Testicular torsion: Evaluation and management

Testicular torsion is described as the twisting of the spermatic cord resulting in acute pain and ischemia. This has a tendency to occur more frequently during adolescence and its cause is unknown. The most common signs and symptoms include red, swollen scrotum and acutely painful testicle, often in the absence of trauma. Nausea and vomiting are common. The most common conditions in the differential diagnosis include epididymitis, strangulated inguinal hernia, traumatic hematoma, testicular tumor, or testicular fracture. Physical examination techniques such as scrotal elevation can be helpful in differentiating between epididymitis and testicular torsion, but emergent imaging with Doppler ultrasound seems to be the most helpful in confirming the diagnosis. Radionuclide testicular scintigraphy with ^99mTc is helpful when past the acute phase (the first 12 hours) and vascular compromise has prolonged. The clinician may attempt to manually reduce the torsion, but many need to be immediately referred to a urologist for a surgical exploration. Long-term prognosis for a functional, nonatrophied testicle is improved the sooner the torsion is diagnosed and treated.     

Hodentorsion: Diagnose, Differenzialdiagnose und Therapie im Kindesalter

Acute scrotum represents an emergency situation although testicular torsion is present in less than 20% of the cases. Sonography has meanwhile become the definitive modality for diagnosis. Its increasing use before surgical intervention has led to technical improvements in ultrasound diagnostics and critical assessment of ultrasound criteria to exclude testicular torsion as well as standardization of examination procedures. Central arterial and venous perfusion shown to be bilaterally equal on Doppler sonography is the most important criterion for excluding torsion.This article discusses other criteria such as the "resistance index," comparison of parenchymal structure of both testes, evidence for spermatic cord torsion, or differences between the sides in perfusion of the testicular parenchyma and highlights the difficulties involved in partial and intermittent testicular torsion. Alternative investigative methods and the significance of sonography in the differential diagnosis of other underlying causes are addressed. In summary, the combination of interpreting B-mode imaging, color Doppler, and power Doppler sonography and analyzing Doppler flow curves after clinical examination results in successful and conclusive evaluation of the testes in cases of acute scrotum in boys.     

Acute testicular torsion in children: the role of sonography in the diagnostic workup

Acute testicular torsion in children is an emergency and has to be diagnosed urgently. D oppler sonography is increasingly used in imaging the acute scrotum. Nevertheless, in uncertain cases, surgical exploration is required. In this study, we attempted to define the role of Doppler sonography in the diagnostic workup of the acutely painful scrotum. All patients admitted between 1999 and 2005 with acute scrotal pain were included. After clinical assessment, patients were imaged by Doppler sonography with a ‘‘high-end’’ instrument. In cases of absent arterial perfusion of the testis in Doppler sonography, surgical exploration was carried out. Patients with unaffected perfusion were followed clinically by ultrasound for up to 2 years. Sixty-one infants and children aged 1 day to 17 years (median: 7.9 years) were included. In 14 cases, sonography demonstrated absent central perfusion, with abnormal parenchymal echogenicity in six. Absence of venous blood flow together with reduction of central arterial perfusion was found in one infant. In these 15 patients, surgical exploration confirmed testicular torsion. Among the other 46 patients, we found four cases with increased testicular perfusion and 27 with increased perfusion of the epididymis. In one infant, a testicular tumour was found sonographically, and orchiectomy confirmed diagnosis of a teratoma. Follow-up examinations of the conservatively treated patients showed good clinical outcome with physiologic central perfusion as well as normal echogenic pattern of both testes. No case of testicular torsion was missed. By means of Doppler sonography, an unequivocal statement regarding testicular perfusion was possible in all cases. The initial Doppler diagnosis was confirmed by operative evaluation and follow-up ultrasound. Testicular torsion can therefore be excluded by correctly performed ultrasound with modern equipment. Patrick Gunther and Jens-Peter Schenk contributed equally to this work     

