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Whitesell RT, Brunner JF, Collins HR, Sheafor DH. Qualitative and quantitative spermatic cord abnormalities at CT predict symptomatic scrotal pathology. Abdom Radiol (NY) 2024; 49:2049-2059. [PMID: 38517545 PMCID: PMC11213788 DOI: 10.1007/s00261-024-04251-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/10/2024] [Accepted: 02/12/2024] [Indexed: 03/24/2024]
Abstract
PURPOSE To evaluate quantitative and qualitative spermatic cord CT abnormalities and presence of unilateral or bilateral symptomatic scrotal pathology (SSP) at ultrasound. METHODS This retrospective study included 122 male patients (mean age 47.8 years) undergoing scrotal ultrasound within 24 h of contrast-enhanced CT (n = 85), non-contrast CT (NECT, n = 32) or CT-Urogram (n = 5). CECT quantitative analysis assessed differential cord enhancement using maximum Hounsfield unit measurements. Three fellowship trained body radiologists independently assessed qualitative cord abnormalities for both CECT and NECT. Qualitative and quantitative findings were compared with the presence of SSP. Reader performance, interobserver agreement and reader confidence were assessed for NECT and CECT. Quantitative cutoff points were identified which maximized accuracy, specificity, negative predictive value, and other measures. RESULTS SSP was present in 36/122 patients (29.5%). Positive cases were unilateral in 30 (83.3%) and bilateral in 6 (16.6%). At quantitative assessment, 25% differential cord enhancement had the highest diagnostic accuracy (88.9%), with 90.5% positive predictive value, 88.4% negative predictive value, 96.8% specificity, and 70.4% sensitivity. At qualitative evaluation, CECT reader performance was excellent (aggregate AUC = 0.86; P < .001); NECT was poorly discriminatory, although remained significant (aggregate AUC = 0.67; P = .002). Readers had significantly higher confidence levels with CECT (P < .001). Qualitative inter-observer agreement was high for both CECT and NECT (ICC = 0.981 and 0.963, respectively). CONCLUSION Simple quantitative assessment of differential cord enhancement is highly accurate and specific for SSP at CECT. Qualitative abnormalities at CECT and NECT are also both predictors of SSP, however, CECT significantly out-performs non-contrast exams.
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Affiliation(s)
| | - John F Brunner
- Midwest Radiology, 2355 Highway 36 West, Roseville, MN, USA
| | - Heather R Collins
- Department of Radiology, Medical University of South Carolina, Charleston, SC, USA
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2
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Wunsch R. [Ultrasound imaging of the testes in children and adolescents]. RADIOLOGIE (HEIDELBERG, GERMANY) 2024; 64:35-44. [PMID: 37853238 DOI: 10.1007/s00117-023-01220-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Ultrasound, the imaging method of choice to evaluate abnormalities of the testes and the scrotum, provides accurate anatomic details and allows the assessment of perfusion using color Doppler and power Doppler. Ultrasound represents a rapid and reliable procedure which in most cases leads to a conclusive diagnosis. DIFFERENTIAL DIAGNOSIS The three most common conditions in the clinical picture of acute scrotum are testicular torsion, torsion of the testicular appendages and inflammatory changes of the testis and the epididymis (epididymo-orchitis). Especially in the case of testicular torsion, rapid diagnosis is essential since time is an important factor to initiate organ-preserving therapy. EQUIPMENT TECHNOLOGY High-frequency linear array transducer (at least 10 MHz), which allows detection of slow flow rates, is recommended.
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Affiliation(s)
- R Wunsch
- Klinik für Radiologie, Kinderradiologie und Nuklearmedizin, St. Elisabeth Gruppe GmbH, Katholische Kliniken Rhein-Ruhr, Marienhospital Witten, Marienplatz 2, 58452, Witten, Deutschland.
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3
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Madsen SMD, Rawashdeh YF. Assessing timeline delays associated with utilization of ultrasound diagnostics in paediatric acute scrotum, pre and per COVID-19 pandemic. J Pediatr Urol 2023; 19:653.e1-653.e7. [PMID: 37544787 DOI: 10.1016/j.jpurol.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/29/2023] [Accepted: 07/07/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION Acute scrotum is a common presentation in the pediatric population and can indicate serious conditions such as testicular torsion, in which quick diagnosis and treatment is crucial for increasing the chances of a favorable outcome. During the COVID-19 pandemic, even patients with serious conditions, had delayed presentations and in-hospital management, resulting in worse outcomes. OBJECTIVE The aim of the study was to evaluate the safety of ultrasound in diagnosing pediatric acute scrotum and to identify delays from onset of symptoms until surgical exploration. Additionally, we wanted to gauge the impact of COVID-19 pandemic on delay and outcome. METHODS Medical records of patients aged 1-16 years seen with acute scrotum at the authors' University Hospital from 2017 to 2020 were reviewed, and 438 patients in 467 individual visits were included. Information on demographics, symptoms, ultrasound results, outcome, and time courses were retrieved and analyzed with regards to outcome and the presence COVID-19. RESULTS We did not find the use of ultrasound to increase the risk of orchiectomy (OR 2.259 (0.387-13.195)), however patients undergoing ultrasound had a significantly longer pre-hospital ischemia time, and therefore an increased orchiectomy rate. Delay between referral and presentation was the greatest predictor of orchiectomy in testicular torsion (OR 1.031 (1.003-1.060)), while in-hospital delay did not increase the risk of orchiectomy (OR 0.998 (0.992-1.004)). Time courses and outcome did not significantly differ before- and during the COVID-19 pandemic. DISCUSSION The primary contributor to ischemic time in testicular torsion was pre-hospital delay, and neither in-hospital delay nor the delay incurred by use of ultrasound affected the outcome. This might be explained by timely in-hospital management and ultrasound only being used selectively in patients with a lower clinical suspicion of testicular torsion and in those with prolonged symptom duration. During the COVID-19 pandemic, pre- and in-hospital delay as well as outcome did not differ significantly from pre-pandemic measures, which indicates that parents felt safe approaching the healthcare system, and resources were sufficient to handle this patient group in spite of an ongoing pandemic. The current study is limited by its retrospective design, and relatively small group of testicular torsion patients. CONCLUSION We found ultrasound to be safe in diagnosing pediatric acute scrotum. Furthermore, it can be inferred that measures aimed at reducing pre-hospital delay could potentially increase the salvage rate in testicular torsion. We did not find COVID-19 to affect either outcome or time to treatment in testicular torsion.
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Affiliation(s)
- Stine M D Madsen
- Department of Urology, Aarhus University Hospital, Aarhus, Denmark.
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4
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Yen CW, Chang YJ, Ming YC, Gau CC, Wu CT, Lee J. Factors Determining Testicular Torsion and Consequent Orchiectomy in Pediatric Patients Presenting With Scrotal Pain. Pediatr Emerg Care 2023; 39:744-750. [PMID: 37624776 PMCID: PMC10547102 DOI: 10.1097/pec.0000000000003037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Abstract
OBJECTIVE Factors associated with testicular torsion (TT) and consequent orchiectomy in patients presenting to pediatric emergency departments (PEDs) with scrotal pain (SP) are not well described. We report the factors predicting TT and consequent orchiectomy in children with SP. METHODS The data on patients (aged ≤18 years) who presented with SP to PEDs at 4 branches of the Chang Gung Hospital through 10 years were analyzed. RESULTS In all, 256 pediatric patients presented with SP. Their mean age was 11.60 ± 4.61 years and 72.7% (n = 186) were aged 10 to 18 years. The pain was left-sided in 54.7% (n = 140) and the interval between SP onset and PED arrival was 22.45 ± 31.27 hours. Overall, 84 (32.8%) patients needed surgery and 72 (28.1%) had TT. Of the patients with TT, 28 (38.9%) patients needed an orchiectomy. After analysis, TT and consequent orchiectomy were associated with a longer interval between SP onset and PED arrival, absent of testicular ultrasonic blood flow, interval between SP onset and surgery of more than 24 hours, and a high degree of TT. None of them experienced recurrent SP symptoms or TT again. CONCLUSIONS The rate of TT in patients presenting to PEDs with an SP was 28.1%, and 38.9% of the patients with TT needed an orchiectomy. Early diagnosis and intervention helped to prevent subsequent orchiectomy in pediatric patients with TT.
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Affiliation(s)
- Chen-Wei Yen
- From the Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yi-Jung Chang
- Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yung-Ching Ming
- Division of Pediatric Surgery, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chun-Chun Gau
- Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan
| | - Chang-Teng Wu
- From the Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jung Lee
- From the Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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5
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Ezzahi M, Malih SE, Ennasery Z, Boumahdi N, Akammar A, Bouardi NE, Haloua M, Alami B, Lamrani MYA, Maaroufi M, Bouabdallah Y, Boubbou M. Neglected trauma-induced testicular torsion: Clinical, sonographic, and surgical correlation in a 13-year-old adolescent. Radiol Case Rep 2023; 18:3457-3462. [PMID: 37502489 PMCID: PMC10369384 DOI: 10.1016/j.radcr.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 07/03/2023] [Indexed: 07/29/2023] Open
Abstract
Post-traumatic testicular torsion is a rare condition, accounting for approximately 4%-8% of all reported cases of testicular torsion in the literature. Prompt clinical suspicion and intervention are crucial; as testicular torsion is considered a medical and surgical emergency that may lead to testicular necrosis. Ultrasound imaging plays an important role in assessing the integrity of the traumatized scrotum and facilitating early detection of associated testicular torsion. In this case report, we present a neglected post-traumatic testicular torsion in a 13-year-old child that led to orchiectomy.
