Testicular Torsion as a Cause of Acute Scrotum

Is it possible to distinguish testicular torsion and other causes of acute scrotum in patients who underwent scrotal exploration? A multi-center, clinical trial

ABSTRACT

Objectives: We assessed the importance of the clinical presentation of boys who underwent surgical exploration for acute scrotum.

Materials and Methods: We retrospectively analyzed the records of 97 boys (≤25 years old) who underwent surgical exploration for acute scrotum between May 2007 and July 2013. Diagnosis of acute scrotum was confirmed by physical examination, colour Doppler ultrasound (CDUS) and laboratory findings.

Results: In total, 97 scrotal explorations were carried out for acute scrotal pain. 74.2% (n=72) had testicular torsion (TT), 25.8% (n=25) had other pathologies included torsion of testicular appendage (n=13), epididymo-orchitis (n=8), testicular trauma (n=2), and Henoch-Schönlein purpura (n=2). In the TT group, 32 cases (44.4%) presented to hospital within the less than 6 hours after pain onset, and more than half (64%) others group cases presented >24 hours after pain onset. Fever and pyuria appeared more frequently in the others group than in the TT group, and the results reached statistical significance. Patients with TT had more testicular tenderness compared to the others group (p<0.001). Our testicular salvage rate was 59.7% and missed testicular torsion rate was 40.3%.

Conclusions: CDUS was largely predicted the diagnosis of TT (sensitivity, 98.6%). Clinical findings such as testicular tenderness, fever and pyuria may be helpful in making the differentiation in TT and others (nonsurgical) group.

Key words: surgical acute scrotum; non-surgical acute scrotum; testicular torsion; torsion of testicular appendages; epididymo-orchitis; scrotal exploration.

INTRODUCTION

When acute scrotal pain is experienced by a child or teenage boy in his adolescence, one should always treat this condition as an emergent condition, whether or not it is accompanied by swelling. Torsion of the spermatic cord, epididymo-orchitis, torsion of testicular appendages, trauma, tumor, hernia, idiopathic scrotal edema vasculitis and cellulitis are signs looked for when diagnosing acute scrotum. Although the majority of these conditions are non-emergent, when torsion of the spermatic cord occurs, it is vital that it be immediately diagnosed and treated. If it is not, the testicle could suffer permanent ischemic damage (1). The most common causes of acute scrotum in young people are testicular torsion (TT), epididymo-orchitis (EO), torsion of testicular appendage (TTA), and epididymo-orchitis (EO) (2-4). Because of the possible risk of permanent damage to the testicle, it is vitally important to determine whether the acute scrotal pain is caused by testicular torsion or something else. In the past, medical professionals have used sonography and clinical findings to help determine the cause (5,6).

This study examines the results of scrotal exploration, the symptoms and signs of acute scrotum and ways to distinguish whether testicular torsion or other factors are the cause of acute scrotum in young patients.

MATERIALS AND METHODS

97 patients underwent exploration of scrotum for acute scrotal pain between May 2007 and July 2013. A retrospective review off all boys up to the age of 25 years. Data were obtained retrospectively maintained hospital databases of all patients who underwent scrotal exploration in four tertiary referral centres (Suleyman Demirel University Faculty of Medicine, Isparta, Haydarpasa Training and Research Hospital, Istanbul, Tepecik Training and Research Hospital, Izmir, and Fatih Sultan Mehmet Training and Research Hospital, Istanbul).

Patient selection

The case notes of all the operated patients with acute scrotum were selected for evaluation. All participants were examined physically by a resident or the consultant of Urologist. Physical findings included scrotal erythema, swelling, tender scrotum was recorded. Patients’ ages, clinical findings, the affected side, pain duration, previous history, fever (>38°C), nausea-vomiting, final diagnosis, and type of surgery were evaluated. In all cases, a white blood cell (WBC) and urinalysis (pyuria) were requested.

Patients with a recent surgery of the external genitalia, an incarcerated hernia, tumor and extravaginal neonatal spermatic cord torsion were excluded from the study.

