Testicular torsion is a surgical emergency, and delayed treatment is associated with testis loss. The incidence of testicular torsion in males younger than 18 years is estimated to be 3 per 100,000 per annum. While testicular torsion can occur at any age, it typically occurs either as a perinatal “extravaginal” torsion or peripubertal as an intravaginal torsion from or around 12 years of age. The more common intravaginal torsion occurs due to a congenital defect with the fixation of the testis to the tunica vaginalis. A high gubernaculum attachment occurs, causing excessive mobility, known as a “bell-and-clapper” deformity. This deformity causes the affected testis to rotate around its axis, causing compression of the testicular vasculature and leading to ischemia and the symptoms of testicular torsion.
Testicular torsion presents with sudden testicular pain, vague lower abdominal pain, nausea and vomiting, testicular tenderness, high-riding testicle, and horizontal lie of the testicle. The absence of the cremasteric reflex is highly suspicious for testicular torsion. The diagnosis is based primarily on clinical features. Doppler ultrasound is used as an adjunct to diagnosis, but no investigation should cause a delay in prompt surgical intervention. Decreased or absent testicular blood flow or twisting of the spermatic cord are signs seen on Doppler ultrasound that suggest testicular torsion.
Management of patients with suspected testicular torsion often requires emergent surgical exploration, detorsion, and fixation or removal of the affected testis. Reducing the time from symptoms onset to surgical exploration is paramount. Studies have shown that a 4–8-h window period is optimal due to the reversibility of the condition. Patients treated after the 8-h window are more likely to have lifelong altered spermatogenesis and decreased fertility. These changes are likely due to ischemia and oxidative stress following surgical detorsion. Testicular salvage rates in patients operated on within 6 h of symptoms onset were as high as 90% to 100%. Salvage rates drop to 50% if symptoms are present for more than 12 h and <10% for 24 h or more.[3,9,10]
Due to the high incidence of bilateral “bell-and-clapper” deformity, bilateral testicular fixation is becoming standard in a patient with testicular torsion undergoing surgical exploration.[2,11] There is currently neither consensus in the British, European, or American Guidelines on the technical methods of scrotal exploration nor the accepted outcomes of scrotal exploration. The current practice at King Hamad University Hospital in Bahrain requires any patient presenting with testicular pain to be reviewed and referred to either the on-call surgical urology team or the on-call pediatric surgery team, depending on the patient’s age. There is a low threshold for surgical exploration, emphasizing the on-call physician’s clinical judgment rather than Doppler ultrasound results.
This study aims to review cases of testicular torsion that underwent testicular exploration in a University Hospital in the Middle East, assessing the initial presentation, physical examination, ultrasonographic findings, operative findings, timings, and surgical technique.
PATIENTS AND METHODS
This study is a retrospective review of all the patients in a hospital covering the Muharraq district in Bahrain presenting with testicular pain. Patients were included by assessing the relevant International Classification of Disease (ICD-10) diagnoses [Appendix 1]. The inclusion criteria included all males above 1 year old who underwent surgical exploration from January 2015 to November 2021.
A pro forma was created containing demographic data, aspects from the history, physical examination, and operative findings [Appendix 2]. As a quality index, the timing from presentation to operation was assessed. This study obtained institutional review board approval (Reference number 20-381).
The data analysis was done using SPSS (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.). This study used descriptive statistics to compute the frequencies and percentages of the categorical variables. This study described the mean and the range for the continuous variables. Cross-tabulation analysis was done to determine the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).
During the 6 years, 535 patients with testicular pain were identified by their ICD-10 diagnosis. After removing 205 duplicates, 84 incorrect code entries, 160 patients with other diagnoses, 38 patients with normal examination/ultrasound findings, and 48 patients with testicular torsion were identified, with a mean age of 18.4 and a median age of 16 [Figure 1]. Other diagnoses are summarized in Table 1, and other scrotal pathologies are summarized in Table 2.