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Affiliation(s)
- Manar Ezzahi
- Department of Mother and Child Radiology, CHU Hassan II Fez, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | - Sara El Malih
- Department of Mother and Child Radiology, CHU Hassan II Fez, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | - Zaid Ennasery
- Department of Mother and Child Radiology, CHU Hassan II Fez, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | - Naoufal Boumahdi
- Department of Pediatric Surgery, CHU Hassan II Fez, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | - Amal Akammar
- Department of Mother and Child Radiology, CHU Hassan II Fez, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | - Nizar El Bouardi
- Department of Adult Radiology, CHU Hassan II Fez, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | - Meriem Haloua
- Department of Mother and Child Radiology, CHU Hassan II Fez, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | - Badreeddine Alami
- Department of Adult Radiology, CHU Hassan II Fez, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | | | - Mustapha Maaroufi
- Department of Adult Radiology, CHU Hassan II Fez, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | - Youssef Bouabdallah
- Department of Pediatric Surgery, CHU Hassan II Fez, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | - Meryem Boubbou
- Department of Mother and Child Radiology, CHU Hassan II Fez, Sidi Mohammed Ben Abdellah University, Fez, Morocco
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6
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Yu B, Meng M, Qin R, Xu Q, Zhang N, Fu N. Case Report: A testicular torsion as an initial presentation of a patient with metastatic cecum signet-ring cell cancer. Front Oncol 2023; 13:1189552. [PMID: 37746291 PMCID: PMC10515214 DOI: 10.3389/fonc.2023.1189552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/23/2023] [Indexed: 09/26/2023] Open
Abstract
Secondary neoplasms of the testes from solid tumors are rare and usually present as a painless mass. Metastatic cecum signet-ring cell cancer of the testis is extremely rare. The orchioncus usually shows hypervascularity on color Doppler ultrasound. The present study reports an unusual case of testicular secondary signet-ring cell carcinoma mimicking missed testicular torsion in a 55-year-old male patient with right scrotal swelling and intermittent pain for 10 days. As color Doppler ultrasound showed an avascular distribution of the enlarged right testis, missed testicular torsion was initially diagnosed. Right-sided orchiectomy was performed, and pathology of the resected testis revealed an intestinal-type adenocarcinoma with mucinous and signet-ring cell features. This pathological feature led to further endoscopic colorectal biopsy of the digestive tract, which revealed poorly differentiated adenocarcinoma of the cecum with signet ring cell features similar to those of testicular specimens. In conclusion, differential diagnosis should be considered for rare testicular neoplasms, as was seen in this rare occurrence of testicular torsion in a patient who initially presented with metastatic colorectal cancer. A correct preoperative diagnosis can change the management and outcome. This report shares our reasons for misdiagnosis and opinions on diagnosing and treating this kind of case.
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Affiliation(s)
- Bo Yu
- Department of Urology, The Second Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Mi Meng
- Department of Oncology, The Second Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Rui Qin
- Department of Urology, The Second Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Qiang Xu
- Department of Urology, The Second Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Neng Zhang
- Department of Urology, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Ni Fu
- Department of Urology, The Second Affiliated Hospital of Zunyi Medical University, Zunyi, China
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7
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Ultrasound Guidelines: Emergency, Point-of-Care, and Clinical Ultrasound Guidelines in Medicine. Ann Emerg Med 2023; 82:e115-e155. [PMID: 37596025 DOI: 10.1016/j.annemergmed.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 08/20/2023]
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8
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Yang Q, Yang L, Peng C, Zhu X, Wu Z, Huang L, Luo Y. Testicular torsion diagnosis and injury assessment using photoacoustic oxygenation imaging. PHOTOACOUSTICS 2023; 31:100499. [PMID: 37180959 PMCID: PMC10172716 DOI: 10.1016/j.pacs.2023.100499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 05/16/2023]
Abstract
Testicular torsion (TT) is a medical emergency that requires immediate diagnostic evaluation. Photoacoustic imaging (PAI) has the potential to provide spatially resolved oxygen saturation (sO2), which can serve as a valuable marker in TT diagnosis. We investigated the potential of PAI as an alternative method for TT diagnosis and testicular injury assessment. We measured sO2 levels in different degrees of TT models using PAI at various time points. Based on histopathological results, we found that the averaged sO2 per pixel (sO2®) and reduction of sO2® (rsO2) in twisted testicles had significant correlations with hypoxic conditions. Both sO2® and rsO2 exhibited excellent diagnostic abilities in detecting TT and identifying ischemia/hypoxia injury following TT. Furthermore, PAI-measured sO2 demonstrated favorable diagnostic capabilities in discriminating if the testicle had suffered irreversible injury. In summary, PAI presents a potentially promising novel approach in evaluating TT and warrants further clinical investigation.
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Affiliation(s)
- Qianru Yang
- Department of Ultrasound, West China Hospital/West China School of Medicine, Sichuan University, Chengdu 610041, People's Republic of China
| | - Lulu Yang
- Department of Ultrasound, West China Hospital/West China School of Medicine, Sichuan University, Chengdu 610041, People's Republic of China
| | - Chihan Peng
- Department of Ultrasound, West China Hospital/West China School of Medicine, Sichuan University, Chengdu 610041, People's Republic of China
| | - Xiaoxia Zhu
- Department of Ultrasound, West China Hospital/West China School of Medicine, Sichuan University, Chengdu 610041, People's Republic of China
| | - Zhenru Wu
- Institute of Clinical Pathology, Key Laboratory of Transplant Engineering and Immunology, NHC, West China Hospital, Sichuan University, Chengdu 610041, People's Republic of China
| | - Lin Huang
- School of Electronic Science and Engineering, University of Electronic Science and Technology of China, Chengdu 611731, People’s Republic of China
- Corresponding authors.
| | - Yan Luo
- Department of Ultrasound, West China Hospital/West China School of Medicine, Sichuan University, Chengdu 610041, People's Republic of China
- Corresponding authors.
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Lukosiute-Urboniene A, Nekrosius D, Dekeryte I, Kilda A, Malcius D. Clinical risk factors for testicular torsion and a warning against falsely reassuring ultrasound scans: a 10-year single-centre experience. Emerg Med J 2023; 40:134-139. [PMID: 36526335 DOI: 10.1136/emermed-2021-211946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 12/03/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND We sought to determine which demographic, clinical and ultrasonography characteristics are predictive of testicular torsion (TT) and to determine factors associated with time to treatment. METHODS We retrospectively reviewed all medical records of patients (0-17 years) with acute scrotal syndrome (ASS) who were treated in our hospital in Lithuania between 2011 and 2020. We extracted patients' demographic data, in-hospital time intervals, clinical, US and surgical findings. TT was determined at surgery or clinically after manual detorsion. Test characteristics of demographic, clinical and US findings for the diagnosis of TT versus other causes of ASS were determined. We performed a multivariate analysis to identify independent clinical predictors of torsion, and factors associated with surgical delay. RESULTS A search of medical records yielded 555 cases: 196 (35%) patients with TT and 359 (65%) patients with other ASS causes. Multivariate logistic regression analysis showed that age between 13 and 17 years (OR 8.39; 95% CI 5.12 to 13.76), duration of symptoms <7 hours (OR 3.41; 95% CI 2.03 to 5.72), palpated hard testis (OR 4.65; 95% CI 2.02 to 10.67), scrotal swelling (OR 2.37; 95% CI 1.31 to 4.30), nausea/vomiting (OR 4.37; 95% CI 2.03 to 9.43), abdominal pain (OR 2.38; 95% CI 1.27 to 4.45) were independent clinical predictors of TT. No testicular blood flow in Doppler US had a specificity of 98.2% and a positive predictive value of 94.6%. However, 75 (41.7%) patients with TT had normal testicular blood flow, yielding low sensitivity (58.3%) and negative predictive value of 81.3% for this US finding. In-hospital waiting time for surgery was longer in patients with TT with normal testicular blood flow by USS (195 min) compared with no blood flow (123 min), p<0.01. Higher orchiectomy rates were associated with longer duration of symptoms (p<0.001) and longer waiting time for USS (p=0.029) but not with false-negative US. CONCLUSIONS Pubertal age, symptoms duration of <7 hours, nausea/vomiting, palpated hard testis, abdominal pain and scrotal swelling are predictive factors for TT. Time lost between symptom onset and seeking medical care, and between arrival and US are associated with the need for orchiectomy. Preserved blood flow in USS does not rule out TT and may contribute to delays to surgery.
