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Intermittent testicular torsion in a 5-year-old boy who presented with left scrotal pain. (a) After spontaneous detorsion, the left testicular blood flow is increased. (b) Findings at scrotal exploration show traces of twisting.
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As testicular torsion is a medical emergency, it requires quick diagnosis and treatment. Color Doppler ultrasound (CDUS) is useful for the diagnosis of testicular torsion. An accurate diagnosis can be difficult when CDUS indicates the preservation of blood flow in the testis. We examined the accuracy of testicular torsion diagnosis in patients with...
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A male neonate born at gestational age of 40 weeks was found to have an enlarged and darkened right hemiscrotum after birth. Left testicle was descended and normal. No clinical signs of distress were evident. A color Doppler ultrasound showed an absence of testicular blood flow, consistent with perinatal testicular torsion. The patient underwent a...
Citations
... If DUS reveals a loss of blood flow, it signifies prolonged ischemia in the patient's testicle, reducing the likelihood of testicular salvage and increasing the risk of orchidectomy. Scrotal exploration should be promptly conducted, even though testicular blood flow is observed, when there is suspicion of TT based on medical history and physical examination findings 22 . Manual detorsion can alleviate ischemia, providing immediate symptom relief. ...
This study aimed to investigate the clinical and social factors of delayed treatment for testicular torsion (TT) and to explore the risk factors of testicular excision in China. The clinical data of 1005 patients with TT who were admitted to 48 medical institutions in Chongqing city (China) from January 2012 to December 2021 were retrospectively analyzed. It was revealed that the misdiagnosis rates of non-senior (junior and middle) grade doctors and senior doctors were 25.1% and 9.6%, respectively. The proportion of TT patients who received timely treatment (within 6 h after onset of symptoms) was 23.8%. The results of the multivariable logistic regression analysis indicated that absent cremasteric reflex was a protective factor for delayed surgery of more than 6 h from onset of symptoms to surgery. Misdiagnosis, consultation with a non-urologist as the first consultant doctor, absence blood flow in color Doppler ultrasound, negative high-riding testis findings, the presence of fever, and non-manual detorsion were identified as risk factors associated with delayed surgery (more than 6 h from the onset of symptoms) for TT. Furthermore, misdiagnosis, non-urologist first-consultant doctor, absent blood flow in DUS, non-manual detorsion, fever, degree of cord twisting > 180, and the initial diagnosis in tertiary hospitals were risk factors for orchidectomy. Having TT on the right side, and the presence of nausea and vomiting were identified as protective factors for orchidectomy. Technical training in the diagnosis and treatment of TT should be extended to primary hospitals and doctors to significantly improve their accuracy in managing this condition.
... Testicular torsion is usually diagnosed based on the presence of the following ultrasonographic findings [23][24][25][26][27]: ...
... Failure of manual detorsion is defined as residual spermatic cord twisting. The following ultrasonographic findings can be used to determine the success or failure of manual detorsion [13,17,24,25,27,34,61,66]. ...
Testicular torsion is a urological emergency caused by the loss of testicular tissue due to ischemic damage. Rapid diagnosis and urgent treatment play a crucial role in the management of testicular torsion. Manual detorsion can be performed at the bedside, thereby reducing the duration of ischemia. Recent studies have reported the use of point-of-care ultrasonography for diagnosing testicular torsion; however, no review article has focused on the ultrasonographic findings pertaining to manual detorsion. This review describes the diagnosis of testicular torsion and the ultrasonographic indications for manual detorsion. Spermatic cord twisting or the whirlpool sign, absence of or decreased blood flow within the affected testis, abnormal testicu-lar axis, abnormal echogenicity, and enlargement of the affected testis and epididymis due to ischemia are the sonographic findings associated with testicular torsion. The following findings are considered indications for manual detorsion: direction of testicular torsion, i.e., inner or outer direction (ultrasonographic accuracy of 70%), and the degree of spermatic cord twist. The following sonographic findings are used to determine whether the treatment was successful: presence of the whirlpool sign and the degree and extent of perfusion of the affected testis. Misdiagnosis of the direction of manual detorsion, a high degree of spermatic cord twisting and insufficient detorsion, testicular compartment syndrome, and testicular necrosis were found to result in treatment failure. The success of manual detorsion is determined based on the symptoms and sonographic findings. Subsequent surgical exploration is recommended in all cases, regardless of the success of manual detorsion.
... Biopsy is performed for both diagnostic and therapeutic purposes in the case of obtaining spermatozoa for assisted reproductive technologies. The biopsy was preceded by a mandatory ultrasound diagnosis of the portal system [15,18]. The biopsy was performed using the method of open operative access. ...
