Testicular torsion: a urological emergency Torsion of the testis is a urological . Scintigraphy has almost 100% sensitivity for identifying patients with torsion; however, it takes longer and is less readily available than Doppler ultrasound. 1. Abstract Doppler ultrasound can diagnose testicular torsion with high sensitivity and specificity but may delay surgical treatment. Ringdahl E, Teague L. Testicular torsion. Doctors often diagnose testicular torsion with a physical exam of the scrotum, testicles, abdomen and groin. The reduction or absence of affected testicular flow has a high diagnostic accuracy with a sensitivity of 86-100%, . Complete torsion occurs when the testis twists 360 or more, usually leading to absence of intratesticular blood flow that can be identified on color Doppler ultrasound examination. 1-5 Testicular torsion can occur at any age but commonly affects 1 in 4000 males younger than 25 years old each year. POCUS has a high sensitivity and specificity in the diagnosis of testicular torsion and its implementation in the work-up for acute scrotal pain has been reported to decrease the time to intervention [7-9]. Testicular torsion is most common between ages 12 and 18, but it can occur at any age, even before birth. Testicular torsion is the twisting of the spermatic cord within the scrotum. The absence of blood flow in the testis on ultrasound examination is the gold standard for diagnosis of testicular torsion. These modalities are limited by availability and operator experience with interpretation. Physical exam, history and imaging all have significant limitations. What Happens Normally? This condition requires emergency care. . This can cause the testes to twist around the spermatic chord. . In this online presentation, we review the causes of absent, abnormal, or reduced flow in the testes, with an emphasis on less common causes. This reflex might not occur if you have testicular torsion. Side-by-side comparison of the testicles is critical to evaluate for size, fluid collections, changes of echotexture, and discrepancies of color Doppler. However, the . color flow doppler alone has a sensitivity of 86%, specificity of 100%, and accuracy of 97% in diagnosing testicular torsion. Regarding applicability, at least one patient younger than 19 years was included in almost all studies, and high-risk concerns were present in patient selection. It is a urological emergency requiring urgent surgical intervention. This study aims to assess whether the use of doppler ultrasound, in cases with intermediate clinical suspicion of testicular torsion, can improve diagnostic accuracy compared to clinical assessment alone. with a sensitivity approaching 100 per cent. It has a sensitivity ranging from 79 to 86% and a specificity of nearly 100%. Intermittent torsion is defined as sudden onset of unilateral testicular pain of short duration with spontaneous resolution. Nausea or Vomiting (OR >8.9, occurs in 90% of patients) 9 in paediatric patients as well, its sensitivity and specificity exceed 90%. 35 after confirming the presence of blood flow in the testis with color flow doppler, it should always be confirmed by spectral doppler to avoid It found that the sensitivity of color Doppler ultrasound was 84.85% while that of high-resolution ultrasonography was 93.94%. It accounts for 10% to 15% of. Raed Hameed Al-Marzooq, MD, FRCSI* Amal Ahmed Noor Al-Rayes, MD* Fadi Mirza Altawash, MD** . In total, fifty seven pediatric ultrasound images with testicular torsion were identified from the PACS. A study conducted in Oman that included 33 patients with surgically confirmed testicular torsion assessed the sensitivity of color Doppler ultrasonography and high-resolution ultrasonography. Bahrain Medical Bulletin, Vol.25, No. Scintigraphy has almost 100% sensitivity for identifying patients with torsion; however, it takes longer and is less readily available than Doppler ultrasound. 6 Start with the unaffected testicle to optimize your settings (the auto-calibrate button can help!) Testicular torsion is primarily a disease of adolescents and neonates. A score 5 diagnosed testicular torsion with a sensitivity of 76 percent, specificity of 100 percent, and a positive predictive value of 100 percent (prevalence 15 . Imaging such as Doppler ultrasound is used in the detection of testicular torsion, with a sensitivity range from 69% to 100% and specificity from 77% to 100%, respectively (Lam, 2005). If the blood supply is not returned to the testicle quickly (within six hours), the testicle may be surgically removed. Torsion occurs when an abnormally mobile testis twists on the spermatic cord, obstructing its blood supply. Time is Testes Historically, we thought the time window for possible salvage and survival of a torsed testicle is 6-8 hours. Our experts recommend against using the TWIST score to rule out torsion, however a score of 7 may warrant urgent urology consult with the aim of immediate surgical intervention without doppler ultrasound confirmation. Testicular Torsion is cause of sudden unilateral Scrotal Pain in 16-42% of boys. When this happens, it cuts off the blood flow to the testicle. Ultrasound is a sensitive test for testicular torsion but associated with an average two-hour delay to theatre and a higher rate of intraoperative finding of non-viable testicle in this centre. It can either be due to an intravaginal ('bell-clapper deformity') or extravaginal cause. 