In the “EMRAP Interview with Rob Orman on Testicular Torsion” on YouTube Dr. Mellick discusses his article “Torsion Of The Testicle: Is It Time To Stop Tossing The Dice” [PubMed Abstract] January 2012Pediatric emergency care 28(1):80-6.
I’ve just listened to the interview and it is outstanding.
The (PDF) of Torsion of the Testicle It Is Time to Stop Tossing the Dice can be downloaded from Researchgate. Thank you, Dr. Mellick.
Here are some excerpts from Dr. Mellick’s outstanding article, Resource (1) below:
Abstract:
In this review, long-held myths and misperceptions about the evaluation and management of testicular torsion are discussed, and recommendations for the management of patients who present with acute scrotal pain are presented.
CASE
A 6-year-old boy was transferred from an outside hospital
for evaluation of abdominal pain. His pain had begun earlier
that morning when he awakened with nausea and vomiting. The
initial complaint of pain was localized to the abdomen and a
computed tomographic scan was performed because of suspected appendicitis. The patient’s scrotum and testicles were never examined during the first evaluation. During the evaluation in the pediatric emergency department, the history of testicular trauma while swimming the day prior was elicited. The possibility of a testicular blunt trauma injury was entertained prior to the color Doppler ultrasound (CDS). The examiners, which included a pediatric urologist, noted testicular tenderness and possible bruising. However, no history or physical findings clearly diagnostic of testicular torsion (TT) were noted by the examiners. The cremasteric reflex was intact. The ultrasound demonstrated no blood flow to the left testicle (Fig. 1). During surgical exploration of the scrotum, the testicle was found to be torsed 720 degrees and could not be salvaged. Interestingly, the torsion occurred in a lateral direction and not medially, which is the most common direction.MEDICOLEGAL RISKS
Testicular torsion is the third most common cause of a
malpractice lawsuit in adolescent males 12 to 17 years.1 The
misdiagnosis of TT is not a recent problem, an unavoidable
event, or one owned primarily by emergency physicians. In
2001, Matteson et al2 reviewed closed case files specifically
involving TT from the years 1979 to 1997 of a large medical
malpractice insurance company based in New Jersey. The major liabilities for paid claims were an error in diagnosis (74%), the most common misdiagnosis was epididymitis (72%), urologists were named most frequently (48%) and atypical presentations of testicular torsion were common (31%).Torsion of the testicle is a relatively rare condition occurring
with an annual incidence of 4.5 in 100,000 in males 1 to
25 years.4 Consequently, the incidence of TT presenting to
emergency departments is low in contrast to other scrotal complaints, and there are signs and symptoms that are admittedly more commonly found with the testicle undergoing torsion.5Y8 This, however, is the perfect storm that sets up health care providers for overconfidence in their clinical diagnosis as well as the perpetuation of clinical myths and misperceptions.In this review, long-held myths and misperceptions about
the evaluation and management of TT are discussed and recommendations for the management of patients who present with acute scrotal pain are presented.Myth 1: Testicular Torsion Can Be Consistently
Ruled Out by Physical Examination AloneThe literature confirms that it is not possible to consistently
and accurately differentiate testicular torsion (TT) from epididymo-orchitis (EO) and other scrotal pathologic abnormality by physical examination alone.In a 25-year review of 199 children presenting with an acute scrotum, Sidler et al15 stated that, ‘‘no discriminating features in either history or examination conclusively differentiated the correct diagnosis.’’ And, ironically, one author who expressed confidence in the physical examination reported a 12.5% incidence of TT misdiagnosis.16
One of the major tripwires is the belief that the presence
of a cremasteric reflex essentially rules out a TT. . . . [It does not.] Consequently, reliance on the [presence or absence] of cremasteric reflex for a decision to go to surgery or imaging should be a cause for concern.Although the cremasteric reflex is commonly absent in
conditions other than TT, it is also present in a significant
number of patients with TT. . . . To use this examination for an imaging or consultation decision in the diagnosis of TT is an unnecessary gamble. Unfortunately, that is happening.Scrotal erythema, edema, and testicular swelling are other
physical findings that are commonly reported and described in
patients with TT. Unfortunately, these findings are also very
common in patients with EO and torsion of the appendix testis
(TAT).8Y10,16,17,22,27Y29Another physical finding often considered strongly suggestive
of epididymitis is pain around the upper pole of the
testicle or epididymis. However, it also occurs with torsion of
the testicle and the testicular appendage.In addition, an enlarged epididymis may be common in
patients with epididymitis, but it is also found in patients with TT. Multiple ultrasound studies have documented enlargement
of the epididymis in the presence of a TT.12,26,30Y32Although the lie of the testicle in torsion is frequently
transverse, a vertical orientation is also common in patients withTT.27,29 Abul et al29 reported that a transverse elevated lie of the testis was observed in only 4 (36.4%) TT patients. A normal lie was described in 54% of the TT patients described in a small series by Kadish and Bolte.11Myth 2: Testicular Torsion Can Be Differentiated From Other Causes of Scrotal Pathology by Its Pathognomonic History
Torsion of the testicle and its appendages and epididymitis
have a significant overlap in their reported symptoms. Acute excruciating scrotal pain of relatively short duration before arrival in the emergency department is highly suggestive of TT.28,29 However, rapid onset can be seen in epididymitis and torsion of the testicular appendage and gradual in TT.Although urinary signs and symptoms are expected to occur
with EO patients, they can also be found in patients with TT. In the series by Cass et al,28 urinary symptoms of frequency and/or burning were documented to be present with equal frequency in both TT and EO patients (7%). Lewis et al7 described 2 sexually active TT patients who presented with pyuria and were initially misdiagnosed and treated as a sexually transmitted disease.Nausea and vomiting are common with torsion of the testicle,5,35 but they also occur with epididymitis.