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Affiliation(s)
- Ausra Lukosiute-Urboniene
- Department of Pediatric Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Department of Pediatric Surgery, Lithuanian University of Health Sciences Hospital Kauno klinikos, Kaunas, Lithuania
| | - Deividas Nekrosius
- Department of Pediatric Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Department of Pediatric Surgery, Lithuanian University of Health Sciences Hospital Kauno klinikos, Kaunas, Lithuania
| | - Inga Dekeryte
- Department of Pediatric Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Department of Pediatric Surgery, Lithuanian University of Health Sciences Hospital Kauno klinikos, Kaunas, Lithuania
| | - Arturas Kilda
- Department of Pediatric Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Department of Pediatric Surgery, Lithuanian University of Health Sciences Hospital Kauno klinikos, Kaunas, Lithuania
| | - Dalius Malcius
- Department of Pediatric Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Department of Pediatric Surgery, Lithuanian University of Health Sciences Hospital Kauno klinikos, Kaunas, Lithuania
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10
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Mori T, Ihara T, Nomura O. Diagnostic accuracy of point-of-care ultrasound for paediatric testicular torsion: a systematic review and meta-analysis. J Accid Emerg Med 2023; 40:140-146. [PMID: 35523539 DOI: 10.1136/emermed-2021-212281] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 04/24/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Previous studies have examined the utility of ultrasonography performed by radiologists for diagnosing paediatric testicular torsion. While point-of-care ultrasound (POCUS) is used in paediatric emergency medicine, its diagnostic accuracy is still unknown. OBJECTIVES The present systematic review and meta-analysis aimed to clarify the accuracy of POCUS in diagnosing testicular torsion in children. METHODS Following the Preferred Reporting Items for Systematic Review and Meta-analysis of Diagnostic Test Accuracy guidelines, a systematic review was performed using the indices of MEDLINE, EMBASE plus EMBASE classics, PubMed and the Cochrane database from inception to November 2020. Any study investigating the diagnostic accuracy of POCUS for paediatric testicular torsion was extracted. The primary outcome was the assessment of the diagnostic accuracy of POCUS for paediatric testicular torsion. The pooled sensitivity and specificity were calculated. Quality analysis was conducted using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). RESULTS Four studies enrolling 784 patients in total were included. The pooled sensitivity, specificity, and positive and negative likelihood ratios of POCUS were 98.4% (95% CI: 88.5% to 99.8%), 97.2% (95% CI: 87.2% to 99.4%), 34.7 (95% CI: 7.4 to 164.4) and 0.017 (95% CI: 0.002 to 0.12), respectively. Risk-of-bias assessment using QUADAS-2 revealed that two of the studies had a high risk of bias in patient selection. CONCLUSION The present systematic review and meta-analysis showed that POCUS had high sensitivity and specificity for identifying testicular torsion in paediatric patients although the risk of bias was high in the studies analysed.
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Affiliation(s)
- Takaaki Mori
- Division of Pediatric Emergency Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan .,Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
| | - Takateru Ihara
- Division of Pediatric Emergency Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Osamu Nomura
- Department of Emergency and Disaster Medicine, Hirosaki University, Hirosaki, Japan
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11
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Hasan O, Al Rashed AA, Isa QM, Awad N. Testicular Germ Cell Tumor Presenting as Torsion in a Young Patient. Cureus 2022; 14:e27506. [PMID: 36060396 PMCID: PMC9426637 DOI: 10.7759/cureus.27506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2022] [Indexed: 11/26/2022] Open
Abstract
Testicular torsion is a relatively common urological emergency, which involves the twisting of the spermatic cord and its contents leading to ischemia to the testes, which usually presents as sudden, severe scrotal pain. In comparison, testicular neoplasms are far less commonly encountered in the emergency department as they often present as painless hard masses that grow slowly over longer periods of time. Extremely rare cases of testicular neoplasms present as sudden scrotal pain that causes a challenging task in the emergency department as physical examinations and ultrasound findings could vary and not be specific enough in confirming the diagnosis. In this case, we report a 22-year-old male who was referred from the emergency department (ED) as a case of testicular torsion from the presenting history; however, his physical examination and Doppler ultrasound findings were suspicious of testicular malignancy. The patient presented with a history of right scrotal pain for a few hours with no predisposing factors; however, examination and imaging were highly suspicious of an underlying neoplasm. The patient underwent an inguinal orchidectomy, and histology confirmed the presence of a germ cell tumor of varying components. In conclusion, a high index of suspicion for testicular torsion should always be present when a patient presents with sudden onset testicular pain; however, the differential diagnosis including testicular neoplasms should not be overlooked as it can change the management and outcome.
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12
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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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13
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Davenport M, Coles V, Murphy F, Yardley I, Hallows R. Response to commentary to 'The acute scrotum in infancy: A retrospective regional study'. J Pediatr Urol 2022; 18:233-234. [PMID: 34799239 DOI: 10.1016/j.jpurol.2021.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Mark Davenport
- Departments of Paediatric Surgery, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
| | - Vanessa Coles
- Departments of Paediatric Surgery, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
| | - Feilim Murphy
- St George's University Hospital, Tooting, London, SW17 0QT, UK.
| | - Iain Yardley
- The Evelina London Children's Hospital, Lambeth, London, SE1 7EH, UK.
| | - Ruth Hallows
- Brighton Children's Hospital, Brighton, BN2 5BE, UK.
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Sintim-Damoa A, Cohen HL. Pearls and Pitfalls of Pediatric Scrotal Imaging. Semin Ultrasound CT MR 2022; 43:115-129. [PMID: 35164905 DOI: 10.1053/j.sult.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Ultrasonography (US) is the primary imaging modality for the evaluation of pediatric scrotal disease. The ability to obtain exceptional anatomical detail and testicular perfusion information without ionizing radiation makes it the essential tool for evaluating scrotal pain and palpable masses. Challenges arise in both the performance and interpretation of scrotal US in the child. Optimizing imaging parameters and recognizing key differentiating US features help minimize misinterpretations that can lead to poor patient outcomes. Key pearls and pitfalls in pediatric scrotal ultrasound methods and diagnoses are reviewed. Knowledge of what is normal for the various ages of childhood from neonate through adolescence is necessary for accurate US analysis. Imaging evaluation of key causes of the acute painful scrotum including testicular appendage torsion, epididymitis, and testicular torsion are discussed. Sonographic features for the diagnosis of benign and malignant scrotal masses, microlithiasis, and cryptorchidism are reviewed.
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Affiliation(s)
- Akosua Sintim-Damoa
- Department of Radiology, LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Harris L Cohen
- Department of Radiology, LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN.
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15
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Smith T, Gross CL, Ryan M, Hwang CW. A rare case of bilateral testicular torsion in a 57-year-old man. J Am Coll Emerg Physicians Open 2021; 2:e12545. [PMID: 34553190 PMCID: PMC8443216 DOI: 10.1002/emp2.12545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/11/2021] [Accepted: 08/10/2021] [Indexed: 11/30/2022] Open
Abstract
CONTEXT Testicular torsion, the twisting of the testis or spermatic cord, places the testis at risk of vascular compromise and is a surgical emergency. Testicular torsion is predominantly unilateral (98% of torsion cases) and primarily affects neonates and adolescents in a bimodal distribution. Bilateral testicular torsion is exceedingly rare (2% of cases) and is associated with neonates. To the authors' best knowledge, there have been no reports of bilateral torsion in adult males over the age of 24. CASE DETAILS A 57-year-old man presented to the emergency department 9 days after developing testicular pain while lifting his lawnmower. Ultrasonography performed at an outside facility was unremarkable. He was encouraged to followup with urology as an outpatient. Despite outpatient analgesia, he continued to experience pain and returned to the ED, where repeat ultrasonography demonstrated bilateral torsion with hypoperfusion. DISCUSSION Although testicular torsion is uncommon, the clinician must recognize torsion; if left untreated, torsion leads to infertility. Previous publications suggest that ultrasonographic findings of bilateral testicular torsion should be attributed to "technical failure" rather than a plausible diagnosis. However, this case demonstrates the importance of maintaining a high index of suspicion, especially with an atypical age range and pathological presentation, particularly among men during their reproductive years.
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Affiliation(s)
- Tierra Smith
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | | | - Matthew Ryan
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Charles W. Hwang
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
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Visalli C, Vinci SL, Mondello S, Kobeissy F, Salamone I, Coglitore A, Trimarchi R, Tessitore A, Impellizzeri P, Mormina E. Microvascular imaging ultrasound (MicroV) and power Doppler vascularization analysis in a pediatric population with early scrotal pain onset. Jpn J Radiol 2021; 40:192-201. [PMID: 34515926 DOI: 10.1007/s11604-021-01194-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 09/01/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The power Doppler is a useful tool in the evaluation of pediatric acute scrotal pain. Nonetheless, it may have some inherent limitations in scrotal vascularization analysis, potentially causing unnecessary surgery. The microvascular imaging ultrasound (MicroV) is an innovative Doppler technique able to improve the detection of very low flow. This retrospective study aims to compare both power Doppler and MicroV in the evaluation of a pediatric population with early-stage scrotal pain onset, first in testis vascularization analysis, and second in their diagnostic performances. MATERIALS AND METHODS 69 patients met the following inclusion criteria, age < 18-year-old, a clinical diagnosis of acute scrotal disease, pain onset ≤ 6 h, ultrasound examination (including B-mode, power Doppler, and MicroV), 3-months follow-up. For both power Doppler and MicroV, through a defined vascularization scale, it was evaluated the agreement in vascularization detection, and the sensitivity and specificity in US diagnostic abilities. RESULTS Retrospective diagnoses were of 8 testicular torsion, 15 orchi-epididymitis, and 46 children with other scrotal conditions. Power Doppler provided inconclusive US evaluation in 37.68% of the cases, while MicroV only in the 1.45% (p < 0.0001). Testicular torsion and orchi-epididymitis were identified, respectively, with MicroV in 100% (sensitivity, specificity, PPV, NPV, and accuracy of 100%) and 80% of patients (80% sensitivity, 100% specificity and PPV, 94.73% NPV, 95.65% accuracy); with power Doppler the identification was, respectively, of 87.5% (87.5% sensitivity, 100% specificity and PPV, 98.38% NPV and accuracy) and of 73.3% (73.33% sensitivity, 98.14% specificity, 91.66% PPV, 92.98% NPV, 92.75% accuracy). CONCLUSIONS Our findings indicate that MicroV is a reliable technique in vascularization detection of pediatric testes, being able also to detect vascularization in healthy testicles with no-flow at power Doppler examination. Moreover, MicroV could be a valuable ally in the US diagnostic of children with early-stage scrotal pain onset.
