Suspected testicular torsion in children: diagnostic dilemma and recommendation for a lower threshold for initiation of surgical exploration

Abstract

PurposeTesticular 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.MethodsWe 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.ResultsOf 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.ConclusionIt 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.

Case Report: Testicular Torsion in Unilateral Supernumerary Testis

“…Color Doppler ultrasound is the best tool to diagnose testicular torsion ( 11 ). But Abbas et al argued that there is no single clinical or imaging sign that can prove or rule out testicular torsion ( 12 ). Emergent exploration is recommended when testicular torsion is suspected ( 10 , 12 , 13 ).…”

Incidental findings in and around the prostate on prostate MRI: a pictorial review

“…Hydroceles, may be acquired or congenital, are common and present with painless enlargement of the scrotum. Congenital hydroceles are more common in children and may be subdivided into communicating or spermatic cord hydrocele [ 28 ]. Acquired hydroceles can develop subsequent to trauma, epididymitis, testicular torsion, neoplasm or infarction [ 28 ] (Fig.…”

Diagnostic Accuracy of Doppler Ultrasound in Testicular Torsion Keeping Surgical Findings as the Gold Standard

“…10 However, residual perfusion in incomplete or early torsion cases can result in false negative results. 6 The Whirlpool pattern of vascularity can also be appreciated within the spermatic cord corresponding to the greyscale whirl-pool sign. 9 Testicular viability can reliably be assessed from greyscale and colour Doppler findings.…”

“…1,5 The presenting features of testicular torsion are sudden onset of severe scrotal pain and acute scrotal swelling frequently accompanied by nausea and vomiting as well. 6 transverse testis, an absent cremasteric reflex and a negative Prehn's sign-relief of pain with elevation of the testicle. 5,6 However, the clinical assessment cannot reliably differentiate between the various causes of the acute scrotum, which include a) Epididymo-orchitis, b)Torsion of appendix testis, c) Idiopathic scrotal oedema, d) Segmental testicular infarction e) Strangulated hernia.…”

“…6 transverse testis, an absent cremasteric reflex and a negative Prehn's sign-relief of pain with elevation of the testicle. 5,6 However, the clinical assessment cannot reliably differentiate between the various causes of the acute scrotum, which include a) Epididymo-orchitis, b)Torsion of appendix testis, c) Idiopathic scrotal oedema, d) Segmental testicular infarction e) Strangulated hernia. 1,7 The role of imaging is to exclude these confounding differentials and to establish whether an acute scrotum needs medical management or surgical intervention.…”