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Concept: Testicular torsion

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Abstract Objective.Acute scrotal pain is a common presentation to the paediatric emergency department. Testicular torsion is one of the most common causes of acute scrotal pain. Testicular torsion is a surgical emergency requiring immediate surgical exploration to prevent permanent testicular damage or loss. The aim of this study was to determine the surgical outcome of all scrotal explorations and to assess the use of colour Doppler ultrasound (CDUS) in the assessment of acute scrotal pain in two tertiary referral paediatric units. Material and methods. A retrospective review of a prospectively maintained database was carried out for all scrotal explorations between 1999 and 2010. Results.In total, 155 scrotal explorations were carried out for acute scrotal pain. The mean age was 9.1 years (range 0-15 years). The pathology in 46.5% (n = 72) was testicular torsion, 30.3% (n = 47) were torsion of a testicular appendage, 16.1% (n = 25) were epididymitis, 3.3% (n = 5) had no obvious pathology identified and other pathology accounted for 4%. There was a significant difference in age of presentation between those with testicular torsion and those with torsion of a testicular appendage (9 vs 10 years, p = 0.0074). CDUS was performed by a trained radiologist on 40 patients. Overall sensitivity, specificity, positive predictive value and negative predictive value for CDUS predicting testicular torsion were 96.9%, 88.9%, 96.9% and 89%, respectively. Overall, 36 patients (23%) with acute scrotal pain (50% of patients in the group with confirmed testicular torsion at exploration) required orchidectomy. Conclusion. This study supports the practice of immediate surgical exploration with a clinical suspicion of testicular torsion in a paediatric population.

Concepts: Positive predictive value, Negative predictive value, Hospital, Sensitivity and specificity, Andrology, Testicle, Epididymitis, Testicular torsion

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PURPOSE: Although colour-coded duplex sonography (CCDS) is a useful tool for visualizing testicular perfusion in patients with clinical suspicion of testicular torsion, fear of overlooking the condition itself remains. Thus, routine scrotal exploration in every patient with acute scrotal pain is common in many centres. The aim of this study was to assess the efficacy of CCDS in predicting the need for scrotal exploration in patients with clinical suspicion of testicular torsion. MATERIALS AND METHODS: We carried out a prospective study between 1995 and 2012 to assess the diagnostic value of CCDS in 236 patients (median age: 13 years; range: 0-53 years) with clinical suspicion of testicular torsion. All patients were examined by CCDS, and subsequently underwent exploration, whereby the surgeon was blinded to the CCDS results. The sensitivity, specificity, positive predictive value and negative predictive value of CCDS with regard to diagnosing testicular torsion were calculated on the basis of preoperative CCDS findings and compared to the final diagnosis after surgical exploration. RESULTS: Testicular torsion was the most common cause in 119/236 cases (50.4%), followed by torsion of the testicular appendages in 82 cases (34.8%), epididymo-orchitis in 18 cases (7.6%), and various pathologies in 17 cases (7.2%). The sensitivity, specificity, positive predictive values and negative predictive values of CCDS for detecting testicular torsion were 100%, 75.2%, 80.4%, and 100%, respectively. CONCLUSION: Our data provide evidence that routine surgical exploration is no longer justified in patients with clinical suspicion of testicular torsion if CCDS has revealed normal intratesticular perfusion.

Concepts: Positive predictive value, Negative predictive value, Hospital, Sensitivity and specificity, Testicle, Binary classification, Epididymitis, Testicular torsion

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Testicular infarction is an uncommon finding in paediatric age and is usually due to testicular torsion or trauma causing venous rupture with thrombosis and/or arteriolar obstruction. Other causes of segmental infarction of the testes are represented by polyarteritis nodosa, thromboangioiitis obliterans and hypersensitivity angiitis. A few cases of testicular infarction due to epididymitis have been described in the literature related mainly to adult patients. Epididymitis is usually treated in the outpatient setting with close follow-up, but according to our present experience, and reviewing the literature, there may be some cases in which, surgical exploration is mandatory in order to avoid testicular damage.

Concepts: Hospital, Andrology, Testicle, Testicular cancer, Polyarteritis nodosa, Epididymis, Spermatic cord, Testicular torsion

