validated when scored by urologists, its diagnostic accuracy among nonurological providers is unknown. We assessed the usefulness of the TWIST score when determined by nonurological nonphysician providers, mirroring emergency room evaluation of acute scrotal pain. MATERIALS AND METHODS Children with unilateral acute scrotum were prospectively enrolled in a National Institutes of Health clinical trial. After undergoing basic history and physical examination training, emergency medical technicians calculated TWIST score and determined Tanner stage per pictorial diagram. Clinical torsion was confirmed by surgical exploration. All data were captured into REDCap™ and ROC curves were used to evaluate the diagnostic usefulness of TWIST. RESULTS Of 128 patients (mean age 11.3 years) 44 (13.0 years) had torsion. TWIST score cutoff values of 0 and 6 derived from ROC analysis identified 31 high, 57 intermediate and 40 low risk cases (positive predictive value 93.5%, negative predictive value 100%). CONCLUSIONS TWIST score assessed by nonurologists, such as emergency medical technicians, is accurate. Low risk patients do not require ultrasound to rule out torsion. High risk patients can proceed directly to surgery, with more than 50% avoiding ultrasound. In the future emergency medical technicians and/or emergency room triage personnel may be able to calculate TWIST score to guide radiological evaluation and immediate surgical intervention at initial assessment long before urological consultation.
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Affiliation(s)
- Kunj R Sheth
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Melise Keays
- Children's Hospital of East Ontario, Ottawa, Ontario, Canada
| | | | | | - Vani S Menon
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas
| | | | | | | | | | | | - Clanton B Harrison
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas
| | - Micah A Jacobs
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas
| | | | - Berk Burgu
- Nationwide Children's Hospital, Columbus, Ohio
| | - Halim Hennes
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas
| | - Bruce J Schlomer
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas
| | - Linda A Baker
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas.
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25
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Fehér ÁM, Bajory Z. A review of main controversial aspects of acute testicular torsion. JOURNAL OF ACUTE DISEASE 2016. [DOI: 10.1016/j.joad.2015.06.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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26
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[Scrotal ultrasound examinations in infants and toddlers]. Urologe A 2015; 55:3-9. [PMID: 26659829 DOI: 10.1007/s00120-015-0009-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Besides physical examination, ultrasonography is the most valuable diagnostic tool to assess the scrotum and testes in the case of an acute scrotum or scrotal pathology. PROBLEMS In infants and toddlers the examination can be challenging. Due to the limited patient compliance, the small testicular size (< 0.5 ml), and low blood flow velocity (< 3 cm/s), it can be difficult to achieve a proper flow curve when assessing blood flow. CONCLUSION The examiner's skills are as important as adequate equipment (i. e., linear ultrasound probe, 12-14 MHz) and optimal program settings (Doppler scale < 3 cm/s, gate 1 mm). However, if there is doubt, surgical exploration is unavoidable.
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27
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Sun Z, Xie M, Xiang F, Song Y, Yu C, Zhang Y, Ramdhany S, Wang J. Utility of Real-Time Shear Wave Elastography in the Assessment of Testicular Torsion. PLoS One 2015; 10:e0138523. [PMID: 26382244 PMCID: PMC4575189 DOI: 10.1371/journal.pone.0138523] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 09/01/2015] [Indexed: 12/14/2022] Open
Abstract
Real-time shear-wave elastography (SWE) is a newly developed method which can obtain the stiffness of tissues and organs based on tracking of shear wave propagation through a structure. Several studies have demonstrated its potential in the differentiation between diseased and normal tissue in clinical practices, however the applicability to testicular disease has not been well elucidated. We investigated the feasibility and reproducibility of SWE in the detection of testicular torsion. This prospective study comprised 15 patients with complete testicular torsion. Results obtained from SWE along with conventional gray-scale and color Doppler sonography and post-operative pathology were compared. The results revealed that (i) the size of injured testis was increased and the twisted testis parenchyma was heterogeneous. The blood flow signals in injured testis were barely visible or absent; (ii) The Young’s modulus, including Emean, Emax, Emin and SD values in the border area of torsional testis were higher than those of normal testis (Emean, 78.07±9.01kPa vs 22.0±5.10kPa; Emax,94.07±6.53kPa vs 27.87±5.78kPa; Emin, 60.73±7.84 kPa vs 18.90±4.39kPa; SD, 7.67±0.60 kPa vs 2.30±0.36 kPa, [P<0.05]); The Emax and SD values in the central area of the torsional testis were higher than the corresponding area of the normal testis (Emax, 8.23±0.30 kPa vs 3.97±0.95kPa; SD, 1.5±0.26kPa vs 0.67±0.35kPa,[P<0.05]) and Emin values was lower than those of normal testicles(0.93±0.51kPa vs 1.6±0.36kPa; [P<0.05]); (iii) The Young's modulus measurement between two physicians showed good agreement. The pathological findings were accordance with SWE measurement. SWE is a non-invasive, convenient and high reproducible method and may serve as an important alternative tool in the diagnosis and monitoring the progression of the acute scrotums, in additional to conventional Doppler sonography.