Scrotal pathology in pediatrics with sonographic imaging

Scrotal pathology in pediatrics ranges from the more benign hydrocele and varicocele to acute testicular torsion requiring emergent surgery. Malignant testicular tumors can be insidious in onset or may present acutely when trauma brings a swollen scrotum to the patient's or physician's attention. Three common conditions can present as an acute scrotum, all of which can suggest testicular torsion clinically. Epididymitis often has a less acute onset than testicular torsion, although it does not always present with a straightforward diagnosis. Although it is generally an inflammatory process affecting males from 9 to 14 years of age, it can be seen in younger males with Henoch-Schonlein purpura and Kawasaki disease. Torsion of the appendix of the testis and epididymis can present acutely and mimic acute testicular torsion and generally occurs from 6 to 12 years of age. Testicular torsion itself usually occurs from 12 to 18 years of age and usually results from the anatomical “bell-and-clapper” deformity. Infarction of the testis can occur within as early as 4 to 6 hours after torsion, depending on the duration of symptoms and degree of twist of the spermatic cord. Advances in ultrasound technology in recent years have made ultrasound the examination of choice for imaging scrotal pathology, whether acute or chronic in nature. Doppler technology has tremendously increased the radiologist's ability to assess flow within the prepubertal testicle, which allows assessment of viability in the undescended testis as well as in neonatal torsion. The ability of ultrasound to diagnose the pathogenesis of the acute scrotum is unsurpassed by any other imaging modality. Ultrasound is a readily available, noninvasive examination without radiation that provides excellent anatomic detail and serves as an important and tremendously helpful imaging modality in all types of pediatric scrotal pathology.     

Testicular imaging

Clinicians have relied on radionuclide scanning for evaluating acute scrotal pain and on ultrasonography for chronic scrotal pain and anatomic lesions (testicular and paratesticular structures). This review reinforces the utility of these established imaging techniques and also introduces color Doppler ultrasonography as an integral component in the advancement of testicular imaging, particularly in effective and timely diagnosis of spermatic cord torsion. The expanding capability of MR imaging for scrotal disorders is presented.     

核素显像在阴囊急症的临床应用价值

目的 探讨放射性核素阴囊显像在急性睾丸扭转与急性睾丸附睾炎鉴别诊断中的临床应用价值。方法 对阴囊急症13例行SPECT核素阴囊显像，“弹丸”注射^99mTcO^-4 370 MBq后即刻行动态血流灌注显像，15min后行静态血池显像并进行显像结果分析。结果 10例血流灌注相呈血流减低，静态血池相放射性缺损，经急诊手术证实了9例为睾丸扭转，其中3例因及时确诊及手术纠正扭转而保留患睾。3例血流灌注相呈血流增高，静态血池相放射性分布仍明显高于对侧，符合睾丸附睾炎表现．经内科保守治疗后症状消失。结论 睾丸缺血的时间是影响其存活的重要因素。核素阴囊显像简便、快速、非创伤，对阴囊急症的鉴别诊断、治疗方法的选择具有重要的临床指导价值。     

急性阴囊疾病的彩色多普勒超声诊断

目的探讨彩色多普勒超声对急性阴囊病变的诊断与鉴别诊断价值。方法对急性睾丸炎、急性附睾炎、睾丸损伤、睾丸扭转及附件扭转52例急性阴囊疾病的彩色多普勒超声图像进行对比分析。结果本组急性阴囊疾病的超声检查结果与临床最后诊断及手术结果完全一致。本组52例中，急性睾丸炎10例，急性附睾炎16例，睾丸损伤12例，睾丸扭转9例以及睾丸附件扭转5例。结论彩色多普勒超声可作为诊断与鉴别诊断急性阴囊疾病的首选的无创临床检查手段。     

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. Received: 3 May 2000/Accepted: 8 June 2000     

Clinical study of scrotum scintigraphy in 49 patients with acute scrotal pain: A comparison with ultrasonography

The significance of scrotum scintigraphy in differentiating acute testicular torsion from acute orchiepididymitis was evaluated. In this report, 49 patients with acute scrotal pain were examined with radionuclide scrotum scintigraphy and ultrasonography in parallel for comparison. Of 37 patients with decreased radioactivity in the abnormal side scrotum, 35 were diagnosed with testicular torsion surgically and the other 2 were diagnosed with indirect inguinal hernia. Only 17 among the 35 patients were diagnosed by ultrasonography as having testicular torsion. The remaining 12 patients with increased radioactivity in the abnormal side of the scrotum were all diagnosed with orchiepididymitis through conservative treatment and clinical follow-up, but only 8 of the 12 were correctly and exactly diagnosed by ultrasonography. In the process of diagnosing acute scrotal pain, radionuclide scrotum scintigraphy has obvious advantage over ultrasonography. It also has the advantage of being simple, fast and accurate but without any detrimental effect on the human body.     