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Affiliation(s)
- Carmela Visalli
- Department of Biomedical and Dental Sciences and of Morphofunctional Imaging, University of Messina, AOU Policlinico Universitario "G. Martino", Via Consolare Valeria 1, 98122, Messina, Italy
| | - Sergio Lucio Vinci
- Department of Biomedical and Dental Sciences and of Morphofunctional Imaging, University of Messina, AOU Policlinico Universitario "G. Martino", Via Consolare Valeria 1, 98122, Messina, Italy
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and of Morphofunctional Imaging, University of Messina, AOU Policlinico Universitario "G. Martino", Via Consolare Valeria 1, 98122, Messina, Italy
| | - Firas Kobeissy
- Department of Psychiatry and Neuroscience, McKnight Brain Institute, University of Florida, Gainesville, FL, USA.,Department of Biochemistry and Molecular Genetics, American University of Beirut, Beirut, Lebanon
| | - Ignazio Salamone
- Department of Biomedical and Dental Sciences and of Morphofunctional Imaging, University of Messina, AOU Policlinico Universitario "G. Martino", Via Consolare Valeria 1, 98122, Messina, Italy
| | - Alessandra Coglitore
- Department of Biomedical and Dental Sciences and of Morphofunctional Imaging, University of Messina, AOU Policlinico Universitario "G. Martino", Via Consolare Valeria 1, 98122, Messina, Italy.
| | - Renato Trimarchi
- Department of Biomedical and Dental Sciences and of Morphofunctional Imaging, University of Messina, AOU Policlinico Universitario "G. Martino", Via Consolare Valeria 1, 98122, Messina, Italy
| | - Agostino Tessitore
- Department of Biomedical and Dental Sciences and of Morphofunctional Imaging, University of Messina, AOU Policlinico Universitario "G. Martino", Via Consolare Valeria 1, 98122, Messina, Italy
| | - Pietro Impellizzeri
- Department of Human Pathology in Adults and Developmental Age, Division of Pediatric Surgery, University of Messina, Messina, Italy
| | - Enricomaria Mormina
- Department of Biomedical and Dental Sciences and of Morphofunctional Imaging, University of Messina, AOU Policlinico Universitario "G. Martino", Via Consolare Valeria 1, 98122, Messina, Italy
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17
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Kim MJ, Lee YH, Kim YR. Unusual Presentation of a Testicular Lymphoma Mimicking a Missed Testicular Torsion: A Case Report. TAEHAN YONGSANG UIHAKHOE CHI 2021; 82:1287-1291. [PMID: 36238396 PMCID: PMC9432361 DOI: 10.3348/jksr.2020.0167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 12/15/2020] [Accepted: 02/01/2021] [Indexed: 11/17/2022]
Abstract
Testicular lymphoma is an uncommon testicular tumor that usually presents as a painless mass. It usually shows hypervascularity on color Doppler ultrasound (US) and a mild enhancement on enhanced CT or MRI. We present an unusual case of a testicular lymphoma mimicking a missed testicular torsion in a 67-year-old male patient with right scrotal swelling and intermittent pain for 2 months. Color Doppler US demonstrated the absence of vascularity in the enlarged right testis, and the initial diagnosis was a missed testicular torsion. CT demonstrated a poorly enhancing mass rather than a missed testicular torsion with enhanced small nodular foci at the periphery. The final pathological diagnosis was testicular lymphoma.
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18
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Spaziani M, Lecis C, Tarantino C, Sbardella E, Pozza C, Gianfrilli D. The role of scrotal ultrasonography from infancy to puberty. Andrology 2021; 9:1306-1321. [PMID: 34048149 PMCID: PMC8596602 DOI: 10.1111/andr.13056] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/16/2021] [Accepted: 05/24/2021] [Indexed: 01/11/2023]
Abstract
Background Scrotal ultrasonography is an essential diagnostic tool in daily clinical practice. The availability of new‐generation ultrasound machines characterized by clearly improved image quality, low health cost, and higher patient safety, represents only some characteristics of ultrasound investigation. The usefulness of scrotal ultrasonography is particularly evident in the period of life from infancy to puberty, during which males undergo important morphofunctional changes, and several pathological conditions may occur. Objectives This pictorial review primarily aimed to investigate the aspects of ultrasonography related to the normal physiological development of the gonads from mini‐puberty to pubertal onset. This study also aimed to provide an update on the use of ultrasonography in main andrological pathologies that may occur during this period. The conditions that are discussed in depth are: cryptorchidism, inguinoscrotal hernias, and hydrocele in the neonatal phase; acute scrotum, epididymo‐orchitis, and testicular cancers in childhood; and hypogonadism, varicoceles, testicular microlithiasis, and oncohematological pathology in puberty. Discussion We provided an ultrasound slant for all the above‐mentioned pathologies while purposely avoiding excessive deepening of the pathogenetic, clinical, and therapeutic aspects. Studying the ultrasound aspects of the gonads also facilitates differential diagnosis between various conditions and represents a good aid in evaluating therapeutic success (e.g., in hypogonadism or postsurgical evaluation of varicoceles and cryptorchidism). Conclusion Scrotal ultrasonography is now globally recognized as the necessary completion of clinical–laboratory overview in gonads evaluation. This diagnostic procedure is even more indispensable in the infancy–childhood–puberty period for the evaluation of normal gonadal development as well as diagnosis of other possible diseases.
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Affiliation(s)
- Matteo Spaziani
- Section of Medical Pathophysiology and Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.,Centre for Rare Diseases, Policlinico Umberto I, Rome, Italy
| | - Claudio Lecis
- Section of Medical Pathophysiology and Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Chiara Tarantino
- Section of Medical Pathophysiology and Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.,Centre for Rare Diseases, Policlinico Umberto I, Rome, Italy
| | - Emilia Sbardella
- Section of Medical Pathophysiology and Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.,Centre for Rare Diseases, Policlinico Umberto I, Rome, Italy
| | - Carlotta Pozza
- Section of Medical Pathophysiology and Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Daniele Gianfrilli
- Section of Medical Pathophysiology and Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
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19
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AIUM Practice Parameter for the Performance of Scrotal Ultrasound Examinations. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:E30-E33. [PMID: 33660888 DOI: 10.1002/jum.15667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 06/12/2023]
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20
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Gkantseva-Patsoura S, Katsaras G, Georgiadou P, Lainakis N, Liovarou E, Theofanopoulos R, Theodoraki M. Idiopathic scrotal hematoma in a neonate. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2021; 19:Doc01. [PMID: 33642965 PMCID: PMC7894276 DOI: 10.3205/000288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background: Neonatal scrotal hematoma is considered a surgical emergency in the neonatal period. Up to recently, immediate surgical exploration was considered the gold standard for the diagnosis and treatment in the underlying causes. Objective: In this article, we present a case of idiopathic scrotal hematoma in a neonate. Method: It was managed conservatively with clinical and ultrasonographic follow-up. Result: The hematoma had gradually subsided, and any surgical intervention was avoided to the neonate. Conclusion: With good clinical and imaging follow-up, some cases could be managed nonoperatively.
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Affiliation(s)
| | - George Katsaras
- Paediatric Department, General Hospital of Pella - Hospital Unit of Edessa, Greece
| | - Petroula Georgiadou
- Neonatal Intensive Care Unit, General State Hospital of Nikaia "Agios Panteleimon", Piraeus, Greece
| | - Nikolaos Lainakis
- Paediatric Surgery Department, General State Hospital of Nikaia "Agios Panteleimon", Piraeus, Greece
| | - Eirini Liovarou
- Radiology Department, General State Hospital of Nikaia "Agios Panteleimon", Piraeus, Greece
| | - Rita Theofanopoulos
- Neonatal Intensive Care Unit, General State Hospital of Nikaia "Agios Panteleimon", Piraeus, Greece
| | - Martha Theodoraki
- Neonatal Intensive Care Unit, General State Hospital of Nikaia "Agios Panteleimon", Piraeus, Greece
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21
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McLaren PSM. A systematic review on the utility of ultrasonography in the diagnosis of testicular torsion in acute scrotum patients. Radiography (Lond) 2021; 27:943-949. [PMID: 33451883 DOI: 10.1016/j.radi.2020.12.012] [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: 09/26/2020] [Revised: 12/18/2020] [Accepted: 12/26/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Ultrasound is a valuable tool in establishing the cause of acute scrotum pain. However, its role in testicular torsion (TT) detection remains controversial. This review aims integrate pre-existing data to assess the value of B-mode and colour Doppler ultrasound (CDS) features combined in the detection of TT in acute scrotum pain patients of all ages. METHODS A search through electronic databases, grey literature and hand searching using specific search terms was conducted to identify relevant literature. Search results were subjected to a three-step selection process to ensure the inclusion criteria of this review were met. Statistical data pertaining to the accuracy, sensitivity, and specificity of the B-mode, CDS and combined B-mode CDS features were extracted. These results subsequently underwent a narrative analysis. RESULTS Five studies met the inclusion criteria. A variety of B-mode features were identified. Most studies showed that reliance on CDS alone can be prone to false-negative results. The combination of B-mode and CDS features were found to increase the overall sensitivity of ultrasound towards TT (up to 100% in 3 studies). All studies recommended correlation with clinical examination findings. Several limitations in methodology of the included studies were noted: small sample populations and lack of information on the experience of ultrasound practitioners. This highlighted the need for a primary study with a larger sample population to validate the findings of this review. CONCLUSION The combination of B-mode and CDS ultrasound is a useful and reliable triage tool in the detection of TT, particularly in equivocal or low suspicion cases but its findings should always be adjunct with clinical examination. Nevertheless, it is noted that appropriate service level agreements, pathways, and training are key factors in ensuring effectiveness of the process. IMPLICATIONS FOR PRACTICE Dedicated training and appropriate departmental protocol are key in ensuring accurate diagnosis across all levels of practice.