10 point-of-care ultrasound (pocus) is also used at the bedside to facilitate timely diagnosis in paediatric care and by physicians Key Points. 1 Early diagnosis is imperative for this condition, as every hour spent without treatment increases the likelihood of permanent damage to the affected testicle. In partial or incomplete torsion, the spermatic cord is twisted less than 360, allowing some . Scintigraphy has almost 100% sensitivity for identifying patients with torsion; however, it takes longer and is less readily available than Doppler ultrasound. New ultrasound techniques that attempt to identify a twisted cord as opposed to blood flow to the testicle appear promising. This study aims to assess whether the use of doppler ultrasound, in cases with intermediate clinical suspicion of testicular torsion, can improve diagnostic accuracy compared to clinical assessment alone. In our study, it accurately diagnosed complete testicular torsion with 100% sensitivity, based on the criteria of decreased or lack of contrast enhancement. Causes of acute scrotal pain, such as testicular torsion, epididymitis, or incarcerated hernia, can be rapidly evaluated using point-of-care ultrasound. Risk factors include cryptorchidism, horizontally-lying testes, and testicular tumours. . A spherical shape and size of 6 mm with no internal vascularity and peripheral vascularity on Doppler scan are highly suggestive of torsion. The diagnosis is often made clinically but if it is in doubt, an ultrasound is helpful in confirming the diagnosis. Despite its high sensitivity and specificity, both false-negative and false-positive findings occur. Testicular trauma is the third most common cause of acute scrotal pain. The most common symptom is acute testicular pain and the most common underlying cause, a bell-clapper deformity. Urology 216.444.5600. Some studies found worse results, the detection of a testicular blood flow should be questioned, when patients present with typical signs and symptoms of testicular torsion. Painless Testicular Torsion may occur (if nerve is ischemic on twisting with vascular supply) Intermittent pain may occur if the Testicle recurrently torses and detorses. Testicular sonography has contributed greatly to the preoperative diagnosis of testicular torsion in the pediatric patient and is the mainstay for evaluation of acute scrotal pain. Ultrasound confirmed testicular torsion (patient's ultrasound images shown below. PPV 100% when 7 points. 34 blood flow within the testis can be quantified using spectral doppler. Testicular Torsion is when tissues around the testicle (also known as the "testis") are not attached well. However, other conditions can result in vascular abnormalities. A horizontal lie, or bell clapper deformity, can occur from abnormal attachment of the tunica vaginalis and is associated with intermittent testicular torsion. Ringdahl E, Teague L. Testicular torsion. Point-of-care testicular ultrasonography by emergency physicians has a high sensitivity (95%) and specificity (94%). Testicular torsion usually requires emergency surgery. Torsion of the appendix testis is frequently accompanied by hydrocele and scrotal wall thickening 3. Torsion can be intermittent and can undergo spontaneous detorsion. Testicular torsion occurs when the tissues around the testis are loosely attached, which causes rotation of the testis. Ultrasound Appendix testis is increased in size with an increase or decrease in echogenicity. Although the high sensitivity (89%) and specificity . In partial or incomplete torsion, the degree of spermatic cord twist is less than 360, allowing for some residual perfusion to the testis. This is a urological emergency; early diagnosis and treatment are vital to saving the testicle and preserving future fertility. 1. Therefore, seven cases were included in the final study. Point-of-care ultrasound (POCUS) can be used by emergency physicians to detect testicular torsion. Color or power Doppler ultrasound (US) has been used for initial evaluation of patients with acute scrotal symptoms (4-11). Scintigraphy has sensitivities from 7 to 100% and specificity of 89 to 100%. The TWIST (Testicular Workup for Ischemia and Suspected Torsion) scoring system was developed for the purpose of determining the risk of testicular torsion on clinical grounds, thus. Testicular torsion can be complete, partial, or intermittent. A bell clapper deformity is a predisposing factor in testicular torsion where the tunica vaginalis attaches high on the spermatic cord, leaving the testis free to rotate within the tunica vaginalis. High-riding testicle. Testicular Doppler-Sonography Doppler ultrasound of the testis can detect a lack of blood flow in the testis: 90% sensitivity and 99% specificity, 1% false positive results. Testicular Torsion. Ultrasound Test Sensitivity is decreased in small, prepubertal Testes Early Ultrasound may have normal Doppler Ultrasound First hour may have normal flow despite torsion Testicular Swelling and hypoechoic Ultrasound may not appear for first 4-6 hours Intermittent torsion may occur (but be absent at Ultrasound) Testicular torsion refers to the torsion of the spermatic cord structures and subsequent loss of the blood supply to the ipsilateral testicle. High-frequency ultrasonography (US) with a linear-array transducer is the modality of choice for the initial evaluation of patients with acute scrotal pain after trauma. It is common in younger age groups between twelve and eighteen. 