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retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages
Pediatrics, July 1998

Objective

The purpose of this study was to compare historical features and physical examination findings among epididymitis, testicular torsion, and torsion of the appendix testis and to determine the reliability of color Doppler ultrasound in diagnosing testicular torsion.

Methods

A retrospective chart review of all patients <18 years of age who were discharged from a tertiary pediatric care center with a diagnosis of epididymitis, testicular torsion, or torsion of appendix testis from 1994-1996. Historical and physical examination findings were reviewed, as were urinalysis and Doppler ultrasound results, if performed.

Results

Study Population
Ninety patients were included in the study (64 with epididymitis, 13 with testicular torsion, 13 with torsion of appendix testis). Historical features did not differ among groups except for duration of symptoms.

Symptoms and Signs
When compared with patients with epididymitis, patients with testicular torsion or torsion of appendix testis had a shorter duration of symptoms (<12 hours) before seeking medical attention. 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%). Sixty-two (97%) of patients with epididymitis had a tender epididymis and 43 (67%) had scrotal erythema/edema.

Doppler Findings
Doppler ultrasound showed decreased or absent blood flow in 8 patients, 7 of whom were diagnosed with testicular torsion. Ten of the 13 patients with testicular torsion had a salvageable testicle at the time of surgery.

Conclusion

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.

Reviewers’ Comments

Any male presenting with acute scrotal pain, particularly between the ages of 12-18 years, should be considered to have testicular torsion until proven otherwise. Testicular torsion is a surgical emergency due to the risk of gonadal loss within 6-8 hours of the torsion. In testicular torsion, the testis and spermatic cord twist resulting in blockage of arterial blood flow and venous drainage. This results in scrotal edema and the physical findings of pain and testicular tenderness secondary to ischemia.
 Because of the twisted spermatic cord resulting in nerve compression, there is almost always absence of the cremasteric reflex in testicular torsion. Diagnosis is made by history and physical exam. However, as this study demonstrated, there are some cases of acute scrotum that may have equivocal signs.
 Doppler ultrasound has been reported in numerous studies to have a sensitivity of 90-95% for testicular torsion. The characteristic finding is reduced blood flow to the testicle in question. This is a good test; however, it is very user-dependent and open to much interpreter variability.
 Another test, not discussed in this study, is the testicular scan. This is a radionuclide scan that can distinguish between inflammatory and ischemic conditions. Areas of reduced blood flow are defined as "cold spots", i.e. no appearance of radionuclide. In contrast, areas of inflammation show brightly and are called "hot spots." This test is also limited in that it is expensive, not available in all hospitals, and requires time for injection then imaging, time that may be valuable to saving the testicle. When history and physical exam strongly suggest testicular torsion, these tests should be bypassed and the patient taken immediately to the operating room.

 Other common causes of acute scrotum include epididymitis and torsion of the appendix testis. Epididymitis usually presents in adolescence, but any age can be affected. Common findings include dysuria, scrotal swelling and pain. These patients have an intact cremasteric reflex and no testicular tenderness. Torsion of the appendix testis is more common in the prepubescent male and results in gradual onset of pain, with exquisite tenderness of the upper pole of the testicle. In some cases, the torsed appendage may be visible as a "blue dot." As with epididymitis, these children usually have an intact cremasteric reflex.