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Affiliation(s)
- P S M McLaren
- Royal Victoria Infirmary, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Queen Victoria Road, NE1 4LP, Newcastle upon Tyne, United Kingdom.
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22
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Vasconcelos-Castro S, Flor-de-Lima B, Campos JM, Soares-Oliveira M. Manual detorsion in testicular torsion: 5 years of experience at a single center. J Pediatr Surg 2020; 55:2728-2731. [PMID: 32169343 DOI: 10.1016/j.jpedsurg.2020.02.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 01/25/2020] [Accepted: 02/19/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Testicular torsion is one of the most common causes of acute scrotum in pediatric age. The present study aimed to evaluate the role of preoperative manual detorsion in the management of testicular torsion. METHODS Retrospective data analysis of pediatric patients treated for acute testicular torsion at a tertiary center over the last 5 years. Manual detorsion was attempted by surgeon's preference. Successful manual detorsion was defined as complete pain resolution with a normal color Doppler ultrasound. All patients underwent surgical exploration. Patient data analyzed included: age, pain duration, site of onset, attempt of manual detorsion, pain relief after manual detorsion, color Doppler ultrasound results, surgical findings and outcome. RESULTS One hundred twenty-two patients were included. Manual detorsion was attempted in 48% (58/122) cases. Manual detorsion was successful in 26% (15/58) patients. In the unsuccessful, residual cord torsion was found at surgery in 27.5% (16/58); in the remaining 27, there was no cord torsion at surgery. Five patients (5/15) with successful manual detorsion underwent elective orchiopexy. Gonadal loss after manual detorsion (9%, 5/58) occurred after unsuccessful manual detorsion, all submitted to emergency surgery. CONCLUSIONS Testicular torsion warrants prompt detorsion. Manual detorsion is simple, immediately available, and maximizes testis salvage. A successful maneuver permits nonemergency orchiopexy. An algorithm for the management of testicular torsion that includes an attempt of manual detorsion prior to surgery is proposed. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Sofia Vasconcelos-Castro
- Department of Pediatric Surgery, Centro Hospitalar Universitário São João, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal.
| | - Beatriz Flor-de-Lima
- Department of Radiology, Centro Hospitalar Universitário São João, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
| | - José Miguel Campos
- Department of Pediatric Surgery, Centro Hospitalar Universitário São João, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Miguel Soares-Oliveira
- Department of Pediatric Surgery, Centro Hospitalar Universitário São João, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal; Faculty of Medicine, Universidade do Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
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23
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Elifranji M, Elawad A, Stafrace S, Salle JLP, Vallasciani S. Segmental Testicular Infarction Associated to Torsion: First Case Report in Childhood. Urology 2020; 149:227-229. [PMID: 32791290 DOI: 10.1016/j.urology.2020.07.056] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/13/2020] [Accepted: 07/20/2020] [Indexed: 11/29/2022]
Abstract
Testicular torsion in children is not uncommon emergency problem which occur due to twist in the spermatic cord leading to ischemia or infarction to testicle. Hemorrhagic infarction can occur following testicular torsion is globally; however, in extremely rare situation, such infarction can be segmental. Segmental testicular infarction (STI) was reported in an infant due to epididymitis and a newborn with STI in 1 testicle with complete infarction in the contralateral testicle due to birth trauma. To best of our knowledge, our case of STI in a child associated with testicular torsion is the first described in the literature.
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Affiliation(s)
- Mohammed Elifranji
- Division of Pediatric Urology, Department of Surgery, Sidra Medical and Research Center, Doha, Qatar.
| | - Abubakr Elawad
- Division of Pediatric Urology, Department of Surgery, Sidra Medical and Research Center, Doha, Qatar
| | - Samuel Stafrace
- Department of Pediatric Radiology, Sidra Medical and Research Center, Doha, Qatar
| | - Joao Luiz Pippi Salle
- Division of Pediatric Urology, Department of Surgery, Sidra Medical and Research Center, Doha, Qatar
| | - Santiago Vallasciani
- Division of Pediatric Urology, Department of Surgery, Sidra Medical and Research Center, Doha, Qatar
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Acute scrotal pain in pediatric patients: diagnosis with an innovative Doppler technique (MicroV). Emerg Radiol 2020; 28:209-214. [PMID: 32591921 DOI: 10.1007/s10140-020-01812-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 06/19/2020] [Indexed: 10/24/2022]
Abstract
Acute scrotal pain is one of the most frequent symptoms in pediatric patients visited in the Emergency Department. Ultrasonography with color and power Doppler represents the first-line method that clinicians use to carry out the differential diagnosis between spermatic cord torsion and inflammation, but sensitivity and specificity are 63-100% and 97-100%, respectively; this variability may be related to operator's experience and testis vascular hemodynamics and also to machine performance and patient age. Recent technological innovations have made possible to create a new Doppler mode called ultrasound microvascular imaging. This technique exploits algorithms capable of separating low frequencies of static tissue artifacts from ones of very weak flows. It is known as MicroV (from Esaote) and Superb microvascular imaging (from Toshiba). It provides both macrocirculation vascular maps, as a typical Doppler feature, and microcirculation vascular maps. Furthermore, the use of background subtraction could improve the visibility of small vascular structures. We report a case of a pediatric patient suffering from acute scrotal pain assessed ultrasonographically with this innovative Doppler technique (MicroV) that may give more confidence in detecting testicular vascular signals if compared with traditional Doppler techniques.
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25
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Sengul G, Ertekin C. Human cremaster muscle and cremasteric reflex: A comprehensive review. Clin Neurophysiol 2020; 131:1354-1364. [DOI: 10.1016/j.clinph.2020.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 02/28/2020] [Accepted: 03/09/2020] [Indexed: 11/28/2022]
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26
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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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27
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Song SH, Afşarlar ÇE, Xie HW, Hung AJ, Koh CJ. Estimating the time of onset of testicular torsion using ultrasonography in an experimental rat model. Ultrasonography 2020; 39:152-158. [PMID: 32098458 PMCID: PMC7065987 DOI: 10.14366/usg.19055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/04/2020] [Indexed: 11/05/2022] Open
Abstract
Purpose We aimed to document the time of onset of ultrasonographic and histologic changes in the testes of a rat model following testicular torsion. Methods Twenty-five Sprague-Dawley rats were divided into four groups. All animals underwent preoperative Doppler ultrasonography. Groups 1, 2, and 3 underwent unilateral surgical torsion of the testis lasting for 72, 24, and 6 hours, respectively. Group 4 underwent a sham operation. The animals were followed with Doppler ultrasonography at 6, 24, 48, and 72 hours postoperatively. Histologic examinations were performed at the designated final time point for each group. Results After torsion, enlargement of the epididymal head and thickening of the spermatic cord over time were noted. Based on the ultrasonographic dimensions,
the ratio of the epididymal volume increased with time following torsion (p=0.002). The torsed testes had an average weight gain of 0.27 g at 6 hours compared to the control testes, but an average weight loss of 0.22 g at 72 hours (P=0.006). Changes in testicular echotexture were noted as soon as 6 hours after torsion, but there was no consistent pattern of echotexture change thereafter. Histologically, viable tubules were seen 6 hours after torsion, while extensive hemorrhagic necrosis was found at 72 hours. Conclusion In evaluating testicular torsion, the enlargement ratio of the epididymis and thickening of the spermatic cord on Doppler ultrasonography may be useful for determining the urgency of immediate surgery. Changes in testicular echotexture may not be a reliable indicator of the time of onset.
