Paediatrics
Clinical and sonographic features predict
testicular torsion in children: a prospective study
Michael Boettcher, Thomas Krebs, Robert Bergholz, Katharina Wenke, Daniel Aronson
and Konrad Reinshagen
Department of Paediatric Surgery, UKE Medical School, Hamburg, Germany
Objective
• To test the clinical and sonographic predictors of testicular
torsion (TT) with the aim of reducing negative exploration
rates.
Patients and Methods
• We performed a prospective study of all boys treated for
‘acute scrotum’ at our institute between January 2001 and
April 2012 and clinical findings were documented.
• If available, ultrasonography (US) was added to the
diagnostic evaluation.
• A prediction of the diagnosis was based on clinical and
sonographic features, and was followed by surgical
exploration in all patients.
Results
• A total of 104 patients were included in the 16-month
period of the study.
• No single finding excluded TT. The clinical features (pain
<24 h, nausea/vomiting, abnormal cremasteric reflex, high
Introduction
Testicular torsion (TT), epididymo-orchitis (EO), and torsion
of the testicular appendix (AT) are the three most common
causes of ‘acute scrotum’ in children [1,2]. The annual
incidence of TT is 3.8% in males aged <18 years [3]. It has a
bimodal distribution, with peaks in the perinatal period
and in adolescence, which reflects the clinical distinction
between extravaginal torsion in newborns and intravaginal
torsion in older children. TT accounts for 5–25% of acute
scrotum in children, and a delay in its diagnosis may result in
loss of the testis [1,2,4], so typical history and clinical findings
merit immediate intervention; however, when no scoring
system is applied or no additional diagnostic measures are
undertaken, the negative surgical exploration is very high
(86%) [4].
© 2013 The Authors
BJU International © 2013 BJU International | doi:10.1111/bju.12229
Published by John Wiley & Sons Ltd. www.bjui.org
position of the testis) appeared predictive (100% sensitivity)
and the clinical scoring system was proven to be reliable,
reducing the negative exploration rate by >55%.
• Ultrasound predictors alone were not able to identify all
boys with TT.
Conclusions
• It is safe to refrain from routine surgical exploration in
every child with acute scrotum if the clinical score is
applied, which results in a marked reduction of negative
explorations.
• A reliable diagnosis could not be obtained based on US
alone. As scrotal US is unpleasant for the child, we propose
to refrain from this if the clinical score is positive. Patients
with a negative clinical score are suitable candidates for US
to establish and secure diagnosis.
Keywords
testicular torsion, children, clinical, sonographic, prediction,
score
In children and adolescents, a variety of clinical predictors
such as a short pain duration, nausea or vomiting, high
position of the testicle, abnormal ipsilateral cremasteric reflex
and scrotal skin changes have been identified, mostly in
retrospective studies, as being associated with an increased
likelihood of TT [4–6]. Seasonal variations have even been
implicated in contributing to TT, with the lower temperatures
and humidity in winter and spring being associated with
increased incidence rates [7,8].
The imaging methods MRI and nuclear scintigraphy have
very high accuracy rates, with a sensitivity and specificity
of 93 and 100% and 100 and 59%, respectively [9,10];
however, they are expensive, not universally available,
scintigraphy involves exposure to ionizing radiation, and,
more importantly, they are time-consuming and may thus
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Boettcher et al.
significantly delay diagnosis. Hence, in addition to clinical
examination, Doppler ultrasonography (US) is increasingly
used in the management of patients with suspicion of TT. It
gives excellent imaging of anatomical details and perfusion,
with a reported sensitivity of 69–90% and specificity 98–100%
[11,12]. Because of its usual prompt availability, short duration
and low costs, US has become the standard imaging method
for acute scrotum [13]. Nevertheless, US has its limitations,
such as a high operator dependency and the occurrence of
false-negative results, leading to a non-surgical strategy
potentially dangerous to the testis [14].
After compiling a retrospective inventory of the results from
our institution, we identified the most sensitive clinical
predictors of TT [4]. The aim of the present study was to test
a clinical scoring system derived from these predictors and
Doppler US prospectively, without changing our preoperative