The most difficult form of male infertility to treat is azoospermia. It is identified as a complete absence of sperm in the ejaculate. Depending on the nature and causes of impaired spermatogenesis, azoospermia is divided into obstructive (excretory, OA) and non-obstructive (secretory, NOA). Testicular biopsy is the most effective method of diagnosis and a component of possible treatment for azoospermia. It is the only objective method of differential diagnosis between non-obstructive and obstructive forms of azoospermia. The aim: histological analysis of testicular biopsies of men with various forms of azoospermia. Мaterials and Methods. 78 infertile men with azoospermia were examined. They were divided into two groups: the first group, men with NOA (n = 28); the second group, men with OA (n = 50). The biopsy was preceded by a mandatory ultrasound diagnosis of the portal system. The biopsy was performed using the method of open operative access. Biopsies were mostly taken from the more palpable testicle or from both testicles. Biopsies were fixed in buffered 10% formalin (pH 7.2). After 1 day, they were dehydrated in 70% ethanol and embedded in paraffin. For histological studies, sections with a thickness of 5 μm were stained with hematoxylin and eosin. Biopsies were evaluated in accordance with previously described methods. Results. Histological analysis of testicular biopsies from 28.7% of patients with a non-obstructive form of azoospermia showed swelling of the testicular stroma, destructive changes in testosterone-producing cells, disruption of the structure of the syncytial complexes of the spermatogenic epithelium, and the complete absence of the process of spermatogenesis in individual tortuous seminiferous tubules, the absence of contacts between sustentocytes, and in erythrocyte sludge in the lumen of vessels. 42.8% of patients had fibrosis of the testicular stroma, stroma swelling, thinning of the wall of convoluted seminiferous tubules, violation of the structure of the syncytial complexes of the spermatogenic epithelium, proliferation of the wall of the convoluted seminiferous tubules into their lumen, and infiltration of the testicular stroma with lymphocytes. In 54.0% of patients with preserved spermatogenesis and an obstructive form of azoospermia, it was possible to find a history of orchoepididymitis in the anamnesis; one patient (2.0%) underwent bilateral orchopexy at the age of 5 years due to cryptorchidism; 6.0% recalled the trauma calculi in the anamnesis; and 38.0% denied any factors affecting fecundity in the anamnesis. Conclusions. The non-obstructive form of azoospermia is characterized by the following parameters: mostly a violation of the structure of the spermatogenic epithelium, a complete absence of the process of spermatogenesis in individual convoluted seminiferous tubules, a violation of the structure of the hematotesticular barrier, and a violation of blood microcirculation. The histological picture of preserved spermatogenesis is of the same type in 88.0% of patients with an obstructive form of azoospermia. In most tubules, a fixed number of cell rows is preserved, and cells of various stages of spermatogenesis are determined in them: spermatogonies, spermatocytes, a moderate number of spermatids. In the lumen of the tubules, exfoliated cells and a moderate number of spermatozoa are found.
... 9 15 However, our study showed that presence of testicular blood flow in US is common in TT cases (75 out of 180), suggesting high risk of false-negative errors in TT diagnosis. Other studies also suggest that blood flow in both testicles may look symmetrical with preserved arterial and venous flow and still represent TT. 22 23 Possible explanation for a high number of patients with TT with normal testicular blood flow by US could be the lack of diagnostic accuracy by doctors working in ED, 24 however in our case USS were performed by radiologists working in ED, although they are not subspecialised in paediatric radiology. Regardless, if patients wait for the US, and it shows normal blood flow, the paediatric surgeon will not be called immediately, although testicle might be torsed. ...
Background
We sought to determine which demographic, clinical and ultrasonography characteristics are predictive of testicular torsion (TT) and to determine factors associated with time to treatment.
Methods
We 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.
Results
A 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.
Conclusions
Pubertal 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.
... Even with complete testicular torsion where the degree of twisting is 360 degrees or greater usually resulting in absent testicular blood flow, situations may arise when the flow is preserved or decreased [19]. Therefore, the presence of intratesticular flow does not exclude testicular torsion, and scrotal exploration should not be delayed if the medical history (characteristic symptoms of testicular torsion and short duration of pain) and physical examination strongly suggest testicular torsion [7,19,20]. ...
Background: Testicular torsion poses a pediatric surgical emergency that necessitates rapid diagnosis and surgery to prevent testicular loss. We sought to determine whether any particular findings on Doppler ultrasound (US) were predictive of testicular viability in pediatric patients with testicular torsion.
Materials and Methods: We identified males ages 1-18 years who experienced testicular torsion over a 6-year period (January 1, 2015- December 31, 2020). All patients were evaluated at our Institution’s Emergency Department by a pediatric urologist and underwent a Doppler scrotal US.