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Affiliation(s)
- Sang Hoon Song
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, USA.,Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA.,Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Çağatay E Afşarlar
- Department of Pediatric Surgery, Faculty of Medicine, Hitit University, Corum, Turkey
| | - Hui Wen Xie
- Division of Pediatric Urology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Andrew J Hung
- University of Southern California (USC) Institute of Urology, Keck School of Medicine, USC, Los Angeles, CA, USA
| | - Chester J Koh
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, USA.,Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
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Tanaka K, Ogasawara Y, Nikai K, Yamada S, Fujiwara K, Okazaki T. Acute scrotum and testicular torsion in children: a retrospective study in a single institution. J Pediatr Urol 2020; 16:55-60. [PMID: 31874735 DOI: 10.1016/j.jpurol.2019.11.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 11/20/2019] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Testicular torsion (TT), as per the reported incidences in children and preadolescents, is an emergency medical condition that requires prompt surgical treatment. In cases of TT, early and accurate diagnosis of acute scrotum (AS) is important to preserve testicular fertility. In this study, the authors aimed to determine the incidence, clinical examination, etiology, clinical predictors, and treatment of patients with AS and TT. MATERIAL AND METHODS The authors retrospectively reviewed all children (age, ≤15 years) with AS who visited their hospital between January 2012 and June 2019. Data on age and diagnosis, clinical findings, mode of treatment, and blood examination results were collected. RESULTS The authors examined 165 children aged between 0 days and 15 years (mean age, 9.4 years). Final diagnosis identified 72 patients with torsion of the appendix testis, 44 patients with epididymitis, and 38 patients with TT. Testes were salvaged in 23 of the 38 patients with TT (60.5%). Statistically significant variables revealed that the risk factors of TT were age (older than 12 years), white blood cell (WBC) count (>12,000 cells/mm3), and laterality (left side). The level of C-reactive protein (CRP), duration of symptoms, and degree of torsion were significantly higher in the non-salvageable testis group than in the salvageable testis group. Furthermore, the significant predictive factor for non-salvageable testis was the level of CRP >1.0 mg/dl. CONCLUSION The study results indicates that age, WBC count, and laterality are key factors to distinguish TT from AS. Salvageability largely depended on the duration of symptoms and the degree of TT. The salvage rate of the testis can be improved by educating pediatricians, parents, patients, and medical staff about the early diagnosis and treatment of torsion.
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Affiliation(s)
- Keiichiro Tanaka
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, 2-1-1, Tomioka, Urayasu-shi, Chiba, 279-0021, Japan.
| | - Yuki Ogasawara
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, 2-1-1, Tomioka, Urayasu-shi, Chiba, 279-0021, Japan
| | - Koki Nikai
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, 2-1-1, Tomioka, Urayasu-shi, Chiba, 279-0021, Japan
| | - Shunsuke Yamada
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, 2-1-1, Tomioka, Urayasu-shi, Chiba, 279-0021, Japan
| | - Kentaro Fujiwara
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, 2-1-1, Tomioka, Urayasu-shi, Chiba, 279-0021, Japan
| | - Tadaharu Okazaki
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, 2-1-1, Tomioka, Urayasu-shi, Chiba, 279-0021, Japan
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Klinke M, Elrod J, Stiel C, Ghadban T, Wenskus J, Herrmann J, Junge CM, Reinshagen K, Boettcher M. The BAL-Score Almost Perfectly Predicts Testicular Torsion in Children: A Two-Center Cohort Study. Front Pediatr 2020; 8:601892. [PMID: 33365292 PMCID: PMC7750324 DOI: 10.3389/fped.2020.601892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/17/2020] [Indexed: 12/02/2022] Open
Abstract
Introduction: Testicular torsion (TT) is a common emergency that warrants immediate exploration to prevent infertility or testicular loss. To improve diagnostic reliability, various scoring systems have been published. The aim of this study was to evaluate and validate different testicular torsion scores in a large cohort of children with acute scrotum. Methods: Retrospective analysis of all male children that were admitted for acute scrotum at the Pediatric Surgery Department of the Altonaer Kinderkrankenhaus and University medical Center Hamburg-Eppendorf from 01/2013 to 03/2019. Two testicular torsion scores (Boettcher Alert Score, Testicular Workup for Ischemia and Suspected Torsion Score) were applied to all data sets. Furthermore, an artificial intelligence (AI)-based score was developed and compared to the two current scores. Results: In total, 460 boys were included in the study. Of those, 48 (10.4%) had TT. Children with TT suffered most often from short duration of pain, nausea and vomiting, high riding testicle and absent cremasteric reflex. The BALS and the AI-based score had excellent predictive values and all patients with TT would have been detected. Conclusion: The BAL and the AI score show excellent predictive capabilities and may be used to identify all cases of TT in a pediatric population. The scores are easy to apply. As the BALS was slightly better, we advocate to use this score but to validate our findings in prospective multicenter studies.
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Affiliation(s)
- Michaela Klinke
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Elrod
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carolin Stiel
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tarik Ghadban
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Wenskus
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jochen Herrmann
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Section of Pediatric Radiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carl-Martin Junge
- Department of Pediatric Radiology, Altonaer Kinderkrankenhaus, Hamburg, Germany
| | - Konrad Reinshagen
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Boettcher
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Abstract
CLINICAL/METHODICAL ISSUE Acute, non-traumatic abdominal pain is one of the main reasons for medical consultation in pediatric patients. Knowledge of different diseases and their age dependence is essential for correct diagnosis and treatment. STANDARD RADIOLOGICAL METHODS Ultrasonography is the imaging method of choice. X‑ray is only used in case of emergency, e. g., suspected perforation. METHODICAL INNOVATIONS Contrast-enhanced ultrasonography (CEUS) and elastography complement ultrasonography. PERFORMANCE Magnetic resonance imaging is of increasing relevance for differential diagnosis of unclear sonographic results. PRACTICAL RECOMMENDATIONS The primary imaging modality in pediatric patients is ultrasonography. Cross-sectional imaging should only be used in cases of unclear sonographic findings.
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Affiliation(s)
- P C Krüger
- Sektion Pädiatrische Radiologie, Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| | - H J Mentzel
- Sektion Pädiatrische Radiologie, Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland.
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Chan EP, Wang PZT, Myslik F, Chen H, Dave S. Identifying systems delays in assessment, diagnosis, and operative management for testicular torsion in a single-payer health-care system. J Pediatr Urol 2019; 15:251.e1-251.e7. [PMID: 31005635 DOI: 10.1016/j.jpurol.2019.03.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/21/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Testicular torsion (TT) is a common pediatric urologic emergency. Management of TT is time sensitive and often confirmed on scrotal Doppler ultrasound (DUS). Acquiring DUS, however, can result in delays in the management of TT, affecting testicular salvage rates. OBJECTIVE The objective of this study is to identify delays in the assessment and diagnosis for patients presenting with TT to a Canadian academic hospital using patient flow analysis. STUDY DESIGN A retrospective review was performed for patients presenting to the emergency department (ED) who received a scrotal DUS to rule out possible TT between 2012 and 2017. The primary outcome measured cycle-time measurements (median time) between points along the clinical flow pathway for a patient with suspected TT. The secondary outcome assessed diagnostic sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of standard scrotal DUS components (Doppler flow, arterial waveform, heterogeneous echotexture). RESULTS A total of 609 patients presented with an acute scrotum warranting a scrotal DUS to rule out TT; of which, 46 underwent scrotal exploration. Testicular salvage rate was 82.6% in the series (38 testes salvaged, 8 required orchiectomy). Median time from symptom onset to ED presentation for patients with possible TT was 4 h. After triage, a median of 79.8 min was required for ED physician assessment and an additional 48 min for scrotal DUS to be performed. Absence of Doppler flow on scrotal DUS had a 97.4% PPV for diagnosing TT confirmed during scrotal exploration. DISCUSSION Almost 4 h of in-ED time is required from triage to surgical intervention for potential TT at the institution. One area of delay is the time needed to conduct a scrotal DUS (48-128 min; Fig. 1). This represents an area of opportunity for patient flow optimization through the use of standardized clinical pathways and diagnostic adjuncts, such as point-of-care ultrasound. This study is limited in its retrospective nature and does not include patients with overt signs of TT who underwent surgical detorsion without need for scrotal DUS. CONCLUSION Patient flow delays to surgical intervention for patients with TT represent a preventable cause of orchiectomy in young men. This study identifies intervention points in patient-care flow pathways where delays to surgical intervention can be potentially reduced by up to 2 h. The findings support the need for further studies into the optimization of patient flow and management protocols to reduce delays in the diagnosis and management of TT.
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Affiliation(s)
- E P Chan
- Department of Surgery, Division of Urology, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - P Z T Wang
- Department of Surgery, Division of Urology, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Department of Surgery, Division of Paediatric Surgery, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - F Myslik
- Department of Medicine, Division of Emergency Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - H Chen
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - S Dave
- Department of Surgery, Division of Urology, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Department of Surgery, Division of Paediatric Surgery, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.
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Wang CL, Aryal B, Oto A, Allen BC, Akin O, Alexander LF, Bardo DM, Chong J, Froemming AT, Fulgham PF, Heller MT, Maranchie JK, Mody RN, Patel BN, Schieda N, Turkbey IB, Venkatesan AM, Yoo DC, Lockhart ME. ACR Appropriateness Criteria® Acute Onset of Scrotal Pain-Without Trauma, Without Antecedent Mass. J Am Coll Radiol 2019; 16:S38-S43. [DOI: 10.1016/j.jacr.2019.02.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 10/26/2022]
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Abbas TO, Abdelkareem M, Alhadi A, Kini V, Chandra P, Al-Ansari A, Ali M. Suspected testicular torsion in children: diagnostic dilemma and recommendation for a lower threshold for initiation of surgical exploration. Res Rep Urol 2018; 10:241-249. [PMID: 30584529 PMCID: PMC6287511 DOI: 10.2147/rru.s186112] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Testicular torsion (TT) represents a clinical challenge that needs emergency surgical assessment. It is common to have negative scrotal exploration due to confounding symptoms and signs which makes it sometimes difficult to differentiate from similar surgical emergencies that do not warrant surgery. At the same time, several occasions of misdiagnoses or late interventions occur with devastating effects. We aim at delineating the significance of the different clinical, laboratory, and radiological variables in the detection of TT. Methods We retrospectively reviewed the charts of 52 patients who were surgically explored with a preoperative working diagnosis of suspected TT in our center over the period from 2011 to 2015. All the patients were examined by pediatric surgeons in the emergency room and had undergone ultrasound imaging of the testes. The ultrasound images were retrospectively reviewed by a pediatric radiologist who was blinded to the intraoperative findings. Univariate and multivariate and logistic regression analyses were performed. Results Of the studied group of patients, the majority (84.6%) had TT upon surgical exploration. The most frequently presented symptom was pain (80.8%), and only a minority (11.5%) presented with vomiting. Radiological findings with the highest sensitivity were heterogeneous echogenicity in favor of TT and enlarged epididymis indicating that TT is unlikely. However, the predictability of TT by any of the assessed clinical and imaging factors was statistically insignificant. Conclusion It is important to gather all relevant data from clinical, laboratory, and imaging sources when assessing pediatric patients with suspected TT given the inaccuracy of each single one of them if used alone. Keeping this in mind, Doppler ultrasound has a significant role to aid in the accuracy of the diagnosis and hence the appropriate decision-making thereafter. However, we found no single clinical or imaging sign that is sensitive enough to prove or rule out TT. Therefore, surgical exploration should take place in a timely manner. Moreover, further research is necessary to construct scoring systems where different predictors collectively have higher reliability.