clinical evaluation strategy. Our ultimate goal was to change
our future preoperative management only if the application of
the scoring system was proven safe and if a reduction in
surgical explorations would not have resulted in increased risk
of missed TT.
Patients and Methods
All patients treated for acute scrotum at the Emergency
Department of the Hamburg-Eppendorf University Medical
Centre and the Altona Children’s Hospital between January
2011 and April 2012 were included in the study. Institutional
review board approval was obtained before beginning the
investigation.
Data gathered for medical history included duration of
symptoms, associated symptoms, history of trauma, previous
episodes of pain, medications, other medical problems and
sexual activity.
All participants were examined physically by a resident or the
consultant of Paediatric Surgery. Aspects of the physical
examination that were included were the involved testicle side,
the presence of erythema, swelling, or tenderness of the
testicle and/or epididymis, the position of the testicle in
relation to the contralateral side, the blue dot sign, urethral
discharge, and the presence of a normal cremasteric reflex.
This reflex is elicited by stroking or pinching the medial thigh,
causing contraction of the cremaster muscle, which elevates
the testis. The cremasteric reflex was considered pathological if
the testicle moved <0.5 cm on the ipsilateral side and was
normal on the contralateral side.
Based on the retrospective analysis and identification of
prognostic clinical features, a score was created that was
completed for every patient presenting with acute scrotum.
The diagnostic prediction was based on four symptoms:
duration of pain (<24 h), nausea/vomiting, high testicular
position and abnormal cremasteric reflex. TT was predicted if
at least one of the four symptoms were present.
© 2013 The Authors
1202 BJU International © 2013 BJU International
Urine analysis was performed in the Emergency Department
using a urine dipstick (Combur; Roche Diagnostics GmbH,
Mannheim, Germany). For the purpose of the analysis, the test
was considered abnormal if leukocytes, erythrocytes or protein
levels were at least twice the normal value.
Ultrasonography was performed during office hours by
experienced paediatric radiologists using a high-resolution
12-5-MHz linear-array transducer (HDI 5000 SonoCT, Philips
Medical Systems, Eindhoven, the Netherlands). US could
not be performed during night hours. The radiologist was
not informed of the outcome of the clinical prediction.
Determination of the sonomorphology of the scrotum and
epididymis, including echogenicity and echotexture, was
performed. Two terms were used to describe echogenicity, as
in the study by Chmelnik et al. [15], normal echogenicity (a
homogeneous pattern) and diffuse or focal hyper- or
hypoechogenicity (a heterogeneous and homogeneous
pattern). The evaluation included measuring the bilateral
testicular volume using a double ellipsoid method on two
dimensions. Finally, central and peripheral perfusion of the
testicle with colour Doppler US in comparison with the other
side was assessed. An ultrasound diagnosis of TT was made if
central perfusion was absent or uncertain. Based on the
clinical prediction, and the Doppler US findings, the eventual
prediction was made (TT or non-TT) before the surgical
exploration took place.
According to local protocol, surgical exploration was
performed in all patients. Under general anaesthesia the
scrotum was opened through a short transverse mid-scrotal
incision. The testis was exposed, and if torsion was present, it
was detorqued and wrapped in warm saline sponges for
30 min. If no signs of perfusion were present, the testis was
removed. If the testicle appeared viable it was secured in the
correct position with two or three sutures. In the case of TT,
contralateral orchidopexy was routinely performed in the
same session. Postoperatively, patients received pain
medication and, depending on the eventual diagnosis,
antibiotic therapy.
Statistical analysis was performed using SAS 9.0 and SPSS
17.0. Data are presented as mean (SD) values. Differences
between groups and predictive values were calculated using
ANOVA, chi-squared test or CART for univariate or
multivariate analysis, respectively, and are expressed by value
with 95% CIs. A P value <0.05 was considered to indicate
statistical significance.
Results
During the study period 104 boys presented with acute
scrotum. Of these, 12 (11.5%) had TT, 71 (68.3%) had AT and
17 (16.3%) had EO. These diagnoses were based on the results
of the surgical exploration. Other pathologies included

