Point-of-Care Ultrasound for the Diagnosis of Pediatric Testicular Torsion

Abstract

Objectives: Acute testicular torsion is a surgical emergency that warrants prompt treatment. The diagnosis is typically confirmed by ultrasonography interpreted by a radiologist (RADUS); however, in this study, we describe the clinical course of 23 patients for whom point-of-care ultrasound (POCUS) was performed by pediatric emergency medicine physicians during the initial assessment for testicular torsion in the pediatric emergency department (PED).Methods: A retrospective case series analysis of patients aged 0 to 18 years who were diagnosed with acute testicular torsion after undergoing scrotal POCUS through our PED.Results: Between June 2015 and December 2020, 155 boys received an International Classification of Diseases-9 code of Torsion of Testis after presenting to our PED. Seventy-three patients were imaged preoperatively, of which 50 (68.5%) were diagnosed via RADUS alone. Twenty-three patients (31.5%) underwent POCUS (median age 14.1 years [interquartile range {IQR}: 11.4-15.9 years]), of which 14 (60.9%) were imaged by POCUS alone, whereas the remaining 9 patients (39.1%) underwent POCUS before RADUS. Thirteen of the 23 patients (56.5%) who underwent POCUS had intraoperative findings consistent with acute testicular torsion, whereas another 3 patients (13.0%) required manual detorsion in the PED before orchiopexy. Six patients required orchiectomy. All patients for which POCUS findings were suggestive of acute testicular torsion were correctly classified.The median length of stay from time to admission to orchiopexy for those who received RADUS only versus POCUS only was 184 minutes (IQR: 136-255), and 121 minutes (IQR: 80-202), respectively (P = 0.036). Among the patients who experienced POCUS, the median length of stay for those who underwent RADUS in addition to POCUS compared with those who underwent POCUS alone was 202 minutes (IQR: 136-338.4) (P = 0.031).Conclusions: Point-of-care ultrasound performed by pediatric emergency medicine physicians can be used to expedite surgical management and streamline the management of pediatric patients suspected of acute testicular torsion.

Implementing Point‐of‐Care Ultrasound for Acute Scrotal Pain in the Pediatric Emergency Department

“…A recent case series reported results on surgical exploration after only performing POCUS without a comprehensive RADUS. 12 POCUS demonstrated efficiency in the early recognition of TT and there were no false-positive results. Two patients in our study who underwent surgical exploration without RADUS, leading to a shorter EDLOS (113 and 166 hours versus 197 hours) and shorter door-to-surgery time (134 and 163 hours versus 212 hours) compared with that of all patients with TT.…”

“…3,11 To reduce unnecessary delays in ED, the use of pointof-care ultrasound (POCUS), which can be quickly performed by the ED physician, has been increasing and being investigated recently in the same manner as other pediatric emergencies, including intussusception, acute appendicitis, and infantile hypertrophic pyloric stenosis. [12][13][14][15][16][17] Mori et al reported high sensitivity and specificity for diagnosing TT using POCUS. 13 Koppel et al reported advantages, such as a shortened ED length of stay (EDLOS), when using POCUS as a confirmatory test for surgery.…”

“…13 Koppel et al reported advantages, such as a shortened ED length of stay (EDLOS), when using POCUS as a confirmatory test for surgery. 12 To date, studies on the diagnostic performance of POCUS, performed by pediatric emergency physicians, are limited. Furthermore, the feasibility of using POCUS as a screening test in ED for patients with scrotal pain, most of whom are not patients with TT, is questionable.…”

Successful Outcome of Manual Testicular Detorsion Using Point-of-Care Ultrasound Guidance

“…12 In addition, in a retrospective case series analysis involving 155 patients, POCUS performed by pediatric emergency physicians reduced the time from admission to orchiopexy by 63 minutes. 13 POCUS can provide good guidance for manual detorsion and increase the success rate of blood flow restoration in the testis. Research using ultrasound guidance during manual detorsion is lacking, especially when performed by emergency physicians.…”

“…In a review study of 120 patients, POCUS performed by pediatric emergency physicians had a diagnostic accuracy rate of 70% for testicular torsion 12 . In addition, in a retrospective case series analysis involving 155 patients, POCUS performed by pediatric emergency physicians reduced the time from admission to orchiopexy by 63 minutes 13 …”