ARTICLE

Testicular Torsion and Risk Factors for Orchiectomy
Jonathan M. Mansbach, MD; Peter Forbes, MA; Craig Peters, MD

Objective: To determine risk factors for testicular loss due to testicular torsion. Design and Participants: Medical records of patients aged 1 to 25 years with a principal diagnosis of testicular torsion were extracted from the 1998 Nationwide Inpatient Sample. Population-based rates of testicular torsion and orchiectomy were determined. Logistic regression was used to create a predictive model for orchiectomy. For comparison, medical records of patients aged 1 to 25 years with a principal diagnosis of testicular neoplasm were extracted. Results: The sample comprised 436 participants. The

benign and malignant testicular tumors is 1.2 cases per 100 000. Of the estimated 2248 males diagnosed nationally in 1998 with testicular torsion, 762 (34%) had an orchiectomy. In the final multivariate model estimating the probability of orchiectomy, only age was significant.
Conclusions: For males aged 1 to 25 years, testicular torsion is more common than testicular tumors, and increasing age is the sole identifiable risk factor for orchiectomy. We suggest that health care professionals educate prepubertal male patients about testicular torsion and the necessity of seeking timely care to reduce the risk of orchiectomy and of possible subsequent reduced fertility.

estimated incidence of testicular torsion for males aged 1 to 25 years in the United States is 4.5 cases per 100 000 male subjects per year, and the estimated incidence of

Arch Pediatr Adolesc Med. 2005;159:1167-1171 nography is a helpful tool to differentiate torsion from other causes of an acutely painful scrotum.5 Further delays in diagnosis or treatment may be caused by individual patient factors. Appendicitis is a similar acute surgical condition in which delayed diagnosis or delayed surgery may lead to morbidity, specifically rupture of the appendix. In this condition, differences in the individual patient factors, including insurance status and race, have been associated with the risk of rupture of the appendix.6,7 The objectives of this study were to determine by using a national database if there are identifiable risk factors for testicular loss due to testicular torsion and to place the epidemiology of testicular torsion in the context of the more commonly discussed condition of testicular neoplasm.
METHODS The 1998 Nationwide Inpatient Sample (NIS) is part of the Healthcare Cost and Utilization Project, sponsored by the Agency for Healthcare Research and Quality.8 The NIS is a database of hospital inpatient stays, containing data from approximately 7 million hospital stays. The 1998 NIS contains all discharge data from

Author Affiliations: Divisions of Adolescent/Young Adult Medicine (Dr Mansbach) and Urology (Dr Peters) and Clinical Research Program (Mr Forbes), Children’s Hospital Boston, Harvard Medical School, Boston, Mass.

urologic emergency. There is approximately a 4- to 8-hour window from the onset of torsion symptoms until surgical intervention is required to save the affected testis.1 Delays in care may necessitate orchiectomy, which has been associated with reduced fertility.2 One study3 found that 57% of patients had low sperm counts a median of 5 years after unilateral testicular loss from torsion. Providing the necessary medical and surgical services for a patient with testicular torsion requires 3 steps, namely, timely presentation, rapid diagnosis, and curative intervention. The surgical procedure performed would be orchiectomy for those patients with a nonviable testicle and septopexy for those with viable testes. One potential barrier to providing ideal care is delayed presentation. In fact, male subjects may be hesitant to seek medical attention for conditions involving their genitals, even for torsion.4 Fortunately, once a patient presents to a health care professional, the diagnosis of testicular torsion can usually be made from his history and physical examination. However, when the clinical diagnosis is uncertain, color Doppler ultraso-

