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.     

On unilateral testicular and epididymal torsion: no effect on the contralateral testis

It is often stated that unilateral testicular torsion results in damage to the contralateral testis; however, there are a growing number of experimental and clinical papers which suggest this is not so. Conflicting results from experimental studies confuse the issue and may be due, among other things, to some specifics of the experimental model. In the present paper, we have examined bilateral rat testes 30 and 60 days after 720 degrees torsion to determine 1) the effect of unilateral testicular torsion with and without the inclusion of epididymal torsion, 2) the effect of relatively chronic torsion (24 hr., 10 day) versus relatively acute torsion (two hr., four hr.), and 3) the effect of establishing the model using scrotal surgery versus using an abdominal approach. Bilateral testicular histology, testis wt. (gm.), cauda epididymal sperm concentrations (sp./ml.), and cauda sperm motility scores (0-4) were examined. Ipsilateral testicular torsion or testicular plus epididymal torsion of two hr. or four hr. duration significantly reduced (p less than .05) ipsilateral testis weights, sperm concentrations, and motility scores, and disrupted normal tissue histology. Contralateral testicles were not altered. Epididymal ischemia alone produced no significant ipsilateral or contralateral effects. Chronic torsion (one day, 10 days) also destroyed ipsilateral testis function without altering the contralateral testicles. The occult cryptorchidism associated with the scrotal approach to establishing the torsion model had no effect on contralateral testicles. In no group, using either Lewis rats or Sprague-Dawley rats, were contralateral testicles altered by unilateral testicular torsion. These results plus recent clinical reports indicate that contralateral testicular damage due to ipsilateral torsion is hardly a proven phenomenon, let alone a significant factor contributing to male infertility.     

Is the vanished testis always a scrotal event?

OBJECTIVE: To determine if perinatal testicular torsion resulting in a vanished testis is an event that primarily occurs in the scrotum. PATIENTS AND METHODS: The records of 54 boys identified as having a solitary testis were reviewed. The side of absence, size of the solitary testis, method of surgical evaluation (scrotal, inguinal or abdominal), surgical findings and histology of the tissue removed were noted. RESULTS: The testis was absent twice as often on the left side, the solitary testis was hypertrophic in 25 of 42 boys in whom it was evaluated, and tissue grossly or histologically consistent with a testicular 'nubbin' was removed in 52 boys. Scrotal (47) or inguinal (seven) exploration was carried out in all. Laparoscopy (28) or abdominal exploration (two) was undertaken to confirm that no testicular tissue was present in the abdomen in 30 boys, including the two in whom no tissue was found on scrotal or inguinal exploration. CONCLUSIONS: Perinatal testicular torsion occurs after descent but before fixation of the tunica vaginalis to the scrotal wall. These testes atrophy, leaving a remnant of tissue in the scrotum that can be identified on scrotal exploration in almost all cases. Therefore, it is recommended that the evaluation of the child with a solitary palpable testis start with scrotal exploration. Laparoscopy should be reserved for those in whom no tissue consistent with a testicular nubbin is found in the scrotum.     

Clinical study on acute scrotum]

Between April 1986 and July 1990, we experienced 13 cases of acute scrotum with surgical exploration. Six of the patients had torsion of the spermatic cord; three had torsion of an appendix of the epididymis, one had torsion of a testicular appendix, one had testicular rupture, one had acute epididymitis and one was normal. Their ages ranged from 3 months to 55 years (mean: 17.7 years), and the patients with torsion of the spermatic cord ranged from 5 to 25 years in age (mean: 16.3 years). No specific symptoms, signs, or laboratory findings were noted in patients with torsion of the spermatic cord. In the majority of cases, scrotal swelling and redness of the scrotal skin were present, and we could not distinguish parts of the scrotal contents. From 2 to 92 hours had passed before the patients presented, and patients who first attended other clinics tended to be treated in an inappropriate manner. Orchidopexy was performed in all patients with torsion of the spermatic cord. At present, only one testis which was treated after a delay of 92 hours has proven to be atrophic. Early consultation of a urological clinic and early surgical exploration are important in the treatment of the acute scrotum.     