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Affiliation(s)
- Zhenxing Sun
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China 430022
| | - Mingxing Xie
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China 430022
| | - Feixiang Xiang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China 430022
| | - Yue Song
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China 430022
| | - Cheng Yu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China 430022
| | - Yanrong Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China 430022
| | - Sachin Ramdhany
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China 430022
| | - Jing Wang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China 430022
- * E-mail:
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28
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Güneş M, Umul M, Altok M, Akyüz M, İşoğlu CS, Uruç F, Aras B, Sertkaya Z, Ürkmez A, Baş E, Keleş MO. Is it possible to distinguish testicular torsion from other causes of acute scrotum in patients who underwent scrotal exploration? A multi-center clinical trial. Cent European J Urol 2015; 68:252-6. [PMID: 26251755 PMCID: PMC4526613 DOI: 10.5173/ceju.2015.542] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 01/27/2015] [Accepted: 04/07/2015] [Indexed: 02/02/2023] Open
Abstract
Introduction To assess the clinical presentation of patients who underwent surgical exploration for acute scrotum and to investigate the potentially related factors for differential dignosis. Material and methods We retrospectively analyzed the medical records of 97 patients who underwent surgical exploration for acute scrotum between May 2007 and July 2013. The patients were divided into two groups as follows: Group1 included patients with testicular torsion (TT) and Group 2 contained patients with acute scrotal pathologies other than TT, including torsion of the testicular appendage, epididymo-orchitis, trauma and Henoch-Schönlein purpura. The physical examination findings, colour Doppler ultrasound (CDUS) and laboratory findings for the groups were compared. Results In total, 97 scrotal explorations were carried out for acute scrotum. Group 1 included 72 patients (74.2%) and Group 2 included 25 patients (25.8%). Group 2 was comprised of patients with torsion of the testicular appendage (n = 13), epididymo-orchitis (n = 8), testicular trauma (n = 2) and Henoch-Schönlein purpura (n = 2). In Group 1, 32 cases (44.4%) presented to a hospital less than 6 hours after onset of pain. More than half (64%) of Group 2's cases presented more than 24 hours after pain onset. Fever and pyuria appeared more frequently in Group 2 than in Group 1 and the results reached statistical significance (p = 0.001 and p = 0.044, respectively). Group 1 had more testicular tenderness than Group 2 (p <0.001). Our testicular salvage rate was 59.7%, and 40.3% of patients underwent orchiectomy. Conclusions CDUS predicted the diagnosis of TT (sensitivity 98.6%). Furthermore, clinical findings may also play a substantial role in the differential diagnosis of acute scrotum.
