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Testicular Torsion Can Be Diagnosed Based On Physical Exam, Without Ultrasound Confirmation

Question

  • 14-year old male presents to the ED with acute onset of testicular pain, exam consistent with testicular torsion. Is ultrasound necessary for diagnosis, prior to surgical intervention? Should surgical intervention be delayed to obtain ultrasound for diagnostic confirmation?

Clinical Bottom Lines

  1. Patient presenting to the ED with acute scrotal/testicular pain, swelling, or mass - potential surgical emergency. Most common etiology in pediatric patients: epididymitis (E), testicular torsion (TT), torsion of the appendix testes (TAT).1
  2. 'Gold Standard' diagnosis of TT - color Doppler ultrasound. Sensitivity 86-100%, specificity 98.8-100%, PPV 73%, NPV 100%, false + rate 1%. In reviewed study, + LR 33.1-5
  3. Cannot rely on historical data to increase post-test probability of testicular torsion in patients with acute onset of testicular pain.
  4. Physical exam findings can increase post-test probability beyond treatment threshold, eliminating need for ultrasound, saving time, money, and testes. Abnormal testicular lie +LR infinite, absent cremasteric reflex +LR 8.3, age >12 years +LR 3.5. If absent cremasteric and 12+years old, combined +LR 29, nearly equal to +LR for color Doppler ultrasound.1


Summary of Key Evidence

  1. Objective: Compare historical features/physical exam findings of epididymitis, testicular torsion, and torsion of appendix testes to determine reliability of color Doppler ultrasound in the diagnosis of testicular torsion. Design: Retrospective study/chart review. Setting: Large children's hospital providing secondary/tertiary care, major referral center for 5 NW states.1
  2. Participants: Charts of all males <18 discharged w/dx of E, TT, TAT over 3 year period reviewed. Included: 90 pts dx w/one of the three conditions by treating Pediatric Emergency Medicine Physician/Urology Consultant. Excluded (5 pts): Recent urologic surgery (3 pts) and unclear etiology for scrotal pain/swelling (2pts).
  3. Results: 13 w/testicular torsion, 64 w/epididymitis, 13 w/torsion appendix testis.
Diagnostic Test Sensitivity Specificity + LR - LR
Color Doppler Ultrasound 100% 97% 33 0.0
Exam Finding Sensitivity Specificity + LR - LR

Abnormal testicular lie

46%

100%

infinity

0.54

Absent Cremasteric reflex

100%

88%

8.30

0.00

Age>12 years

77%

78%

3.50

0.29

Tender testicle

100%

38%

1.60

0.00

Temperature >38.1

8%

91%

0.89

1.01

Scrotal erythema/edema

38%

43%

0.67

1.44

Tender epididymis

23%

19%

0.28

4.05

"Blue dot sign"

0%

96%

0.00

1.04

Isolated tenderness (superior pole test)

0%

83%

0.00

1.20


Additional Comments

  • Clinical Relevance:
    • Testicular torsion: incidence 1/4,000 males, pubescent males most frequently affected, average testicular salvage rate 50-77%, can result in infertility.6,7
    • Longer delay of surgical intervention, increased risk of ischemia/infertility.
    • Obtaining unnecessary ultrasounds for confirmation of diagnosis delays surgical intervention, increases testicular loss, and is not cost effective.
  • Limitations of study:
    • Gold standard for diagnosis not identified. Not all patients in study underwent color Doppler ultrasound-was ordered at discretion of treating physician. Authors do not state how diagnosis was concretely established.
    • Retrospective study - if information was not documented in chart, assumed negative response (i.e. if did not specify fever, assumed afebrile). Authors did not report how much data was missing in chart review.

Citation

  1. Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics 1998; 102:73-6.
  2. Weber DM, Rosslein R, Fliegel C. Color Doppler sonography in the diagnosis of acute scrotum in boys. European Journal of Pediatric Surgery 2000; 10(4):235-41.
  3. Baker LA, Sigman D, Mathers RI, Benson J, Docimo SG. An analysis of clinical outcomes using color Doppler testicular ultrasound for testicular torsion. Pediatrics 2000; 105:604-7.
  4. Yazbeck S, Patriquin HB. Accuracy of Doppler sonography in the evaluation of acute conditions of the scrotum in children. Journal of Pediatric Surgery 1994; 29(9):1270-2.
  5. Burks DD, Markey BJ, Burkhard TK, Balsara ZN, Haluszka MM, Canning DA. Suspected testicular torsion and ischemia: evaluation with color Doppler sonography. Radiology 1990; 175(3):815-21.
  6. Dunne PJ, O'Loughlin BS. Testicular torsion: time is the enemy. ANZ Journal of Surgery 2000;70(6):441-2.
  7. Blaivas M, Batts M, Lambert M. Ultrasonographic diagnosis of testicular torsion by emergency physicians. American Journal of Emergency Medicine 2000; 18(2):198-200.

CAT Author: Nicole S. Sroufe, MD, MPH

CAT Appraisers: John G. Frohna, MD, MPH

Date appraised: January 28, 2002

Last updated January 26, 2003
Department of Pediatrics and Communicable Diseases
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