Torsion Of Testicular Appendages Research Articles

Outcomes of scrotal exploration for acute scrotal pain suspicious of testicular torsion: a consecutive case series of 173 patients

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Acute scrotal pain is a urological emergency. Prompt assessment is required to diagnose the cause.Patients older than 11 years are unlikely to have torsion of a testicular appendage and assessment should focus on discriminating between testicular torsion and epididymo‐orchitis. Reasons for delay in presentation with acute scrotal pain need to be addressed. There is an association between testicular torsion and cold weather.OBJECTIVE• To determine the surgical outcome of all scrotal explorations performed on patients presenting with acute scrotal pain suspicious of testicular torsion.PATIENTS AND METHODS• Data was collected prospectively from a consecutive case series of patients of all ages who had scrotal exploration for acute testicular pain from 1998 to 2008.• The main outcome measures were pathology found during scrotal exploration, relationship between patient age and cause of scrotal pain, orchidectomy rate and the association between testicular torsion and cold weather.RESULTS• Data for 173 patients out of 179 was available for analysis.• The median age of the patients was 14 (0–92) years. 51% (n = 89) had testicular torsion, 24% (n = 42) had torsion of testicular appendages, 9% (n = 16) had epididymo‐orchitis, and other pathology made up 5%.• No obvious pathology was seen in 10% (n = 17).• Patients with Torsion of Appendages were significantly younger than other patients with scrotal pain (P < 0.0001).• Age was not useful in discriminating between patients with Testicular Torsion from other patients with scrotal pain. 9% (n = 16) of all patients required an orchidectomy.• Frequency of Testicular Torsion was higher during the colder half of the year (n = 0.02).CONCLUSIONS• Testicular torsion was the most common finding at surgical exploration, followed by torsion of testicular appendages.• Age had limited value in diagnosing the cause of acute scrotal pain.• Testicular torsion was associated with cold weather.• Our findings support the practice of surgical exploration for acute scrotal pain suspicious of testicular torsion in patients of any age.

Sonographic Differential Diagnosis of Acute Scrotum

The purpose of this study was to prospectively investigate the role of high-resolution and color Doppler sonography in the differential diagnosis of acute scrotum and testicular torsion in particular. Patients who underwent sonography for acute scrotum between April 2000 and September 2005 were included in the study. Gray scale and color Doppler sonography of the scrotum was performed. The spermatic cord was studied on longitudinal and transverse scans from the inguinal region up to the testis, and the whirlpool sign was looked for. During this period, 221 patients underwent sonography for acute scrotum. Sixty-five had epididymo-orchitis with a straight spermatic cord, a swollen epididymis, testis, or both, an absent focal lesion in the testis, and increased flow on color Doppler studies along with the clinical features of infection. Three had testicular abscesses. Sonography revealed features of torsion of testicular appendages in 23 patients and acute idiopathic scrotal edema in 19. Complete torsion was seen in 61 patients who had the whirlpool sign on gray scale imaging and absent flow distal to the whirlpool. There was incomplete torsion in 4 patients in whom the whirlpool sign was seen on both gray scale and color Doppler imaging. Nine patients had segmental testicular infarction, and 1 had a torsion-detorsion sequence revealing testicular hyperemia. In 14 patients, the findings were equivocal. There was a complicated hydrocele, mumps orchitis, and vasculitis of Henoch-Schönlein purpura in 1 patient each. Five patients had normal findings. Fourteen were lost for follow-up. Sonography of acute scrotum should include study of the spermatic cord. The sonographic real-time whirlpool sign is the most specific and sensitive sign of torsion, both complete and incomplete. Intermittent testicular torsion is a challenging clinical condition with a spectrum of clinical and sonographic features.