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Affiliation(s)
- Mustafa Güneş
- Suleyman Demirel University, Faculty of Medicine, Department of Urology, Isparta, Turkey
| | - Mehmet Umul
- Suleyman Demirel University, Faculty of Medicine, Department of Urology, Isparta, Turkey
| | - Muammer Altok
- Suleyman Demirel University, Faculty of Medicine, Department of Urology, Isparta, Turkey
| | - Mehmet Akyüz
- Haydarpasa Training and Research Hospital, Department of Urology, Istanbul, Turkey
| | - Cemal Selçuk İşoğlu
- Tepecik Training and Research Hospital, Department of Urology, Izmir, Turkey
| | - Fatih Uruç
- Fatih Sultan Mehmet Training and Research Hospital, Department of Urology, Istanbul, Turkey
| | - Bekir Aras
- Dumlupınar University, Faculty of Medicine, Department of Urology, Kutahya, Turkey
| | - Zülfü Sertkaya
- Haydarpasa Training and Research Hospital, Department of Urology, Istanbul, Turkey
| | - Ahmet Ürkmez
- Fatih Sultan Mehmet Training and Research Hospital, Department of Urology, Istanbul, Turkey
| | - Ercan Baş
- Suleyman Demirel University, Faculty of Medicine, Department of Urology, Isparta, Turkey
| | - Muzaffer Oğuz Keleş
- Haydarpasa Training and Research Hospital, Department of Urology, Istanbul, Turkey
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29
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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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Ghalige HS, N B, Maibam C, Sharma MB, Singh TSC. Testicular Torsion in Cerebral Palsy - Resident's Grey Area. J Clin Diagn Res 2014; 8:ND07-9. [PMID: 25478396 DOI: 10.7860/jcdr/2014/10154.5054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 07/17/2014] [Indexed: 11/24/2022]
Abstract
The association of testicular torsion and cerebral palsy is a well-known fact. But the infrequent presentation to emergency room makes the clinician sceptical. Such a presentation often puzzles the residents regarding the diagnosis and the treatment. Here we present a case of an adolescent boy aged with cerebral palsy 13 years with incessant crying and not feeding well for last 3days. Right inguinal region showed a tender globular swelling with absence of testis in scrotum along with signs of septicaemia. The inguinal exploration was performed under general anaesthesia which revealed gangrenous right testis. Right orchidectomy and left orchidopexy was performed and the patient recovered well. This case is reported for its complexity due to lack of reliable history, delayed presentation and associated comorbidities posing challenges to the treating surgeons.
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Affiliation(s)
- Hemanth S Ghalige
- Junior resident, Department of Surgery, Regional Institute of Medical Sciences , Imphal, Manipur, India
| | - Babitha N
- Junior resident, Department of Surgery, Regional Institute of Medical Sciences , Imphal, Manipur, India
| | - Chetan Maibam
- Senior Registrar, Department of Surgery, Regional Institute of Medical Sciences , Imphal, Manipur, India
| | - M Birkumar Sharma
- Professor, Department of Surgery, Regional Institute of Medical Sciences , Imphal, Manipur, India
| | - Th Sudhir Chandra Singh
- Professor, Department of Surgery, Regional Institute of Medical Sciences , Imphal, Manipur, India
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Epididymitis: A 21-Year Retrospective Review of Presentations to an Outpatient Urology Clinic. J Urol 2014; 192:1203-7. [DOI: 10.1016/j.juro.2014.04.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2014] [Indexed: 11/20/2022]
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Gkentzis A, Lee L. The aetiology and current management of prepubertal epididymitis. Ann R Coll Surg Engl 2014; 96:181-3. [PMID: 24780779 PMCID: PMC4474044 DOI: 10.1308/003588414x13814021679311] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2013] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The aim of this study was to review the published evidence on the pathogenesis and management of acute epididymitis (AE) in prepubertal boys after the authors encountered an unexpectedly large number of such cases in their institution. METHODS Using MEDLINE(®), a literature search was performed for articles in English with the words "pre-pubertal" OR "boys" OR "p(a)ediatric" OR "children" AND "epididymitis" OR "epididymo-orchitis". RESULTS The literature suggests that it is rare to find a bacterial infection or anatomical anomaly as a cause for AE in this population. A postviral infectious phenomenon is the most likely explanation. The management should be supportive and antibiotics reserved for those with pyuria or positive cultures. Urodynamic studies and renal tract ultrasonography have been advocated for those with recurrent epididymitis. CONCLUSIONS AE in prepubertal boys is more common than believed previously. A careful history for recent viral illnesses should be included. Antibiotics, urinary tract imaging and functional studies should be used in selected cases.