Metachronous bilateral torsion of the testicular appendices

BACKGROUND: Torsion of the appendix testis is a common cause of scrotal pain in children and a common cause for surgical exploration of the pediatric scrotum. The first case of metachronous bilateral torsion of the testicular appendices managed by a non-operative approach is reported. METHODS/RESULTS: A case report and a computer-assisted review of the literature are presented. Physical findings of a tender, mobile mass over the anterior surface of the testis characterize the presentation. Doppler findings of normal blood flow to the testes with increased flow to the adjacent appendix testis can be utilized as an adjunct to diagnosis. Ultrasonographic findings of a pedunculated mass with a central hypoechoic area at the superior aspect of the testis support the diagnosis. Accurate non-operative diagnosis of torsion of the appendix testis permits successful conservative management with non-steroidal anti-inflammatory agents. CONCLUSIONS: Improvements in ultrasonographic and Doppler imaging of torsion of the appendix testis have facilitated the diagnosis of this entity and decreased the need for surgical exploration of the scrotum.     

Torsion of the testis and allied conditions.

In 15 years at Bristol there have been 293 cases of torsion of the testis, 55 cases of torsion of a testicular appendage and 5 cases of testicular ischaemia due to other causes. The risk of a male developing torsion of the testis or its appendix by the age of 25 is about 1 in 160. Both conditions occurred primarily in adolescents, but among prepubertal boys torsion of an appendage was as common as torsion of a normally descended testis. There was a slight left-sided preponderance in testicular torsion, more marked in torsion of the appendages; the incidence of bilateral torsion was 2-0 and 1-8 per cent respectively. The clinical features and differential diagnosis of the two conditions are compared. Torsion of a testicular appendage is the most commonly misdiagnosed scrotal lesion, the preoperative diagnosis being correct in only 11 per cent of cases compared with 90 per cent for torsion of the testis. Twenty-one cases of recurrent torsion underwent prophylactic bilateral orchidopexy. There were 20 cases of torsion of undescended testes, with a salvage rate of only 20 per cent. The overall testicular survival rate was 55-3 per cent. Viability depends upon the possibility of spontaneous reduction, the preoperative delay after the onset of symptoms, the degree of torsion of the cord and the length of follow-up in doubtful cases. Urgent scrotal exploration is advised in every case of acute testicular pain unless there is overwhelming evidence of epididymoorchitis. Exploration of the opposite side is mandatory in torsion of the testis and advisable in torsion of an appendage.     

Neonatal testicular torsion and infarction: aetiology and management

Thirty neonates presented with signs of testicular ischaemia over a 20-year period. Eighteen children had primary exploration revealing extravaginal torsion (10), intravaginal torsion (3), infarction without torsion (2) and torsion of the appendix testis (1). The other two children had simple biopsy of necrotic testes. In two instances the testis was untwisted and retained but both subsequently atrophied. The remainder underwent orchiectomy. Twelve children did not have initial exploration and 11 of these had subsequent testicular atrophy. At contralateral testis fixation, performed in 17 cases, signs of contralateral involvement in the ischaemic process were found in seven, suggesting that the primary event in the condition is infarction, with torsion occurring secondarily.     

Polyorchidism and torsion. A lesson from 2 cases

Two cases of polyorchidism with 2 left scrotal testes are referred. In both patients, the segmented gonads showed a “bell clapper” deformity. In the first patient, the contralateral gonad also presented a large mesorchium and absence of scrotal ligament, whereas in the second case, the right gonad was firmly adhered to the tunica vaginalis because of a previous appendix testis torsion. Orchidopexy of all testes, judged at risk for torsion, was performed. Contrary to what is recommended by recent literature, we consider scrotal exploration and testis fixation mandatory of the contralateral, apparently normal gonad as well, even in the absence of clinical and ultrasound signs of associated abnormalities or complications.     

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.     