Indications for conservative management of acute scrotal pain in children

Forty-three boys who presented with acute scrotal pain were studied retrospectively. Of these, 40 had torsion of scrotal contents. Torsion of testicular appendages, a self limiting condition, tended to present later than testicular torsion (P = 0.002). The testis was saved in all 11 cases of testicular torsion explored within 12h of the onset of pain but orchidectomy was required in four who presented later. In 11 cases, a torted testicular appendage diagnosed as a tender nodule was found on examining the upper pole of the testis. The remaining 14 cases of torted appendage were diagnosed at operation because testicular torsion could not be excluded due to scrotal swelling. Most (12) of this operated group were not seen until 3 days after the onset of pain. This study suggested that urgent operation was unnecessary in those in whom a tender nodule was found (pathognomonic of a torted appendage) and in those presenting after more than 24h of pain with scrotal erythema and oedema. The likely diagnosis in the latter case is a torted appendage and in cases of torsion of the testis there is no prospect of salvage at this stage. These guidelines were applied to a group of 20 boys studied prospectively. In eight, all with less than 24h of pain, immediate exploration was undertaken and testicular torsion was confirmed in six. The remaining 12 fulfilled the criteria for conservative management and were observed. All had normal testes at late review. Careful clinical assessment in boys with scrotal pain indicates which cases may be treated by non-operative management without fear of losing a salvageable testis.

The acute scrotum in childhood

The vast majority of acute scrotums are caused by four conditions: testicular torsion, torsion of testicular appendage, epididymo-orchitis or idiopathic scrotal oedema. The incidence and presentation of these conditions changes with age. Overall, testicular torsion is most common in the post-pubertal period and torsion of testicular appendage is most common in pre-pubertal males. In general, diagnosis is more difficult in pre-pubertal boys due to the variety of differential diagnoses and less obvious signs and symptoms. Testicular torsion is one of the few true surgical emergencies. Surgical treatment of a torted testicular appendage is optional depending on presentation. Management of epididymo-orchitis and idiopathic scrotal oedema is conservative. There are several areas of controversy in the acute scrotum, including the true and relative incidences of these conditions at various ages; the method of fixing testes after torsion; the efficacy of investigations in the management of the acute scrotum; the treatment of neonatal torsion; and the effect of unilateral torsion on the function of the contralateral testis. While the old surgical adage of ‘if in doubt, explore’ may still be valid (particularly in the pre-pubertal age group), astute clinical assessment (combined with ultrasound) enables improved accuracy of diagnosis and appropriate exploration.

Acute scrotum - Etiology and management.

Acute scrotal pain is a common urological emergency. Urgent exploration is the standard means of management, since no investigation can confidently exclude torsion of testis from the differential diagnosis. A review of all boys presenting with acute scrotal pain who underwent emergency scrotal exploration between January 1983 and March 2003 was performed. 195 boys were included in this study. They were divided into 3 groups: group 1-73 with epididymo-orchitis, group 2-63 with torsion of testicular appendages and group 3-57 with spermatic cord torsion. The patients in group 2 were older than group 1, also patients in group 1 were older than group 3. During neonatal period the most common pathology was spermatic cord torsion, whereas in prepubertal period torsion of appendages was more common. In all boys, mean duration of pain at presentation was 2.11 days. Epididymo-orchitis was diagnosed in 37% of patients, with torsion of the appendages being the next most common entity. Testicular torsion was diagnosed in 29% of patients. In the group with testicular torsion salvage rate of testis was 37% because of late admission. The perioperative morbidity and mortality was not seen in any of the groups. We believe that any boy with acute scrotal pain and any suspicion of testicular torsion in physical examination must be applied routine surgical exploration.