Results: Of the 140 patients with testicular torsion, 56 (40%) had a non-viable testis and underwent an orchiectomy, while 84 (60%) had a viable testis and orchiopexy. Testicular heterogeneity (47 [84%] vs 48 [57%], p=0.001), epididymis heterogeneity (23 [41%] vs 21 [25%], p=0.063), and scrotal wall thickening (25 [45%] vs 5 [6%], p<0.001) were significantly associated with a non-viable testis. Epididymis heterogeneity (adj. OR=0.33 [0.13,0.79], p=0.013) and scrotal wall thickening (adj. OR=0.08 [0.03,0.24], p<0.001) exhibited a significantly lower odds for viability. Testicular heterogeneity and scrotal wall thickening were more likely to develop with a longer duration of symptoms (both p<0.001).
Conclusion: Our study determined that certain Doppler scrotal US findings, specifically, testicular and epididymal heterogeneity as well as a thickened scrotal wall are associated with testicular demise in patients with testicular torsion. As testicular heterogeneity and scrotal wall thickening are more likely to arise with a longer symptom duration, an urgent diagnosis and prompt surgical intervention are imperative to avert testicular loss.
... Radiology physicians are not always available in the hospital, and there may be concerns of emergency physicians about requesting ultrasonography. Also, ultrasonography may not be available in every healthcare institutions in low economic countries [2,3]. ...
Background and objectives: Infrared thermal (IR) camera is used to assess various clinical conditions such as diabetic foot, carotid artery stenosis, and superficial infection. The present study was designed to determine the usefulness of IR thermal camera in scrotal temperature measurement before color Doppler ultrasonography (CDUS) in patients admitted to the emergency department with acute scrotal pain.
Method: This study was prospectively conducted on 49 patients with acute scrotal pain and 30 control participants. The findings of CDUS and scrotal temperature measurements by an IR camera were separately evaluated by different physicians. In all patients, temperature measurements with IR camera were made under the same environmental conditions.
Results: Of the 49 patients included in the study, four were diagnosed with torsion, 12 with epididymitis, 4 with orchitis, 3 with epididymo-orchitis, and 2 with varicocele. A significant difference was observed between the scrotal temperature of the patients with scrotal pain and the mean testicular temperature of the control group based on the IR camera measurement (p
... On the other hand, removing the testicles that have the capacity to revive is also a bigger problem. Considering that Color Doppler ultrasound sensitivity is about 70% [29], the medical and legal consequences of removing intact testicular tissue can be troublesome for surgeons. Biopsy of testicular tissue during torsion surgery may be ethically objectionable, but if there is, appendix testicular tissue can be removed or a thin needle biopsy from the testicle itself can be taken more ethically and harmlessly. ...
Background and Objectives: It is of great importance to obtain information about the severity of ischemic damage and duration of testicular torsion for an effective treatment strategy. Nucleolar-organizing regions (NORs) are sites of the ribosomal genes composed of ribosomal DNA and proteins. Post-silver staining NORs are termed “AgNOR”. Since AgNORs clearly reveals the self-renewal potential of cells damaged in ischemic events, we performed the current study. Materials and Methods: The study was carried out in four groups as control, sham, early, and late T/D. In the surgical groups, testes were corrected after a 4-h ischemia period. Testicular tissue samples were taken on the third day after detorsion in group 1, 2, 3, and on the tenth day after detorsion in group 4. TUNEL and silver stainings were applied to all samples. Results: The differences were significant among the groups for both mean AgNOR number and total AgNOR area/total nuclear area (TAA/TNA). Moreover, the differences between control and early torsion-detorsion (T/D), between control and late T/D, between sham and early T/D, between sham and late T/D, and between early T/D and late were statistically significant for AgNOR amount. Furthermore, statistically significant differences among the groups for an average number of apoptotic cells per tubule and the percentage of apoptotic tubule values were detected. Discussion: The apoptotic index gives the ratio of cells that are damaged and will die in a programmed way and cells that remain intact, rather than show the viability of the returning testicle. However, by measuring cells that regenerate with AgNOR, we can show not only those that survive but also cells that can repair themselves. Conclusion: AgNOR proteins are usable for the early observation of ischemic injury levels. The amount of AgNOR protein can enlighten us about the extent of testicular damage after T/D treatment. It may also help the physician in the development of effective treatment strategies for cases.
... 6 Nakayama et al. had evaluated the on duty urology resident done ultrasound Doppler accuracy, they found that about 30 percent of the testicles which showed flow, actually had torsed testis in exploration. 21 Kalfa et al. had conducted a multicentric trail in 11 European university hospitals with 919 patients enrolled. 22 They have focused on high resolution ultrasound of the cord to find the twist and it has 96 % sensitivity and 99 % specificity and these are much higher than Doppler evaluation for intratesticular blood flow in detecting torsion (76 % sensitivity). ...