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and the relationship between orchiectomy and age category (youngest vs oldest males) was reassessed. and appendix epididymis. 0. Cumulative number of patients with testicular torsion and with testicular cancer. Statistical analyses were performed using SAS software version 9 (SAS Institute Inc. Under the assumption that some of the youngest nonorchiectomy patients could be misclassified (ie. For comparison. of Patients The final sample comprised 436 eligible participants from 231 hospitals in 22 states. all of whom had a technically unnecessary surgical procedure. these misclassified patients would erroneously lower the percentage of younger males requiring orchiectomies. The missing data from the race variable were analyzed 3 ways. . missing covariates were assigned to the majority covariate level. Race was not significantly associated with orchiectomy no matter how the missing values were assigned. or private insurance). 2001.1-10.400 Cancer (n = 120) Torsion (n = 436) 300 200 100 0 1 5 10 15 20 25 Age. All 436 patients who had a surgical procedure were included in the analysis. in the final analyses. As a result. and testicular neoplasm. RESULTS Cumulative No. The overall goal for the NIS is to create a sample of hospitals that is generalizable to hospitals in the entire United States. that some patients. For comparison. 1. the number of such cases nationally was estimated to be 621 cases (95% CI.2 includes torsion of the testicle. Patients with missing covariate levels ( 4% of the total) were included in logistic regression models by assigning them to the majority covariate level. with an incidence of 2. In univariate analyses.2 includes torsion of the testicle and torsion of the appendix testis and appendix epididymis. and Fisher exact tests were used for categorical variables. we estimated the total male population aged 1 to 25 years in 1998 to be 50. did not have torsion of the testicle but rather torsion of the appendix testis or appendix epididymis. Within the age range considered.0 years (P . with an incidence of 8. the mean ages for the groups were 11. the estimated incidence of benign and malignant testicular tumors is 1. Ninth Revision. The Children’s Hospital Boston Institutional Review Board approved this study.2) in 1998 were extracted. Logistic regressions accounted for clustering and stratification using SAS Proc SurveyLogistic. and annual household income (low income vs other.9 and 222.4-4.1 cases) per 100 000 male subjects per year. therefore. based on the median income of the patient’s ZIP code of residence). The number of torsion cases nationally.1 cases) per 100 000 male subjects per year in the United States.5 cases (95% CI. race (white.8 cases (95% CI. DEC 2005 1168 Downloaded from www. 2000. The NIS data set includes a weight variable for each observation so that a weighted analysis can produce national estimates. Clinical Modification [ICD9-CM] code 608. was 2248 cases (95% confidence interval [CI]. 7. It is possible.archpediatrics. as these youth most likely had torsion of the appendix testis. 19502547 cases). had torsion of the appendix epididymis or appendix testis. most likely the younger ones who had an orchiopexy. 2011 ©2005 American Medical Association. medical records of patients aged 1 to 25 years with a principal diagnosis of testicular neoplasm (ICD-9-CM codes 186. namely. Although the correct proportion of the nonorchiectomy patients to be removed from the youngest age category is not known. 33%.6 cases (95% CI. The July 1998 US male population aged 1 to 25 years was extrapolated from census estimates for this population at July 1. in which urban is within a census statistical metropolitan area). self-pay. insurance status (Medicaid. with the missing data removed from the analysis. 984 hospitals located in 22 states. a sensitivity analysis was performed to determine the potential effect of misclassification on our conclusions. WWW.25 million. the incidence of testicular torsion is 4. we anticipate that much fewer than half of these patients. of total cases and rates of procedures of interest. the database contained 120 patients with benign or malignant testicular tumors. 300912 cases). testicular torsion is most common in males aged 10 to 19 years. We compared the group of patients who received neither orchiectomy nor orchiopexy (n=65) with the group who had a procedure (n=436).9-5. Using the population estimate. Figure 1 shows that 86% of testicular torsion cases occur in males older than 10 years (median age. had an orchiopexy but not torsion of the testicle). t tests and Wilcoxon signed rank tests were used for continuous variables. random samples of 10%. and the disorder is most common in males aged 16 to 24 years.2 cases) per 100 000 male subjects per year. Hospitalspecific variables included census region (4 levels) and hospital location (urban or rural.ARCHPEDIATRICS. Age-specific census estimates of the US male population were used to compute rates of testicular torsion and orchiectomy per 100 000 male subjects. Therefore.8 cases) per 100 000 male subjects per year.and hospital-specific variables on the risk for orchiectomy. Medical records of patients aged 1 to 25 years with the principal diagnosis of testicular torsion (International Classification of Diseases.9 vs 15.COM (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 159. If patients with torsion of the appendix testis or appendix epididymis had an orchiopexy. with confidence intervals. Using a weighted analysis.com on February 9.0) were also extracted.7-1.001). 15 years).2 cases (95% CI. Using census results. The ICD-9-CM code 608. NC). We excluded the 65 patients who did not have a surgical procedure. and 50% of the nonorchiectomy patients in the youngest age category were removed. Using these 2 results. Cary. 3. Because of the stratified and clus- tered sample design used by the NIS. and July 1. and with the missing data assigned to the majority covariate level (white race). orchiectomy. or other). black. y Figure 1. appendix testis. The ICD-9-CM code 608. with the missing data treated as a separate covariate level. estimated using a weighted analysis of the data. The patient-specific variables included age (treated categorically and continuously). the SAS Proc SurveyMeans was used to compute variances for totals and confidence intervals for torsion. approximating a 20% sample of US community hospitals. All rights reserved. Logistic regression was used to model orchiectomy rates controlling for the effects of hospital and patient covariates and to compute adjusted odds ratios. Analyses were conducted to determine the effect of different patient.

