Pediatric Testicular Torsion Epidemiology Using a National

Database: Incidence, Risk of Orchiectomy and Possible Measures

Toward Improving the Quality of Care
Lee C. Zhao,* Timothy B. Lautz, Joshua J. Meeks and Max Maizels
From the Department of Urology (LCZ, JJM, MM) and Department of General Surgery (TBL), Northwestern University, Chicago, Illinois

Purpose: Testicular torsion causes considerable morbidity in the pediatric pop- Abbreviations
ulation but the societal burden is poorly quantified. We determined the modern and Acronyms
incidence of testicular torsion as well as the current rates of orchiectomy and ASC ⫽ ambulatory surgery center
attempted testicular salvage, and identified the risk factors for testicular loss.
ER ⫽ emergency room
Materials and Methods: A cohort analysis was performed of 2,443 boys (age 1
month to less than 18 years) and 152 newborns who underwent surgery for KID ⫽ Kids’ Inpatient Database
testicular torsion in the 2000, 2003 and 2006 Healthcare Cost and Utilization
Project Kids’ Inpatient Database. Patient and hospital characteristics predictive Submitted for publication March 13, 2011.
* Correspondence: Feinberg School of Medi-
of orchiectomy vs attempted testicular salvage were analyzed. cine, Northwestern University, 675 North St. Clair
Results: There was a bimodal distribution of testicular torsion with peaks in the St., Galter 20-150, Chicago, Illinois 60611 (tele-
first year of life and in early adolescence. The overall mean age ⫾ SD at presen- phone: 312-493-1636; FAX: 312-908-7275; e-mail:
tation was 10.6 ⫾ 5.8 years. The estimated yearly incidence of testicular torsion lzhao1@gmail.com).

for males younger than 18 years old was 3.8 per 100,000. Orchiectomy was
performed in 41.9% of boys undergoing surgery for torsion. The adjusted odds
ratio for orchiectomy was highest for children in the youngest age quartile
(younger than 10 years old, OR 1.58, 95% CI 1.25–2.00). Additional independent
predictors of orchiectomy included Medicaid insurance (OR 1.39, 95% CI 1.14 –
1.69), black race (OR 1.33, 95% CI 1.04 –1.71), nonemergency room admission
source (OR 1.97, 95% CI 1.60 –2.42) and surgery at a children’s hospital or unit
(OR 1.64, 95% CI 1.36 –1.98).
Conclusions: Testicular torsion is uncommon but the rate of orchiectomy is high,
especially in the youngest patients.

Key Words: spermatic cord torsion, epidemiology, socioeconomic factors

TESTICULAR torsion is a common pedi- To our knowledge the risk factors

atric urological emergency. Histori-
cally the cumulative incidence of tes-
ticular torsion has been reported as 1
in 4,000 by the age of 25 years.1 In
patients with testicular torsion, detor-
sion within 4 to 8 hours has generally
been accepted as the optimal interval in
which to salvage the affected testis.2
Surgery after this time is more likely to
result in orchiectomy, with a subse-
quent decrease in fertility and hor-
monal function.3–5
for orchiectomy after torsion have not
been studied in a large population.
Most published studies are single in-
stitution, retrospective reviews.6,7 A
review of the Nationwide Inpatient
Sample,8 which captures a smaller
fraction of pediatric discharges, only
identified older age as a significant
risk factor for orchiectomy in a cohort
of 436 patients.
Critical for testicular salvage are
the 3 components of early presenta-