In patients with testicular torsion, 26 (54%) presented to the emergency department in <6 h, 6 (13%) within 6–12 h, 6 (13%) within 13–24 h, 4 (8%) within 25–72 h, and 4 (8%) after 72 h. Data for the time of presentation were missing for two patients.
The history of those who presented with testicular torsion showed that 18.9% of patients were admitted to a previous history of similar pain. The most common physical examination findings in testicular torsion include scrotal edema (64.5%), absence of the cremasteric reflex on the affected side (60.4%), and scrotal tenderness (58.3%). Other physical examination findings are summarized in Table 3.
Table 4 summarizes the number of patients with nonviable testis based on the time from presentation to the emergency department to surgical exploration.
Doppler ultrasound was performed in all 48 patients diagnosed with testicular torsion. Doppler ultrasound confirmed the presence of testicular torsion in 42 (87.5%) patients, 2 (4.2%) had ultrasound features unlikely to be testicular torsion, and 4 (8.3%) patients had either inconclusive findings or no ultrasound reports. Of those with inconclusive results or no ultrasound reports, only one patient had nonviable testis even after the use of adjunctive measures, including high oxygenation and the application of warm compresses. The Doppler ultrasound’s sensitivity and specificity were 87% and 98.5%, respectively, and the PPV and NPV of the Doppler ultrasound were 93% and 97%, respectively [Table 5].
Fourteen patients were found to have a nonviable testis on surgical exploration. The average age of patients with nonviable testis was 16.6 (±6.8) years. These patients took, on average, 13–24 h to present to the emergency department. The average time for these patients from presentation to surgical exploration was between 180 and 239 min. Nearly all patients had nonviable testis on surgical exploration, but one had evidence of testicular torsion on ultrasound. Three patients with abnormal ultrasound results underwent surgical exploration, but no testicular torsion was found.
From the data available, 20 (41.7%) patients underwent fixation of the testis using absorbable sutures. On the other hand, only 10 (20.8%) patients underwent fixation with nonabsorbable sutures.
Of interest, one patient underwent surgical fixation of the ipsilateral testes and later presented with testicular torsion of the contralateral testis 3 months later. In this case, the standard of care in the hospital was not followed, which requires contralateral fixation in every suspected testicular torsion. This patient never presented again after contralateral fixation.
Our study incorporated 48 patients presenting with acute scrotum who underwent exploration, of whom 48 had testicular torsion, and five had no torsion, with a crude accuracy of diagnosis of 90%. The mean age for patients with testicular torsion is 18.4 (±9.2) years, with a median age of 16. Most patients with acute scrotum (54.7%) presented within 6 h of the onset of symptoms to the emergency department to seek medical attention, and 34% of patients underwent surgical exploration within 120–179 min from presentation to the emergency.
A study by Nelson et al. conducted on 77 patients aged from 1.3 to 19.7 years with testicular torsion found a median time from the onset of symptoms to initial presentation of 5.6 h. A study by Holzman et al., incorporating patients from 2 months to 18 years of age, showed a median time of 7.5 h. In 2020, a study by Nelson et al. also assessed the median time in 19 patients with testicular torsion and found the median time from symptoms to initial presentation to be 2.4 h. In our study, the median time from the start of pain to presentation was <6 h.
The majority of patients (64.5%) presented with complaints of scrotal edema, and 18.9% had a history of previous similar pain. In a study by Yagil et al., up to one-third of patients presented with two or more clinical features, including swelling, erythema, and scrotal pain. In our study, 75% of patients presented with two or more clinical features on examination, which is far higher than that seen in other studies. These results could be due to the use of electronic medical records with templates designed by emergency physicians that allow quicker and more accurate documentation of signs and symptoms more quickly and accurately.