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Abstract Background: Histopathologic findings of gonadal torsion in neonates and infants (GTNI) are poorly defined in the literature. We describe herein the histopathologic spectrum of gonadal torsion (GT) with emphasis on the pediatric population and on features specific for NI (<=1 year of age). Design: Twenty-five cases of GTNI (6 females/18 males), 35 cases of GT in older pediatric population (OPP) (19 females/14 males) and 33 cases in adults (25 females/8 males) were found in our pathology files between 2003 and 2011. Results: Our findings disclose two categories of GT: the group of NI as opposed to that of OPP and adults, the latter sharing similar presentation as acute hemorrhagic necrosis of the gonad. Although findings in NI were rather uniform, a few differences were demonstrated between the two genders. All GTNI revealed calcifications, fibrosis, siderophages and extensive necrosis. However, prominent necrotizing palisaded granulomata were seen in most (4/6) cases of ovarian torsion, but not in the testicular counterpart. Furthermore, complete gonad regression was encountered exclusively in neonatal testicular torsion cases. Conclusions: - Pathologic findings in GT are distinctly different between NI and OPP, the latter being more comparable to adults, presenting with acute hemorrhagic necrosis. - The distinctive findings in GTNI of both genders include calcifications, siderophages and fibrosis, in addition to background necrosis. - Of particular note, complete gonadal regression is seen only in the testis in GTNI. - Finally, necrotizing palisaded granulomata are unique to the ovarian subgroup and are often extensive, obscuring the nature of the process.

Concepts: Infant, Testicle, Reproductive system, Necrosis, Endocrine system, Ovary, Gonad, Testicular torsion

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Testicular pain syndrome (TPS), defined as an intermittent or constant pain in one or both testicles for at least 3 months, resulting in significant reduction of daily activities, is common. Microsurgical denervation of the spermatic cord (MDSC) has been suggested as an effective treatment option. The study population comprised 180 TPS patients, admitted to our outpatient urology clinic between 1999 and 2011. On three different occasions, patients were offered a double-blind, placebo-controlled temporary blockade of the spermatic cord. A single blockade consisted of 10 mL 2% lidocaine, 10 mL 0.25% bupivacaine or 10 mL 0.9% sodium chloride. If the results of these blockades were positive, MDSC was offered. All MDSCs were performed by a single urologist (MTWTL) using an inguinal approach. Pain reduction was determined at prospective follow-up. 180 patients were evaluated. Most patients (61.1%) had undergone a scrotal or inguinal procedure. Patients had complaints during sexual activities (51.7%), sitting (37.5%) and/or cycling (36.7%). 189 randomized blockades were offered to all patients. There was a positive response in 37% and a negative response in 51%. MDSC was performed on 58 testicular units including 3 patients with a negative outcome of the blockades. At mean follow-up of 42.8 months, 86.2% had a ⩾50% reduction of pain and 51.7% were completely pain free. MDSC is a valuable treatment option for TPS patients as in this study 86.2% experienced a ⩾50% reduction of pain. To prevent superfluous diagnostics and treatment, it is mandatory to follow a systematic protocol in the treatment of TPS.

Concepts: Sodium chloride, Testicle, Sodium, Male reproductive system, Scrotum, Spermatic cord, Testicular torsion, Blockade

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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).

Concepts: Medicine, Validation, Testicle, Pediatrics, Scrotum, Testicular torsion, Verification and validation

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Testicular sonography has contributed greatly to the preoperative diagnosis of testicular torsion in the pediatric patient and is the mainstay for evaluation of acute scrotal pain. Despite its high sensitivity and specificity, both false-negative and false-positive findings occur. Presence of documented Doppler flow within the testis might be a dissuading factor for surgical exploration with resultant testicular loss in the false-negative cases. Our goal is to illustrate key sonographic features in the spectrum of testicular torsion with preserved testicular flow, and to describe how to differentiate testicular torsion from epididymitis in order to avoid the under-diagnosis of testicular torsion. We simplify the anatomy of the bell clapper testis. We also describe our sonographic protocol for testicular torsion and share valuable tips from our approach to challenging cases.

Concepts: Type I and type II errors, Sensitivity and specificity, Testicle, Testicular torsion

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TWIST (Testicular Workup for Ischemia and Suspected Torsion) score uses urologic history and physical exam to assess risk of testis torsion. The 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 amongst non-urologic providers is unknown. We assessed the utility of the TWIST score when collected by non-urologic non-physician providers, mirroring the ER evaluation of acute scrotal pain.

Concepts: Evaluation, Assessment, Psychometrics, Andrology, Testicle, Scrotum, Spermatic cord, Testicular torsion

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Testicular torsion is a surgical emergency requiring prompt intervention. Although clinical diagnosis is recommended, scrotal ultrasound is frequently ordered, delaying treatment. We created a scoring system to diagnose testicular torsion, decreasing the indication for ultrasound.

Concepts: Medical terms, Diagnosis, Testicle, Scrotum, Testicular torsion, Surgical emergency

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Scrotal pain is a common acute presentation for medical care. Testicular torsion and epididymo-orchitis are two diagnoses for which early detection is critical and their sonographic imaging features have been thoroughly described in the radiologic literature. Other important conditions for which radiologists must be aware have received less attention. This article will highlight key traumatic and non-traumatic causes of acute scrotal pain other than testicular torsion and epididymo-orchitis that may present in the emergency department setting.

Concepts: Andrology, Testicle, Testicular cancer, Radiology, Medical ultrasonography, Epididymis, Epididymitis, Testicular torsion