Clinical Predictors for Differential Diagnosis of Acute Scrotum

Accurate and early diagnosis of acute scrotum is of the utmost importance to avoid testicular loss and/or needless surgery. The aim of this study is to analyze the clinical presentation and physical examination parameters together with the results of imaging studies in order to find out predictors for the differential diagnosis of acute scrotum with special emphasize on testicular torsion (TT). Patients who were treated for acute scrotum in our unit from 1970 up to and including 2000 were reviewed retrospectively. The study group was subdivided into three groups: "testicular torsion (TT)", "torsion of testicular appendage (TTA)", and "epididymoorchitis (EO)" group according to the diagnosis confirmed by radiologic and surgical findings. Presence and/or absence of various parameters related to clinical presentation, physical examination, and results of imaging studies were analyzed by statistical means in each group. One hundred and sixty children with a mean age of 12.2 years formed the study group. The mean duration of symptoms was 15 hours. No significant difference was noted between the three groups with regard to mean age and duration of symptoms. Nuclear scintigraphy and Doppler ultrasound were used as diagnostic aids in 50 and 66 children, respectively. Clinical presentation parameters including the presence of a) previous trauma, b) pain attacks, and c) nausea and vomiting, had the highest sensitivity, specificity, positive and negative predictive values in the TT group and the lowest values in the EO group. In contrast, the EO group had the highest statistical values with regard to presence of dysuria and micturition disorders. Physical examination parameters consisting of a) elevation, b) transverse location of testis, c) anterior rotation of epididymis, and d) absence of cremasteric reflex had the highest statistical values in the TT group. Contrary to this, imaging studies had the highest specificity and positive predictive values in the TTA group and the lowest values in the TT group. Previous history of trauma and pain attacks, presence of nausea and vomiting, and absence of urinary complaints are the main predictors of TT. Elevation and transverse location of testis with an anteriorly rotated epididymis associated with loss of ipsilateral cremasteric reflex strongly indicate TT. Although accuracy of imaging studies is higher for the differential diagnosis of TTA and EO, there is a considerable risk of misdiagnosis. Therefore, differential diagnosis of acute scrotum, particularly TT, still remains a clinical diagnosis, and clinical parameters deserve more importance in surgical decision making.

FAMILIAL MEDITERRANEAN FEVER AS AN UNUSUAL CAUSE OF ACUTE SCROTUM

Correct preoperative diagnosis is the crucial step in the management of acute scrotum. With the adjunct of color Doppler ultrasound, torsion of testicular appendages, epidydimitis and orchitis as the more common nonsurgical causes are differentiated reliably from testicular torsion or incarcerated inguinal hernia. Less frequently, acute scrotal swelling is the initial symptom of systemic disorders. Leukemic infiltration of the testis or scrotal involvement in vasculitis

Imaging of the acute scrotum.

The scrotum is a superficial structure and clinical examination is frequently not enough for making a specific diagnosis. In acute scrotal pain US can confirm the presumptive clinical diagnosis and provide additional relevant information. In testicular torsion, color-Doppler imaging has a central role since it has become possible to identify it at early stage by showing absence of perfusion in the affected testis before any gray-scale abnormality. Scintigraphy remains a satisfactory alternative in evaluating testicular torsion and should be used when color Doppler is inadequate, raising doubts about the suspected torsion. Diagnosis of torsion of testicular appendages is particularly difficult. Ischemic infarction shows a characteristic pattern at gray-scale and color Doppler imaging, whereas hemorrhagic ischemia may require MRI. Inflammatory diseases of the scrotum can be easily investigated by echo color Doppler and conventional radiography, and CT can be particularly useful in the detection of gas bubbles. In scrotal trauma, scrotal hematoma, hematocele, intratesticular hematoma, and testicular rupture can be identified using gray-scale US with very good reliability. Magnetic resonance imaging is indicated when a small tear of tunica albuginea is suspected but not visualized on US.

Synchronous torsion of testicular appendages: a rare mechanical cause of bilateral scrotal pain

We describe a case of synchronous torsion of testicular appendages, a previously unreported cause of bilateral scrotal pain. Exploration and excision was curative.

A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages.

To compare historical features, physical examination findings, and testicular color Doppler ultrasound in pediatric patients with epididymitis, testicular torsion, and torsion of appendix testis. A retrospective review of patients with the diagnosis of epididymitis, testicular torsion, or torsion of appendix testis. Ninety patients were included in the study (64 with epididymitis, 13 with testicular torsion, and 13 with torsion of appendix testis). Historical features did not differ among groups except for duration of symptoms. Of 13 patients with testicular torsion all had a tender testicle and an absent cremasteric reflex. When compared with the testicular torsion group, fewer patients with epididymitis had a tender testicle (69%) or an absent cremasteric reflex (14%). 62 (97%) patients with epididymitis had a tender epididymis and 43 (67%) had scrotal erythema/edema. By comparison, 3 (23%) and 5 (38%) patients with testicular torsion had a tender epididymis or scrotal erythema/edema, respectively. Doppler ultrasound showed decreased or absent blood flow in 8 patients, 7 of whom were diagnosed with testicular torsion. Ten out of 13 patients with testicular torsion had a salvageable testicle at the time of surgery. The physical examination is helpful in distinguishing among epididymitis, testicular torsion, and torsion of appendix testis. Patients presenting with a tender testicle and an absent cremasteric reflex were more likely to have a testicular torsion rather than epididymitis or torsion of appendix testis. An absent cremasteric reflex was the most sensitive physical finding for diagnosing testicular torsion. Color Doppler ultrasound is a useful adjunct in the evaluation of the acute scrotum when physical findings are equivocal.

