Article, Pediatrics

Clinical predictors for testicular torsion as seen in the pediatric ED

Original Contribution

Clinical predictors for testicular torsion as seen in the pediatric ED

Tali Beni-Israel MD a,b, Michael Goldman MD b,c,

Shmual Bar Chaim MD a,b, Eran Kozer MD a,b,?

aPediatric emergency unit, Assaf Harofeh Medical Center, Sackler School of Medicine, Tel Aviv University,

Zerifin 70300, Israel

bAssaf Harofeh Medical Center, Sackler School of Medicine, Tel Aviv University, Zerifin 70300, Israel

cPediatric Ward B Assaf Harofeh Medical Center, Zerifin 70300, Israel

Received 15 March 2009; accepted 31 March 2009

Abstract

Objective: The aim of the study was to identify clinical findings associated with increased likelihood of testicular torsion (TT) in children.

Design: This study used a retrospective case series of children with acute scrotum presenting to a pediatric emergency department (ED).

Results: Five hundred twenty-three ED visits were analyzed. Mean patient age was 10 years 9 months. Seventeen (3.25%) patients had TT. Pain duration of less than 24 hours (odds ratio [OR], 6.66; 95% confidence interval [CI], 1.54-33.33), nausea and/or vomiting (OR, 8.87; 95% CI, 2.6-30.1), abnormal

Cremasteric reflex (OR, 27.77; 95% CI, 7.5-100), abdominal pain (OR, 3.19; 95% CI, 1.15-8.89), and high position of the testis (OR, 58.8; 95% CI, 19.2-166.6) were associated with increased likelihood of torsion.

Conclusions: Testicular torsion is uncommon among pediatric patients presenting to the ED with acute scrotum. Pain duration of less than 24 hours, nausea or vomiting, high position of the testicle, and abnormal cremasteric reflex are associated with higher likelihood of torsion.

(C) 2010

Background

Acute scrotum and testicular pain are common presenting symptoms in pediatric emergency departments (EDs) [1].

Presented (in part) at the13th annual assembly of the Israeli Society for Emergency Medicine, Tel Aviv, March 2008, and at the annual assembly of the Israeli Society for Clinical Pediatrics (CHIPAK), Tel Aviv, February 2009.

* Corresponding author. Pediatric Emergency Medicine, Assaf Harofeh

Medical Center, Zerifin 70300, Israel. Tel.: +972 8 9778131; fax: +972 8

9779138.

E-mail address: [email protected] (E. Kozer).

Distinction between testicular torsion (TT) and other causes of pain is of critical importance because timely surgical exploration is indicated in cases of TT to preserve the affected testicle. Unfortunately, the clinical signs of acute epididymitis, torsion of appendix testis, and TT overlap and clinical distinction are extremely difficult in many cases.

The true incidence of the various causes of acute scrotum and testicular pain in children needs to be elucidated. Many case series of patients with acute scrotum [2-9] found a high incidence of TT, ranging from 17% to 72%. These case series were mainly reported from surgical and urology departments and probably do not reflect the true patient mixture of the ED. Indeed, other studies [1,10-12] performed in an ED

0735-6757/$ - see front matter (C) 2010 doi:10.1016/j.ajem.2009.03.025

setting found lower incidences of TT, ranging from to 12% to 16% . Our Clinical impression was that the incidence of TT is even lower. The objective of the current study was to describe the incidence of the various causes of acute scrotum as seen in the pediatric ED and to identify clinical findings associated with increased likelihood of TT.

Methods

Design

The study used retrospective case series. The hospital research ethics board approved the study protocol.

Setting

The study was done at the ED of Assaf Harofeh medical center, a university-affiliated hospital in central Israel.

Patients

All children aged 1 week to 18 years presenting to the pediatric ED between January 1, 2005, and August 31, 2007, complaining of testicular pain or acute scrotum of less than 1 week of duration.

Methods

Patients were identified using the computerized emer- gency logbook that includes coded diagnoses for all patients. Patients were selected for detailed chart review if one of the following diagnoses was recorded: 608, acute scrotum; 604, epididymitis/orchitis; 6089, torsion of testis; and 6082, other male genital disease.

Patients were evaluated in the ED by the attending pediatrician or senior pediatric resident. Urologic consulta- tion was obtained at the discretion of the senior pediatrician. The decision to perform Doppler sonography was taken by either the pediatrician or the urologic consultant. The results of Doppler sonography were first read by the on-call radiologist and subsequently by a senior radiologist.

One fifth-year medical student (TB) was responsible for data extraction. She reviewed ED charts and, when applicable, patient’s admission charts, and extracted the data into a database. The database included information about patients’ demographics, history, physical examination, Laboratory workup, imaging, diagnosis, and treatment. When needed, the data or whole chart were reviewed by one of the senior investigators (EK).