Color Doppler US in the evaluation of acute scrotal disease

Twenty-seven patients presented with painful acute scrotal swelling. After a clinical impression was established, all patients underwent diagnostic imaging with color Doppler ultrasound (US). Seven patients underwent surgical exploration for testicular torsion diagnosed with color Doppler US (100% operative confirmation), one underwent radical orchiectomy for treatment of seminoma, and one underwent orchidopexy for treatment of a freely mobile testis. Eighteen patients were treated for nonoperable conditions. Diagnoses made with color Doppler US correlated with final clinical diagnoses in all patients. In 10 of 27 patients (38%), the diagnosis was established at color Doppler US. Until now, nuclear scanning has had a paramount role in the evaluation of equivocal cases of acute scrotal disease. Results show that color Doppler US helps accurately correlate anatomy and perfusion in real time and may prove to be the definitive imaging technique for the diagnostic evaluation of acute scrotal pain or swelling.     

Reliability of radionuclide scintigraphy for detection of testicular torsion: an animal study

Sodium pertechnetate Tc99m scintigraphy is a valuable technique for the evaluation of acute testicular torsion in postpubescent males. However, in neonates and children with small testicles, the method is less reliable. Since the testicles of adult rats and young children are of similar size, the reliability of testicular imaging for detecting torsion was evaluated in this species. The utility of the radionuclide angiogram (RA) and static images were determined in 17 anesthetized animals before, 2 h after and 20 h after ligation of the left spermatic cord. The preligation RA was asymmetric in 27% of animals, while the static images were abnormal in 18%. Postligation flow and static images were abnormal in 57% and 82% of the animals (localized to the correct side, 38% and 36%), respectively. The animals with vascular occlusion failed to show any statistically significant greater incidence of decreased radionuclide accumulation on the ligated side. To determine the influence of relative perfusion and extracellular fluid space of the scrotum and testicles on the images, additional studies were performed with 201Tl (representing perfusion) and 99mTcO4- (representing ECF space). Perfusion was approximately equal in the testis and epididymis but significantly higher in the scrotum. These results suggest that scrotal scintigraphy is unreliable for detecting acute torsion of small testicles.     

Color Doppler US of the scrotum.

Color Doppler ultrasonography (US) is an increasingly important tool in the evaluation of the scrotum, especially in acute scrotal disorders. With this modality, arterial flow is readily detected in the normal spermatic cord and testis but is not seen in the epididymis; venous flow is not seen anywhere in the normal scrotum. Scrotal inflammatory lesions appear as hypervascularity of the epididymis or testis, even though gray-scale findings may be normal or nonspecific. Testicular torsion is demonstrated by an absence or marked decrease in the number of visible vessels. Small tumors (less than 1.5 cm) are hypovascular, and larger tumors (greater than 1.5 cm) are hypervascular. The modality also demonstrates Valsalva maneuver-induced venous flow augmentation in varicoceles and altered flow in testicular tumors. Color Doppler US allows for evaluation of morphologic findings and perfusion and enables accurate diagnosis of most scrotal disorders.     

Radionuclide genital imaging

Despite the emergence of newer cross-sectional imaging approaches, radionuclide techniques have maintained a significant role in genital imaging. While ultrasound is clearly superior for evaluation of scrotal anatomy, radionuclide scrotal imaging remains the most effective method for differentiating between testicular torsion and epididymitis. Labeled red blood cells have been used for varicocele detection in infertile men. Since radionuclide techniques can demonstrate the physiologic status of organs, they play a useful role in evaluating men with impotence (penile scan) and infertile women whose tubal patency is in question (radionuclide hysterosalpingogram).     

Radionuclide genital imaging.

Despite the emergence of newer cross-sectional imaging approaches, radionuclide techniques have maintained a significant role in genital imaging. While ultrasound is clearly superior for evaluation of scrotal anatomy, radionuclide scrotal imaging remains the most effective method for differentiating between testicular torsion and epididymitis. Labeled red blood cells have been used for varicocele detection in infertile men. Since radionuclide techniques can demonstrate the physiologic status of organs, they play a useful role in evaluating men with impotence (penile scan) and infertile women whose tubal patency is in question (radionuclide hysterosalpingogram).     

