<< Evidence-Based Diagnosis And Treatment Of Torsion Of The Spermatic Cord In The Pediatric Patient


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Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.

  1. Mansbach JM, Forbes P, Peters C. Testicular Torsion and Risk Factors for Orchiectomy. Arch Pediatr Adolesc Med. 2005;159:1167-1171. (Retrospective; 436 patients)
  2. Anderson JB, Williamson RC. Testicular Torsion in Bristol: A 25 Year Review. Br J Surg. 1998; 75:988-992. (Retrospective; 670 patients)
  3. * Knight PJ, Vassey L. The Diagnosis and Treatment of the Acute Scrotum in Children and Adolescents. Ann Surg. 1984;200(5):664-673. (Retrospective; 395 patients)
  4. Lewis AG, Bukowski TP, Jarvis PD, et al. Evaluation of acute scrotum in the emergency department. J Pediatr Surg. 1995;30(2):277-281. (Retrospective; 238 patients)
  5. Melekos MD, Asbacch HW, Markou SA. Etiology of Acute Scrotum in 100 Boys with Regard to Age Distribution. J Urol. 1987;139:1023-1025. (Retrospective; 100 patients)
  6. Williamson RC. Torsion of the testis and allied conditions. Br J Surg. 1976;63:465-476. (Retrospective; 353 patients)
  7. Beni-Israel T, Goldman M, Bar Chaim S, et al. Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med.2010;28:786-789. (Retrospective case series; 523 patients)
  8. Leape L. Testicular Torsion. In: Ashcraft KW, ed. Pediatric Urology. W.B Saunders Company; 1990:429-436. (Textbook)
  9. The Testicles. In: Standing S, ed. Gray’s Anatomy, The Anatomical Basis of Clinical Practice, 29th ed. Edinburgh: Elsevier;2005:1305-1313. (Textbook)
  10. Jackson RH, Craft AW. Bicycle Saddles and torsion of the testis. Lancet. 1978;1:983. (Case report)
  11. Cos LR, Rabinowitz R. Trauma-induced Testicular Torsion in Children. J Trauma. 1982;22(3):244-246. (Case report; 3 patients)
  12. Shukla RB, Kelly DG, Daly L, et al. Association of Cold Weather with Testicular Torsion. BMJ 1982;285:1459-1460. (Retrospective; 46 patients)
  13. Preshaw RM. Seasonal frequency of testicular torsion. Canadian J Surg. July 1984;27(4):404-405. (Retrospective; 272 cases)
  14. Srinivasan AK, Freyle J, Gitlin JS, et al. Climatic conditions and the risk of testicular torsion in adolescent males. The J of Urology. 2007;178(6):2585-2588. (Retrospective; 58 patients)
  15. Mbibu NH, Maitama HY, Ameh EA, et al. Acute scrotum in Nigeria: an18-year review. Trop Doct. 2004;34(1):34-36. (Retrospective review; 178 patients)
  16. Leape L. Testicular Torsion. In: Ashcraft KW, ed. Pediatric Urology. W.B Saunders Company; 1990:429. (Textbook)
  17. Longo VJ. Point of View - Torsion of the Testis: A New Twist. Urology. 1978;12(6):743. (Expert opinion)
  18. Chalett JM, Nerenberg LT, “Blue Balls”; A diagnostic consideration in testiculoscrotal pain in young adults: A Case Report and Discussion. Pediatrics. 2000;106:843. (Case report)
  19. Sawchuk T, Costabile RA, Howards SS, et al. Spermatic cord torsion in an infant receiving human chorionic gonadatrophin. J Urol. 1991;150(4):1212-1213. (Case report)
  20. * Mäkelä E, Lahdes-Vasama T, Rajakorpi H, et al. A 19-year review of paediatric patients with acute scrotum. Scand J Surg. 2007;96(1):62-66. (Retrospecitve; 388 patients)
  21. * Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics. 1998;102(1):73-76. (Retrospective; 90 patients)
  22. * Krarup, T. The testis after torsion. Brit J Urol. 1978;50:43. (Retrospective; follow up of 48 patients)
  23. Murphy FL, Fletcher L, Pease P. Early scrotal exploration in all cases is the investigation and intervention of choice in the acute paediatric scrotum. Pediatric Surg Int. 1006;5:413-416. (Retrospective; 121 patients)
  24. Mushtaq I, Fung M, Glasson MJ. Retrospective review of paediatric patients with acute scrotum. ANZ J Surg. 2003;73:55-58. (Retrospective; 204 patients)
  25. Rabinowitz R. The importance of the cremasteric reflex in acute scrotal swelling in children. J of Urol. 1984;132(1):89-90. (Retrospective; 245 patients)
  26. Hughes ME, Currier SJ, Della-Giustina D. Normal cremasteric reflex in a case of testicular torsion. Am J Emerg Med. 2001;19:241–242. (Case report)
  27. Practice Guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: A report by the American Society of Anesthesiologist:Task Force on Preoperative Fasting. Anesthesiology 1999;90:896-905. (Guidelines)
  28. Schoenfelder RC, Ponnamma CM, Freyle D, et al. Residual gastric fluid volume and chewing gum before surgery. Anesth Analg. 2006 Feb;102(2):415-417. (Prospective randomized study; 46 subjects)