Intermittent testicular pain: fix the testes

OBJECTIVE: To analyse the presenting features, signs and operative findings of children presenting with intermittent testicular pain, as testicular torsion is a relatively common and serious emergency in children that can lead to testicular loss in up to 80%, although half of these children have previous episodes of pain suggestive of intermittent torsion. PATIENTS AND METHODS: Data were collected prospectively for all patients presenting with recurrent pain between December 2000 and June 2001. Variables assessed included presenting symptoms, age, size, lie and position of the testis when supine and erect, the operative findings and follow-up. RESULTS: Eight children had at least two previous episodes of testicular pain; four of these were admitted on six occasions. Two had undergone previous scrotal exploration. On clinical examination, six boys had a transverse testicle and two a discrepancy in testicular size. All children had their testes fixed. At operation in all patients there was abnormal attachment of the tunica vaginalis with a typical 'bell clapper' deformity. On follow-up only one patient still complains of pain. CONCLUSION: In view of high incidence of abnormalities we consider that to improve the testicular salvage rate and prevent testicular atrophy, bilateral testicular fixation is recommended for boys with intermittent testicular pain and positive clinical findings.     

Perinatal testicular torsion: a unique strategy

Background/Purpose

Perinatal testicular torsion (PTT) is defined as testicular torsion occurring prenatally or within the first 30 days of life. The aim of this study was to evaluate the data obtained from patients with PTT and propose principles of management based on clinical, surgical, and histologic findings.

Methods

A retrospective analysis of 27 boys seen between 1990 and 2005 with surgically documented PTT was conducted. Patients were divided into 2 groups: A, prenatal testicular torsion; B, postnatal testicular torsion. The presence of acute scrotal inflammatory signs defined the urgency to operate.

Results

There were 4 clinical pictures in group A: A1, patients with a nubbin testis (n = 3); A2, patients with a small and hard testis (n = 12); A3, patients with a normal-sized and hard testis (n = 8); and A4, patients with an acute scrotum (n = 2). Group B (n = 2) presented no sign after birth and later developed an acute scrotum. Surgical exploration and histologic examination showed clear signs of a long-standing testicular torsion in groups A1, A2, and A3 or a recent-onset testicular torsion in groups A4 and B. Only one testis could be salvaged (group B).

Conclusions

Clinical signs correlated very well with surgical and histologic findings and can define the need and the urgency to operate. Although testicular salvage rate is very low, the affected side always should be explored to confirm the diagnosis and to fix or remove the affected testicle. The contralateral scrotum also should be explored because of the risk of asynchronous contralateral testicular torsion.     

„Akutes Skrotum“ beim Neugeborenen

The most common causes of an 'acute scrotum' in childhood are testicular torsion, torsion of an appendix testis, epididyoorchitis, idiopathic edema, and hematoma. In rare cases a scrotal hematoma can originate from an extra- or intraperitoneal adrenal bleeding. 12 such cases have been described in the literature, yet. We report on 3 further cases, that occurred in our institution between 1992 and 1997. In the first case we performed a scrotal exploration due to a suspected testicular torsion, but only a normal testicle and liquid hematoma were seen. Postoperatively we discovered an ipsilateral adrenal hemorrhage by sonography. In the latter two cases the adrenal bleeding was recognized primarily as causal for the scrotal mass and operation remained undone. In newborns adrenal hemorrhage is mostly due to birth-trauma, large birth-weight, hypoxia, and asphyxia. This was present as well with our 3 children. If the clinical situation of the child is stable, complete restitution under conservative therapy can be expected.     

The acute scrotum

The list of differential diagnoses for the acute scrotum is extensive, but it is paramount to rule out torsion of the spermatic cord, most common in boys aged 13–17 years and the most common cause of acute scrotal pain and swelling up to 18 years old. Torsion requires emergency surgical exploration and detorsion if the testis is to be salvaged. The management of perinatal torsion is surrounded by some controversy and best dealt with by dedicated paediatric units. Beyond 18 years epididymitis is a more common finding, usually caused by chlamydial, gonococcal or coliform infection. Investigations, antibiotic treatment and follow up should be based on the 2010 national guidelines. Torsion of the appendix testis and appendix epididymis, remnants of the Mullerian and Wolffian ducts, respectively, can mimic the more common diagnoses but most cases resolve spontaneously with non-operative management. Torsion of the testis is more likely if the onset of pain is sudden, the pain is severe and the patient is younger than 20 years of age. When there is any doubt about the diagnosis, an emergency scrotal exploration should be undertaken.     

