Evidence-Based Diagnosis And Treatment Of Torsion Of The Spermatic Cord In The Pediatric Patient
0
TOC Will Appear Here

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

1,746 views
Below is a free preview. Log in or subscribe for full access. Or, get a free sample article ED Assessment and Management of Pediatric Acute Mild Traumatic Brain Injury and Concussion:
Please provide a valid email address.
Table of Contents
 
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal Of The Literature
  5. Epidemiology
  6. Developmental Anatomy
  7. Etiology
  8. Presentation
  9. Differential Diagnosis
  10. Prehospital Care
  11. Emergency Department Evaluation
    1. History
    2. Physical Examination
  12. Laboratory Studies
  13. Imaging Studies
  14. Treatment
    1. Surgical Management
    2. Nonsurgical Management
      1. Detorsion Procedure
      2. Pharmaceutical Treatment
  15. Outcomes
  16. Medicolegal Concerns
  17. Summary
  18. Risk Management Pitfalls In The Emergency Treatment Of Torsion Of The Spermatic Cord
  19. Case Conclusion
  20. Clinical Pathway: Treatment Of The Acute Scrotum
  21. Tables and Figures
    1. Table 1. Differential Diagnosis of Testicular Torsion
    2. Figure 1. Bell Clapper Deformity
    3. Figure 2. The Acute Scrotum In Children
    4. Figure 3. Acute Torsion (High-riding, Horizontal Lie)
    5. Figure 4. Acute Scrotal Hematocele
    6. Figure 5. Infarcted Testis
    7. Figure 6. Results Of Seminal Analysis After Unilateral Orchidopexy For Torsion
    8. Figure 7. Testicular Survival From Onset of Pain To Surgery
  22. References

Abstract

The incidence of acute torsion of the spermatic cord (TOSC) has been estimated to be 4.5 cases per 100,000 population.1 Others have cited an annual incidence of 1 in 4000 males under 25.2 While not especially common in the emergency department (ED), these cases are important to the patient, the clinician, and the consultants who might be needed. Sorting out the etiology can be vexing. Doing so frequently involves not only examination but also imaging and consultation with surgery or urology colleagues. When faced with an acutely swollen and painful scrotum, the surgeon must decide quickly whether or not to explore the scrotum, and if a testicular torsion is found, choose between testicular salvage and removal. Both decisions can have consequences for the patient. The outcome for the patient is as dependent on the time elapsed from the onset of the attack, as it is on the decisions of the surgeon.

Case Presentations

A 14-year-old, previously healthy male presents to the ED on a typically busy Friday evening complaining of scrotal pain that started 2 days ago. His mom is visibly upset and states that the patient was taken to his primary pediatrician 2 days ago for a separate complaint, but he denied having pain despite being asked if anything else was bothering him. When questioned, the patient states he did have scrotal pain at that time, but he was too embarrassed to say anything. Further history reveals that the pain was acute in onset, sharp, left-sided, and has progressively gotten worse. He denies dysuria or other urinary complaints, and there have been no fever or chills. The patient denies suffering any trauma. He admits to nausea but has not vomited. The remainder of the review of systems is negative. The physical examination is remarkable for a tender, swollen left hemiscrotum. The left testis is high-riding compared to the right, and the patient fails to display a cremasteric reflex on the affected side. The right testis is nontender, and the remainder of the examination is noncontributory. You inform the patient’s mom of the likely diagnosis and of your plan to obtain an ultrasound and consult urology. As you walk down the hall, your mind is racing. Is this testicular torsion? What else could it be? How will you determine the diagnosis definitively? Is there something you should be doing right now? You have heard some people say that an attempt to manually detorse is indicated. Is that true? Can it make matters worse? If you do decide to do it, which way should you try to flip the testis? Will ultrasound guidance help you choose the best direction? You also realize the clock is ticking. How long has the problem been going on? When will the function of the organ become irreparably damaged? Is there a time limit on how long the testis itself can survive a torsion of its blood supply? What diagnostic studies should you order? Should you notify the urology 2011service now or wait till you know the diagnosis? Are there any pharmaceuticals you should administer to minimize the injury? If this teen had spoken up sooner, would the outcome have been affected? What should you do first?