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Soyer T, İnal E, Boybeyi Ö, Balci M, Aslan MK, Aydin G. Electrophysiologic evaluation of cremasteric reflex in experimental orchitis. J Pediatr Urol 2013; 9:1098-102. [PMID: 23660491 DOI: 10.1016/j.jpurol.2013.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 03/24/2013] [Indexed: 11/24/2022]
Abstract
AIM Absent cremasteric reflex (CR) is a well known but not reliable sign of testicular torsion. We hypothesized that CR can also be altered in other causes of acute scrotum in children. An experimental study was performed to evaluate the clinical and electrophysiological features of CR in orchitis. METHOD Eighteen Wistar albino rats were allocated into three groups: control (CG), sham (SG) and orchitis (OG). In CG, after anesthetization with ketamine hydrochloride, the medial site of the anterior superior iliac spine was stimulated to obtain CR electrophysiologically, and latency and duration were recorded with a needle electrode placed in the cremasteric muscle. Electrophysiologic evaluations were performed 24 h after injection of 0.1 ml of 10(6) cfu/ml Escherichia coli (0:6 strain) in 1 ml of physiologic saline into the right testicle in OG, and 1 ml of saline only in SG. All testicles were sampled to check for orchitis after the electrophysiologic evaluations. RESULTS CR was obtained in all rats in CG and in 83.3% and 66.6% in SG and OG respectively (p < 0.05). The latency of CR was significantly higher in OG (15.1 ± 0.9 ms) and SG (15.5 ± 1.2 ms) than CG (10.5 ± 0.7 ms) (p < 0.017). The duration of CR was 15.1 ± 3.2 ms in CG, 16.2 ± 4.9 ms in SG and 18.5 ± 3 ms in OG (p > 0.05). Histopathologic confirmation of orchitis was obtained in all testicle samples in OG, and number of neutrophils and total orchitis score was significantly higher in OG than the other groups (p < 0.05). CONCLUSION Electrophysiologic parameters of CR may be altered in orchitis. Prolonged latency of CR in orchitis may be due to inflammation of the genitofemoral nerve or cremasteric muscle.
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Affiliation(s)
- Tutku Soyer
- Department of Pediatric Surgery, Hacettepe University, School of Medicine, Ankara, Turkey.
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Differentiation of Epididymitis and Appendix Testis Torsion by Clinical and Ultrasound Signs in Children. Urology 2013; 82:899-904. [DOI: 10.1016/j.urology.2013.04.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 03/26/2013] [Accepted: 04/01/2013] [Indexed: 11/30/2022]
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A review of ultrasound imaging in scrotal emergencies. J Ultrasound 2013; 16:171-8. [PMID: 24432171 DOI: 10.1007/s40477-013-0033-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 08/01/2013] [Indexed: 02/01/2023] Open
Abstract
Scrotal emergencies represent a small proportion of admissions to the emergency department; however, the intimate nature and potential for serious outcome often cause great anxiety. Rapid assessment is required to exclude fertility-threatening conditions and expedite surgical management. Ultrasound is an essential tool in acute scrotal assessment as it allows rapid, radiation-free, high-resolution imaging and, importantly, assessment of vascularity with colour Doppler imaging. In the presentation of the acute scrotum, the "on-call" practitioner will frequently be asked to exclude pathology requiring surgical management, in particular torsion of the spermatic cord. To provide an accurate evaluation the individual is required to have an understanding of scrotal anatomy, sonographic technique and recognition of pathology. This review article will familiarise the reader with the sonographic findings of common acute scrotal pathology.
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Shah MI, Chantal Caviness A, Mendez DR. Prospective pilot derivation of a decision tool for children at low risk for testicular torsion. Acad Emerg Med 2013; 20:271-8. [PMID: 23517259 DOI: 10.1111/acem.12086] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 09/11/2012] [Accepted: 09/12/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The purpose of this study was to derive a pilot clinical decision tool with 100% negative predictive value for testicular torsion based on prospectively collected data in children with acute scrotal pain. METHODS This was a prospective cohort study of a convenience sample of newborn to 21-year-old males evaluated for acute (72 hours or less) scrotal pain at an urban children's hospital emergency department (ED). A pediatric emergency medicine fellow or attending physician documented history and examination findings on a standardized data collection form. The study investigators used ultrasound (US), operative reports, or clinical follow-up to identify patients who had testicular torsion. Pearson's chi-square test and odds ratios (OR) were used to identify factors associated with the diagnosis of testicular torsion. The authors also used a recursive partitioning model to create a low-risk decision tool for testicular torsion. RESULTS Of the 450 eligible patients, 228 (51%) were enrolled, with a mean (± SD) age of 9.9 (± 4.1) years, including 21 (9.2%, 95% confidence interval [CI] = 5.8% to 13.7%) with testicular torsion. The derived clinical decision tool consisted of three variables: horizontal or inguinal testicular lie (OR = 18.17, 95% CI = 6.2 to 53.2), nausea or vomiting (OR = 5.63, 95% CI = 2.08 to 15.22), and age 11 to 21 years (OR = 3.9, 95% CI = 1.27 to 11.97). These variables had a sensitivity of 100% (95% CI = 98% to 100%) and negative predictive value of 100% (95% CI = 98% to 100%) for the diagnosis of testicular torsion. CONCLUSIONS Based on a decision tool derived with recursive partitioning, study patients with all of the following characteristics had no risk of testicular torsion: normal testicular lie, lack of nausea or vomiting, and age 0 to 10 years. Future research should focus on externally validating this tool to optimize emergent evaluation when testicular torsion is likely, while minimizing routine sonographic evaluation when patients are unlikely to have a serious condition requiring immediate management.
