Background

The patient with testicular pain presents a diagnostic challenge for emergency physicians. While there are multiple causes for testicular pain, including infectious and inflammatory reasons, neoplasms, hernias, and trauma, torsion is one of the most concerning due to the possibility of organ loss which may be prevented by emergent intervention.^1,2 Torsion should be considered in the differential diagnosis for every male presenting with testicular, scrotal, or lower abdominal pain, but it is predominately a condition of the young and very young, occurring in approximately one in 4000 males under the age of 25. Notably, while adult testicular torsion is rare, adult patients may be more likely to have delayed presentations and diagnoses, and thus lower testicular salvage rates.³

Testicular torsion is a urological emergency, as twisting of the spermatic cord compromises first venous, and then arterial blood flow causing acute pain and testicular ischemia. Ruling out testicular torsion is important and time‐sensitive because delays in diagnosis and therapy can result in problems with fertility, organ loss, and a poor cosmetic outcome. Viability and salvageability of the torsed testicle decrease as time from onset of symptoms (e.g., pain) increases, with approximately 90% salvageability with detorsion in <6 hours, nearly 50% viability after 12 hours, and close to 10% after 24 hours. A 20‐year review of cases by Yang et al.² included 118 cases with a median duration of symptoms of 64 hours, only 39% of whom had viable testes at surgery. The median duration of symptoms for those with viable testes was 12 hours, while those in whom testes could not be salvaged had a median duration of 90 hours. Due to the importance that time plays in the treatment of testicular torsion, patients with historical and physical exam findings suggestive of the disease should have emergent urologic evaluation. In unclear cases, imaging may be helpful and, in the emergency department (ED), ultrasound has replaced scintigraphy as the standard imaging modality for diagnosing testicular torsion due to its widespread availability and the limited availability of nuclear imaging.

Clinical question

Which historical and physical exam findings can help diagnose or exclude testicular torsion?

Two pediatric studies have focused on the diagnostic utility of the history and physical exam findings for testicular torsion. Beni‐Israel et al.⁴ conducted a retrospective review of 523 patients with scrotal pain presenting to their pediatric ED, using ultrasound and surgical findings as their criterion standard. In a population with a mean age of 10 years and 9 months, the authors found an incidence of testicular torsion of 3.3% and, on univariate analysis, determined that five clinical variables were associated with testicular torsion: duration of symptoms <24 hours (odds ratio [OR] 6.7, confidence interval [CI] 1.6–33), nausea and/or vomiting (OR 8.9, CI 2.6–30), abdominal pain (OR 3.2, CI 1.2–8.9), high position of the testes (OR 58.8, CI 19–167), and abnormal cremasteric reflex (OR 27.8, CI 7.5–100). However, it should be noted that patients who were discharged without ultrasound were not followed up and may have presented elsewhere with missed testicular torsion. This lack of an acceptable criterion standard or meaningful estimates of diagnostic accuracy such as positive likelihood ratio (LR+) or negative likelihood ratio (LR−), as well as the retrospective nature of this study, preclude any possibility of using these associated symptoms to rule out or rule in torsion.

Srinivasan et al.⁵ performed a prospective study on 79 consecutive pediatric patients with a mean age of 11 years who were evaluated in the ED by urology residents. There was an inherent selection bias (see Chapter 6) in that not all patients presenting to the ED with scrotal pain were included (urologic consultation had to be obtained), but they were able to follow up with all patients enrolled and used either this clinical follow‐up or surgical findings as their criterion standards. Using multivariate regression with 11 historical and 12 physical examination parameters, they found three that were predictive of testicular torsion: absence of the ipsilateral cremasteric reflex (p < 0.001) presence of nausea or vomiting (p < 0.05), and scrotal skin changes (p < 0.001) (Table 45.1).⁵ They then developed a decision rule using these three parameters, finding that the absence of all three resulted in a negative predictive value (NPV) of 100% while the presence of all three resulted in a positive predictive value (PPV) of 100%. While this retrospectively derived rule needs validation before it can be used with confidence (see Chapter 4), it may someday form the basis for a decision rule for testicular torsion.

A prospective study of 338 children with acute scrotal pain, including 51 with testicular torsion, proposed a clinical scoring system. All patients had physical exam performed by a urologist and underwent ultrasound. The score included: testicular swelling (2 points), hard testicle (2), absent cremasteric reflex (1), nausea/vomiting (1), and high riding testis (1). A score ≤2 could exclude testicular torsion with a sensitivity of 100% (CI 91–100), specificity 82% (CI 77–86), and NPV 100% (CI 98–100); however, further validation is needed before this can be implemented Barbosa et al.⁶

While the two studies noted in this chapter evaluated all patients with suspected torsion, Eaton et al.⁷

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