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Torsion of the TestisInvitation to Error
Abstract
One hundred forty-eight consecutive cases of scrotal pain and swelling in boys under the age of 16 have been reviewed. Eighty-nine of these suffered from torsion, either of the testis or appendix testis. Similarity in clinical history and physical findings makes differentiation of torsion from epididymo-orchitis difficult. Operation in all appears to be the only safe treatment. Delay in operation is disastrous with no testicular salvage after 24 hours. On the other hand, 17 of 19 operated upon on the day of onset of symptoms had viable testes.
Testicular torsion is a common entity in adolescent males with trauma-induced testicular torsion reported incidence to be around 4-8 %. A 24-year-old boy presented to us with a history of trauma 10 days earlier with right-sided testicular pain. USG shows no flow in right testis though clinically does not look like. 1 Orchidectomy was done. The message is clear that testicular torsion can be due to trauma and the patient should approach the clinician as early as possible.
Objective
To evaluate smartphone thermal imaging as a point of care test in the detection of testicular ischemia. Thermal imaging detects the infrared (heat) pattern of an object and the technology is now available as an inexpensive attachment to smartphones.
Materials and Methods
Smartphone thermal imaging was studied as a point-of-care diagnostic test for testicular ischemia in an IACUC approved study that prioritized survival of all animal subjects. Thirty canines weighing over 12 kg were observed during elective neuter procedures with consent from owners. Randomization determined ligation of the right vs left spermatic cord. With both testicles remaining in the scrotum, blinded inspection was performed with a FLIR ONE Pro thermal imaging camera for smartphone use. The bilateral orchiectomy procedures were then completed as planned.
Results
Within 11 minutes of ligation of the randomized spermatic cord, an obvious change in the thermal imaging pattern allowed for the correct diagnosis of the ischemic testicle in 30/30 (100%) of subjects in a blinded fashion. Temperature differences between testicles at the time of ischemia diagnosis ranged from 0.7o to 3.7°C with an average difference of 1.79°C lower in the ischemic testicle [95% CI: (1.50, 2.08)]. A thermal imaging evaluation of the testicles takes 30 seconds to perform.
Conclusions
Smartphone thermal imaging correctly diagnosed testicular ischemia in 100% of animal subjects in a blinded fashion. The clinical utility of this emerging point-of-care technique in the evaluation of testicular torsion is currently unknown.
We identified factors associated with delay in presentation and misdiagnosis of testicular torsion. Compared with acute cases, delayed presentations were more likely to report isolated abdominal pain, developmental disorders, and history of recent genital trauma. Failure to perform a genitourinary examination or scrotal imaging was associated with misdiagnosis.
Torsion of the testis, also referred to as torsion of the spermatic cord, is a subject of debate among physicians and surgeons. Testicular torsion is an acute vascular event causing the rotation of the vascular pedicle of the testis, thereby impeding the blood flow to the testis and the scrotal contents. It could be either within or outside the tunica vaginalis. Testicular torsion causes immediate circulatory changes and long-term sequelae such as testicular function and fertility. It is considered a surgical emergency, as a delay causes irreversible testicular damage. The diagnosis and treatment of testicular torsion are discussed in this review, which also illustrates an algorithm and a scoring system for the diagnosis and management of this condition based on current literature.
Torsion of the testis, also referred to as torsion of the spermatic cord, is a subject of debate among physicians and surgeons. Testicular torsion is an acute vascular event causing the rotation of the vascular pedicle of the testis, thereby impeding the blood flow to the testis and the scrotal contents. It could be either within or outside the tunica vaginalis. Testicular torsion causes immediate circulatory changes and long-term sequelae such as testicular function and fertility. It is considered a surgical emergency, as a delay causes irreversible testicular damage. The diagnosis and treatment of testicular torsion are discussed in this review, which also illustrates an algorithm and a scoring system for the diagnosis and management of this condition based on current literature.
In this review, long-held myths and misperceptions about the evaluation and management of testicular torsion are discussed, and recommendations for the management of patients who present with acute scrotal pain are presented.