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Affiliation(s)
- Manish I. Shah
- Department of Pediatrics; Section of Emergency Medicine; Baylor College of Medicine; Houston TX
| | - A. Chantal Caviness
- Department of Pediatrics; Section of Emergency Medicine; Baylor College of Medicine; Houston TX
| | - Donna R. Mendez
- Department of Pediatrics; Section of Emergency Medicine; Baylor College of Medicine; Houston TX
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Barbosa JA, Tiseo BC, Barayan GA, Rosman BM, Torricelli FCM, Passerotti CC, Srougi M, Retik AB, Nguyen HT. Development and initial validation of a scoring system to diagnose testicular torsion in children. J Urol 2012; 189:1859-64. [PMID: 23103800 DOI: 10.1016/j.juro.2012.10.056] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 10/16/2012] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- João A Barbosa
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts 02115, USA.
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Affiliation(s)
- Anthony M Cox
- Department of Ear Nose and Throat Surgery, St Mary's Hospital, London W2 1NY.
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Clinical predictors of testicular torsion in children. Urology 2012; 79:670-4. [PMID: 22386422 DOI: 10.1016/j.urology.2011.10.041] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 10/21/2011] [Accepted: 10/21/2011] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To distinguish the prognostic factors that decrease the probability of a negative exploration for "acute scrotum." In some institutes, patients with "acute scrotum" undergo immediate exploration after clinical evaluation. Because testicular torsion (TT) accounts only for a fraction of these cases, most infants can be treated conservatively. METHODS We performed a retrospective study of all patients treated at our institute from January 2008 to December 2009 for the diagnosis of "acute scrotum." Differences between groups were calculated using the chi-square test or analysis of variance and Mann-Whitney-Wilcoxon test for univariate or multivariate analysis, expressed as odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS The data from 138 patients were analyzed. The mean age was 9 years, 8 months. Of the 138 patients, 19 (13.8%) had TT. This group was compared with the boys without TT at exploration. The patients with TT were older on average (11 years, 1 month vs 9 years, 1 month, p = .035). Pain for <24 hours (OR 4.2, 95% CI 1.3-13.4), nausea and/or vomiting (OR 21.6, 95% CI 4.9-93.4), abnormal cremasteric reflex (OR 4.8 95% CI 0.7-35.2), and a high position of the testis (OR 18.0 95% CI 1.8-177.1) were associated with an increased likelihood of torsion. In the group of boys with ≥ 2 of these findings present, 100% had TT at exploration, with 0% false-positive results. CONCLUSION TT is uncommon among the group of boys treated for "acute scrotum." In particular, a pain duration <24 hours, nausea or vomiting, a high position of the testis, and an abnormal cremasteric reflex had a positive prognostic value for TT. A clinical score might help to avoid unnecessary explorations. In the future, we intend to test the diagnostic set described combined with ultrasonography.
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Spermatic cord knot: a clinical finding in patients with spermatic cord torsion. Adv Urol 2011; 2011:310123. [PMID: 22190915 PMCID: PMC3235495 DOI: 10.1155/2011/310123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2011] [Revised: 10/05/2011] [Accepted: 10/05/2011] [Indexed: 11/17/2022] Open
Abstract
Pertinent history taking and careful examination often taper the differentials of the acute scrotum; congruently the ability to diagnose acute spermatic cord torsion (SCT) when radiological adjuncts are not available is highly imperative. This observational study serves to present a series of 46 cases of spermatic cord torsion whereby we hypothesize the identification of a clinical knot on scrotal examination as an important clinical aid in making a decision to surgical exploration in patients with acute and subacute SCT, especially in centers where imaging resources are unavailable.