idiopathic scrotal oedema and haematoma. US was performed
in 67 boys, which included all but one boy with TT.
Before surgery, TT was predicted by the clinical scoring
system in 47 (45.2%) boys, which included all 12 boys who
truly had TT, so no testis at risk would have been missed by
using the score. Of the other 35 boys explored, 60% had AT,
13% had epididymitis, and one had idiopathic scrotal oedema.
In all the boys with TT, the score assigned to them was ≥1
(score of 1, n = 3; score of 2, n = 5; score of 3, n = 3 and score
of 4, n = 1). As described in Table 2, 11 boys with TT had a
short pain history (<24 h), four had nausea and/or vomiting,
six had a pathological cremasteric reflex on the ipsilateral side
and five had a testicle higher in position.
Application of the clinical score alone would have reduced our
negative exploration rate by 55%. The clinical score showed a
sensitivity of 100% (95% CI: 71.6–100%), a specificity of 63%
(95% CI: 59.3–63.0%), and an accuracy of 66% (95% CI:
59.8–66.3%). If features detected by US alone had been
applied, one boy with TT would have been missed. The
sensitivity of US was 91% (95% CI: 61.2–99.5%), specificity
87% (95% CI: 81.3–89.0%), and accuracy was 90% (95% CI:
79.9–92.4%). If clinical score and Duplex US were combined
the negative exploration rate would have been reduced by
51%; the sensitivity of this combination was 100% (95% CI:
69.5–100%), specificity 57% (95% CI: 53.4–57.0%), and
accuracy 61% (95% CI: 55.1–61.5%). The highest reduction
(59%) in negative exploration without risking to miss TT was
achieved when combining short duration of symptoms with
reduced central perfusion; the sensitivity was 100% (95% CI:
69.6.-100%), specificity 66% (95% CI: 62.0–65.6%) and
accuracy 69% (95% CI: 62.8–69.2%).
The analysis of the positive predictive factors for TT is shown
in Table 1. A fast onset of pain (pain <24 h, odds ratio [OR]:
22.7, 95% CI: 2.8–493), nausea and/or vomiting (OR: 22.5, 95%
Table 1 Variables with a positive and negative association with TT.
Features OR (95% CI)
Pain duration <24 h 22.7 (2.8–493)
Nausea/vomiting 22.5 (2.9–217)
Abdominal pain 1.3 (0.1–13.1)
Erythema 1.7 (0.3–11.9)
Swelling 2.6 (0.3–51.3)
High position 21.2 (3.4–149)
Pathological cremasteric reflex 45.0 (6.1–425)
Blue dot sign 0.0 (0.0–1.4)
Fever >38.5 °C 0.0 (0.0–19.2)
Testicular hyper-/hypoechogenity 34.7 (5.3–281)
Affected testicle larger 1.1 (0.2–4.9)
Reduced central perfusion 47.1 (6.4–453)
Prediction of testicular torsion in children
CI: 2.9–217), abnormal cremasteric reflex (OR: 45.0, 95%
CI: 6.1–425) and high position of the testis (OR: 21.2, 95%
CI: 3.4–149), as well as focal or segment testicular
hyper-/hypoechogenity (OR: 34.7, 95% CI: 5.3–281) and
reduced central perfusion (OR: 47.2, 95% CI: 6.4–453), were
associated with TT.
Additionally, factors were identified that made TT unlikely,
which were a slow onset of symptoms (pain >24 h, negative
predictive value [NPV] 98%, 95% CI: 93–99%), absence of
swelling (NPV 94%, 95% CI: 74–99%), normal cremasteric
reflex (NPV 94%, 95% CI: 91–95%), testicular
hyper-/hypoechogenity (NPV 95%, 95% CI: 89–98%) and
reduced central perfusion (NPV 95%, 95% CI: 89–98%). TT
could have been excluded in all boys who had a combination
of long pain duration (>24 h) and no nausea and vomiting or
normal cremasteric reflex or normal echogenicity.
In boys with TT, US examination detected testicular
hyper-/hypoechogenity more often than in boys
without TT (8/11 vs 4/92, P < 0.001). Scrotal hyper-/
hypoechogenity was more often found in boys without TT
than those with TT (6/92 vs 0/11 patients, P > 0.05), whereas
hyper-/hypoechogenity of the epididymis was more frequent
in boys with EO (8/9) than AT (12/92) or TT (0/11, P <
0.001). The involved testicle was enlarged in the majority of
the boys (65/104, P > 0.05). Doppler US showed reduced
central perfusion of the affected testis (TT 8/12 vs non-TT
5/92, P < 0.001). Increased peripheral perfusion on the
involved side was found more frequently in boys with EO
(8/9) than in those with AT (16/92) or TT (1/11, P < 0.001).
The reported symptoms as well as clinical and US findings of
the study population are shown in Table 2. The median
(range) age of the study population was 10 (0–16) years. There
was no significant difference in mean age between those
with or without TT: the mean (SD) age of boys with TT
was 9.6 (6.3) years (P > 0.05), with a trimodal peak age
PPV, % (95% CI) NPV, % (95% CI)
27 (18–29) 98 (93–99)
67 (25–94) 92 (89–93)
14 (1–55) 89 (88–92)
13 (8–15) 92 (78–99)
13 (9–14) 94 (74–99)
63 (28–89) 93 (90–95)
75 (38–95) 94 (91–95)
0 (0–15) 85 (85–89)
0 (0–68) 88 (88–90)
67 (40–84) 95 (89–98)
17 (9–23) 84 (71–94)
73 (44–90) 95 (89–98)
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Boettcher et al.