0022-5347/11/1865-2009/0 Vol. 186, 2009-2013, November 2011

THE JOURNAL OF UROLOGY® Printed in U.S.A.
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© 2011 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC. DOI:10.1016/j.juro.2011.07.024
2010 RISK FACTORS FOR TESTICULAR LOSS DUE TO TORSION
tion, correct diagnosis and prompt treatment. Inef-
fectiveness in any of these components may decrease
testicular salvage rates. For example, differences in
patient age or health care access may affect the time
to presentation. Infants may not be able to articu-
late pain, while families with impaired access to
health care may seek care later than those with
ready access to health care. The availability of con-
sulting pediatric urologists or surgeons may also
affect time to treatment.
In this study we aim to improve knowledge of the
epidemiology of pediatric testis torsion. We deter-
mined the current incidence of testicular torsion as
well as the current rates of orchiectomy and at-
tempted testicular salvage, and identified risk fac-
tors for testis loss. We used a national database of
inpatient admissions to identify a large and nation-
ally representative sample of patients with testicu-
lar torsion.
METHODS
Database Inquiry
Data on children in the United States hospitalized for
testicular torsion in 2000, 2003 and 2006 were obtained
from the Agency for Healthcare Research and Quality
sponsored Healthcare Cost and Utilization Project KID.
The KID is an administrative data set of patients 20 years
old or younger with data on more than 10 million hospi-
talizations from 38 states. Versions of the KID are re-
leased in 3-year cycles and the 3 most recent releases were
used in this study. The KID uses a sampling of pediatric
discharges and the data are subsequently weighted to
produce national estimates on study outcomes. The KID
samples 10% of routine births and 80% of pediatric cases
from each hospital, and is estimated to capture 87% of the
United States pediatric population.9 Outpatient clinic and
ASC encounters are not included in the KID. Thus, the
frequency with which patients have testicular torsion in
this setting cannot be ascertained from this data set. How-
ever, patients who present to emergency departments,
undergo surgery and are discharged home the same day
are included in the KID. Since testicular torsion is a
surgical emergency, it is expected that many cases would
present at emergency departments rather than at outpa-
tient clinics. However, the incidence calculations from this
data set would ultimately underestimate the true inci-
dence.
Patients younger than 18 years diagnosed with testic-
ular torsion were identified using ICD-9 codes 608.2,
608.20, 608.21 and 608.22. Surgical procedures for these
cases were categorized as attempted testicular salvage
(orchiopexy or detorsion, ICD-9 procedure codes 62.5 or
63.52) or orchiectomy (ICD-9 procedure codes 62.3 or
62.4). Patients with a diagnosis of testicular torsion who
did not undergo surgery may be placed in 1 of 3 groups,
namely 1) those with a preliminary diagnosis of torsion
who ultimately did not have torsion, 2) those who had
detorsion without surgery and 3) those who were trans-
ferred to other hospitals or ASCs for surgery. Limitations
of the data set make determining the size of each of these
groups impossible. Thus, analysis was limited to patients
who had a diagnosis of testicular torsion and underwent
attempted testicular salvage or orchiectomy. Given that
patients were initially identified based on the diagnosis of
testicular torsion, those who underwent orchiectomy for
any other reason were not included in the study. Patients
with codes for orchiopexy and orchiectomy were included
in the orchiectomy group for analysis. Of note, torsion of
the appendix testis is represented by a different ICD-9
code (608.23) and was specifically excluded from analysis.
The annual incidence of testicular torsion in children
and adolescents (younger than 18 years old) was esti-
mated using only the 2006 KID database. Weighted na-
tional estimates of torsion accounting for hospital strata,
clustering and discharge weights in the KID were calcu-
lated using the complex samples module of SPSS® version
18. The annual national incidence of torsion was then
calculated by comparing the number of cases to the esti-
mated population of males younger than 18 years old
according to United States census data.10
Patient and hospital specific characteristics were com-
pared between patients with torsion who underwent at-
tempted testicular salvage vs orchiectomy. Newborns (30
days or younger), for whom the anatomy and clinical pre-
sentation of testicular torsion were quite different, were
excluded from analysis. Characteristics studied included
age in years, race/ethnicity, primary insurance payer, me-
dian quartile income by zip code, region of the country,
admission day of the week, calendar year, admission
source and hospital type. A category for other/unknown
was included in the analysis for all factors for which
more than 5% of cases were not otherwise categorized.
Age was grouped into quartiles. The sizes of the 4 age
groups were not exactly equal because age was reported
in whole number increments in the KID. Race and eth-
nicity were categorized as white, black, Hispanic and
other/unknown. Primary payer was categorized as Med-
icaid, private insurance and other/unknown. Median
quartile income was not patient specific, but rather was an
average for the patient’s home zip code. Region of country
was divided into Northeast, Midwest, South and West.
Admission day of the week was categorized as weekday or
weekend (Saturday or Sunday). The KID assigns each
hospital to 1 of 4 center types based on the National
Association of Children’s Hospitals and Related Institu-
tions designation, including freestanding children’s hospi-
tal, children’s specialty hospital, children’s units within
general hospitals and general/nonchildren’s hospitals.11
All children’s hospitals and units were compared to gen-
eral/nonchildren’s hospitals.
Statistics
Preliminary inferential statistics were calculated for all
variables using chi-square tests for categorical data and
the Mann-Whitney U test for continuous data. Logistic
regression models were used to identify factors associated
with orchiectomy among patients operated on for torsion.
All factors with a p ⬍0.2 on univariate analysis were
entered into the regression model. Model quality was eval-
uated through assessment of the c statistic and the Hos-
mer-Lemeshow goodness of fit statistic. For all analyses
 RISK FACTORS FOR TESTICULAR LOSS DUE TO TORSION 2011