Reports of testicular pain are common to patients presenting
with TT, TAT, and EO. Mushtaq et al16 noted that testicular
pain was reported in 92% of TAT patients, in 88% of TT patients, and in 76% of EO patients.Reports of abdominal pain alone are also found commonly
among these conditions.8,25Y28,37,38 Cass et al28 reported that 12.5% of their TT patients presented with only abdominal or
inguinal pain. Anderson and Williamson39 reported that 32 (5%) of 597 patients with TT and a fully descended testicle did not describe any scrotal pain and that 22% of the entire group had abdominal pain, which often preceded and exceeded the scrotal pain. In fact, the appendix was removed in 3 patients before the true diagnosis was made. Inguinal pain alone was described in6% of the cases.39 Isolated abdominal pain is not pathognomonic for TT and also occurs with TAT and EO patients.8,16,28,40 The retrospective review by Mushtaq et al16 reported complaints of abdominal pain in 9% of TAT patients, 28% of TT patients and 21% of EO patients. Ma¨kela¨ et al8 reported that 7% to 8% of boys complained of abdominal pain in each 3 groups of TT, TAT, and EO.Myth 3: Testicular Torsions That Present After 6 Hours Are Not Salvageable and No Longer Need to Be Evaluated in a Timely Manner
[Please see PDF pp 82 + 83 for all the important points dispelling this myth]
Myth 4: Color Doppler Ultrasound Is a Consistently Reliable Tool for Confirming the Diagnosis of Testicular Torsion
Reliance on the history and physical examination alone is
hazardous and the inaccuracy of those elements has been well
documented now for decades. Concurrently, although the accuracy of imaging is quite good, it is also well documented to
have a degree of error and inaccuracy.7,29,59,60,63 The failure of both history and physical examination and color Doppler ultrasound to definitively make the diagnosis in significant percentages of patients is demonstrated in the 2007 multicenter
study by Kalfa et al.60 In that study, 208 patients had spermatic cord torsion proven at surgery. However, the clinical diagnosis of TT before any ultrasonographic examination was judged as highly probable in 78.5% of the cases, possible in 10.2%, and unlikely in 11.3% of these torsed patients. Moreover, CDS failed to establish the diagnosis of spermatic cord torsion in 50 cases (24%) because the testicular vascularization was judged as normal or increased compared with the other testis.60 In a study published in 2005, Lam et al63 expressed high confidence in color Doppler ultrasound for the diagnosis of TT. Yet, in that large series, 323 patients had an initial negative ultrasound finding, but 29 were explored eventually on clinical indications. Four of these patients (1.2% of 323) were diagnosed intraoperatively as TT.DISCUSSION
The ‘‘Classic’’ Case
If imaging is not performed on every patient with a painful scrotum, one is gambling. Even if the criteria for timely consultation and evaluation for surgical exploration are broadened and consistently accomplished, it does not seem to matter whether you are an emergency medicine physician or urologist; a small but significant number of twisted testes will be missed.2,3,6,9Y14,16
Diagnostic Interdependence
Although the history and physical examination are not
reliable, they cannot and should not be discarded. Instead, a
diagnostic triad that includes imaging is a necessity.69 Cautious, methodical and thorough evaluations using all 3 diagnostic tools are mandatory. Even then, it is documented that there will be patients who present with mild pain, few associated symptoms, a relatively normal examination and apparent blood flow on color Doppler sonography who have an intermittent torsion or less than 360 degrees of torsion.25,32,55 The bottom line is that the standard of care should be a timely color Doppler ultrasound or, if Doppler is not available, radionuclide testicular scan of any patient who presents to the emergency department complaining of scrotal or testicular pain and the history and examination is not consistent with TT.70Y72
Resources
(1) Torsion of the testicle: it is time to stop tossing the dice [PubMed Abstract] [Link to Download PDF From Researchgate]. Mellick LB. Pediatr Emerg Care. 2012 Jan;28(1):80-6. doi: 10.1097/PEC.0b013e31823f5ed9.
(2) Testicular Ultrasound Examination For Torsion – Two Part YouTube Video Seminar From UltrasoundPodcast.Com With Links To Additional Resources
Posted on November 7, 2018 by Tom Wade MD
(3) Testicular torsion with preserved flow: key sonographic features and value-added approach to diagnosis [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Pediatr Radiol. 2018 May;48(5):735-744. doi: 10.1007/s00247-018-4093-0. Epub 2018 Feb 21.
At the very end of the HTML online full text version of the article, there are links to 11 avi videos that you can download and play as you review the relevant portion of the article.