Table 2 Incidence of presenting symptoms and clinical and sonographic findings in boys with and
without TT.

Features TT group, N = 12 Non-TT group, N = 92 P

n (%) n (%)

Mean age, years 9.6 9.7 >0.05

Left side 8 (66.7) 49 (53.3) >0.05
Pain duration <24 h 11 (91.7) 30 (32.6) <0.001
Nausea/vomiting 4 (33.3) 2 (2.2) <0.001
Abdominal pain 1 (8.3) 6 (6.5) >0.05
Trauma 0 (0.0) 2 (2.2) >0.05
Erythema 10 (83.3) 69 (75.0) >0.05
Swelling 11 (91.7) 76 (82.6) >0.05
High position 5 (41.7) 3 (3.3) <0.001
Pathological cremasteric reflex 6 (50.0) 2 (2.2) <0.001
Painful epididymis 0 (0.0) 23 (25.0) 0.05
Blue dot sign 0 (0.0) 23 (25.0) 0.05
Fever >38.5 °C 0 (0.0) 3 (3.3) >0.05
Pathological urine analysis 0 (0.0) 5 (5.4) >0.05
Testicular hyper-/hypoechogenity 8 (72.7) 4 (7.1) <0.001
Affected testicle is enlarged 7 (63.6) 35 (62.5) >0.05
Reduced central perfusion 8 (72.7) 5 (8.9) <0.001

of 0–1 year, 10–11 years and 15–16 years. Right-sided
abdominal pain (6.7%) as well as fever (2.9%) was rare in all
boys. Trauma was uncommon (n = 2 in the non-TT group).
Only one boy had dysuria in the EO group and no boy
reported being sexually active. A painful epididymis was
mainly present in boys with EO (58.8%) and rarely in those
with AT (16.9%) or TT (P < 0.001). In boys with AT (31.0%) a
blue dot sign was more frequent than in those EO (n = 1,
5.9%) and no boy had a blue dot sign in the TT group
(P = 0.001).
Urine analysis was normal in all the boys with TT and
occasionally pathological in those with EO (11.8%) and AT
(2.8%, P = 0.05). In 56.7% of all boys i.v. antibiotics were
administered postoperatively (mean 3.3 days after surgery).
Boys in the EO group (82.4%) received antibiotic treatment
more often than those in the AT (46.5%) and TT groups
(66.7%, P < 0.001). Testicular salvage was high (91.7%). Only
in one newborn did the testicle not recover, as is common in
antenatal torsion of the testis.
Discussion
The overlooking of TT is a serious problem with major
potential consequences, e.g. loss of testis with potential
reduced fertility and sperm counts [16]. It is the third most
common cause of malpractice lawsuits in adolescent males
[17] so many peadiatric centres explore all cases of acute
scrotum surgically, but this approach carries the risks of
anaesthesia and surgery for many children that could have
been treated conservatively.
The results of the present study show that our clinical scoring
system would have identified all cases of TT and would have
reduced our negative exploration rate by 55%. Unfortunately,
US studies alone would have missed one boy with TT.
Combining clinical and US findings may improve specificity;
for instance the combination of a fast onset of symptoms and
reduced central perfusion in colour Doppler US had the
highest potential in safely reducing the negative exploration
rate in children with TT; however, it could well be that the
small number of examinations may have negatively influenced
the results of the US.
The four clinical variables chosen for the score had been
previously proven to be highly associated with TT [4]. As in
most previous, predominantly retrospective, studies there was
no single feature that could have excluded TT; however, the
combination of two out of three features (fast onset of
symptoms, high testicle position, and reduced testicular blood
flow) were highly predictive of TT. By contrast, TT becomes
unlikely if patients present with symptoms lasting >24 h and
show no sonomorphological conspicuousness, e.g. hyper- or
hypoechogenity or reduced central Doppler flow. TT may be
excluded entirely in patients without a short pain history and
nausea and vomiting or those with normal cremasteric reflex or
normal echogenicity.
As reported previously, acute scrotal pain of short duration
before first presentation is highly suggestive of TT [4,5,18].
Ischaemia after torsion results in excruciating pain and
prompt presentation at an emergency department. Thus, very
high NPVs were found in several studies ranging from 92 to
98% [4,18]; however, rapid onset can be seen in AT or EO, and
TT may start gradually [19].
A lack of the cremasteric reflex is another feature highly
associated with TT. It was effective as a predictor in half of the
cases of TT in the present study, with a very high OR of 45, a
positive predictive value (PPV) of 75% and an NPV value of
94%. These results are similar to those of previous studies,
with ORs of 27, PPVs of 43–83% and NPVs of 96–98%