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Mäkelä E, Lahdes-Vasama T, Ryymin P, Kähärä V, Suvanto J, Kangasniemi M, Kaipia A. Magnetic Resonance Imaging of Acute Scrotum. Scand J Surg 2011; 100:196-201. [DOI: 10.1177/145749691110000311] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Aims: The aim of the pilot study was to evaluate the feasibility of dynamic contrast enhanced (CE)-magnetic resonance imaging (MRI) in the detection of testicular ischemia and its ability to differentiate testicle torsion from other causes of acute scrotum. Material and Methods: Seventeen boys or young men with an acute scrotum were included in the prospective study during the time period from October 2001 to December 2005. The median age of the patients was 16,4 (7–44) years. The duration of the symptoms preceding the MRI study varied from six hours to 30 days. The study protocol included physical examination by a surgeon, laboratory tests and Doppler ultrasound (DUS) and finally testicles were imaged by using a 1,5 T MRI scanner; T1-weighted and diffusion weighted images were produced. The gadolinium uptake, reported as the region of interest (ROI) perfusion values and presented as curves, was compared between the affected and contralateral testicle. In testicles with normal blood circulation the ROI values increased during the imaging time. Nine patients were operated on, because the spermatic cord torsion could not be excluded by clinical or DUS findings. Results and Conclusions: All the normal testicles gave increasing ROI values meanwhile all three testicles with torsion gave constantly low values referring to no perfusion. Other causes of acute scrotum, such as epididymitis and torsion of testicular appendage seemed to be related with normal perfusion. Dynamic CE-MRI seems to show reliably ischemia of testicle and thus it may be helpful in selecting patients with acute scrotum for urgent operation.
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Affiliation(s)
- E. Mäkelä
- Paediatric Research Centre, Department of Pediatric Surgery, Tampere University Hospital, Tampere, Finland
| | - T. Lahdes-Vasama
- Paediatric Research Centre, Department of Pediatric Surgery, Tampere University Hospital, Tampere, Finland
| | - P. Ryymin
- Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - V. Kähärä
- Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - J. Suvanto
- Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - M. Kangasniemi
- Department of Radiology, Helsinki University Hospital, Helsinki, Finland
| | - A. Kaipia
- Department of Urology, Tampere University Hospital, Tampere, Finland
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Srinivasan A, Cinman N, Feber KM, Gitlin J, Palmer LS. History and physical examination findings predictive of testicular torsion: an attempt to promote clinical diagnosis by house staff. J Pediatr Urol 2011; 7:470-4. [PMID: 21454130 DOI: 10.1016/j.jpurol.2010.12.010] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 12/11/2010] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To standardize the history and physical examination of boys who present with acute scrotum and identify parameters that best predict testicular torsion. MATERIALS AND METHODS Over a 5-month period, a standardized history and physical examination form with 22 items was used for all boys presenting with scrotal pain. Management decisions for radiological evaluation and surgical intervention were based on the results. Data were statistically analyzed in correlation with the eventual diagnosis. RESULTS Of the 79 boys evaluated, 8 (10.1%) had testicular torsion. On univariate analysis, age, worsening pain, nausea/vomiting, severe pain at rest, absence of ipsilateral cremaster reflex, abnormal testicular position and scrotal skin changes were statistically predictive of torsion. After multivariate analysis and adjusting for confounding effect of other co-existing variables, absence of ipsilateral cremaster reflex (P < 0.001), nausea/vomiting (P < 0.05) and scrotal skin changes (P < 0.001) were the only consistent predictive factors of testicular torsion. CONCLUSION An accurate history and physical examination of boys with acute scrotum should be primary in deciding upon further radiographic or surgical evaluation. While several forces have led to less consistent overnight resident staffing, consistent and reliable clinical evaluation of the acute scrotum using a standardized approach should reduce error, improve patient care and potentially reduce health care costs.