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Affiliation(s)
- Tariq O Abbas
- Department of Pediatric Surgery, Hamad General Hospital, Doha, Qatar, .,College of Medicine, Qatar University, Doha, Qatar, .,Weill Cornell Medical College-Qatar, Doha, Qatar,
| | | | | | | | - Prem Chandra
- Medical Research Center, Hamad Medical Corporation, Doha, Qatar
| | | | - Mansour Ali
- Department of Pediatric Surgery, Hamad General Hospital, Doha, Qatar,
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Arevalo MK, Sheth KR, Menon VS, Ostrov L, Hennes H, Singla N, Koral K, Schlomer BJ, Baker LA. Straight to the Operating Room: An Emergent Surgery Track for Acute Testicular Torsion Transfers. J Pediatr 2018; 192:178-183. [PMID: 29246339 PMCID: PMC5737783 DOI: 10.1016/j.jpeds.2017.09.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 07/19/2017] [Accepted: 09/07/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the effect of implementing an emergency surgery track for testicular torsion transfers. We hypothesized that transferring children from other facilities diagnosed with torsion straight to the operating room (STOR) would decrease ischemia time, lower costs, and reduce testicular loss. STUDY DESIGN Demographics, arrival to incision time, hospital cost in dollars, and testicular outcome (determined by testicular ultrasound) at follow-up were retrospectively compared in all patients transferred to our tertiary care children's hospital with a diagnosis of testicular torsion from 2012 to 2016. Clinical data for STOR and non-STOR patients were compared by Wilcoxon rank-sum, 2-tailed t test, or Fisher exact test as appropriate. RESULTS Sixty-eight patients met inclusion criteria: 35 STOR and 33 non-STOR. Children taken STOR had a shorter median arrival to incision time (STOR: 54 minutes vs non-STOR: 94 minutes, P < .0001) and lower median total hospital costs (STOR: $3882 vs non-STOR: $4419, P < .0001). However, only 46.8% of STOR patients and 48.4% of non-STOR patients achieved surgery within 6 hours of symptom onset. Testicular salvage rates in STOR and non-STOR patients were not significantly different (STOR: 68.4% vs non-STOR: 36.8%, P = .1), but follow-up was poor. CONCLUSIONS STOR decreased arrival to incision time and hospital cost but did not affect testicular loss. The bulk of ischemia time in torsion transfers occurred before arrival at our tertiary care center. Further interventions addressing delays in diagnosis and transfer are needed to truly improve testicular salvage rates in these patients.
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Affiliation(s)
| | - Kunj R Sheth
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Vani S Menon
- Children’s Health, Dallas, TX,University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Halim Hennes
- Children’s Health, Dallas, TX,University of Texas Southwestern Medical Center, Dallas, TX
| | - Nirmish Singla
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Korgun Koral
- Children’s Health, Dallas, TX,University of Texas Southwestern Medical Center, Dallas, TX
| | - Bruce J Schlomer
- Children’s Health, Dallas, TX,University of Texas Southwestern Medical Center, Dallas, TX
| | - Linda A Baker
- Children’s Health, Dallas, TX,University of Texas Southwestern Medical Center, Dallas, TX
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Manohar CS, Gupta A, Keshavamurthy R, Shivalingaiah M, Sharanbasappa BR, Singh VK. Evaluation of Testicular Workup for Ischemia and Suspected Torsion score in patients presenting with acute scrotum. Urol Ann 2018; 10:20-23. [PMID: 29416270 PMCID: PMC5791452 DOI: 10.4103/ua.ua_35_17] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Testicular torsion is one of the causes of acute scrotum and it requires timely evaluation and surgical treatment. Color Doppler is considered investigation of choice, but it may delay treatment, as, many times, it may not be available for emergency situations. Barbosa et al. created Testicular Workup for Ischemia and Suspected Torsion (TWIST) score based on clinical parameters for clinical diagnosis of testicular torsion. We have evaluated this score in our population. Materials and Methods We retrospectively calculated TWIST score in patients of acute scrotum admitted to tertiary teaching institute. Patients without complete TWIST score were excluded from the study. The scoring system consisted of testicular swelling (2 points), hard testicle (2), absent cremasteric reflex (1), nausea/vomiting (1), and high-riding testis (1). Statistical analysis was done to evaluate the validity of scores. Results A total of 118 patients were included in the study, out of which 45 (38%) patients had testicular torsion. The mean age of patients was 16.6 years in testicular torsion patients and 15.2 years in other patients. Cutoff for low-risk and high-risk patients was two and five, respectively. Fifty percent, 26.2%, and 23.8% of patients were present in low-, intermediate-, and high-risk groups. Negative predictive value of TWIST score for low-risk patients was 96.61% while positive predictive value for high-risk patients was 92.86%. Conclusions TWIST score has high predictive value and can be used for clinical diagnosis of testicular torsion. It can decrease the need of color Doppler in about 50% of cases and can prevent delay in treatment.
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Affiliation(s)
- C S Manohar
- Department of Urology, Institute of Nephrourology, Bengaluru, Karnataka, India
| | - Avneet Gupta
- Department of Urology, Institute of Nephrourology, Bengaluru, Karnataka, India
| | - R Keshavamurthy
- Department of Urology, Institute of Nephrourology, Bengaluru, Karnataka, India
| | - M Shivalingaiah
- Department of Urology, Institute of Nephrourology, Bengaluru, Karnataka, India
| | - B R Sharanbasappa
- Department of Urology, Institute of Nephrourology, Bengaluru, Karnataka, India
| | - Vinish Kumar Singh
- Department of Urology, Institute of Nephrourology, Bengaluru, Karnataka, India
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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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39
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Alkhori NA, Barth RA. Pediatric scrotal ultrasound: review and update. Pediatr Radiol 2017; 47:1125-1133. [PMID: 28779199 DOI: 10.1007/s00247-017-3923-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 06/06/2017] [Indexed: 11/26/2022]
Abstract
In this pictorial essay the authors review the normal sonographic gray-scale and Doppler appearance of the pediatric scrotum with an emphasis on technique. The authors present an update on ultrasound diagnosis and outcomes in testicular torsion and differentiation from other acute scrotal processes, as well as sonographic imaging of testicular microlithiasis and uncommon or atypical scrotal masses including splenogonadal fusion, polyorchidism, meconium peritonitis and epidermoid cyst. Further, the authors discuss testicular neoplasms in the context of testicular microlithiasis.
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Affiliation(s)
- Noor A Alkhori
- Department of Radiology, Stanford University School of Medicine, Lucile Packard Children's Hospital at Stanford, 725 Welch Road, Room 1890, Stanford, CA, 94304-5913, USA
| | - Richard A Barth
- Department of Radiology, Stanford University School of Medicine, Lucile Packard Children's Hospital at Stanford, 725 Welch Road, Room 1890, Stanford, CA, 94304-5913, USA.
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40
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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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Emam MN, Abd El-latif RN. Effect of immunomodulator, fingolimod, on ischemia reperfusion testicular injury in rats: Targeting the role of sphingolipid rheostat (fingolimod on I/R induced testicular injury). ALEXANDRIA JOURNAL OF MEDICINE 2017. [DOI: 10.1016/j.ajme.2016.06.005] [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: 10/21/2022] Open
Affiliation(s)
- Marwa N. Emam
- Physiology Department, Faculty of Medicine, Tanta University, Egypt
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Chang CD, Lin JW, Lee CC, Chen YT, Huang CC, Lee YW, Ng SH, Ko SF. Acute Epididymo-orchitis-Related Global Testicular Infarction: Clinical and Ultrasound Findings With an Emphasis on the Juxta-epididymal String-of-Bead Sign. Ultrasound Q 2017; 32:283-9. [PMID: 27556195 DOI: 10.1097/ruq.0000000000000225] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Acute epididymo-orchitis (AEO)-related global testicular infarction (GTI) is rare. We report herein the clinical and ultrasound findings of 6 patients with AEO-related GTI. Seventeen patients with torsion-related GTI were also reviewed and compared. The echotexture of AEO-related GTI ranged from mildly inhomogeneous to diffuse heteroechoic, depending on the severity of testicular necrotic changes. All of the patients showed a juxta-epididymal string-of-bead pattern on color Doppler ultrasound, which was ascribed to patent arteries (5/6, 87%) and collateral vessels (1/6, 13%) in the tunica albuginea. There were no significant differences in age, laterality, leukocyte count, testicular volume ratio (infarcted/normal), frequencies of heteroechoic testicular parenchyma, scrotal skin thickening, and hydrocele between the 2 groups. However, the left testis was predominantly affected in both groups. Compared with torsion-related GTI, patients with AEO-related GTI had significantly longer duration from scrotal pain onset to surgery (13.5 ± 5.2 vs 2.6 ± 2.0 days, P < 0.001), a higher level of serum C-reactive protein (110.0 ± 82.0 vs 41.2 ± 35.9 mg/dL, P = 0.013), a higher frequency of the juxta-epididymal string-of-bead sign (100% vs 12%, P < 0.001), and a lower frequency of the whirlpool/knot sign (0% vs 88%, P = 0.002). Although the testis in AEO-related GTI may appear variable from mildly to extensively heteroechoic on gray-scale ultrasound, this unusual disease can be characterized by an avascular testis with a juxta-epididymal string-of-bead sign on color Doppler ultrasound.
