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2 59
3 60
4 Testicular Torsion: Can We Improve the Management 61
5 of Acute Scrotum? 62
6 63
7 TESTICULAR torsion is a urological emergency high risk for testicular torsion because the staff 64
8 requiring prompt diagnosis and intervention. Delay would be able to triage patients directly to urologi- 65
9 in surgical treatment can lead to testis loss since the cal evaluation or the operating room. As expected, 66
10 rate of testicular viability decreases significantly the authors found different cutoffs for the score 67
11 after 6 hours from onset of symptoms. While the when performed by nonphysician providers. In this 68
12 quest for timely diagnosis remains a constant, the prospective study cutoffs for low and high risk were 69
13 strategy for the accurate diagnosis of testicular set at 1 and 6 points, respectively, with 100% 70
14 torsion in the emergency room has changed negative predictive value and 93.5% positive pre- 71
15 considerably through the years. Once based solely dictive value. Another important difference was 72
16 on accurate history, physical examination and that the score functioned with more sensitivity and 73
17 eventually surgical exploration, the differential specificity for Tanner stage 3 to 5 patients, sug- 74
18 diagnosis of acute scrotal pain has become increas- gesting that TWIST should be restricted to older 75
19 ingly dependent on imaging studies following the children, especially when performed by nonphysi- 76
20 widespread use of high resolution and color Doppler cian providers. The authors recommend ultrasound 77
21 ultrasound (US). Nevertheless, the benefit of per- for all Tanner stage 1 to 2 patients. Overall they 78
22 forming examinations for all patients is questioned found that 50% of imaging studies could be avoided. 79
23 because it increases cost and time to surgery. For In clinical practice many providers are becoming 80
24 those patients in whom the index suspicion is high a increasingly dependent on US to make or rule out a 81
25 fast track to the operating room could be more diagnosis of testicular torsion, especially when a 82
26 beneficial in terms of prognosis and viability than urologist may be unavailable for consultation. In 83
27 additional examinations. fact, in some cases the diagnosis of testicular torsion 84
28 EQ1 In this issue of The Journal Sheth et al describe a may remain challenging even after careful clinical 85
29 new strategy to expedite surgery for testicular tor- examination. Use of high resolution scrotal US 86
30 sion.1 The authors evaluated the TWIST (Testicular associated with color Doppler, investigating the sign 87
31 Workup for Ischemia and Suspected Torsion) score of a spermatic cord twist and absent flow, may raise 88
32 for children presenting with acute scrotum with sensitivity of ultrasound to up to 97% and specificity 89
33 data collected by nonurological, nonphysician pro- to 99% when performed by experienced radiologists.3 90
34 viders. The TWIST score, originally developed and However, US is not without inherent limitations. 91
35 validated in a joint study by Harvard University Use of Doppler US alone can be misleading due to 92
36 and the University of S~ ao Paulo,2 stratifies pediatric residual flow in the early phase of torsion. In addi- 93
37 patients with acute scrotum by risk of testicular tion, US is dependent on the observer, and diag- 94
38 torsion, consisting of 5 variables, ie hard testis nostic performance of the examination also varies 95
39 (2 points), testicular swelling (2), absent cremasteric according to available technology.4 Although some 96
40 reflex (1), high riding testis (1) and nausea or vom- authors have advocated use of scrotal US in all pa- 97
41 iting (1). In the original study with physical exam- tients presenting with acute scrotal pain,5 clinical 98
42 ination performed by urologists cutoffs for low and judgment should be enough to warrant surgical 99
43 high risk were set at 2 and 5 points, respectively, exploration in a number of cases. Obtaining US 100
44 with 100% negative and positive predictive values. could represent an unnecessary delay in the treat- 101
45 In prospective and retrospective sets the authors ment of a condition where time is critical. Use of a 102
46 found that up to 80% of USs in the emergency room scoring system can at once provide nonurological, 103
47 could be avoided. nonphysician providers with an algorithm for 104
48 Sheth et al validated the TWIST score as prompt treatment of testicular torsion and offer a 105
49 assessed by emergency medicine providers. This tool to provide a more objective assessment based on 106
50 tool can allow for timely management of patients at validated findings. 107
51 108
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53 0022-5347/16/1956-0001/0 http://dx.doi.org/10.1016/j.juro.2016.03.066 110
54 THE JOURNAL OF UROLOGY® Vol. 195, 1-2, June 2016 111
Ó 2016 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC. Printed in U.S.A.