The demographics and clinical features of pa-

Age distribution of testicular torsion
statistical significance was set at a 2-tailed p ⬍0.05. Sta-
tistical analyses were performed using SPSS version 18.
tients undergoing orchiectomy vs attempted testic-
ular salvage are compared in table 1. Orchiectomy
was more common in younger patients. Mean age
was 10.6 ⫾ 5.8 years (median 13, IQR 6 to 15) among
children who underwent orchiectomy compared to
12.3 ⫾ 4.2 (median 13, IQR 11 to 15) among those
with attempted testicular salvage (p ⬍0.001). Pa-
tients in the youngest age quartile had the highest
rate of orchiectomy (52.3%), and this rate was higher
when limited to just those younger than 1 year old,
who had a 78.9% risk of orchiectomy. Other univar-
iate predictors of orchiectomy included Medicaid vs
private insurance (p ⬍0.001), region of the country
(p ⬍0.001), nonER admission source (p ⬍0.001) and
treatment at a children’s hospital (p ⬍0.001).
Factors associated with orchiectomy with a p ⬍0.2
on univariate analysis were entered into a multivari-

Table 1. Patient and hospital characteristics predictive

of orchiectomy
RESULTS
No. Attempted
Current National Incidence No. Testicular
An estimated 1,431 ⫾ 71 males younger than 18 Orchiectomy (%) Salvage (%) p Value
years underwent an operation for testicular torsion
Age (yrs) quartile: ⬍0.001
in 2006 based on discharge weighting for the 853 Less than 10 310 (52.3) 283 (47.7)
discrete cases sampled in the data set. This estimate 10–12 190 (38.4) 305 (61.6)
corresponded to an annual incidence of at least 3.8 13–14 211 (39.3) 326 (60.7)
cases per 100,000 males younger than 18 years. 15–17 312 (38.1) 506 (61.9)
Since patients treated outside the inpatient setting Primary payer: ⬍0.001
Medicaid 352 (47.7) 386 (52.3)
were not accounted for in this data set, this calcu- Private 553 (38.5) 882 (61.5)
lated incidence may underestimate the true inci- Other/unknown 118 (43.7) 152 (56.3)
dence. Race/ethnicity: 0.199
White 333 (39.0) 520 (61.0)
Clinical Features Black 206 (44.5) 257 (55.5)
Hispanic 185 (43.0) 245 (57.0)
Combining the 2000, 2003 and 2006 KID, a total of
Other/unknown 299 (42.9) 398 (57.1)
3,979 patients had a diagnosis of testicular torsion, Median quartile income: 0.317
of whom 1,221 underwent orchiectomy, 1,450 under- Lowest 216 (42.0) 298 (58.0)
went attempted testicular salvage and 1,308 had no 2nd 241 (44.1) 305 (55.9)
reported operation. The 2,671 patients younger than 3rd 248 (42.6) 334 (57.4)
Highest 295 (39.2) 458 (60.8)
18 years with a diagnosis of testicular torsion and
Region of country: ⬍0.001
who underwent surgery were included in analysis. Northeast 284 (37.9) 466 (62.1)
Mean age of this cohort was 10.6 ⫾ 5.8 years. How- Midwest 149 (46.6) 171 (53.4)
ever, the distribution was bimodal with 1 peak South 361 (49.0) 376 (51.0)
within the first year after birth and another peak West 229 (36.0) 407 (64.0)
Calendar yr: 0.216
around age 12 years (see figure). The length of stay
2000 333 (40.5) 490 (59.5)
was no days for 590 (22.1%) patients, 1 day for 1,549 2003 344 (40.9) 497 (59.1)
(58.0%) and 2 or more days for 532 (19.9%). 2006 346 (44.4) 433 (55.6)
Excluding the 228 newborns with testicular tor- Hospital admission source: ⬍0.001
sion, 2,443 patients 31 days to 17 years old remained ER 719 (37.9) 1,179 (62.1)
Other/unknown 304 (55.8) 241 (44.2)
for analysis. Orchiectomy was performed in 1,023
Hospital admission day: 0.259
(41.9%) patients while attempted testicular salvage Weekday 770 (42.5) 1,040 (57.5)
(detorsion with or without orchiopexy) was per- Weekend 253 (40.0) 380 (60.0)
formed in 1,420 (58.1%). The rate of orchiectomy did Hospital type: ⬍0.001
not change significantly during the study at 40.5% Not children’s 638 (37.4) 1,066 (62.6)
Children’s* 344 (51.8) 320 (48.2)
in 2000, 40.9% in 2003 and 44.4% in 2006 (p ⫽
0.216). * Includes children’s general hospital or children’s unit.
2012 RISK FACTORS FOR TESTICULAR LOSS DUE TO TORSION