The acute scrotum

The list of differential diagnoses for the acute scrotum is extensive, but it is paramount to rule out torsion of the spermatic cord, most common in boys aged 13-17 years and the most common cause of acute scrotal pain and swelling up to 18 years old. Torsion requires emergency surgical exploration and detorsion if the testis is to be salvaged. The management of perinatal torsion is surrounded by some controversy and best dealt with by dedicated paediatric units. Beyond 18 years epididymitis is a more common finding, usually caused by chlamydial, gonococcal or coliform infection and investigations, antibiotic treatment and follow-up should be based on the 2010 national guidelines. Torsion of the appendix testis and appendix epididymis, remnants of the Mullerian and Wolffian ducts respectively, can mimic the more common diagnoses but most cases resolve spontaneously with non operative management. Torsion of the testis is more likely if the onset of pain is sudden, the pain is severe and the patient is younger than 20 years of age. When there is any doubt about the diagnosis, an emergency scrotal exploration should be undertaken.     

精索扭转的循证诊断与治疗

目的:系统评价精索扭转的诊断及处理方法。方法:计算机检索Cochrane图书馆、PubMed、维普资讯、CNKI,查找有关精索扭转的随机对照研究,检索时限均为1990~2012年,研究者对文献质量进行严格评价和资料提取,采用盲法分析。结果:共纳入27篇文献,3 541例患者纳入研究。结果表明:多普勒彩超在诊断阴囊急症明显优于常规超声,成为阴囊急症的首选影像学诊断方法;对任何年龄段的急性阴囊疼痛的患者均应行手术探查,没有足够的证据支持单侧精索扭转行对侧睾丸固定;精索扭转对于患侧睾丸生育功能的影响会随着患者年龄的增长而增加,对于健侧睾丸的影响尚存在争议。结论:对于有阴囊症状的患者应及时行阴囊多普勒彩超筛查,对于已确认精索扭转患者及阴囊急症患者应立即行阴囊手术探查,根据具体情况以决定是否行双侧睾丸固定术,对患者生育功能应加强随访。     

Etiology of acute scrotum at surgical exploration in children, adolescents and adults.

Between January 1970 and December 1989, 171 patients underwent scrotal exploration for acute scrotum (an acute painful swelling of the scrotum or its content), at our hospital. Of 70 children scrotal explorations, torsion of appendages was found in 33 cases (47%). Torsion of testis was found in 24 patients (34%). Of the 84 adolescent scrotal explorations performed, 72 (86%) had torsion of testis, and 8 (9%) had torsion of appendages. Of 17 adults, torsion of testis was found in 15 cases (88%). These results clarify that unnecessary explorations are much more common in children (66%) than in adolescents and adults (14%). We therefore suggest using radionuclear scans and/or Doppler ultrasound to facilitate clinical diagnosis in the children group.     

Neonatal testicular torsion: a survey of current practice amongst paediatric surgeons and urologists in the United Kingdom and Ireland

Purpose

Management of neonatal testicular torsion (NTT) is controversial, with varied opinion regarding the merit(s) and role of “emergent” testicular exploration and/or contralateral orchidopexy of the healthy testis.

Methods

A survey of consultant paediatric surgeons and urologists working in the United Kingdom and Ireland was conducted to ascertain views to guide best practice.