Colour Doppler ultrasonography (CDUS) was performed in all patients. Because of an assumed unreliability of CDUS the decision for surgical exploration was mainly based on the clinical findings because of the implications of missing testicular torsion. Torsion of the testis was managed by either orchidopexy or orchidectomy. The contralateral testis was also fixed. Torsion of the appendix testis was treated by excision. In cases of epididymo-orchitis the ipsilateral testis only was fixed. Orchiectomy was performed in two patients with testicular rupture and hematoma after trauma. Two HSP patients who had not got torsion, underwent bilateral testicular fixation. This study was approved by the Local Ethics Committee of the Suleyman Demirel University, Faculty of Medicine.

Statistical analysis

Statistical analysis was performed with the Statistical Package for the Social Sciences (SPSS) for Windows, version 19.0. A significance value of p<0.05 was accepted as statistically significant. Data are expressed as a mean ± standard deviation for continuous variables, and as a number and percentage for categorical variables. Categorical data between groups were compared using χ2 test or Fisher’s exact test while continuous distributed data were compared using either Mann–Whitney U test or analysis of variance.

RESULTS

A total of 97 patients were included in this study and divided into two groups. Seventy-two patients had TT (74.2%), 25 patients had other acute scrotal pathologies (25.8%). Other pathologies included torsion of testicular appendage (n=13), epididymo-orchitis (n=8), testicular trauma (n=2), and Henoch-Schönlein purpura (n=2). Table 1 presents final diagnoses after exploration.

The characteristics of the two groups are presented in Table 2. The mean age of patients with TT (17.9±4.5 years) and other group (16.6±7.3 years) were similar. In TT patients, the left testicle was more often affected than the right one (58.3% vs 41.7%). The left testicle was more affected in both of the two groups. In terms of pain onset time, the TT group than in the other group referenced in the early hours was observed. (p=0.003). In the TT group, 32 cases (44.4%) presented to hospital within the less than 6 hours after pain onset, and more than half (64%) other group cases presented >24 hours after pain onset.

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Clinical features and physical examination findings are presented in Table 3. Fever and pyuria appeared more frequently in the others group than in the TT group, and the results reached statistical significance (p<0.05). Patients with TT had more testicular tenderness compared to the other group (p<0.001). The prevalence rate of nausea/vomiting, scrotal erythema and swelling among the two groups were not significantly different. Patients in the others group had a higher WBC count than the TT groups, but was not statistically significant.

Scrotal exploration was performed in all patients (100%). Viable testes were found in 43 of 72 patients with TT during operation. Detorsion and fixation of testes were performed. The other 29 patients received orchiectomy for nonviable testis and orchiopexy for unaffected testis to prevent further TT. The salvage rate of TT was 59.7% (Table 4). Only one case was performed manual detorsion before scrotal exploration and fixation.

All patients underwent CDUS (Table 5). Importantly, 71 of 72 TT (98.6%) were correctly identified as torsions.

DISCUSSION

For young people, the most common causes of acute scrotum are TT, EO and TTA (2,3,4,7). Of these three, TT is the cause for 25%-35% of acute pediatric scrotal disease and is found in .025% of males under 25 years of age (8). In our study, values of TT, TTA and EO were found to be 74.2%, 13.4% and 8.2%, respectively. This result is compatible not only with clinical studies (6,7,8,9,10) in which only scrotal exploration was evaluated, but also with clinical studies (11,12,13,14,15) in which surgical and medical treatments were evaluated in terms of three clinical entities. The most common reason for acute scrotum is TT in five of the studies (6,7,9,12,15), TTA in three of them (8,11,13) and EO in 2 of them (10,14). Interestingly, there are studies which find a strangulated inguinal hernia responsible within these most common 3 clinical conditions (16). In our study, TT is discovered to be the cause for most of the cases of acute scrotum. Also, the condition that is most often reported in Turkey is TT.