only age was significant.4) 89 (59. For a 1-year increase in age. We conducted a sensitivity analysis to evaluate the potential effect of misclassification on this result. Other tests did not reach statistical significance. 33% among those aged 10 to 17 years. Fisher exact test.5) 27 (18.0810 =2. respectively (P .45) 1. 33% for those aged 10 to 17 years. the levels of the categories are compared with each category’s reference level.0) 31 (10.86) 1.5) 43 (15.3) 133 (89. and 41% for those aged 18 to 25 years. COMMENT Testicular torsion is a treatable urologic emergency. the rates were 25% and 41%. Comparison of Males Aged 1 to 25 Years With Testicular Torsion Having vs Not Having an Orchiectomy* Orchiectomy (n = 149) 8 (5.12) Reference Reference 0. the estimated orchiectomy rates for the youngest and oldest age categories were 20% and 41%. .4) 2 (1.8) 179 (62.37 *Odds ratios greater than 1 indicate increased likelihood of having an orchiectomy.7) 72 (25. Of the 436 sample participants.9) 47 (31.56 (0.36-1.75 times greater than the incidence of testicular tumors.41) Variable Age.2) 0 244 (85.8) 12 (4. namely.13). an estimated 762 (34%) had an orchiectomy. 149 (34%) had an orchiectomy. y 1-9 10-17 18-25 Race White Black Other Missing Insurance status Medicaid Self-pay Private Missing Annual household income. we observed orchiectomy rates among the youngest and oldest males of 18% and 41%.39) 1. Other characteristics of the sample are given in Table 1. or an increase of 8% in the odds per year.16 (0. We identified no differences in orchiectomy rates for other patient factors such as race.37 . 19% among those aged 1 to 9 years.5) 38 (25.2). DEC 2005 1169 Downloaded from www.73 (0.66-2.19 . When age was grouped for descriptive purposes.2) 30 (20.1) 34 (22. respectively (P=.02) 1.08 (1. *Data are given as number (percentage).8) 68 (23.03 for age. With a random 10% of the males who did not undergo orchiectomy from the youngest age category removed.54-1.ARCHPEDIATRICS.1) 86 (57.3) 14 (9.16 (0. When the cutoff for the low annual household income group was changed from $25 000 to $35 000.Table 1. 18% for those aged 1 to 9 years.94 .1) 51 (34.02). the adjusted odds of having an orchiectomy increased by 1.20 .75 (0. In the weighted analysis. The final multivariate model estimating the probability of having an orchiectomy included adjustment for race.8) 253 (88.003 . 20 years).8) 0 Table 2.3) 11 (7.03-1. the effect of age remained strong even with moderate to large misclassification of the youngest nonorchiectomy subjects.001). In the final model. insurance status.22 (0. Missing value rows were not included in univariate tests for statistical association between individual risk factors and orchiectomy. and 41% among those aged 18 to 25 years.64) 1.08 (95% CI. †The odds ratio indicates the increase in the odds of having an orchiectomy per each 1-year increase in age. With a random 50% removed.4) 5 (3. respectively (P .2) 102 (35.23-1. All rights reserved. the estimated percentage undergoing orchiectomy increased as age increased. $ 25 000 25 000 Census region Northeast Midwest South West Hospital location Urban Rural P Value . annual household income. P = .1) 50 (17.archpediatrics. the odds of having an orchiectomy doubles (1. With a random 33% removed.39-1. 2011 ©2005 American Medical Association.6) 187 (65. Therefore.13) Reference 1. the rates were 31% and 41%. For each 10-year increase in age.8) 97 (33.00 (0.com on February 9.0) 91 (31.99 . of the estimated 2248 males diagnosed nationally as having testicular torsion in 1998.COM (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 159. $ 25 000 25 000 Missing Census region Northeast Midwest South West Hospital location Urban Rural Missing Variable Age† Race White Black Other Insurance status Medicaid Self-pay Private Annual household income. WWW.8) 27 (18. the rates were nearly the same.4) 58 (20.3) No Orchiectomy (n = 287) 34 (11.4) 74 (25. with an incidence that is 3. while 82% of testicular cancer cases occur in males older than 15 years (median age.001).03-1. In the weighted analysis of the full data set. Using the weighted data. or hospital location. respectively (P . namely. the results were comparable.2) 34 (11.7) 2 (1. The frequency of testicular torsion increases before puberty and the sole identifiable risk factor for orchiectomy due to testicular torsion is increasing age. Figure 2 shows the raw data with an overlay of the modeled relationship between age and the proportion of patients with testicular torsion having an orchiectomy.74-2.43 .36) 0.03 (0.5) 34 (22.8) 30 (20. For categorical variables.72 .51-2.7) 52 (34. 1.4) 41 (27.7) 51 (17. the figure displays more age categories than were used in the analysis.2) 42 (14.1) 133 (89.84-2.01) Reference Reference 0.42 (0.001). Multivariate Predictors of Orchiectomy for Males Aged 1 to 25 Years With Testicular Torsion* Odds Ratio (95% Confidence Interval) 1. and hospital location (Table 2). To show the raw data at a finer level of detail. census region. insurance status.61 .50-2.

