Clinical risk factors for testicular torsion and a warning against falsely reassuring ultrasound scans: a 10-year single-centre experience

Abstract

BackgroundWe sought to determine which demographic, clinical and ultrasonography characteristics are predictive of testicular torsion (TT) and to determine factors associated with time to treatment.MethodsWe retrospectively reviewed all medical records of patients (0–17 years) with acute scrotal syndrome (ASS) who were treated in our hospital in Lithuania between 2011 and 2020. We extracted patients’ demographic data, in-hospital time intervals, clinical, US and surgical findings. TT was determined at surgery or clinically after manual detorsion. Test characteristics of demographic, clinical and US findings for the diagnosis of TT versus other causes of ASS were determined. We performed a multivariate analysis to identify independent clinical predictors of torsion, and factors associated with surgical delay.ResultsA search of medical records yielded 555 cases: 196 (35%) patients with TT and 359 (65%) patients with other ASS causes. Multivariate logistic regression analysis showed that age between 13 and 17 years (OR 8.39; 95% CI 5.12 to 13.76), duration of symptoms <7 hours (OR 3.41; 95% CI 2.03 to 5.72), palpated hard testis (OR 4.65; 95% CI 2.02 to 10.67), scrotal swelling (OR 2.37; 95% CI 1.31 to 4.30), nausea/vomiting (OR 4.37; 95% CI 2.03 to 9.43), abdominal pain (OR 2.38; 95% CI 1.27 to 4.45) were independent clinical predictors of TT. No testicular blood flow in Doppler US had a specificity of 98.2% and a positive predictive value of 94.6%. However, 75 (41.7%) patients with TT had normal testicular blood flow, yielding low sensitivity (58.3%) and negative predictive value of 81.3% for this US finding. In-hospital waiting time for surgery was longer in patients with TT with normal testicular blood flow by USS (195 min) compared with no blood flow (123 min), p<0.01. Higher orchiectomy rates were associated with longer duration of symptoms (p<0.001) and longer waiting time for USS (p=0.029) but not with false-negative US.ConclusionsPubertal age, symptoms duration of <7 hours, nausea/vomiting, palpated hard testis, abdominal pain and scrotal swelling are predictive factors for TT. Time lost between symptom onset and seeking medical care, and between arrival and US are associated with the need for orchiectomy. Preserved blood flow in USS does not rule out TT and may contribute to delays to surgery.

Factors Determining Testicular Torsion and Consequent Orchiectomy in Pediatric Patients Presenting With Scrotal Pain

“…Nonspecific symptoms such as inguinal swelling and pain, scrotal swelling, abdominal pain, and nausea or vomiting might delay the management of TT beyond 6 hours. 2,13,19,38 We attributed the good outcomes in our patients with TT to undergoing surgery shortly beyond 6 hours due to the good hospital access, comprehensive population coverage, and short waiting times, as well as prompt urology consultation. 40 Research has evaluated the predictors of TS in children with TT, 12,17 and we identified several risk factors associated with orchiectomy in children with TT in a multivariate analysis, including a longer interval between SP onset and PED arrival, 13,36,37 absent TUBF, 1,3,7,8,16,17,[31][32][33][34] interval between SP onset and surgery of more than 24 hours, 2,7,8,16 and a greater degree of TT.…”

“…The numbers of patients needing surgery, surgically confirmed TT, orchiopexy, orchiectomy, hospital admission, and hospital length of stay (LOS) were also evaluated. Testicular torsion-associated symptoms were defined as inguinal swelling and pain, scrotal skin erythema or dark color, scrotal swelling, scrotal tenderness, a hard testis on palpitation, abdominal pain, and nausea or vomiting 2,13,19 …”

“…Testicular torsion-associated symptoms were defined as inguinal swelling and pain, scrotal skin erythema or dark color, scrotal swelling, scrotal tenderness, a hard testis on palpitation, abdominal pain, and nausea or vomiting. 2 , 13 , 19 …”

“…This retrospective observational study was conducted in PEDs at Chang Gung Medical Hospital (CGMH) in Northern Taiwan from January 1, 2011 to August 31, 2021. Patients presenting with SP with or without nausea, vomiting, or abdominal pain, with testicular tenderness and swelling, an absent cremasteric reflex, and high-riding testicle were considered to have SP, 6,8,[16][17][18][19] whereas patients with traumatic SP and incomplete records were excluded. This study was approved by the CGMH Institutional Review Board (no.…”

“…Testicular torsionassociated symptoms were defined as inguinal swelling and pain, scrotal skin erythema or dark color, scrotal swelling, scrotal tenderness, a hard testis on palpitation, abdominal pain, and nausea or vomiting. 2,13,19 Doppler ultrasound (DUS) was performed by senior urology residents or a pediatrician. If the TUBF on the affected side was reduced or absent compared with the opposite side, or a clinical diagnosis of TT was strongly suspected, surgical exploration was recommended to the patients and their families, and the operation was performed after obtaining informed consent.…”