  29. Haj M, Shasha SM, Loberant N, et al. Effect of external scrotal cooling on the viability of the testis with torsion in rats. Eur Surg Res. 2007;39:160-169. (Animal study)
  30. Miller DC, Peron SE, Keck RW, et al. Effects of hypothermia on testicular ischemia. J Urol. 1990;143(5):1046-1048. (Animal study)
  31. Eaton SH, Cendron MA, Estrada CR, et al. Intermittent testicular torsion: diagnostic features and management outcomes. J Urol. 2005;174(4):1532-1535. (Retrospective; 50 patients)
  32. Hayn MD, Herz DB, Bellinger MF, et al. Intermittent torsion of the spermatic cord portends an increased risk of acute testicular torsion. J Urol. 2008;180:1729-1732. (Retrospective; 47 patients)
  33. Corriere JN. Horizontal lie of the testicle: a diagnostic sign in torsion of the testis. J Urol. 1972;107(4):616-617.
  34. Schulsinger D, Glassberg K, Strashun A. Intermittent torsion: association with horizontal lie of the testicle. J Urol. 1991;145(6):1053-1055. (Case report; 3 patients)
  35. Doehn C, Fornara P, Kausch I, et al. Value of acute-phase proteins in the differential diagnosis of acute scrotum. Eur Urol. 2001;39(2):215-221. (Retrospective; 104 patients)
  36. Asgari SA, Mokhtari G, Falahatkar S, et al. Diagnostic accuracy of C-reactive protein and erythrocyte sedimentation rate in patients with acute scrotum. Urol J. 2006;3(2):104-108. (Prospective; 120 patients)
  37. Rivers KK, Rivers EP, Stricker HJ, et al. The clinical utility of serologic markers in the evaluation of the acute scrotum. Acad Emerg Med. 2000;7(9):1069-1072. (Prospective; 25 patients)
  38. Rupp TJ. Testicular torsion. Emedicine.com. Updated 2010. (Review)
  39. Holder LE, Melloul M, Chen D. Current status of radionuclide scrotal imaging. Semin Nucl Med. 1981;11(4):232-249. (Review)
  40. Chen DC, Holder LE, Melloul M. Radionuclide scrotal imaging: further experience with 210 new patients. Part 2: results and discussion. J Nucl Med. 1983;24(9):841-853. (Prospective; 210 patients)
  41. Fenner MN, Roszhart DA, Texter JH. Testicular scanning: evaluating the acute scrotum in the clinical setting. Urology. 1991;38:237-241. (Retrospective; )
  42. Melloul M, Paz A, Lask D, et al. The value of radionuclide scrotal imaging in the diagnosis of acute testicular torsion. Br J Urol. 1995;76:628-631. (Prospective; 87 patients)
  43. Hod N, Maizlin Z, Strauss S, et al. The relative merits of Doppler sonography in the evaluation of patients with clinically and scintigraphically suspected testicular torsion. Isr Med Assoc J. 2004;6:13-15. (Prospective; 75 patients)
  44. Steinhardt G, Boyarsky S, Mackey R. Testicular torsion: pitfalls of color Doppler sonography. J Urol. 1993;150:461-462. (Case report; 2 patients)
  45. Allen T, Elder J. Shortcomings of color Doppler sonography in the diagnosis of testicular torsion. J Urol. 1995;154:1508–1510. (Case series; 5 patients)
  46. Ingram S, Hollman A, Azmy A. Testicular torsion missed diagnosis on colour Doppler sonography. Pediatr Radiol. 1993;23(4):483. (Case report)
  47. Middleton WD, Siegel BA, Melson GL, et al. Acute scrotal disorders: prospective comparison of color Doppler US and testicular scintigraphy. Radiology. 1990;177(1):177-181. (Prospective; 28 patients)
  48. Nussbaum Blask AR, Bulas D, Shalaby-Rana E, et al. Color Doppler sonography and scintigraphy of the testis: a prospective, comparative analysis in children with acute scrotal pain. Pediatric Emerg Care. 2002;18(2):67-71. (Prospective; 46 patients)
  49. Waldert M, Klatte T, Schmidbauer J, et al. Color Doppler sonography reliably identifies testicular torsion in boys. Urology. 2010;75(5):1170-1174. (Retrospective; 298 patients)
  50. Kalfa N, Veyrac C, Lopez M, et al. Multicenter assessment of ultrasound of the spermatic cord in children with acute scrotum. J Urol. 2007;177:297-301. (Retrospective; 919 patients)
  51. Baker LA, Sigman D, Mathews RI, et al. An analysis of clinical outcomes using color Doppler testicular ultrasound for testicular torsion. Pediatrics. 2000;105:604-607. (Retrospective; 130)
  52. Guidelines on Paediatric Urology. http://www.uroweb.org/fileadmin/tx_eauguidelines/2009/Full/Paediatric_Urology.pdf. Last visited September 8, 2011. (Guideline)
  53. Roche AE. Torsion of the spermatic cord. In: Urology in General Practice. London: H.K. Lewis and Co Ltd.; 1935;238-264. (Textbook)