Ideally, though sometimes clinically impossible, there should be a distinction between TT and other causes not requiring surgery (17). Studies have been made to distinguish TT from other acute scrotal pathologies and reduce the ratio of negative exploration. In these studies, clinical findings such as a pain duration <24 h, nausea/vomiting, a high position of the testis, and an abnormal cremasteric reflex are found to be predictive of TT (18,19). In our study, a comparison is made between the “TT group” and an “others group” consisting of patients not requiring surgery other than two trauma cases who underwent orchiectomy due to testicular rupture. According to our findings, there were no statistically significant differences in the way that the two different groups of patients reacted as far as scrotal erythema/swelling, nausea/vomiting and other clinical presentations. Whereas testicular tenderness was found to be high in the TT group, pyuria and fever were high in the other group both significantly and statistically. This difference observed in pyuria and fever in the other group may be related to urinary system infections which are more common in EO (20).

Over the past 20 years, medical professionals have frequently used the Colour Doppler ultrasound (CDUS) to determine the presence and extent of TT. This machine is helpful in determining when surgical exploration of the scrotum is unnecessary, cutting down the number of unnecessary explorations (21). Nevertheless, the information provided by the CDUS is affected by how the user uses the machine and should be compared with the medical history of the patient and the results of a physical exam (22). In the diagnosis of TT, CDUS is reported to have 69.2-100% sensitivity and 87-100% specificity ratios (23,24). Only in one patient, a false negative result was achieved in the diagnosis of TT, and CDUS sensitivity was found to be 98.6%. It is known that CDUS causes complexity in making diagnosis of ATT and EO cases and causes over diagnosis in EO (20). Although it is reported that CDUS doesn’t deviate in HSP, which is the nonsurgical cause of acute scrotum, asymmetrically reduced blood flow and absence of blood flow in CDUS could not be clinically differentiated from TT due to scrotal hyperemia and edema (25). Bilateral testicular fixation was applied in cases not presenting tortion in scrotal exploration. Although scrotal trauma is usually taken care of with minimal intervention, when the testis is ruptured traumatically this is a signal that immediate surgical exploration is necessary (21). We performed orchiectomy in two trauma cases in which hematoma developed and was followed by traumatic rupture.

The success rate of preserving the testicle in the case of TT closely depends on early admission. Cimador et al (25) reports that testicular infarction initiates after the 2^nd hour of ischemia and that complete infarctus occurs in 6 hours and the irreversible loss of the testicle would develop in 24 hours. Also, it is reported that a non-viabile testicle is a very specific symptom in admissions after 10 hours and that this characteristic would require orchiectomy in all cases. The ratio of preserving testicles varies between 37 to 88% in literature (9,10,13,14,15). In our study, it was observed that the TT group was admitted significantly earlier (55.5% < 12 h) than the others group (p=0.003). In accordance with that, the rate of preserving the testicle was found to be 59.7% (43/72). This result suggests that more TT cases are admitted with the sudden onset of pain when compared to nonsurgical acute scrotum cases.

In our study, non TT acute scrotal pathologies are used for the comparison group. The lower patient number in this group and 2 trauma cases not leading to a 100% homogeneous study can be counted as study restrictions.

Conclusion

In order to avoid the loss of the testicle and unnecessary surgical interventions, it is important to distinguish TT from other acute scrotal pathologies. Thus, CDUS, which presents more specific findings for TT, and clinical findings such as testicular tenderness, fever and pyuria may be helpful in making the differentiation. Again, it should be remembered that TT cases are mostly admitted earlier with the sudden onset of pain.

Conflict of interest: None declared.

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Table 1. Final diagnoses after scrotal exploration.

Table 2. Characteristics both of two patient groups.

TT, testicular torsion; Others, other acute scrotal pathologies

Table 3. Clinical findings and laboratory data both of two patient groups.

TT, testicular torsion; Others, other acute scrotal pathologies

Table 4. Treatment types and salvage rate of patients with testicular torsion.

TT, testicular torsion

Table 5. Results of color Doppler ultrasonography both of two patient groups.

TT, testicular torsion; Others, other acute scrotal pathologies; CDUS, color Doppler ultrasonography