COM (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 159. but there have been no important changes in the management of patients with testicular torsion during this period. and have a timely surgical procedure. or hospital location.13 delayed presentation and age affect orchiectomy rates. For example. CONCLUSIONS These data suggest that testicular torsion is more common than testicular neoplasm. 2011 ©2005 American Medical Association. even for torsion. The national data in our study are consistent with the findings of the more recent study15 and identify a parallel between increasing age and increased orchiectomy rates.19 Other reports have suggested the presence of a congenital testicular dysplasia as the basis for reduced fertility in torsion. we are not aware of a formal recommendation or an adolescent health guideline advising health care providers to discuss the signs and symptoms of testicular torsion with their male patients. DEC 2005 1170 Downloaded from www. All rights reserved. Unfortunately.6 Proportion Having Orchiectomy 0. requires immediate evaluation. In fact. but the actual scope of malpractice claims related to torsion is difficult to determine.22. specifically testicular torsion. However. causing the increased orchiectomy rate.12 The message to patients should be that scrotal pain.21 The conclusions about the role of congenital pathologic conditions. 180°-1080°).21 Because this observation might indicate that reduced fertility in torsion is not preventable.20.0. Moreover. and the basis of some malpractice claims.17 Most concerning for patients. Error bars indicate 95% confidence intervals. males younger than 18 years had delayed presentation and had more orchiectomies than those 18 years and older.0 1 5 10 15 20 25 Age. For a male with testicular torsion to save his testicle. preservation of as much testicular tissue as possible would seem to be a priority. Misdiagnosed testicular torsion resulting in loss of a testicle has legal implications. a more recent 9-year retrospective study15 of 44 patients demonstrated that males aged 21 to 34 years had more orchiectomies than those aged 8 to 20 years. Estimated proportion of patients by age with testicular torsion having an orchiectomy.ARCHPEDIATRICS.5 0.9 One study9 found that 85% of male respondents did not think that it was necessary to seek attention for testicular swelling and that 36% did not think that it was necessary to seek attention for testicular swelling and pain.3 0. the group aged 21 to 34 years was presumed to have a greater degree of spermatic cord twisting. he must recognize the symptoms of torsion.23 The database was not designed to address the possible explanations for the linear association between increasing age and the rate of orchiectomies. it makes sense for health care professionals to educate prepubertal male patients about testicular disorders.archpediatrics. more than 5 years earlier than testicular tumors. One limitation of this study is that these data are from 1998. Although these data by Cummings et al15 confirm that delays in presentation increase orchiectomy rates. were based on the lack of relationship between the histological changes in the contralateral testis and the duration of torsion or the interval since torsion. We suggest that health care providers begin discussing testicular disorders. there is no variable in the data set that permits adjustments for the duration of the torsion before presentation or for the degree of torsion. there was no statistically significant agerelated difference between the 2 age groups in the mean time to presentation. especially severe pain. Because the frequency of testicular torsion begins to increase when males are 10 years old. Because the time to presentation was similar between the 2 groups. y Figure 2.2.2 includes more diagnoses than torsion of the testicle. Moreover.com on February 9. The study is also limited by the fact that the ICD-9-CM code 608. Despite this knowledge gap. but the range in both groups was identical and large (range. experimental data indicate that the contralateral intact testis may be harmed by antisperm antibodies18 or by increased germinal epithelial apoptosis. but our sensitivity analysis suggests that the major finding would remain significant even if half of the group aged 1 to 9 years did not have torsion of the testicle.4 0.2 0. access health care. health care professionals must not only believe that it is an important topic but also be comfortable discussing problems involving the testicle. any male in the peripubertal age group or older with scrotal pain should be presumed to have torsion until proven otherwise. Increasing age is a predictor of orchiectomy due to testicular torsion but not race. Sessions et al16 reported greater median degrees of torsion in patients requiring orchiectomy (median.20.11 To educate preadolescents about testicular disorders during health maintenance visits. . 540°) compared with patients with salvaged testicles (median 360°). is the potential association between unilateral testicular loss due to testicular torsion and reduced fertility and sperm counts. male subjects may be hesitant to seek medical attention for conditions involving their genitals. with prepubertal patients at the time of routine testicular examination. insurance status. older adolescents have a documented knowledge deficit about testicular pathologic conditions10 and have fewer physician visits than preadolescents. however. the lack of an explanation does not alter the message that males need to seek care quickly when they have scrotal pain.4. In contrast. In a 10-year retrospective study14 of 30 patients.1 0. national organizations may want to consider WWW. Although testicular salvage has been reported with prolonged torsion symptoms.3 Although the true pathogenesis of reduced fertility remains unproven.

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