Most patients who presented to the emergency department underwent scrotal ultrasound 60 min from the presentation and underwent surgical exploration within 120–179 min. Considering patients who had undergone a Doppler ultrasound 60 min or more after the presentation, the rate of torsion is approximately 40%, compared to an overall rate of 29%. Although this increase is quite significant, the small sample size of the data makes it difficult to generalize this finding. It can be assumed that the time used in a Doppler ultrasound might have contributed to a relative delay in scrotal exploration and thus the outcome. The practice in our hospital requires the referral of patients to the on-call surgical team and a simultaneous request for a Doppler ultrasound to prevent delay in treatment.
Doppler ultrasound is used to investigate patients presenting with scrotal pain due to the high sensitivity as a preoperative adjunct diagnostic tool to aid in diagnosing acute scrotum. Despite its feasibility and safety, Doppler ultrasound should not delay surgical exploration. The results should not deter surgical exploration when clinical suspicion of torsion is high. In this study, all patients suspected of acute scrotum underwent a Doppler ultrasound. Ultrasound confirmed testicular torsion in 87.5% of cases. The diagnostic performance of Doppler ultrasound in our institution revealed a specificity of 87%, a sensitivity of 98%, a PPV of 93%, and NPV of 97%. These results correspond to the diagnostic performance of Doppler ultrasound seen in the literature with specificity ranging from 87% to 100%, sensitivity ranging from 69% to 86%, a PPV of 100%, and a NPV of 97%. A meta-analysis by Ota et al. assessing the role of ultrasound imaging in patients with testicular torsion reviewing 2116 patients from 26 studies revealed a specificity of 95% and sensitivity of 86%.
A study by Nelson et al. found that orchiectomy was necessary for 17% of patients (13 of 77). In this study, 34 (70.8%) patients had viable testis on exploration, whereas 14 (29.2%) had nonviable testis and underwent orchiectomy. The rate of nonviable testis in our study is higher than that seen in Nelson et al. However, the number of patients in both studies is small, and we believe that further studies with a larger sample size may provide a more accurate reflection of torsion rates in our institute.
Emergent surgery is the mainstay of management for patients with clinical suspicion of testicular torsion. A higher rate of organ salvage is expected when scrotal exploration is conducted within 6 h of the onset of symptoms. Moreover, surgery more than 8 h from the presentation has been associated with a higher risk of irreversible ischemia and consequently necrosis, necessitating an orchiectomy. A review of different surgical approaches found no difference in ipsilateral or contralateral retorsion, which leads us to believe that the risk of retorsion is low regardless of approach.
The most common suture used in our institute during fixation was polyglactin 910, a synthetic absorbable suture. As evidenced by Tuken et al., polyglactin’s slow absorption and high fibrosis-inducing properties make it an ideal suture to avoid early retorsion and late retorsion due to fibrosis formation. The authors also agree with the hypothesis by Sells et al. that direct apposition between the tunica albuginea and the scrotal wall is vital to induce local fibrosis. Nonabsorbable sutures are known to cause chronic orchialgia, abscess, and sinus formation. A systematic review by Moore et al. assessed the type of suture material used during testicular fixation. The study concluded that there is no significant difference between suture types regarding retorsion. However, further research into this matter is still required.
Contralateral fixation of the testis has been an area of debate in surgical management. A meta-analysis by Fehér and Bajory found that 63.3% of the patients underwent contralateral fixation, with no reported contralateral torsion. In comparison, a series of 27 cases of testicular torsion in pubertal boys that have not undergone contralateral fixation found that 78% of the contralateral testis were affected. This is further supported in our review, which had one case of testicular torsion postipsilateral fixation, which later underwent contralateral fixation.
Based on the data obtained in this study, we reiterate current standard practice recommendations, which place far greater value on clinical diagnosis in guiding the management and exploration of testicular torsion than ultrasound diagnosis. We recommend that emergent ultrasound should not delay the time for scrotal exploration. Instead, simultaneous involvement of radiologists and surgeons should be done when suspicion of testicular torsion is raised. We acknowledge the small sample size in our study as a limitation. Therefore, we recommend further review with larger sample sizes to help form a guideline for managing testicular torsion.
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Conflicts of interest
There are no conflicts of interest.
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