Testicular Torsion: District Hospital Experience

There are many symptoms and signs of torsion with variable clinical significance. Also, we have noted variability between examiners, as some attribute greater importance to one point in the history or physical examination than others. The aim of this study was to review some history and physical findings of torsion and their diagnostic value.

Methods

  This retrospective study included all patients who underwent emergency scrotal exploration for suspected torsion in the period from 2013 to 2018. The study was carried out at Prince Hashim Bin Abdullah II Hospital (PHMH).

Patients were recruited from the operation room records of PHMH, then the patients’ files were reviewed. Information collected from the files included the name, age, month of presentation, previous history of scrotal pain attacks (suggesting intermittent torsion), duration of symptoms, side of involvement, Prehn sign status, cremasteric reflex status, lie of the involved testicle and operative findings.

Data were analysed using SPSS version 23 for Windows. Descriptive statistics and student’s t-tests were used for the mean and frequency calculations. The chi-square test and logistic regression were used for binary variables while linear regression was used for other variables. A P-value less than 0.05 was considered statistically significant. The sensitivity, specificity, predictive value and accuracy were calculated for some signs of torsion.

Results

   Of the 48 patients who underwent exploration for suspected torsion, 32 (67%) were found to have testicular torsion. The remaining 16 had other diagnoses, shown in Figure 1. Testicular torsion characteristics and some clinical features of patients are depicted in Table I. The mean age of patients was 17 years, with 50% aged between 13 and 20 years.

                                                               Figure 1: Distribution of patients according to intraoperative findings.

Table I: Characteristics of testicular torsion and clinical features of patients.

The duration of symptoms ranged from 1 to 120 hours, with most patients (75%) presenting before 12 hours. This duration strongly influenced the salvage rate of the torted testicle (P < 0.001). The salvage rates were 94.7%, 57.1% and 0% when the duration was less than 6 hours, from 6 to 12 hours and more than 12 hours, respectively (Figure 2).

                                                  Figure 2: Salvage rate according to the duration of symptoms.

Of the patients found to have torsion, 43% were not asked about previous attacks of scrotal pain, and 56% had experienced previous attacks suggestive of intermittent torsion.

An absent cremasteric reflex was found to be the most sensitive sign of torsion (100% sensitivity); however, it was assessed in less than one-third of cases. The sensitivity, specificity, predictive value, likelihood ratio and accuracy of some clinical signs are presented in Table II.

Table II: Signs of testicular torsion.

PPV, positive predictive value; NPV, negative predictive value; +LR, positive likelihood ratio; -LR, negative likelihood ratio.

Discussion

 Testicular torsion results from twisting of the spermatic cord, which impedes blood flow to the testis and impairs venous drainage, resulting in oedema, ischemia and necrosis.⁶ It occurs in approximately 1 of every 4000 males before 25 years of age.⁷ Torsion can be classified as one of two types: intravaginal, and extravaginal. Extravaginal torsion, as a rule, only occurs in neonates and infants under the age of 1 year, although it is occasionally reported in older children.⁸ Intravaginal torsion is more frequent among adolescents, with about 65% of cases presenting between 12 and 18 years of age.⁹ In our study, 50% of patients were aged between 13 and 20 years, with a mean age of 17 years.

Intermittent torsion of the testis is a definite entity characterised by more than one attack of unilateral scrotal pain of sudden onset and short duration (less than 2 hours) that resolves spontaneously. Recognition of this diagnosis, its relation to acute torsion and performing urgent elective orchidopexy may improve testicular salvage rates.¹⁰ We found that only 57% of all patients were asked about a history of previous attacks, and of those, 56% had a positive previous history consistent with intermittent torsion.

Testicular torsion on the left side of the body occurs slightly more frequently than torsion on the right side (about 52% versus 48% of cases).¹¹ In our study, the left side was involved twice as often as the right side (67.2% versus 32.8%, respectively). Many studies have reported that cold weather is a predisposing factor for testicular torsion, with some even calling it winter syndrome.¹² Consistent with this, we found that 75% of torsions occurred in colder months (October to February).