BACKGROUND Twisting of the spermatic cord resulting in ischemia of the testicles known as testicular torsion is a surgical emergency. Delay in diagnosis or surgery results in loss of testicles. Doppler ultrasound of scrotum is used in evaluating acute scrotum to support or rule out a diagnosis of torsion testis. Our study compares Doppler results with findings at exploration to finding out the accuracy of Doppler diagnosis in this scenario. METHODS This was a record based observational cross-sectional study. Out of all cases of acute scrotum presented to a tertiary care hospital over 14 months time, those patients with Doppler evaluation done were identified (n = 52) and their surgical findings were compared to the Doppler findings. Diagnostic accuracy of Doppler in diagnosing torsion testis was measured using sensitivity, specificity, accuracy, and predictive values. RESULTS Out of these 52 cases, 44 (84.6 %) were testicular torsion on exploration while remaining cases were epididymo-orchitis four (7.7 %) and testicular appendage torsion four (7.7 %). Among 44 cases of torsion testis, 31 (70.5 %) patients underwent orchiectomy (70.45 %) and in remaining 13 (29.5 %) orchiopexy was done. Sensitivity of Doppler to diagnose testicular torsion was 86.4 %, specificity was 87.5 % and accuracy was 86.54 %. Positive predictive value (PPV) was 97.4 % and negative predictive value (NPV) was 53.8 %. CONCLUSIONS Doppler ultrasound can be used as an adjunct to clinical findings in acute scrotum. High positive predictive value suggest that all Doppler diagnosed torsion should undergo emergency exploration as it will be correct in 97.5 % cases. If performing a Doppler study delays the definitive management, and if clinical findings are highly suggestive of testicular torsion, treating doctor can proceed to surgery without Doppler evaluation. KEY WORDS Doppler, Torsion Testis, Scrotum
... 6 Nakayama et al. had evaluated the on duty urology resident done ultrasound Doppler accuracy, they found that about 30 percent of the testicles which showed flow, actually had torsed testis in exploration. 21 Kalfa et al. had conducted a multicentric trail in 11 European university hospitals with 919 patients enrolled. 22 They have focused on high resolution ultrasound of the cord to find the twist and it has 96 % sensitivity and 99 % specificity and these are much higher than Doppler evaluation for intratesticular blood flow in detecting torsion (76 % sensitivity). ...
BACKGROUND Twisting of the spermatic cord resulting in ischemia of the testicles known as testicular torsion is a surgical emergency. Delay in diagnosis or surgery results in loss of testicles. Doppler ultrasound of scrotum is used in evaluating acute scrotum to support or rule out a diagnosis of torsion testis. Our study compares Doppler results with findings at exploration to finding out the accuracy of Doppler diagnosis in this scenario.
... A decrease in intratesticular perfusion starts with obstruction of venous outflow when the degree of spermatic cord twist is <360 • and cessation of arterial flow when the testis twists 360 • or greater, leading to the testicular ischaemia [6]. As time passes, the testis becomes enlarged and a complete absence of blood flow is observed by Doppler examination [6]. ...
... A decrease in intratesticular perfusion starts with obstruction of venous outflow when the degree of spermatic cord twist is <360 • and cessation of arterial flow when the testis twists 360 • or greater, leading to the testicular ischaemia [6]. As time passes, the testis becomes enlarged and a complete absence of blood flow is observed by Doppler examination [6]. Early and timely diagnosis and surgical intervention may salvage the affected testes; however, if there is an excessive delay in patient presentation, this approach will result in orchidectomy [6][7][8]. ...
... As time passes, the testis becomes enlarged and a complete absence of blood flow is observed by Doppler examination [6]. Early and timely diagnosis and surgical intervention may salvage the affected testes; however, if there is an excessive delay in patient presentation, this approach will result in orchidectomy [6][7][8]. Testicular torsion is diagnosed based on a careful physical examination and appropriate colour Doppler ultrasound (CDU) [9]. ...
Testicular torsion is a urologic emergency that requires surgical intervention. Its diagnosis is rarely made in elderly men especially the subset of men on urethral catheter. As a result, delayed diagnosis and surgical exploration occur leading to testicular infarction with necrosis, abscess formation and ultimately orchidectomy. We report a 73-year-old urologic patient referred with a 2-month history of transurethral catheterization to relieve retention of urine with subsequent scrotal pains and fever. Physical examination showed left hemi-scrotal swelling and normal right hemi-scrotal findings. A Doppler scan done showed an intratesticular fluid collection with no blood flow in the left testes. This case illustrates the need to include testicular torsion when diagnosing geriatric men with transurethral catheter presenting with any acute scrotal pains. We, therefore, recommend a detailed history and physical examination in addition to a colour Doppler ultrasound scan in making a diagnosis.