© 2013 The Authors

1204 BJU International © 2013 BJU International

[5,18,20], but the presence of the cremasteric reflex does not
preclude the possibility of torsion, as the reflex was intact in
8% of infants with TT. In previous studies a normal reflex was
found in 29–40% of patients TT [5,18].
The elevated and transverse location of a testis is considered
to be important for the diagnosis of TT [4,5,18,20]. High ORs
(21–59) and NPVs (93–95%) make it a good tool [5,18,20], but
massive swellings may make it impossible to judge testicular
orientation. Yet again, vertical orientation of the testicle does
not exclude TT. As in previous reports, not all patients with
TT showed an atypical position of the affected testis (17–58%)
[4,18,20].
The presence of nausea and vomiting is an important
symptom of TT. Reflex stimulation of the coeliac ganglion
induces nausea and vomiting in patients with TT, with
ORs reported of 9 and 22 [4,5]. Other features, e.g. fever,
abdominal pain, erythema and testicular swelling, are not
specific for TT, as mentioned in previous studies [1].
Reliance on various aspects of the history and physical
examination alone may not be sufficient. We therefore
invesitgated whether the addition of US to the diagnostic
evaluation would achieve a higher diagnostic yield, i.e. would
achieve a further reduction of surgical exploration with a
maintained 100% sensitivity, without negatively affecting the
specificity. Concurrently, although the accuracy of imaging is
excellent, it is well documented as having a degree of error
and inaccuracy [11–13,17]. In particular, normal central
arterial or venous perfusion is considered to be a reliable
diagnostic variable for excluding TT [12]. In the present study,
however, three boys with TT showed no abnormalities in
colour Doppler imaging. False-positive findings showing a
central perfusion are probably attributable to the special
vascular supply of the testes. Even a necrotic testis after
detorsion may demonstrate a certain amount of perfusion,
mimicking vital tissue [17].
Volumetry was not helpful in the differential diagnosis of
acute scrotum. Considering the large variability of testicular
size, volumes ranged from normal to elevated in those with
and without TT [13]; therefore colour Doppler US should be
performed with reference to sonomorphological variables,
including parenchymal echo texture as in the study by
Chmelnik et al. [15]. Despite a very high OR, echogenicity
would not have identified all patients with TT. When
echogenicity and central perfusion status were combined, only
one boy with TT was missed.
Even though US is a valuable diagnostic tool, correct diagnosis
could not be ensured in every case and the method is highly
dependent on the expertise and technique of the investigator.
If a mismatch exists between the clinical suspicion of TT and
the US findings, the patient should undergo surgical
exploration.
Prediction of testicular torsion in children
In conclusion, based on the results of the present study, we
concluded that it is safe to refrain from routine surgical
exploration in every boy with acute scrotum. The application
of the clinical score tested has shown that in >55% of boys
in our study exploration could safely have been omitted
without resulting in loss of a testis owing to undetected
torsion. US is a very useful tool in experienced hands, but
the current sensitivity results from our institution do not
allow a reliable diagnosis based on US alone. As US can be
quite unpleasant for the child and time-consuming to
perform, we propose to refrain from US studies in cases with
a positive clinical score, thus shortening the time until
surgery and reducing costs. Patients with a negative score are
good candidates for US to establish and secure diagnosis.
Nevertheless, physicians not experienced in examining
children should exercise extra caution as the diagnosis of a
high-riding testicle and an abnormal cremasteric reflex can
be a demanding task.
Conflict of Interest
None declared.
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Correspondence: Michael Boettcher M.D., Department of
Pediatric Surgery, University Children’s Hospital Altona and
Eppendorf, Hamburg, Germany.
e-mail: michboettcher@gmail.com
Abbreviations: TT, testicular torsion; EO, epididymo-orchitis;
AT, torsion of the testicular appendix; US, ultrasonography;
OR, odds ratio; PPV, positive predictive value; NPV, negative
predictive value.
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