4, December 2003 . With acute testicular torsions, it can take several hours before ischemic damage is evident on ultrasound. In most cases, however, the clinical findings will not be definitive for or against a testicular torsion and will be similar to epididymitis. . Your doctor might also test your reflexes by lightly rubbing or pinching the inside of your thigh on the affected side. This imaging finding is seen in the vast majority of patients with. Aim: To investigate the symptoms and signs associated with testicular torsion and to study the Ultrasound is the primary modality for the evaluation of patients with acute scrotal pathologies ( 3, 4) and testicular torsion can cause changes in grey-scale, color, and spectral Doppler sonography depending on the degree of twist and the duration of symptoms ( 2 ). ultrasound is justifiable if the clinical picture is doubtful and an experienced Testicular torsion (TT) is a true urologic emergency and must be differentiated from other causes of acute testicular pain because a delay in diagnosis and management can lead to loss of the testis and infertility. The ischemia can lead to testicular necrosis if not corrected within 5-6 hours of the onset of pain. Normally, this causes the testicle to contract. Of these, 50 cases without detectable blood flow were excluded. The literature cites sensitivities of 78.6-100% and specificities of 76.9-100%, with a NPV of 100% (Liang 2013; Agrawal, 2014). Background . NPV 96% when <5 points. Resistive Index = (Peak Systolic Velocity-End Diastolic Velocity)/Peak Systolic Velocity. The spermatic cord is responsible for transporting blood to the scrotum, and testicular torsion causes the twisting of the spermatic cord to lose blood flow. Studies report varying sensitivities as low as 60% ( Mellick 2012) Horizontal (instead of vertical) testicular lie Diagnosis The diagnosis of testicular torsion should be pursued in any patient with acute scrotal pain. The gold standard in diagnosing testicular torsion is color Doppler ultrasound, which demonstrates a sensitivity of 86% to 100%, a specificity of 98.8% to 100%, a positive predictive value. 1,4 Diagnosis of partial testicular torsion (PTT) and torsion . Testicular torsion occurs when a testis torts on the spermatic cord resulting in the cutting off of blood supply. Testicular malignancy; Scrotal wall hematoma; Evaluation Work-Up. See also However there is no spontaneous resolution of pain [ 1 ]. Testicular torsion is a serious condition where the testicle twists and loses its blood supply. Treatment Doppler ultrasound can diagnose testicular torsion with high sensitivity and specificity but may delay surgical treatment. Patients present with acute onset of severe testicular pain. A working knowledge of Doppler ultrasound, including color power Doppler, adds significant value to the evaluation of the testicles and the epididymis. The meta-analysis revealed that ultrasound was an effective diagnostic tool for testicular torsion, with an overall sensitivity and specificity of 0.86 and 0.95, respectively. Testicular torsion is a twisting of the spermatic cord and its contents and is a surgical emergency affecting 3.8 per 100,000 males younger than 18 years annually. . The results presented do not suggest that ultrasonography alone can rule out testicular torsion. Testis tumor Epididymitis Hydrocele Traumatic hematoma Orchitis Loss of testis He was taken emergently to the OR and was found to have a salvageable but cyanotic testicle. Test. Ultrasound use in suspected testicular torsion: an association with delay to theatre and increased intraoperative finding of non-viable testicle Normal is 0.5-0.7 cm/sec. Test. Nausea or vomiting. It can cause pain and swelling, and should be treated as an emergency. If there is a high suspicion of testicular torsion, an ultrasound SHOULD NOT be performed and the patient should be taken to theatre as soon as possible for exploration. us conducted by radiologists to diagnose testicular torsion in adults has a sensitivity and specificity of 86% and 95%, respectively. Testicular torsion occurs when a testicle rotates, twisting the spermatic cord that brings blood to the scrotum. Normally, the testes have a vertical lie. The reduced blood flow causes sudden and often severe pain and swelling. For some patients testicular torsion does . If the testicle is torsed, there will often be a hydrocele present with a testicle with reduced color or power flow. The sonographic diagnosis of torsion is often accompanied by absent or abnormal Doppler US flow in the painful testis. A "torsion knot" may also be seen by US, in which redundant, tortuous spermatic cord twists, often around a small, reactive hydrocele. The most recent data, from a large study conducted by Yagil and colleagues (2010), reported that sensitivity, specificity, and accuracy of US was 94%, 96%, and 99.5% for testicular torsion, 92%, 95%, and 94% for testicular malignancy, and 100%, 98.5%, 98.5% for testicular hematoma, respectively. decreased uptake of radioactive technetium-99m to the affected testicle in patients with testicular torsion. Do not delay urologic consultation for work-up Consult urology immediately if strongly suspicious for torsion; Urinalysis; Ultrasound for equivocal cases Bedside U/S has a SN 0.95 and SP 0.94 compared to a gold standard of radiology U/S; Lab workup for surgery; TWIST Score .
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