  54. Kass JK, Stone KT, Cacciarelli AA, et al. Do all children with an acute scrotum require exploration? J Urol. 1993;150:667-669. (Prospective; 77)
  55. Puri P, Burton D, O’Donnel B. Prepubertal testicular torsion: subsequent fertility. J Pedatr Surg. 1985;20:598. (Retrospective; 18 patients)
  56. Nagler HM, White RD. The Effect of Testicular Torsion on the Contralateral Testis. J Urol. 1982;128:1343-1348. (Animal study, prospective, controlled)
  57. Mor Y, Pinthus JH, Nadu A, et al. Testicular fixation following torsion of the spermatic cord-does it guarantee prevention of recurrent torsion events? J Urol. 2006; 2006;175(1):171-174. (Retrospective; 179)
  58. Gesino A, Bachman De Santos ME. Spermatic cord torsion after testicular fixation. A different surgical approach and a revision of current techniques. Eur J Pediatr Surg. 2001;11:404. (Prospective; 100 operations)
  59. Frank JD, O’Brien M. Fixation of the testis. BJU Int. 2002;89:331. (Review)
  60. Kutikov A, Casale P, White MA, et al. Testicular compartment syndrome: a new approach to conceptualizing and managing testicular torsion. Urology. 2008;72:786-789. (Prospective; 3 patients)
  61. Kolski JM, Mazolewski PJ, Stephenson LL, et al. Effect of hyperbaric oxygen therapy on testicular ischemia-reperfusion injury. J Urol. 1998;160:601-604. (Prospective, animal study)
  62. Cornel EB, Karthaus HFM. Manual derotation of the twisted spermatic cord. BJU Int. 1999;83:672-674. (Retrospective; 17 patients)
  63. Caldemone AA, Valvo JR, Rabiowitz R, et al. Acute Scrotal Swelling in Children. J Ped Surg. 1984;19(5):581-584. (Retrospective; 150 patients)
  64. Sessions AE, Rabinowitz R, Hulbert WC, et al. Testicular Torsion: Direction, Degree, Duration and Disinformation. J Urol. 2003;169:663-665. (Retrospective; 186 cases)
  65. Sonda LP, Lapides J. Experimental torsion of the spermatic cord. Surg Forum. 1961;12:502-504. (Prospective, animal study; 186 cases)
  66. Frazier WJ, Bucy JG. Manipulation of torsion of the testicle. J Urol. 1975;114:410-411.
  67. Harvey M, Chanwai G, Cave G. Manual testicular detorsion under propofol sedation. Case Report Med. 2009;2009:529346. Epub 2009 Oct 8. (Case report)
  68. Payabvash S, Salmasi AH, Kiumehr S, et al. Salutary effects of N-acetylcysteine on apoptotic damage in a rat model of testicular torsion. Urol Int. 2007;79:248-254. (Prospective, animal study)
  69. Avlan D, Erdougan K, Cimen B, et al. The protective effect of selenium on ipsilateral and contralateral testes in testicular reperfusion injury. Pediatr Surg Int. 2005;21:274-278. (Prospective, animal study)
  70. Beheshtian A, Salmasi AH, Payabvash S, et al. Protective effects of sildenafil administration on testicular torsion/detorsion damage in rats. World J Urol. 2008;26:197-202. (Prospective, animal study)
  71. Cosentino MJ, Nishida M, Rabinowitz R, et al. Histological changes occurring in the contralateral testes of prepubertal rats subjected to various duration’s of unilateral spermatic cord torsion. J Urol. 1985;133(5):906-911. (Prospective; animal study)
  72. Ozkan KU, Kucukaydin M, Muhtaroglu S, et al. Evaluation of the contralateral testicular damage after unilateral testicular torsion by serum inhibin B Levels. J Ped Surg. 2001;36:1050-1053. (Prospective; animal study)
  73. Madgar B, Lunenfeld S, Mashiach B, et al. Effect of testicular torsion on contralateral testis and fertility in mature rats. Arch Androl. 1987;19(3):237-241. (Prospective; animal study)
  74. Arap MA, Vicentini FC, Cocuzza M, et al. Late hormonal levels, semen parameters, and presence of antisperm antibodies in patients treated for testicular torsion. J Androl. 2007;28(4):528-532. (Retrospective;24 patients)
  75. Macnicol, MF. Torsion of the testis in childhood. Br J Surg. 1974;61(11):905-908.
  76. Woodruff DY, Horwitz G, Weigel J, et al. Fertility preservation following torsion and severe ischemic injury of a solitary testis. Fertil Steril. 2010;94:352.e4-e5. (Case report)
  77. Matterson JR, Stock JA, Nagler HM, et al. Medicolegal Aspects of Testicular Torsion. Urology. 2001;57:783-786. (Retrospective; 39 cases)
  78. Authors’ personal communication with State Volunteer Mutual Insurance Company of Tennessee in November 2010.
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Martin I. Herman; Jonathan Jacobs

Publication Date

October 1, 2011

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