The value of radionuclide scrotal imaging in the diagnosis of acute testicular torsion

To assess the accuracy of radionuclide scrotal imaging (RSI) in the diagnosis of testicular torsion and torsion of testicular appendages. Eighty-seven patients (mean age 30.1 years, range 8-65) who presented with acute scrotal pain were evaluated by RSI and the results correlated with the clinical and surgical findings. Of the 87 patients, 44 underwent scrotal exploration and 42 patients were treated conservatively. One patient with a 'missed torsion' pattern on RSI refused operation and was lost to follow-up. Of the 44 patients who underwent surgery, testicular torsion was found in 30 and torsion of testicular appendages in 14 patients. The specificity of the RSI in diagnosing testicular torsion was 100% and the sensitivity was 98%. An area of increased tracer activity in the presence of a normal radionuclide angiogram was suggestive of torsion of testicular appendages with a specificity of 93%. Of the 42 patients who were treated conservatively, 19 had epididymitis, according to clinical and RSI findings, 10 had torsion of testicular appendages, two had orchiepididymitis, two had hydrocele, two had haematocele and seven patients had normal testes. At a follow-up examination, normal testicles were found in all 42 patients. The RSI may assist in the evaluation of nontraumatic acute scrotum, and can clearly distinguish among testicular torsion, torsion of testicular appendages and epididymitis.

Acute Scrotal Pathology

Acute diseases that require either emergency surgical intervention or specific medical therapy are emphasized in this review. Included are discussions of testicular torsion, epididymitis, torsion of testicular appendages, and miscellaneous acute scrotal pathology such as idiopathic scrotal edema.

Torsion of Testicular Appendages in Men

Torsion of testicular appendages has never been reported in patients more than 18 years old. We herein review 6 surgically proved cases. The possibility of this condition should be considered in the differential diagnosis of scrotal pain and swelling in men.

Torsion of testicular appendages: Presentation of 43 new cases and a collective review : R. W. Skoglund, J. W. McRoberts, and H. Ragde. J. Urol. 104:598–600 (October), 1970

Torsion of testicular appendages: Presentation of 43 new cases and a collective review : R. W. Skoglund, J. W. McRoberts, and H. Ragde. J. Urol. 104:598–600 (October), 1970

Torsion of Testicular Appendages: Presentation of 43 New Cases and A Collective Review

Torsion of Testicular Appendages: Presentation of 43 New Cases and A Collective Review

Anatomical Incidence of Testicular Appendages

No AccessJournal of Urology1 Dec 1968Anatomical Incidence of Testicular Appendages Donald Rolnick, Setsuo Kawanoue, Paul Szanto, and Irving M. Bush Donald RolnickDonald Rolnick More articles by this author , Setsuo KawanoueSetsuo Kawanoue More articles by this author , Paul SzantoPaul Szanto More articles by this author , and Irving M. BushIrving M. Bush More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(17)62618-1AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Anatomical Incidence of Testicular Appendages." The Journal of Urology, 100(6), pp. 755–756 © 1968 by The American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited ByRose M and Pambakian H (2018) Bilateral Torsion of the Appendix TestisJournal of Urology, VOL. 110, NO. 4, (408-409), Online publication date: 1-Oct-1973.Skoglund R, Mcroberts J and Ragde H (2018) Torsion of Testicular Appendages: Presentation of 43 New Cases and A Collective ReviewJournal of Urology, VOL. 104, NO. 4, (598-600), Online publication date: 1-Oct-1970. Volume 100Issue 6December 1968Page: 755-756 Advertisement Copyright & Permissions© 1968 by The American Urological Association Education and Research, Inc.MetricsAuthor Information Donald Rolnick More articles by this author Setsuo Kawanoue More articles by this author Paul Szanto More articles by this author Irving M. Bush More articles by this author Expand All Advertisement PDF DownloadLoading ...

Two unusual cases of torsion of testicular appendages.

Two unusual cases of torsion of testicular appendages.