Data gathered for history included duration of symptoms, associated symptoms, history of trauma, previous episodes of pain, medications, Sexual activity (depending on age), and other medical problems. Aspects of the physical examination that were investigated included the side of the involved

testicle, presence of erythema, swelling, tenderness over the testicle and epididymis, position of the testicle, blue dot sign, urethral discharge, and the presence of a normal cremasteric reflex. Absent or reduced cremasteric reflex was considered as abnormal.

Urinalysis was performed in the ED by using a Urine dipstick (Combur10 test M, Roche, Mannheim, Germany). For analysis purpose, the test was considered abnormal if leukocytes were 2+ (N25/uL); erythrocytes, 2+ (N10/uL); or protein, 2+ (N30 mg/dL).

The diagnosis we used for analysis was the diagnosis recorded on the ED discharge form if the patient was discharged from the ED or the hospital discharge letter for admitted patients.

Analysis

Descriptive statistics were used to describe the study population. The relation between historical and clinical characteristics and TT was first tested by single variant analysis. The ?2 or Fisher exact tests were used for categorical variables and the Student t test or Mann-Whitney test (as appropriate) for continuous variables.

Results

Initial search revealed 783 ED visits with the aforemen- tioned diagnoses. Of these, 740 (94.5%) charts were available for review. Two hundred seventeen patients did not meet the inclusion criteria. Most patients who did not

Table 1 Demographics and symptoms of patients presenting to the ED with acute scrotum

Patient details

Age (y +- SD) Ethnic origin

  • Jewish
  • Arab History
  • Previous episodes of acute scrotum
  • Sexually active
  • Scrotal trauma Pain duration
  • b6 h
  • 6-12 h
  • 12-24 h
  • N24 h

Associated symptoms

  • Abdominal pain
  • Dysuria
  • Nausea and/or vomiting
  • Fever (N38?C)
  • Urethral discharge

n = 523 (%)

10.75 (+-5)

485 (92.7%)

38 (7.3%)

78 (14.9%)

21 (4%)

88 (16.8%)

106 (20.3%)

83 (15.9%)

90 (17.2%)

243 (46.5%)

79 (15.1%)

31 (5.9%)

20 (3.8%)

18 (3.4%)

2 (0.4%)

Diagnosis

n (%)

Epididymitis

169

(32.3%)

Scrotal pain of unknown etiology

178

(34%)

Trauma

47

(9%)

Torsion of appendix testis

40

(7.7%)

Other

24

(4.7%)

Torsion of testis

17

(3.3%)

Idiopathic scrotal edema

16

(3%)

Varicocele

20

(3.7%)

Hydrocele

8

(1.5%)

meet the inclusion criteria were coded as “other male genital disease” and had conditions such as penile swelling (40 patients), circumcision complications (28 patients), dysuria (26 patients), and others.

Table 2 Final diagnosis in patients presenting to the ED with acute scrotum

Four hundred ninety-two patients met the inclusion criteria, of which 31 patients were seen twice, and therefore, 523 ED visits were included in the final analysis. The mean patient age was 10 years 9 months (+-59 months) ranging from 3.5 months to 18 years. The demographics and clinical findings of the study population are presented in Table 1.

Ultrasonography was performed in 356 patients (68%) and scintography in 8 (1.5%) patients. Thirty-eight patients (7.3%) were admitted, and 22 underwent surgical explora- tion. Of these, 17 (3.25%) were diagnosed with TT. Orchiectomy was performed in 3 cases. None of the patients discharged from the ED returned with TT.

In most cases, the diagnoses of epididymitis or torsion of appendix testis were based on the clinical examination combined with Doppler sonography findings. The final diagnoses at discharge from the ED are presented in Table 2. In a univariate analysis (Table 3), the following variables were associated with increased likelihood of TT: pain duration of less than 24 hours (OR, 6.66; 95% CI, 1.54-

33.33), nausea and/or vomiting (OR, 8.87; 95% CI, 2.6-

30.1), abdominal pain (OR, 3.19; 95% CI, 1.15-8.89), high position of the testicle (OR, 58.8; 95% CI, 19.1-166.6), and abnormal cremasteric reflex (OR, 27.77; 95% CI, 7.5-100.0).

Discussion

In this large series of children presenting to the pediatric ED with acute scrotum, the prevalence of TT was only 3.25%. Pain duration of less than 24 hours, the presence of nausea or vomiting, high position of the testicle, and abnormal cremasteric reflex were associated with higher likelihood of TT.

