Acute testicular torsion in children: the role of sonography in the diagnostic workup

Abstract

Acute testicular torsion in children is an emergency and has to be diagnosed urgently. Doppler sonography is increasingly used in imaging the acute scrotum. Nevertheless, in uncertain cases, surgical exploration is required. In this study, we attempted to define the role of Doppler sonography in the diagnostic workup of the acutely painful scrotum. All patients admitted between 1999 and 2005 with acute scrotal pain were included. After clinical assessment, patients were imaged by Doppler sonography with a ''high-end'' instrument. In cases of absent arterial perfusion of the testis in Doppler sonography, surgical exploration was carried out. Patients with unaffected perfusion were followed clinically by ultrasound for up to 2 years. Sixty-one infants and children aged 1 day to 17 years (median: 7.9 years) were included. In 14 cases, sonography demonstrated absent central perfusion, with abnormal parenchymal echogenicity in six. Absence of venous blood flow together with reduction of central arterial perfusion was found in one infant. In these 15 patients, surgical exploration confirmed testicular torsion. Among the other 46 patients, we found four cases with increased testicular perfusion and 27 with increased perfusion of the epididymis. In one infant, a testicular tumour was found sonographically, and orchiectomy confirmed diagnosis of a teratoma. Follow-up examinations of the conservatively treated patients showed good clinical outcome with physiologic central perfusion as well as normal echogenic pattern of both testes. No case of testicular torsion was missed. By means of Doppler sonography, an unequivocal statement regarding testicular perfusion was possible in all cases. The initial Doppler diagnosis was confirmed by operative evaluation and follow-up ultrasound. Testicular torsion can therefore be excluded by correctly performed ultrasound with modern equipment.

Surgical management of testicular torsion

“…Other studies have also shown similarly high sensitivity (95.7-100%) and specificity (85.3-100%) for CDS in diagnosing testicular torsion. [26][27][28] However, CDS can be inaccurate and false-negatives can occur, especially in cases of early TT, intermittent torsion or incomplete torsion of the spermatic cord. Several studies have demonstrated arterial flow in affected testes, which were subsequently shown to be torted at surgery.…”

The dilemma in the diagnosis of acute scrotum: clinical clues for differentiating between testicular torsion and epididymo-orchitis

“…(18) Gunther et al suggested that if Doppler sonography is performed correctly as a standard procedure, it may replace surgical exploration, which would only be indicated in cases of doubt. (1) They suggested that the diagnostic benefit of routine surgical evaluation is small in comparison with the risks of aspiration and wound infection and that total costs may be reduced by replacing surgery with ultrasound. Another controversial issue is whether twisted testicles need to be removed and whether a retained ischemic testicle may expose the patient to the potential risk of autoimmunization and consequent damage to the contralateral gonad.…”

“…(1) To date, no single reliable clinical feature or examination can give 100% diagnostic accuracy. (2) In addition to testicular torsion, the origin of acute scrotal pain could be inflammatory disease, hydrocele, inguinal hernia, testicular tumor and underlying causes such as Schoenlein-Henoch purpura.…”

Ultrasound assessment of perinatal testicular torsion

“…HCDU can not only greatly reduce the likelihood (75%) 3 and false-positive rate (55%) 4 of surgical exploration, but it also has a high sensitivity (69-90%) 5 and specificity 98-100% 6 for TT. Therefore, its application in perinatal acute testicular disease is clinically appropriate.…”