Testicular infarction secondary to acute inflammatory disease: demonstration by B-scan ultrasound

Acute epididymitis can lead to obstruction of the adjacent testicular blood supply, resulting in focal or diffuse infarction of the testis or epididymis in the absence of torsion. Four cases are presented to demonstrate the spectrum of B-scan ultrasound findings, ranging from focal necrosis of the epididymis and ischemic infarction of the testis to diffuse testicular infarction. Epididymal enlargement and skin thickening are consistently seen on ultrasound as well as swelling and decreased echogenicity of the testicle. The authors suggest a protocol for acute scrotal symptoms, incorporating clinical findings and (where appropriate) radionuclide scans.     

Subacute scrotal pain: evaluation of torsion versus epididymitis with MR imaging

Torsion knot and whirlpool patterns result from the twisting of the spermatic cord, which produces distortion of cord structures. These two findings, along with spermatic cord vascularity, were used to prospectively differentiate testicular torsion from epididymitis in 11 patients with subacute scrotal pain who underwent magnetic resonance (MR) imaging. The final diagnosis was established clinically in four patients and surgically in five. MR imaging enabled the recognition of each entity without error. Retrospective review of findings highlighted other potential discriminating features, the most important of which were testicular size and vascularity. Because of its ability to highlight vessels and detail normal and abnormal intrascrotal anatomy, MR imaging in this small series enabled the differentiation of subacute torsion from epididymitis with 100% accuracy. This high degree of accuracy warrants further investigation.     

The acute paediatric scrotum: the role of colour doppler ultrasound

Combined grey scale ultrasound and colour Doppler imaging of the acute paediatric scrotum provides a non-invasive means of assessing the structure and perfusion of the testis. Colour flow ultrasound is a sensitive and specific diagnostic tool for differentiating ischaemic pathology (in which blood flow rate is reduced) from inflammatory disease in which it is commonly increased. Using this technique the number of unnecessary surgical explorations of the scrotum can be reduced. The differential diagnosis of acute testicular pathology and the imaging characteristics of each disorder are described. Close collaboration between paediatric surgeons and radiologists is required to determine the optimal clinical and investigational strategy for each child.     

彩色多普勒超声在急性阴囊肿痛诊断中的应用

目的评价彩色多普勒超声(CD)在急性阴囊肿痛诊断及鉴别诊断中的应用价值。方法应用CD对53例急性阴囊肿痛患者进行急诊检查。观察阴囊内容物的形态、回声、结构及血流变化。经手术或临床治疗随访证实诊断。结果53例阴囊急症中,37例经非手术治疗及超声随访证实诊断,16例经手术及病理确诊。CD诊断准确率98%(52/53)。其中,睾丸扭转92%(12/13),睾丸、附睾炎100%(28/28),阴囊外伤100%(9/9),阴囊皮肤感染100%(3/3)。结论CD不仅能够区别睾丸扭转和炎症,并能鉴别肿瘤与炎症,还可评价阴囊外伤的程度及预后,因而它可作为诊断急性阴囊肿痛的首选方法。     

Suspected testicular torsion and ischemia: evaluation with color Doppler sonography

Color Doppler sonography was performed in 32 patients with a painful scrotum in whom testicular ischemia from torsion or postherniorrhaphy was clinically suspected. Surgical correlation was available in 15 patients, and scintigraphic correlation was available in 17 patients. Seven of the 32 patients were diagnosed as having testicular ischemia from torsion. Color Doppler flow imaging demonstrated a lack of intratesticular flow in six of the seven testes with torsion and relatively normal intratesticular flow in one of the patients with acute torsion. Normal or increased intratesticular flow was demonstrated by color Doppler in all 57 of the nonischemic testes. Using the single criterion of presence or absence of identifiable intratesticular flow, the authors found that color Doppler was 86% sensitive, 100% specific, and 97% accurate in the diagnosis of torsion and ischemia in the painful scrotum. Color Doppler sonography is an accurate, noninvasive means of rapidly assessing perfusion of the testis in the painful scrotum.