As the records did not provide information on the time elapsed between the patient being seen in the emergency room to surgical exploration, we depended on the duration of symptoms to determine the salvage rate. This rate is strongly dependent on the duration of symptoms (P < 0.001), as seen in Figure 2. While 94.7% of testicles were salvaged when the duration was less than 6 hours, no testicles were salvaged when the patient presented after 12 hours. These findings are comparable to other studies.^13-16

A surprising finding was that the cremasteric reflex was examined in less than one-third of cases, even though its absence has been confirmed to be the most sensitive sign of testicular torsion in other studies¹⁷ in addition to our study (sensitivity of 100%). Until now, there has only been one case report of testicular torsion in the presence of an intact cremasteric reflex.¹⁸ The sensitivity, specificity, predictive value, likelihood ratio and accuracy of some clinical signs are presented in Table II.

Conclusion

   The importance of history and physical examination in the diagnosis of testicular torsion cannot be overemphasised, and every point has its own significance and implication. The patient can be advised to undergo surgical exploration solely based on clinical findings, as a delay in diagnosis is the most important variable that can lead to testicle loss.

Acknowledgements

None.

References

1.  Sparks JP. Torsion of the testis. Ann R Coll Surg Engl 1971; 49(2):77–91.

2. Michael Boettcher, Thomas Krebs, Robert Bergholz, Katharina Wenke, Daniel Aronson, Konrad Reinshagen. Clinical and sonographic features predict testicular torsion in children: a prospective study. BJU International 2013; 112:1201–6.

3.  Evarist Baruga, Ian Guyton Munabi. Case series on testicular torsion: an educational emergency for sub-Saharan Africa. The Pan African Medical Journal 2013; 14:18.

4.  John M. Gatti, J. Patrick Murphy. Acute testicular disorders. Pediatrics in Review 2008; 29:235–41.

5.  Fernando Korkes, Paulo Roberto dos Anjos Cabral, Caio Dal Moro Alves, Mariana Lorenzi Savioli, Antonio Carlos Lima Pompeo. Testicular torsion and weather conditions: analysis of 21,289 cases in Brazil. International Braz J Urol 2012; 38:222–8.

6. Chad S Kessler, Julie Bauml. Non-traumatic urologic emergencies in men: a clinical review. West J Emerg Med 2009; 10(4):281–7.

7. Shan Yin, MPH, Jennifer L. Trainor. Diagnosis and management of testicular torsion, torsion of the appendix testis, and epididymitis. Clin Ped Emerg Med 2009; 10:38–44

8. Gustavo García-Fernández, Alberto Bravo-Hernández, Raúl Bautista-Cruz. Testicular torsion: a case report. Cirugía y Cirujanos 2017; 85(5):432–5.

9. Yasser Abdel Razek Mohame Selim, Said Abdullah Albroumi. Acute torsion of the testis in children and young adults: role of high resolution and color Doppler ultrasonography. The Egyptian Journal of Radiology and Nuclear Medicine 2015; 46(1):151–7.

10. Sol Min Lee, Jung-Sik Huh, Minki Baek, Koo Han Yoo, Gyeong Eun Min, Hyung-Lae Lee, et al. A nationwide epidemiological study of testicular torsion in Korea. J Korean Med Sci 2014; 29(12):1684–7.

11.  Sessions AE, Rabinowitz R, Hulbert WC, Goldstein MM, Mevorach RA. Testicular torsion: direction, degree, duration and disinformation. J Urol 2003; 169(2):663–5.

12. Daniel DaJusta, Candace F. Granberg, Carlos Villanueva, Linda A. Baker. Contemporary review of testicular torsion: new concepts, emerging technologies and potential therapeutics. J Pediatr Urol 2013; 9(6):723–30.

13.  Davenport M. ABC of general surgery in children: acute problems of the scrotum. BMJ 1996; 312:435–7.

14. Rampaul MS, Hosking SW. Testicular torsion: most delay occurs outside hospital. Ann R Coll Surg Engl 1998; 80:169–72.

15. Ringdahl E, Teague L. Testicular torsion. Am Fam Physician 2006; 74(10):1739–43.

16. Victoria J. Sharp, Kathleen Kieran, Angela M. Arlen. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician 2013; 88(12):835–40.

17. Erika Ringdahl, Mlynn Teague. Testicular torsion. Am Fam Physician 2006; 74(10):1739–43.

18.  Hughes ME, Currier SJ, Della-Giustina D. Normal cremasteric reflex in a case of testicular torsion. Am J Emerg Med 2001; 19(3):241–2.