able logistic regression model (table 2). Compared to chiectomy rate of 42%, this condition represents a
the oldest age quartile, those in the youngest quartile considerable cause of morbidity in pediatrics.
(younger than 10 years old) had an adjusted odds ratio Orchiectomy at the time of scrotal exploration for
for orchiectomy of 1.58 (95% CI 1.25–2.00). The ad- testicular torsion was associated with age, insur-
justed odds of orchiectomy were also higher in patients ance, location of presentation and treatment at a
with Medicaid insurance (OR 1.39, 95% CI 1.14 –1.69) children’s hospital. We infer that the increased or-
and in black children (OR 1.33, 95% CI 1.04 –1.71). chiectomy risk for younger patients may be related
Other independent predictors of orchiectomy included to the decreased ability of young children to articu-
the Midwest and Southern regions of the country, late scrotal pain. While Barada et al documented
nonER admission source and care at a children’s hos- considerable delay in presentation, up to 20 hours,
pital or unit. in patients younger than 18 years old with testicular
torsion,12 the authors did not specify the age of pa-
tients younger than 18 years old, and so no conclu-
DISCUSSION sions could be drawn regarding the effect of age for
The cumulative historical incidence of testicular tor- patients younger than age 18 years. Mansbach et al
sion is commonly reported as 1 per 4,000 males by used the Nationwide Inpatient Sample to investi-
age 25 years.1 In this nationally representative gate testicular torsion and found that older patients
study we reported a yearly incidence of at least 3.8 were more likely to undergo orchiectomy.8 No other
cases of operatively confirmed testicular torsion per factors were found to be significant. Given the con-
100,000 for males younger than 18 years old. There siderably larger sample size of our study (2,443 vs
was a bimodal distribution of testicular torsion, with 436 patients), we believe our findings more accu-
1 peak at age 1 month and another at age 12 years, rately reflect the national trend.
which may reflect the clinical distinction between Factors such as race/ethnicity, socioeconomic sta-
extravaginal torsion in newborns, and intravaginal tus and insurance coverage are well-known to im-
torsion in older infants and children. Based on the pact the risk of adverse outcomes in conditions in
current data it is expected that approximately 1 in which timely access to care is essential. Ponsky et al
1,500 males will require surgery for testicular tor- demonstrated an increased odds of appendiceal rup-
sion by age 18 years, which is higher than the 1 in ture in children of nonwhite race and in those with-
4,000 rate previously reported.1 Recognizing an or- out private health insurance.13 In a study of the risk
of salvage for ovarian torsion, lower household in-
Table 2. Factors predictive of orchiectomy in multivariable
come correlated with an increased risk of ovarian
logistic regression loss.14 Testicular torsion represents a similar sce-
nario. Patients present acutely, and timely access to
Adjusted OR (95% CI)
care is essential for avoiding an adverse outcome, in
Age (yrs) quartile: this case orchiectomy. In our analysis the odds ratio
Less than 10 1.58 (1.25–2.00) for orchiectomy was 1.39 with Medicaid insurance
10–12 0.98 (0.77–1.25)
and 1.33 in black children.
13–14 1.07 (0.84–1.35)
15–17 1.0 (Reference) There appear to be significant differences in rate
Primary payer: of orchiectomy based on the region of the country on
Medicaid 1.39 (1.14–1.69) univariate and multivariate analysis, with higher
Private 1.0 (Reference) rates in the South and Midwest. Geographic vari-
Other/unknown 1.39 (1.05–1.84)
Race/ethnicity: ability in travel distance to hospitals may result in
White 1.0 (Reference) delay between time of disease onset and presenta-
Black 1.33 (1.04–1.71) tion. Differing practice patterns among surgeons
Hispanic 1.07 (0.83–1.39) may also have an effect on whether testicular sal-
Other/unknown 1.14 (0.91–1.44)
vage is attempted.
Region of country:
Northeast 1.0 (Reference) Presentation directly to the emergency depart-
Midwest 1.36 (1.02–1.82) ment favored attempted testicular salvage. This
South 1.42 (1.14–1.78) finding was expected since any initial evaluation at
West 0.92 (0.73–1.17) an outpatient clinic or transfer from another hospi-
Hospital admission source:
ER 1.0 (Reference)
tal would inevitably produce some delay. Prior stud-
Other/unknown 1.97 (1.60–2.42) ies have demonstrated considerable pre-hospital de-
Hospital type: lay in cases of suspected testicular torsion.15 Thus,
Not children’s 1.0 (Reference) bypass of the primary physician and direct presen-
Children’s 1.64 (1.36–1.98)
tation to the emergency department have been ad-
Hosmer-Lemeshow test p ⫽ 0.20, c statistic 0.638. vocated for cases of suspected testicular torsion.
 RISK FACTORS FOR TESTICULAR LOSS DUE TO TORSION 2013

