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Acute scrotum and testicular torsion in children: Retrospective study in a single

institution

Keiichiro Tanaka, Yuki Ogasawara, Koki Nikai, Shunsuke Yamada, Kentaro Fujiwara,
Tadaharu Okazaki

PII: S1477-5131(19)30389-4
DOI: https://doi.org/10.1016/j.jpurol.2019.11.007
Reference: JPUROL 3323

To appear in: Journal of Pediatric Urology

Received Date: 17 September 2019

Accepted Date: 20 November 2019

Please cite this article as: Tanaka K, Ogasawara Y, Nikai K, Yamada S, Fujiwara K, Okazaki T, Acute
scrotum and testicular torsion in children: Retrospective study in a single institution, Journal of Pediatric
Urology, https://doi.org/10.1016/j.jpurol.2019.11.007.

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Acute scrotum and testicular torsion in children: Retrospective study in a single

institution

Keiichiro Tanaka, Yuki Ogasawara, Koki Nikai, Shunsuke Yamada, Kentaro Fujiwara,

Tadaharu Okazaki

Department of Pediatric Surgery, Juntendo University Urayasu Hospital

2-1-1, Tomioka, Urayasu-shi, Chiba 279-0021, Japan

Corresponding Author:

Keiichiro Tanaka

Address correspondence and reprint requests to Keiichiro Tanaka M.D., Ph.D.

Department of Pediatric Surgery, Juntendo University Urayasu Hospital, 2-1-1, Tomioka,

Urayasu-shi, Chiba 279-0021, Japan.

TEL: +81-47-353-3111, Fax: +81-47-353-0526

e-mail: kc-tanaka@juntendo.ac.jp

Running Title: Acute scrotum and testicular torsion

1
Summary

Introduction

Testicular torsion (TT), as per the reported incidences in children and preadolescents, is

an emergency medical condition that requires prompt surgical treatment. In cases of TT,

early and accurate diagnosis of acute scrotum (AS) is important to preserve testicular

fertility. In this study, we aimed to determine the incidence, clinical examination,

etiology, clinical predictors, and treatment of patients with AS including TT.

Material and Methods

We retrospectively reviewed all children (age, ≤15 years) with AS who visited our

hospital between January 2012 and June 2019. Data on age and diagnosis, clinical

findings, mode of treatment and blood examination results were collected.

Results

We examined 165 children aged between 0 days and 15 years (mean age, 9.4 years).

Final diagnosis identified 72 patients with torsion of the appendix testis, 44 patients

with epididymitis and 38 patients with TT. Testes were salvaged in 23 of the 38 patients

with TT (60.5%). Statistically significant variables revealed that the risk factors of TT

were age (older than 12 years), white blood cell (WBC) count (>12,000 cells/mm3) and

laterality (left side). The level of C-reactive protein (CRP), duration of symptoms and

1
degree of torsion were significantly higher in the non-salvageable testis group than in

the salvageable testis group. Furthermore, the significant predictive factor for

non-salvageable testis was the level of CRP >1.0 mg/dl.

Conclusion

Our results indicates that age, WBC count and laterality are key factors to distinguish

TT from AS. Salvageability largely depended on the duration of symptoms and the

degree of TT. Salvage rate of testis can be improved by educating pediatricians, parents,

patients and medical staff about the early diagnosis and treatment of torsion.

2
Table.1 Detail of patients with AS (N=165)
Age (yrs) 9.4 ± 0.6
Surgical Conservative
Final diagnosis
treatment treatment
Torsion of appendix
72 (43.6%) 51 21
testis
Epididymitis 44 (26.7%) 19 25
TT 38 (23.0%) 38 0
Torsion of appendix
5 (3.0%) 5 0
epididymis
Scrotal dermatitis 2 (1.2%) 0 2
Torsion of epididymis 1 (0.6%) 1 0
Tumor of spermatic
1 (0.6%) 1 0
cord
Acute hydrocele 1 (0.6%) 0 1
Trauma 1 (0.6%) 0 1
Total 165 (100%) 115 50
Laterality
Right side 66 (40.0%)
Left side 93 (56.4%)
Both sides 6 (3.6%)

First diagnosis
TT Not TT
TT 38 0
Final dignosis
Not TT 23 127

Sensitivity 38/38 (100%)

Specificity 127/150(84.7%)
AS: Acute scrotum
TT: Testicular torsion

Keywords Acute scrotum; Testicular torsion; Epididymitis

Abbreviations

AS, Acute scrotum

TT, Testicular torsion

WBC, White blood cell

3
CRP, C-reactive protein

Introduction

Acute scrotum (AS), including scrotal pain, scrotal swelling, and testicular pain, is a

commonly presenting symptom at the pediatric emergency department [1]. Acute

scrotum (AS) often occurs secondary to vascular compromise or inflammatory lesions