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Affiliation(s)
- Ching-Di Chang
- *Departments of Radiology and †Pathology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine; ‡Department of Biomedical Engineering, I-Shou University; and §Division of Urology, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China
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43
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Fenton LZ, Karakas SP, Baskin L, Campbell JB. Sonography of pediatric blunt scrotal trauma: what the pediatric urologist wants to know. Pediatr Radiol 2016; 46:1049-58. [PMID: 27112160 DOI: 10.1007/s00247-016-3600-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 02/02/2016] [Accepted: 02/25/2016] [Indexed: 11/28/2022]
Abstract
Pediatric blunt scrotal trauma is most often the consequence of sports injury and presents a diagnostic challenge because swelling and pain make a scrotal physical exam difficult. US with color flow and duplex Doppler is the first-line imaging modality with the goal of accurate and timely diagnosis of injury requiring surgery to preserve fertility and hormonal function. US imaging findings following blunt scrotal trauma include hydrocele, hematocele, testicular hematoma, testicular fracture, testicular rupture, compromised perfusion/testicular torsion and testicular dislocation. Importantly, several of these findings may coexist. Our goal is to present the pertinent intrascrotal anatomy, US imaging findings for each testicular injury, and contemporary management for each, with emphasis on what our pediatric urology colleagues need to know for optimal patient care.
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Affiliation(s)
- Laura Z Fenton
- Department of Pediatric Radiology, Children's Hospital Colorado, affiliated with the University of Colorado School of Medicine, 13123 East 16th Ave., B125, Aurora, CO, 80045, USA.
| | - S Pinar Karakas
- Department of Radiology, UCSF Benioff Children's Hospital, Oakland, CA, USA
| | - Laurence Baskin
- Department of Pediatric Urology, UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Jeffrey B Campbell
- Department of Pediatric Urology, Children's Hospital Colorado, affiliated with the University of Colorado School of Medicine, Aurora, CO, USA
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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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45
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Abstract
Acute abdominal pain in childhood is a frequent reason for a medical consultation. The main diseases that lead to the clinical situation of acute abdomen show a significant age dependency. It is reasonable to group such ailments into three age categories: (1) the neonatal and infant period, (2) toddlerhood to kindergarten and (3) school age children. The task of the pediatric radiological examination is the differential diagnostic correlation of symptoms to the respective diseases. In children ultrasound is the appropriate method of choice.
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Affiliation(s)
- R Wunsch
- Abteilung Radiologie, Sonographie und Magnetresonanztomographie, Vestische Kinder- und Jugendklinik Datteln, Universität Witten/Herdecke, Dr.-Friedrich-Steiner-Str. 5, 45711, Datteln, Deutschland,
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46
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Yu Y, Zhang F, An Q, Wang L, Li C, Xu Z. Scrotal Exploration for Testicular Torsion and Testicular Appendage Torsion: Emergency and Reality. IRANIAN JOURNAL OF PEDIATRICS 2015. [PMID: 26199690 PMCID: PMC4505972 DOI: 10.5812/ijp.248] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Scrotal exploration is considered the procedure of choice for acute scrotum. OBJECTIVES We evaluated the importance of early diagnosis and testicular salvage on the therapeutic outcomes of patients with pediatric testicular torsion (TT) and testicular appendage torsion (TAT) in our geographic area. PATIENTS AND METHODS We performed a retrospective database analysis of patients who underwent emergency surgery for TT or TAT between January 1996 and June 2009. Patient history, physical examination findings, laboratory test results, color Doppler sonography (CDS) results, and surgical findings were reviewed. RESULTS A total of 65 cases were included in our analysis. Forty-two cases were followed up for at least 3 months. Testicular tenderness was identified as the major clinical manifestation of TT, while only a few patients with TAT presented with swelling. CDS was an important diagnostic modality. The orchiectomy rate was 71% in the TT group. CONCLUSIONS Cases of acute scrotum require attention in our area. Early diagnosis and scrotal exploration could salvage the testis or preserve normal function without the need for surgery.
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Affiliation(s)
- You Yu
- Department of Pediatric Surgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Feng Zhang
- Department of Radiation Oncology, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Qun An
- Department of Pediatric Surgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Long Wang
- Department of Pediatric Surgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Chao Li
- Department of Pediatric Surgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Zhilin Xu
- Department of Pediatric Surgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
- Corresponding author: Zhilin Xu, Department of Pediatric Surgery, First Affiliated Hospital of Harbin Medical University, Harbin 150001, China. Tel: +86-45185555139, Fax: +86-45153670428, E-mail:
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47
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Artul S, Fahoum B, Nseir W, Habib G. Testicular Ischemia Due to a Band Around the Spermatic Cord. J Clin Imaging Sci 2015; 5:36. [PMID: 26180659 PMCID: PMC4490577 DOI: 10.4103/2156-7514.157856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 04/29/2015] [Indexed: 11/30/2022] Open
Abstract
We present a case of an 18-year-old boy who was admitted to our hospital with a 2-day history of pain in the right scrotum. Ultrasound examination showed signs of ischemia, with dampened testicular arterial flow and bell-clapper deformity. Surgery revealed a constricting fibrous band around the distal spermatic cord resembling the bell-clapper deformity.
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Affiliation(s)
- Suheil Artul
- Department of Radiology, Nazareth Hospital, Nazareth, Israel ; Department of Medicine, Bar-Ilan University, Safed, Israel
| | - Basel Fahoum
- Department of Urology, Urology Surgery Unit, Nazareth Hospital, Nazareth, Israel
| | - William Nseir
- Department of Medicine, Bar-Ilan University, Safed, Israel ; Department of Medicine, Nazareth Hospital, Nazareth, Israel
| | - George Habib
- Department of Medicine, Nazareth Hospital, Nazareth, Israel
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Agrawal AM, Tripathi PS, Shankhwar A, Naveen C. Role of ultrasound with color Doppler in acute scrotum management. J Family Med Prim Care 2015; 3:409-12. [PMID: 25657954 PMCID: PMC4311353 DOI: 10.4103/2249-4863.148130] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background and Objective: An acute scrotum is defined as acute pain with or without scrotal swelling, may be accompanied by local signs or general symptoms. Acute scrotal pain is a medical emergency. Depending on cause, the management is entirely different. Torsion of testis and strangulated hernia are surgical emergency; whereas, epididymo-orchitis is treated by medicines. Testicular trauma and obstructed hernia can be differentiated by taking history from patient. Physical examination adds only a little information. Color Doppler ultrasound (US) is the modality of choice to differentiate testicular torsion from inflammatory conditions and can thus help in avoiding unnecessary surgical explorations. Subjects and Methods: A study on 50 patients was conducted who were referred with history of acute scrotal pain to our department between January 2013 and January 2014. Trauma and scrotal mass were excluded from the study. The clinical presentation, outcome, and US results were analyzed. Results: Color Doppler sonography yielded a positive and negative predictive value (PPV and NPV) of 100% each for torsion, whereas, 93.9 and 70.6% for epididymo-orchitis, respectively; a sensitivity and specificity of 100% for torsion, whereas, for epididymo-orchitis it was found to be 86.1 and 85.7%, respectively. In cases of incomplete or early torsion, some residual perfusion may be detected leading to false-negative results. Conclusion: We therefore conclude that color Doppler sonography can reliably rule out testicular torsion and can thus help in avoiding unnecessary surgical explorations. Hence, it can significantly improve outcome and decrease morbidity of patient. It is an accurate, rapid, nonexpensive, nonionizing, important adjunct to clinical assessment of scrotum.
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Affiliation(s)
- Alka M Agrawal
- Department of Radiodiagnosis, Mahatma Gandhi Memorial Medical College and Maharaja Yeshwantrao Hospital, Indore, Madhya Pradesh, India
| | - Prem Siddharth Tripathi
- Department of Radiodiagnosis, Mahatma Gandhi Memorial Medical College and Maharaja Yeshwantrao Hospital, Indore, Madhya Pradesh, India
| | - Amit Shankhwar
- Department of Radiodiagnosis, Mahatma Gandhi Memorial Medical College and Maharaja Yeshwantrao Hospital, Indore, Madhya Pradesh, India
| | - C Naveen
- Department of Radiodiagnosis, Mahatma Gandhi Memorial Medical College and Maharaja Yeshwantrao Hospital, Indore, Madhya Pradesh, India
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