The incidence of TT in the current study was lower than in previous reports [1-12]. There are several possible explana- tions for this difference. The current study included all children presenting with acute scrotal symptoms, including

those presenting with testicular pain with no abnormalities on physical examination. In such patients, the incidence of TT may be lower. The setting in which the study was conducted is another possible explanation for the relatively low incidence of TT. Studies conducted in the surgical or urologic wards [2-5,7-9] reported a very high incidence of

TT. The final diagnosis in those studies was based in most cases on surgical exploration. Although the final diagnosis was based on the “gold standard” (ie, surgery), the patient population in those studies does not represent the typical child presenting to the ED with immediate onset of scrotal symptoms. Indeed, studies conducted in the ED setting [1,10-12] reported lower incidences of TT, although still higher than the current study. The low incidence of TT in the current study, one of the largest conducted so far, may also reflect differences in referral patterns in Israel compared to other countries.

We identified 4 variables associated with increased likelihood of TT. As in previous studies [4,8,11,13], pain duration of less than 24 hours was associated with increased likelihood of TT. The shorter duration of pain in patients with TT probably reflects the ischemic nature of the pain. Similar to the findings of Ciftci [14], Jefferson [3], and Knight [4], the presence of nausea and/or vomiting was also associated with increased likelihood of TT.

Previous series involving 90 [11] and 245 [15] children found an abnormal cremasteric reflex in 100% of the patients with TT. In the current study, which included more than 500 ED visits, 5 of the 17 patients with TT had a normal cremasteric reflex. Our findings are similar to the findings

Table 3 Univariate analysis for variables associated with TT

Laboratory findings

  • Abnormal urinalysis

2.48

0.68-9

Variable

OR

95% CI

From the history

  • Duration of symptoms of b24 h

6.66

1.54-33.33
  • Previous episodes of testicular

2.44

0.84-7.12

pain or acute scrotum

  • Nausea and/or vomiting 8.87 2.6-30.1
  • Fever (temperature, N38?C) 0.16 0-6.7
  • Abdominal pain 3.19 1.15-8.89
  • Sexual activity 0.84 0.11-6.67
  • Trauma of testis 0.65 0.15-2.9

From the physical examination

  • Involvement of right testicle 0.89 0.33-2.33
  • High position of the testis 58.8 19.2-166.6
  • Abnormal (absent or reduced) 27.77 7.5-100

cremasteric reflex

  • Erythema of scrotum

1.37

0.47-3.95
  • Testicular tenderness

1.69

0.38-7.61
  • Swollen testis

2.57

0.87-7.64
  • Tenderness over the epididymis

2.53

0.26-24.69
  • Blue dot sign

0.37

0-5.82
  • Urethral discharge

0.15

0-61

of Van Glabeke [9] and Karmazyn [13] and suggest that the presence of a normal cremasteric reflex does not rule out TT. High position of the testicle is expected in patients with TT, yet this finding was noted in only half of the patients with

TT. It is possible that this sign was missed in some of the children because there are some differences in height between the 2 testicles in all children.

Although no single clinical finding had 100% sensitivity for the presence of TT, all patients with TT had 1 or more of the 4 identified risk factors (ie, nausea or vomiting, pain duration of less than 24 hours, high position of the testis, and abnormal cremasteric reflex) for TT. The absence of these 4 clinical variables has a very high negative predictive value for TT.

Murphy and his colleagues [16] reviewed 121 patients with acute scrotum and concluded that clinical findings could not differentiate between patients with TT and those with other causes of testicular pain. They also found Doppler sonography to be unreliable and suggested that all children presenting with acute scrotum should undergo surgical exploration. The low sensitivity of ultrasonography in Murphy’s study is in contrast to many other studies [17,18], which reported a negative predictive value for TT of normal Doppler sonography of 92% to 97%. Applying Murphy’s approach to our population would result in an unacceptable number of superfluous operations.

A significant limitation of the current study was that in one third of the cases the cause of testicular pain could not be determined. In many other cases, the diagnosis was based on Doppler sonography that cannot provide a definitive diagnosis. Similar to previous reports [11], sonography was not performed in all cases, and theoretically, some of these patients could have had TT. However, none of the patients who were discharged from the ED without sonography returned with TT. We do not know if any of these patients was treated in another hospital.

Distinction between torsion of the appendix testis and epididymitis was based mainly on Doppler sonography results. One should remember that, in many cases, such a distinction is impossible or not reliable. Because epididymi- tis in prepubertal children is usually noninfectious, such distinction is less important in the ED.

In conclusion, acute scrotum and scrotal pain are common causes of presentation to the pediatric ED. Less than 5% of these patients have TT. Short duration of pain, nausea and vomiting, high position of the testis, and abnormal cremasteric reflex are associated with increased risk of TT, and in such cases, physicians should rule out the presence of

TT. We cautiously suggest that in selected patients presenting with acute scrotum or scrotal pain in the absence of these 4 variables TT can be ruled out without further studies.

Acknowledgment

This work was performed in partial fulfillment of the requirements for a Doctor of Medicine degree of Tali Beni-Israel, Sackler Faculty of Medicine, Tel Aviv University, Israel.

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