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Affiliation(s)
- Arun Srinivasan
- Division of Pediatric Urology, Cohen Children's Medical Center of New York, North Shore-Long Island Jewish Health System, Long Island, Lake Success, NY 11042, USA
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Sinikumpu JJ, Serlo W. Persistent scrotal pain and suspected orchido-epididymitis of a young boy during pinworm (Enterobius vermicularis) infection in the bowel. Acta Paediatr 2011; 100:e89-90. [PMID: 21272069 DOI: 10.1111/j.1651-2227.2011.02177.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM Pinworm (Enterobius vermicularis) is the most common parasite among mankind. Ectopic pinworm infections in number of organs are broadly reported. The aim of this report is to review the pinworm infection in the scrotum on the basis of our case. METHODS AND RESULTS Our patient is a young boy with persistent pain in the scrotums together with abdominal symptoms. He underwent several urgent operations. Pinworm was finally found in appendix vermiformis. We hypothesize that concurrent unresponsive orchido-epididymitis was caused by pinworm as well. Eradication happened finally with pyvrinembonate. CONCLUSION Pinworm is a parasite that lives usually in the bowel. Many ectopic locations, like scrotum, are known. Orchido-epididymitis by pinworm has to be kept in mind when treating boys with persistent scrotal pain.
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Affiliation(s)
- J-J Sinikumpu
- Division of pediatric surgery, Department of Children and Adolescence, Oulu University Hospital, Oulu, Finland.
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Abstract
OBJECTIVES To determine the percentage of cases of epididymitis in pediatric patients that is of bacterial cause and to identify factors that predict a positive urine culture. METHODS We conducted a retrospective chart review of patients diagnosed with acute epididymitis or epididymo-orchitis in 1 pediatric emergency department for 11 years. Charts were reviewed for historical, physical, laboratory, and radiologic data. A positive urine culture was used to identify patients with a bacterial cause of epididymitis. RESULTS A total of 160 patient records were initially identified as having a diagnosis of epididymitis; of these, 20 met exclusion criteria or did not have records available for review and 140 cases of epididymitis were reviewed. Patients' age ranged from 2 months to 17 years, with a median age of 11 years. Of these patients, 91% received empiric antibiotic therapy. Also, of these patients, 97 (69%) had a urine culture sent, of whom 4 (4.1%; 95% confidence interval, 1.1%-10.2%) were positive. Of the 4 positive urine cultures, 3 had organisms not sensitive to usual empiric therapy for urinary tract infections. The boys with positive urine cultures were not significantly different from the other patients in age, maximum temperature, or number of white blood cells on urinalysis. CONCLUSIONS Given the low incidence of urinary tract infections in boys with epididymitis, in prepubertal patients, antibiotic therapy can be reserved for young infants and those with pyuria or positive urine cultures. Because it is difficult to predict which patients will have a positive urine culture, urine cultures should be sent on all pediatric patients with epididymitis.
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Graham SM, Gatti JM. Painful testicle in a young boy. CMAJ 2010; 182:1543-4. [PMID: 20501782 DOI: 10.1503/cmaj.090499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Stephen M Graham
- Department of Urology, University of Kansas Medical Center, Kansas City, USA
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Beni-Israel T, Goldman M, Bar Chaim S, Kozer E. Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med 2010; 28:786-9. [PMID: 20837255 DOI: 10.1016/j.ajem.2009.03.025] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2009] [Accepted: 03/31/2009] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The aim of the study was to identify clinical findings associated with increased likelihood of testicular torsion (TT) in children. DESIGN This study used a retrospective case series of children with acute scrotum presenting to a pediatric emergency department (ED). RESULTS Five hundred twenty-three ED visits were analyzed. Mean patient age was 10 years 9 months. Seventeen (3.25%) patients had TT. Pain duration of less than 24 hours (odds ratio [OR], 6.66; 95% confidence interval [CI], 1.54-33.33), nausea and/or vomiting (OR, 8.87; 95% CI, 2.6-30.1), abnormal cremasteric reflex (OR, 27.77; 95% CI, 7.5-100), abdominal pain (OR, 3.19; 95% CI, 1.15-8.89), and high position of the testis (OR, 58.8; 95% CI, 19.2-166.6) were associated with increased likelihood of torsion. CONCLUSIONS Testicular torsion is uncommon among pediatric patients presenting to the ED with acute scrotum. Pain duration of less than 24 hours, nausea or vomiting, high position of the testicle, and abnormal cremasteric reflex are associated with higher likelihood of torsion.