[2]. The differential diagnosis of AS includes testicular torsion (TT), torsion of appendix

testis, torsion of appendix epididymis, epididymitis, trauma, varicocele, communicating

hydrocele, acute hydrocele, inguinal hernia, trauma, and tumors [3-5]. Additionally, all

these diseases can cause scrotal inflammation with extension of local inflammation. TT

is an emergency condition that requires prompt surgical treatment. The incidence of TT

among patients with AS varies from 3% to 72%, depending on patient age, hospital

location, hospital characteristics and diagnostic method (with or without color Doppler

ultrasonography) [1-8]. If the treatment for TT is not started within 6 hours, the testis

may not be salvageable [8-10]. According to the literature, the testicular salvage rate of

patients with TT varies from 30% to 70% [7,8,10-15]. Unfortunately, the true cause of

AS is difficult to distinguish by differential diagnosis owing to the similarity of clinical

signs and examination overlap. In many reports, color Doppler ultrasonography, which

4
is a highly sensitive and specific preoperative diagnostic tool, has proven to be a reliable

method that could help in preventing unnecessary surgical treatment [2-4]. However, an

experienced surgeon and radiologist may not always be available. In cases where TT

cannot be excluded, prompt surgical exploration is recommended. At present, there is a

paucity of data relating AS to TT.

In this study, we aimed to determine the incidence, clinical examination, etiology,

clinical predictors, salvageability of testis and treatment of patients with AS including

TT at our hospital.

Material and Methods

We retrospectively reviewed all patients with AS (age, ≤15 years) who visited the

Juntendo University Urayasu Hospital between January 2012 and June 2019. Acute

scrotum (AS) included scrotal pain, testicular pain, scrotal erythema and scrotal

swelling. All patients with AS were examined by color Doppler ultrasonography

performed by pediatric surgeons to check the scrotum and testicular blood flow. When

TT was diagnosed or could not be completely excluded, surgical treatment was

performed. Patients with AS in whom TT was excluded received conservative treatment,

which included cephem antibiotics administered for 2–3 days until the symptoms

5
decreased. Manual detorsion of the testis by external rotation was avoided because the

outcome of this maneuver is uncertain.

Patients were analyzed according to their age, treatment, diagnosis, duration of

symptoms, laterality, presence of salvageable or non-salvageable testis, degree of

torsion, the season during which the surgery and blood examinations were performed. In

Japan, the following four seasons are observed: spring (March–May), summer (June–

August), autumn (September–November), and winter (December–February).

All surgical procedures were performed with the patient under general anesthesia

and in the supine position. We checked the testis after making a skin incision in the

scrotum. When TT was confirmed, we released the torsion. However, if testicular blood

flow was not restored, we performed orchiectomy. In addition, fixation of the

contralateral testis to the dartos fascia with two stitches was performed in every case.

When torsion of appendix testis, appendix epididymis, and/or tumor of the spermatic

cord were observed, we removed these and performed testis fixation with same

procedure. For other diseases, we performed only testis fixation. All wounds were

closed without insertion of a drainage tube, and cephem antibiotics were administered

for 1 day for prevent infection.

Statistical analyses were performed using a statistical program (Stat View software

6
ver.5.0, SAS institute, Cary, NC, USA). All data were compared using nonparametric

statistical analysis with Student’s t-test, Chi-square test, Mann-Whitney U test and

Fisher’s exact test for categorical variables. In all analyses, p < 0.05 was considered

statistically significant.

This study was approved by the Ethics Committee of Juntendo University Urayasu

Hospital with the Helsinki Declaration of 1975 (revised 1983).

Results

Overall, 165 boys with AS visited our hospital. The median age of the patients was 9.4

years (mean±0.6; age range, from 0 day to 15 years). In total, 115 boys underwent

surgical treatment and 50 boys received conservative treatment for the management of

AS. After scrotal exploration, final diagnosis of AS identified the following: torsion of

appendix testis (72 patients, 43.6%), epididymitis (44 patients, 26.7%), TT (38 patients,

23.0%), torsion of appendix epididymis (5 patients, 3.0%), scrotal dermatitis (2 patients,

1.2%), torsion of epididymis (1 patient, 0.6%), tumor of the spermatic cord diagnosed

fibromatous perispermatitis (1 patient, 0.6%), acute hydrocele (1 patient, 0.6%), and

trauma (1 patient, 0.6%) (Table 1). The left scrotum was more often affected in all

patients with AS (93 patients, 56.4%). In the first examination, 61 patients with TT were

7
diagnosed and true TT was not missed. Sensitivity of TT in AS was 100% (38/38

patients) and specificity was 84.7% (127/150 patients).