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56 www.jurology.com j 1 113
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115 Alternative diagnostic modalities investigated so do not reach 100%. The hazardous consequences of 160
116 far have failed to show additional benefit to high a missed diagnosis of testicular torsion markedly 161
117 resolution scrotal US with color Doppler. Nuclear outweigh those of a nontherapeutic exploration. 162
118 scintigraphy and magnetic resonance imaging have Moreover, physicians should consider the possibil- 163
119 164
been used to evaluate testicular blood flow. While ity of intermittent torsion, which may present with
120 165
121
sensitive, these tests are limited by the need for inconsistent history and physical examination, 166
122 intravenous injection of contrast medium, potential resulting in a challenging diagnosis. As an 167
123 need for anesthesia and longer period to perform the example, in the study by Sheth et al the only 2 168
124 examination. As a novel approach, evaluation of cases of torsion with a score below 2 were those 169
125 testicular oxygen saturation with near-infrared that had been manually detorsed before presenta- 170
126 spectroscopy (NIRS) has been investigated and tion.1 Likewise intermittent torsion may be missed 171
127 used as a diagnostic modality for testicular torsion.6 on scrotal ultrasound.4 This fact underscores 172
128 Although NIRS may be promising in that tissue the equivocal presentation of such cases and the 173
129 oxygenation values are objective measures and necessity of careful clinical and radiological 174
130 readily available, the efficacy of this technique has evaluation. 175
131 176
yet to be demonstrated in a large population. It is
132 177
133
noteworthy that a possible limitation of NIRS would 178
~o Arthur Brunhara Alves Barbosa and
Joa
134 be in the early phase of testicular torsion, in which 179
Francisco Tibor Denes
135 residual blood flow is still present, as in false- Division of Urology 180
136 negative cases for color Doppler US when consid- University of São Paulo School of Medicine 181
137 ered alone.3 To date, NIRS still needs proof of São Paulo, Brazil 182
138 reliability and cost-effectiveness in the management 183
139 of acute scrotum. 184
140 and Hiep T. Nguyen 185
Surgical exploration of dubious cases must Urology Service
141 always be considered since sensitivity and speci- 186
Cardon Children’s Medical Center
142 ficity of physical examination and imaging studies Mesa, Arizona
187
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145 190
146 REFERENCES 191
147 192
1. Sheth KR, Keays M, Grimsby GM et al: Diagnosing 3. Kalfa N, Veyrac C, Lopez M et al: Multicenter 5. Liguori G, Bucci S, Zordani A et al: Role of US in
148 193
testicular torsion before urological consultation assessment of ultrasound of the spermatic cord acute scrotal pain. World J Urol 2011; 29: 639.
149 194
and imaging: validation of the TWIST score. J Urol in children with acute scrotum. J Urol 2007;
150 2016; 195: 000. 177: 297. 195
151 196
152 2. Barbosa JA, Tiseo BC, Barayan GA et al: Devel- 4. Yazbeck S and Patriquin HB: Accuracy of Doppler 6. Burgu B, Aydogdu O, Huang R et al: Pilot feasi- 197
153 opment and initial validation of a scoring system sonography in the evaluation of acute conditions bility study of transscrotal near infrared spec- 198
to diagnose testicular torsion in children. J Urol of the scrotum in children. J Pediatr Surg 1994; troscopy in the evaluation of adult acute scrotum.
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2013; 189: 1859. 29: 1270. J Urol 2013; 190: 124.
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