In 15 years at Bristol there have been 293 cases of torsion of the testis, 55 cases of torsion of a testicular appendage and 5 cases of testicular ischaemia due to other causes. The risk of a male developing torsion of the testis or its appendix by the age of 25 is about 1 in 160. Both conditions occurred primarily in adolescents, but among prepubertal boys torsion of an appendage was as common as torsion of a normally descended testis. There was a slight left-sided preponderance in testicular torsion, more marked in torsion of the appendages; the incidence of bilateral torsion was 2.0 and 1.8 per cent respectively.
The clinical features and differential diagnosis of the two conditions are compared. Torsion of a testicular appendage is the most commonly misdiagnosed scrotal lesion, the preoperative diagnosis being correct in only 11 per cent of cases compared with 90 per cent fix torsion of the testis. Twenty-one cases of recurrent torsion underwent prophylactic bilateral orchidopexy. There were 20 cases of torsion of undescended testes, with a salvage rate of only 20 per cent.
The overall testicular survival rate was 55.3 per cent. Viability depends upon the possibility of spontaneous reduction, the preoperative delay after the onset of symptoms, the degree of torsion of the cord and the length of follow-up in doubtful cases. Urgent scrotal exploration is advised in every case of acute testicular pain unless there is overwhelming evidence of epididymo-orchitis. Exploration of' the opposite side is mandatory in torsion of the testis and advisable in torsion of an appendage.
Torsion of the testis remains a clinical diagnosis and confirmatory testing is not required when the classic signs and symptoms are present. Conflicting laboratory data or adjunctive diagnostic studies should not dissuade the surgeon from exploration when the clinical index of suspicion is high. In those patients having equivocal clinical findings when the diagnosis of torsion is not clear-cut radionuclide scrotal imaging may be useful. In this series a negative scrotal scan at the time of acute scrotal pain did predict reliably the diagnosis of non-torsion, suggesting that in the appropriate clinical setting scrotal imaging is useful in avoiding surgical exploration.
In an experimental study on 36 male guinea pigs testicular torsion was induced in 10, epididymitis in 10, surgical trauma in 6 and only ether anaesthesia was given to 10 animals. Serum creatine phosphokinase (CPK) levels at 0, 4, 8, 20, 28 and 40 hours were determined in each group.
Serum CPK levels were found to rise significantly in the torsion group. Determination of serum CPK levels may be an auxiliary alternative in the diagnosis of testicular torsion.
Testicular torsion is a surgical emergency that requires prompt diagnosis and treatment to maximize testicular survival. When the clinical diagnosis is uncertain, testicular scintigraphy can be performed to evaluate testicular perfusion. This noninvasive imaging study is widely validated and highly accurate in predicting nontorsion, which excludes the need for exploration.
Blunt scrotal trauma may result in a variety of injuries, including testicular rupture, torsion, dislocation, hematoma, or contusion, as well as epididymal, scrotal, and urethral injuries. Testicular rupture occurs in 50% of patients with traumatic hematocele, and is probably frequently misdiagnosed. If not aggressively diagnosed and surgically repaired, testicular rupture may lead to testicular atrophy and loss. Traumatic testicular torsion must also be diagnosed early to preclude testicular loss. Testicular scan, when rapidly available, is indicated in any case of suspected traumatic torsion. If testicular scanning is unavailable or equivocal, surgical exploration is indicated. Once torsion is ruled out, ultrasound is a useful diagnostic technique in acute scrotal trauma to differentiate those scrotal and testicular injuries requiring surgical intervention.
This article reviews the concepts basic to the management of the undescended testis and testicular torsion and provides specific guidelines for the management of the many variations of these entities.
The records of 80 patients at this institution diagnosed as having testicular torsion during a 5-year period were examined to establish the characteristics and peculiarities, if any, of the disease in Nigeria. There were 74 suitable cases. Similar symptoms and physical signs were identified in Nigeria as have occurred elsewhere. However, contrary to reports from Europe and America the majority (57 per cent) of the patients with testicular torsion in this study were 20 or more years old. Also, torsion occurred significantly more often (9 per cent) in men 30 or more years old than has been reported in other areas. Only 5 per cent of the patients were less than 10 years old. There is no ready explanation why testicular torsion becomes manifest during adulthood in Nigeria. The testes were explored in 73 cases. Of the testes 25 per cent could not be salvaged because of infarction with acute torsion. However, the immediate testicular salvage rate of 75 per cent does not necessarily ensure long-term normal exocrine and endocrine testicular function.