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Affiliation(s)
- Tali Beni-Israel
- Pediatric Emergency Unit, Assaf Harofeh Medical Center, Sackler School of Medicine, Tel Aviv University, Zerifin 70300, Israel
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Waldert M, Klatte T, Schmidbauer J, Remzi M, Lackner J, Marberger M. Color Doppler sonography reliably identifies testicular torsion in boys. Urology 2009; 75:1170-4. [PMID: 19913882 DOI: 10.1016/j.urology.2009.07.1298] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2009] [Revised: 07/18/2009] [Accepted: 07/31/2009] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To compare the results of preoperative scrotal color Doppler ultrasonography (CDS) and final diagnosis of subsequent surgical exploration in cases of suspected testicular torsion (TT). METHODS This retrospective study included 298 boys with acute scrotum whose clinical presentation was suspicious of TT and who subsequently underwent emergency surgery regardless of CDS results. RESULTS Mean patient age was 11.4 +/- 4.1 years. The mean time of duration of symptoms up to surgical exploration was 26.4 +/- 37.3 hours. All patients had standardized CDS of the scrotum. At surgery, 62 boys (20.9%) were diagnosed with TT, 168 (56.4%) with torsion of a testicular appendage (TA), and 24 (8.1%) with epididymitis. In 34 patients (11.4%), the cause of pain could not be identified during surgery. Overall CDS sensitivity, specificity, positive predictive value, and negative predictive value for TT diagnosis was 96.8%, 97.9%, 92.1%, and 99.1%, respectively. The mean age for the occurrence of TA and TT was 11.2 and 13.4 years, respectively (P <.0001). The peak incidence of TT was between age 14 and 16. Boys with TT sought medical attention statistically significantly earlier than those with TA or epididymitis obviously because of more severe pain (P <.0001). At the time of exploration for TT the affected testicle could be preserved in 32 boys (85.5%). In the remaining 9 boys the testis was considered nonviable and removed. CONCLUSIONS About 20% of boys presenting with an acute scrotum actually have TT. CDS is a reliable tool to identify TT.
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Affiliation(s)
- Matthias Waldert
- Department of Urology, Medical University of Vienna, Vienna, Austria.
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Klotz A, Moormann O. [Special pain conditions in urology. Summary, literature review and suggestions]. Urologe A 2009; 48:1170, 1172-4. [PMID: 19777203 DOI: 10.1007/s00120-009-2037-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The diagnosis of acute or chronic pain syndromes of the urogenital system can be verified and successfully treated by exact exploration of the patients medical history, the physical examination and a few image-guided or laboratory analyses Pain conditions which remain of unknown etiology even after extensive investigations are difficult to treat by the urologist alone. In cases where no causally determined morphological changes can be found or the alteration is disproportionate to the discomfort sensed by the patient, a multidisciplinary therapy strategy offers an approach to find a solution.
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Affiliation(s)
- A Klotz
- Paracelsus-Klinik Golzheim, Düsseldorf.
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Lyronis ID, Ploumis N, Vlahakis I, Charissis G. Acute scrotum -etiology, clinical presentation and seasonal variation. Indian J Pediatr 2009; 76:407-10. [PMID: 19205631 DOI: 10.1007/s12098-009-0008-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Accepted: 06/30/2008] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of the present study was to evaluate the etiology, history, physical examination findings, and seasonal variation of acute scrotal problems in children. METHODS A retrospective review of all boys, presenting with acute scrotum to the Pediatric Surgery Clinic of the University Hospital Heraklion between January 1989 and December 2006 was performed. RESULTS A total of 140 boys presented with scrotal pain were included. Overall the commonest cause of acute scrotum was epididymo-orchitis (35%, 95%CI: 27%-43%), followed by torsion of appendages. In contrast the most common cause in boys of preschool age was spermatic cord torsion (P<0.020). All cases of spermatic cord torsion were characterized by severe testicular pain and an absent cremasteric reflex. The interval between pain initiation and presentation to our clinic was 11.4 hours (SD:3.07) when the testis was salvaged by detorsion, and 19.0 hours (SD:6.32) when the testis was removed. The difference between means was statistical significant (p<0.001). The incidence of torsion of appendages (p<0.036) and/or spermatic cord (p<0.047) was increased in winter. CONCLUSION The absence of cremasteric reflex in association with testicular tenderness strongly suggests testicular torsion. The low temperatures during winter may account for the increased incidence of the torsion of both the spermatic cord torsion and the appendages.
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