Introduction

Acute scrotal emergencies are not the most frequent crisis faced in an emergency department (ED). It is said that an acute scrotum occurs with 1/20th of the frequency of an acute abdomen.3 Cincinnati Children’s Hospital found that in a 2 year period, there were 238 acute scrotal emergencies which represented only 0.13 % of their ED patients.4 The incidence of acute TOSC has been estimated to be 4.5 cases per 100,000 population.1 Others have cited an annual incidence of 1:4000 males under 25, with torsion presenting most often during 2 time periods of a males life. The first peak in incidence involves those under a year of age, and the second peak occurs around age 13.2,5 These cases are important to the patient, the clinician, and the consultants who might be needed. Sorting out the etiology can be vexing. Doing so frequently involves not only examination but also imaging and consultation with surgery or urology colleagues. When faced with an acutely swollen and painful scrotum, the surgeon must decide quickly whether or not to explore the scrotum. If a testicular torsion is found, the surgeon must choose between testicular salvage and removal. Both decisions can have consequences for the patient.

This month’s issue of Pediatric Emergency Medicine Practice will delve into the problem of the male with a possible TOSC. The authors examine existing literature to develop a strong strategy for clinicians that explains what to do and when to do it in the diagnosis and treatment of TOSC.

Critical Appraisal Of The Literature

Ovid MEDLINE® and PubMed were searched for literature published in core English-language clinical journals from 1970-2010 on the subject of human subjects aged 1 month to 18 years with TOSC. Search terms included torsion, testicular cord, and spermatic cord. Results containing patients with neonatal testicular torsion were excluded. This search resulted in 640 articles. Modifiers were added in order to filter the search. “Diagnosis” resulted in 160 articles, “treatment” in 119, “incidence” in 56, “ultrasound” in 65, “risk factors” in 19, and “outcomes” in 14. These lists were reviewed for appropriate articles as were the reference pages of thorough review articles and other papers related to testicular torsion.

Risk Management Pitfalls In The Emergency Treatment Of Torsion Of The Spermatic Cord

  1. “I didn’t think I needed to perform a genital examination in a crying infant.” Remember that the incidence of torsion is high in the first year of life, decreasing in incidence until the pubertal years, 14 and up.
  2. “I didn’t consider acute torsion in my patient with abdominal pain.” Risk factors for TOSC include recent trauma, sexual activity, exposure to cold, cryptorchidism, recurrent episodes of testicular or scrotal pain, abdominal pain, nausea, and/or vomiting.
  3. “My patient has abdominal pain and vomiting, but he has a normal appearing scrotum, so it can’t be torsion of a cryptorchid testis.” Though the absence of rugae usually indicates cryptorchid testis, cases do exist where the patient’s testes appeared normal.
  4. “I performed manual detorsion, and my patient immediately felt relief. The procedure was 100% successful.” Even with ultrasound guidance and palpable relief of torsion, some twist may persist. Even if the twist is 100% relieved, the chance that the patient will have a bell clapper deformity of the involved testis is high, not to mention the chance that the contralateral testis is also abnormally secured in its hemiscrotum.
  5. “I untwisted a torsed spermatic cord after giving my patient an inguinal block with lidocaine. I thought that the pain relief signaled a successful procedure.” Since the nerve is blocked, pain cannot be used as a guide to the success or failure of the procedure.
  6. “My patient has complained of pain before, but it was awhile ago and it doesn’t happen regularly.” Failure to recognize recurrent episodes of pain may herald torsion. Many patients have a history of similar pain that remits spontaneously before actually presenting with a twist requiring surgery. These patients may benefit from an orchiopexy even if they haven’t had unremittant torsion.
  7. “My patient’s testis was pink and vibrant in the scrotum after torsion, so the testis was left intact.” Studies have demonstrated adverse effects on the contralateral testis presumably from antibodies against normal testicular cells formed after an ischemic event.
  8. “This patient had no cremaster reflex, so I ruled out torsion of the spermatic cord.” While the presence of a cremaster reflex was 100% sensitive in one study, the sample size may not have been large enough to generalize these findings to all cases with all examiners.21 The wiser choice is to back up your diagnosis with an imaging study like color Doppler sonography of the scrotum.
  9. “I never realized that pyuria does not rule out torsion.” Yes, pyuria is found most often in patients with acute epididymitis; some patients with torsion may have pyuria.
  10. “I relied on Prehn sign to rule out torsion and rule in epididymitis.” Prehn sign (relief of scrotal pain with elevation of the sac) is only 45% sensitive, meaning it can’t rule out torsion in over half of the cases.

Tables and Figures

Table 1. Differential Diagnosis of Testicular Torsion

References

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.
  79. Krarup T. Torsion Of The Testis. Ugeskr Laeger. 1976;138(12):729-734.
Already purchased this course?
Log in to read.
Purchase a subscription

Price: $449/year

140+ Credits!

Money-back Guarantee
Publication Information
Authors

Martin I. Herman; Jonathan Jacobs

Publication Date

October 1, 2011

Get Permission

Get A Sample Issue Of Emergency Medicine Practice
Enter your email to get your copy today! Plus receive updates on EB Medicine every month.
Please provide a valid email address.