The increased risk of orchiectomy at children’s
hospitals vs nonchildren’s hospitals was an unex-
pected finding and the explanation is likely multi-
factorial. More than 35% of patients with torsion
treated at children’s hospitals were younger than 10
years old compared to 20% of those treated at non-
children’s hospitals. As previously mentioned this
youngest age group has the highest rate of orchiec-
tomy. However, even after controlling for these fac-
tors on multivariate analysis the association per-
sisted. A limitation of the KID is that patients
transferred from 1 emergency department to an-
other are not coded as hospital transfers since the
ultimate source of admission is from the final hospi-
tal’s own emergency department. We suspect that a
significant number of patients ultimately treated at
children’s hospitals received pre-hospital care at an
emergency department elsewhere, which is not rec-
ognized in the database. Children’s hospitals also
have a fivefold higher rate of interhospital transfer
in this data set. Given that interhospital transfer
would lead to delay in surgery, the increased rate of
orchiectomy may be the result of these hospital
transfers.
There are several additional limitations inherent
in the use of an administrative data set. The KID
does not allow for the determination of time of dis-
ease onset. Pre-hospital information, including the
delay from the onset of symptoms until the patient
sought medical care, is not known. Outpatient clinic
and ASC encounters are also not included. Followup
data on whether the attempted testicular salvage
procedure was effective in preserving fertility or hor-
monal function are unknown. As mentioned, details
about care at other institutions may also be missing
if the patient was transferred to the emergency de-
partment at the final hospital. Interpretation of
cases in which a child had a diagnosis of testicular
torsion but did not undergo surgery is difficult.
These cases were presumed to represent errors in
diagnosis or coding and were excluded from our
analysis. It is also possible that these patients had
intermittent testis torsion and after discharge home
underwent surgery as an outpatient or during a
separate hospital admission.
CONCLUSIONS
We used a national database to estimate the inci-
dence of testicular torsion in the pediatric popula-
tion, which is 3.8 per 100,000 with a 41.9% rate of
orchiectomy. Since prompt presentation, diagnosis
and treatment are critical for testicular salvage,
multiple patient and hospital specific factors may
influence orchiectomy rates.

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