Results

A total of 148 questionnaires were mailed, of which 110 were returned (74% response rate). Of these, 60 (54.5%) surgeons considered NTT secondary to torsion of the spermatic cord and 8 (7.2%) thought primary vascular infarction of the testis responsible. Twelve (10.9%) use Doppler ultrasound to guide management and exclude tumour. Eighty-two surgeons (74.5%) explore the scrotum, and 59 (71.9%) perform ipsilateral orchidectomy and contralateral orchidopexy of the “healthy” testis. Few surgeons undertake emergent exploration. Only 11 (10%) surgeons have ever found a viable testis. Seven (6.4%) cases of synchronous NTT were reported. Twenty-four (21.8%) surgeons do not perform contralateral orchidopexy with concerns of damaging a healthy testis. Orchidopexy is favoured by 89 surgeons, with 46 (52%) using nonabsorbable suture fixation and 28 (31.4%) creating a sutureless extradartos pouch. In boys later found to have a “solitary scrotal testis” and a contralateral testicular remnant, 38 (36.5%) of 104 would always “pex” the testis to avert anorchia.

Conclusions

Surgeons' opinions with NTT in the United Kingdom and Ireland remain diverse. Strong argument can be made for scrotal exploration with/without contralateral orchidopexy. Parents should be counselled on the merits of varied strategies to gain better understanding of the long-term outcomes for their male child.     

Management of acute scrotum in children--the impact of Doppler ultrasound

Background

Investigation of the value of scrotal Doppler ultrasound (DUS) in the diagnosis of acute scrotum and its impact on the treatment strategy was undertaken.

Method

Seventy-nine children (mean age, 9.2 years) with acute scrotum were prospectively studied. The protocol included history, clinical examination, scrotal DUS, and standard laboratory analysis. Depending on scrotal DUS findings, the children were treated either nonoperatively (normal or increased testicular blood flow) or surgically (reduced or absent testicular blood flow). A follow-up investigation 6 weeks after discharge included a scrotal DUS.

Results

In 66 children (84%), the result of DUS determined the management; 26 children with hyperperfusion (epididymitis and orchitis), 18 children with appendix testis torsion (ATT), and 9 children with normal perfusion (edema and hematoma) were treated nonoperatively. The follow-up examination revealed no testicular atrophy and confirmed the primary diagnosis. Ten children without testicular perfusion and suspected torsion and 3 children with orchitis and pyocele were surgically explored, and again, the initial DUS diagnosis was verified. In the remaining 13 patients (16%), the result of the ultrasound examination was unclear. Of these, 6 children were noncompliant and refused to undergo ultrasonography. Another 4 children were explored because of persistence of symptoms. In 3 additional patients, a testicular tumor was suspected. All these 13 children underwent surgical exploration, revealing inflammation (epididymitis) in 6 children and acute ATT in 4 children, whereas the suspected tumor emerged as postacute ATT in 3 boys.

Conclusion

In 84% of children with acute scrotal pain, the DUS was able to differentiate between surgical emergencies and other etiologies. In 16% of our pediatric patients, the DUS remained unclear, thereby necessitating surgical exploration.     

小儿服囊急症

目的：总结小儿阴囊急症手术或非手术治疗的可行性。方法：回顾性研究５２６例小儿阴囊急症患者的临床资料和诊疗经验。睾丸附件扭转３６８例（７０．０％）,急性鞘膜炎４９例（９．４％）,睾丸扭转４２例（８．０％）,急性附睾炎１９例（３．５％）,急性阴囊感染１８例（３．４％）,阴囊血肿１８例（３．４％）,睾丸炎６例（１．１％）,特发性阴囊水肿６例（１．１％）。前４种常见疾病共４７８例,占９０．９％。住院前误诊     

Scrotal swelling in the Sch?nlein-Henoch syndrome.

Testicular and scrotal hemorrhage is uncommon in the Sch?nlein-Henoch syndrome. The diagnosis of testicular torsion is difficult to make when it is complicated by vasculitis of the testis. Since both conditions can occur simultaneously, torsion of the testis must be considered and surgical exploration performed whenever acute testicular pain and swelling occur during the course of the Sch?nlein-Henoch syndrome. Two patients with this syndrome as well as scrotal and testicular involvement are described.