Levels of evidence (1a-4) and grades of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
Diagnosis
Patients usually present with scrotal pain. The duration of symptoms is shorter in testicular torsion (69% present within 12 hours) compared to torsion of the appendix testes (62%) and acute epididymitis (31%).
In the early phase, location of the pain can lead to the diagnosis. Patients with acute epididymitis experience a tender epididymitis, while patients with testicular torsion are more likely to have a tender testicle and patients with torsion of the appendix testis feel isolated tenderness of the superior pole of the testis.
An abnormal position of the testis was more frequent in testicular torsion than in patients with epididymitis. Looking for the absence of the cremasteric reflex is a simple method with a sensitivity of 100% and specificity of 66% for the presence of testicular torsion (Level of evidence: 3; Grade of recommendation: C).
Fever occurs often in epididymitis (11-19%). The classical sign of a 'blue dot' was found only in 10-23% patients with torsion of the appendix testis.
In many cases, it is not easy to determine the cause of acute scrotum based on history and physical examination alone.
A positive urine culture is only found in a few patients with epididymitis. It should be remembered that a normal urinalysis does not exclude epididymitis. Similarly, an abnormal urinalysis does not exclude testicular torsion.
Doppler ultrasound is useful to evaluate an acute scrotum, with a sensitivity of 63.6-100% and a specificity of 97-100%, and a positive predictive value of 100% and negative predictive value 97.5% (Level of evidence: 3; Grade of recommendation: C). The use of Doppler ultrasound may reduce the number of patients with acute scrotum undergoing scrotal exploration, but it is operator-dependent and can be difficult to perform in prepubertal patients. It may also show a misleading arterial flow in the early phases of torsion and in partial or intermittent torsion: persistent arterial flow does not exclude testicular torsion. In a multicentre study of 208 boys with torsion of the testis, 24% patients had normal or increased testicular vascularization. Better results were reported using high-resolution ultrasonography (HRUS) for direct visualization of the spermatic cord twist with a sensitivity of 97.3% and a specificity of 99% (Level of evidence: 2; Grade of recommendation: C).
Scintigraphy and, more recently, dynamic contrast-enhanced subtraction magnetic resonance imaging (MRI) of the scrotum also provide a comparable sensitivity and specificity to ultrasound. These investigations may be used when diagnosis is less likely and if torsion of the testis still cannot be excluded from history and physical examination. This should be done without inordinate delays for emergent intervention.
The diagnosis of acute epididymitis in boys is mainly based on clinical judgement and adjunctive investigation. However, it should be remembered that findings of secondary inflammatory changes in the absence of evidence of an extra-testicular nodule by Doppler ultrasound might suggest an erroneous diagnosis of epididymitis in children with torsion of appendix testes.
Prepubertal boys with acute epididymitis have an incidence of underlying urogenital anomalies in 25-27.6%. Complete urological evaluation in all children with acute epididymitis is still debatable.
Treatment
Epididymitis
In prepubertal boys, the aetiology is usually unclear, with an underlying pathology in about 25%. A urine culture is usually negative, and unlike in older boys, a sexually transmitted disease is very rare.
Antibiotic treatment, although often started, is not indicated in most cases unless urinalysis and urine culture show a bacterial infection. Epididymitis is usually self-limiting and with supportive therapy (i.e., minimal physical activity and analgesics) heals without any sequelae (Level of evidence: 3; Grade of recommendation: C). However, bacterial epididymitis can be complicated by abscess or necrotic testis and surgical exploration is required.
Torsion of the appendix testis can be managed conservatively (Level of evidence: 4; Grade of recommendation: C). During 6 weeks' follow-up, clinically and with ultrasound, no testicular atrophy was revealed. Surgical exploration is done in equivocal cases and in patients with persistent pain.
Testicular Torsion
Manual detorsion of the testis is done without anaesthesia. It should initially be done by outwards rotation of the testis unless the pain increases or if there is obvious resistance. Success is defined as the immediate relief of all symptoms and normal findings at physical examination (Level of evidence: 3; Grade of recommendation: C). Doppler ultrasound may be used for guidance.
Bilateral orchiopexy is still required after successful detorsion. This should not be done as an elective procedure, but rather immediately following detorsion. One study reported residual torsion during exploration in 17 out of 53 patients, including 11 patients who had reported pain relief after manual detorsion.
Surgical Treatment
Testicular torsion is an urgent condition, which requires prompt surgical treatment. The two most important determinants of early salvage rate of the testis are the time between onset of symptoms and the detorsion and degree of twisting of the cord. Severe testicular atrophy occurred after torsion for as little as 4 hours when the turn was more than 360 degrees. In cases of incomplete torsion (180 degrees to 360 degrees), with symptom duration up to 12 hours, no atrophy was observed. However, an absent or severely atrophied testis was found in all cases of torsion of more than 360 degrees and symptom duration of more than 24 hours.
Early surgical intervention with detorsion (mean torsion time <13 hours) was found to preserve fertility. Urgent surgical exploration is mandatory in all cases of testicular torsion within 24 hours of the onset of symptoms.
In those patients with testicular torsion of more than 24 hours, semi-elective exploration is necessary (Level of evidence: 3; Grade of recommendation: C). Until now, there is still controversy to carry out detorsion and to preserve the ipsilateral testis, or to perform an orchiectomy, in order to preserve contralateral function and fertility after testicular torsion of long duration (>24 hours).
A recent study in humans found that sperm quality was preserved in both orchiectomy and orchiopexy groups in comparison to control normal men, although orchiectomy resulted in better sperm morphology.
During exploration, fixation of the contralateral testis is also performed. Recurrence after orchiopexy is rare (4.5%) and may occur several years after operation. There is no common recommendation about the preferred type of fixation and suture material; however, many urologists currently use a Dartos pouch orchiopexy.
External cooling before exploration and several medical treatments seem effective in reducing ischaemia-reperfusion injury and preserving the viability of the torsed testis and the contralateral testis.
Perinatal Torsion
Most cases are extravaginal torsion in contrast to the usual intravaginal torsion, which occurs during puberty.
Intrauterine torsion may present as:
- Patients with a testicular nubbin
- Patients with a small and hard testis
- Patients with a normal-sized and hard testis
- Patients with an acute scrotum
Torsion occurring in the postnatal period within the first month of life presents with signs of an acute scrotum. The clinical signs correlate well with surgical and histological findings and thus define the need and the urgency to explore the history. Doppler ultrasound can be an additional diagnosis tool. The sensitivity for diagnosis of torsion of the testis is high, though the specificity is unknown for neonates. Doppler ultrasound may also be used to exclude congenital testicular neoplasm. Neonates with acute scrotal signs as well as bilateral cases should be treated as surgical emergencies.
In cases of postnatal torsion, one study reported 40% of testes were salvaged with emergency exploration. The contralateral scrotum should also be explored because of the risk of asynchronous contralateral testicular torsion in as many as 33% of cases.
Definitions:
Levels of Evidence
1a Evidence obtained from meta-analysis of randomized trials
1b Evidence obtained from at least one randomized trial
2a Evidence obtained from at least one well-designed controlled study without randomization
2b Evidence obtained from at least one other type of well-designed quasi-experimental study
3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports
4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities
Grades of Recommendation
- Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
- Based on well-conducted clinical studies, but without randomized clinical studies
- Made despite the absence of directly applicable clinical studies of good quality