Acute diseases that require either emergency surgical intervention or specific medical therapy are emphasized in this review. Included are discussions of testicular torsion, epididymitis, torsion of testicular appendages, and miscellaneous acute scrotal pathology such as idiopathic scrotal edema.
Diagnosis is particularly urgent for patients with torsion, which mandates prompt surgery for testicular salvage.
Doppler examination of the "acute scrotum" was performed in 37 boys. The results of these examinations were consistent with the findings at operation in all but 4 boys. Of the latter, 3 were amongst the group of 11 with torsion of the spermatic cord, and the other was an infant with an irreducible inguinal hernia. At present, the results of ultrasound examination of blood flow are unreliable in the diagnosis of acute scrotal pathology in boys. This lack of reliability is particularly noticeable when symptoms have been present for more than 24 h.
Diagnosing acute scrotal pain and swelling in children and adolescents is urgent and often difficult. A review of 395 boys hospitalized with acute scrotal pain and/or swelling shows that a useful approach is to divide these patients into four groups--those with intermittent but recurrent episodes of pain, those with pathognomonic physical findings, those with definite epididymitis, and a remaining group with nonspecific swelling and tenderness. Five per cent of boys in this series presented with recurring episodes of scrotal pain; these boys should undergo a simple scrotal operation that yields excellent results. Eight per cent had pathognomonic physical findings; treatment in these boys is straightforward. Eighteen per cent had a definite diagnosis of acute epididymitis (i.e., three nonpathognomonic but suggestive findings of acute epididymitis or two suggestive findings plus a radionuclide scan showing bilateral perfusion); nonoperative therapy is indicated in this group. In the remaining boys, scrotal exploration is the diagnostic (and usually therapeutic) procedure of choice.
We have found that the blanket philosophy of emergency scrotal exploration in all cases of acute scrotal swelling in boys results in an unacceptably large number of unnecessary explorations. The use of specific aspects of the clinical examination, in conjunction with the radioisotope testicular scan in selected instances, has guided our management of 150 consecutive boys presenting with acute scrotal symptoms.
Torsion of the testis is a common urological emergency. Blunt scrotal trauma also may precipitate an emergency. We recently treated 2 adolescent boys in whom blunt scrotal trauma induced testicular torsion. A retrospective review of the charts of 138 patients explored for acute scrotal pain at our hospital revealed a history of scrotal trauma in 3 of 57 patients (5 per cent) with testicular torsion and 7 of 73 (10 per cent) with torsion of the testicular appendages. The possibility of torsion must be considered in cases of scrotal trauma.
Physical exertion, sexual activity or trauma can precipitate cremasteric contraction and result in torsion of a testicle with an underlying congenital anomaly. A high index of suspicion is required by the primary care doctor if acute torsion is to be diagnosed early for immediate reduction. The duration of torsion and the degree of twisting determine the long-term salvage rate of testicular tissue. An aggressive policy of immediate exploration of the unilateral acute scrotum in young men resulted in exploration of twice as many cases of acute epididymitis as torsion of the testis or its appendages but also resulted in an immediate orchiopexy (salvage) rate of 90 per cent and a long-term salvage rate of 73 per cent of patients with acute torsion of the testis.
Ultrasonography (US) is well suited to the study of pathologic conditions of the scrotum in children. US provides excellent anatomic detail; when color Doppler and power Doppler imaging are added, testicular perfusion can be assessed. Gray-scale, color Doppler, and power Doppler US were used to study a spectrum of scrotal disorders in 750 boys aged 1 day to 17 years. The entities studied included processus vaginalis-related disorders (cryptorchidism, inguinal-scrotal hernia, and hydrocele); varicocele; acute scrotum (epididymo-orchitis, torsion of the testicular appendages, and testicular torsion); scrotal tumors; testicular microlithiasis; scrotal trauma; and systemic diseases with scrotal involvement. When combined with the results of clinical and physical examination, the information obtained with US is sufficient to enable diagnosis in most cases of scrotal disease. Moreover, color Doppler imaging is essential for differentiation between processes such as epididymo-orchitis or torsion of the testicular appendages and testicular torsion, which have similar clinical manifestations (pain, swelling, and redness) but are managed differently.
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