Further, 38 boys were definitively diagnosed with TT by surgical procedures. The

median age of the patients was 10.55 ± 1.47 years (age range, 0–15 years). The

incidence of TT was highest in patients aged 12–15 years, with significant differences

noted among the patients in this regard (Table 2). The median duration of symptoms in

patients visiting our hospital was 41.44 ± 29.35 hours (range, 1–504 hours). The left

scrotum was significantly affected in most cases with TT (76.3%). The testis were

salvageable in 23 of the 38 patients with TT (60.5%). Notably, no significant differences

were observed regarding to the seasonal occurrence of TT.

In the comparison between TT (38 patients) and Not TT (127 patients), the peak

incidence of TT was observed in patients in the age group of 12–15 years, whereas the

peak of Not TT was observed in patients in the age group of 8–11 years. The ages of

patients with TT were significantly higher than those of patients with Not TT (Table 3).

In 4-11-year-old patients, the incidence of TT was significantly lower than the incidence

of Not TT. Further analysis of the clinical findings and blood examination results

revealed that statistically significant variables were white blood cell (WBC) count and

laterality, and other factors were not significant. Risk factors of TT were age (older than

8
12 years), WBC count (>12,000 cells/mm3) and laterality (left side).

Furthermore, we compared the data of patients with TT in the non-salvageable and

salvageable testis groups (Table 4). The level of C-reactive protein (CRP) in blood tests

was significantly higher in the non-salvageable testis group (0.99 ± 1.01 mg/dl [range,

0.2–3.2 mg/dl]) than in the salvageable testis group (0.27 ± 0.09 mg/dl [range, 0.1–0.5

mg/dl]). The mean duration of symptoms was significantly longer in the

non-salvageable testis group (84.3 ± 128.0 h [range, 2–504 h]) than in the salvageable

testis group (14.2 ± 19.9 h [range, 1–96 h]). Additionally, the degree of torsion was

higher in the non-salvageable testis group (441.8 ± 259.1 degrees) than in the

salvageable testis group (168.3 ± 141.8 degrees). However, there were no significant

differences between the groups in terms of age or WBC count in blood test results.

Moreover, we reanalyzed the data with a cut-off point to identify the predictive

factors of salvageability. Further analysis revealed that the significant predictive factor

for non-salvageable testis was the level of CRP >1.0 mg/dl (Table 5). There were no

significant differences between the groups in terms of age, WBC count, duration of

symptoms of >6 h and degree of torsion of >180°.

No intraoperative or postoperative complications, such as testicular atrophy, were

observed during inpatient or follow-up care (range, from 4 months to 7 and half years).

9
Discussion

The annual incidence of TT is 3.8 per 100,000 males who are younger than 18 years and

one in 4,000 males aged <25 years [4-7,11,12,14,15]. TT has two peaks with regard to

the age at presentation in the pediatric population; adolescence and newborns

[4,11,15,16]. It has been suggested that if the torsion is successfully repaired within 6

hours of symptom onset, there is an 80%–100% salvage rate, whereas the salvage rate

drops to 20% at 12 hours after symptom onset, and to <10% after 24 hours after

symptom onset [2,4,5,7]. Experimental studies showed that infarction of the testis starts

2 hours after complete occlusion of the testicular artery, irreversible ischemia starts after

6 hours, and complete infarction of the testis develops after 24 hours [3,7]. Therefore, it

is of utmost importance that the correct diagnosis be made promptly and accurately, and

treatment should be initiated as soon as possible.

Color Doppler ultrasonography, which has a highly sensitive (85%–100%) and

specific (85%–100%) preoperative diagnostic rate, is the most commonly used imaging

modality for the diagnosis of TT [2,4]. Color Doppler ultrasonography evaluates the

size, shape, echogenicity and perfusion of both testis and has proven to be a reliable

method that could help in preventing unnecessary surgical treatment [2,6,7]. Color

10
Doppler imaging of TT demonstrates a relative decrease or absence of blood flow

within the affected testis. If blood flow is absent and other symptoms indicate torsion,

immediate surgical exploration is recommended. However, an experienced surgeon and

radiologist may not always be available. Previous studies have reported that 92%–97%

of the patients with TT had normal blood flow in the affected testis [8,17]. Hence, they

advocated that prompt surgical exploration in all boys with AS can minimize testicular

loss [8,17].

Our study included 165 children who visited our hospital for the management of

AS for over 7 years. 115 boys received surgical treatment and 50 boys received

conservative treatment. Retrospectively, 38 patients with TT and 1 patient with torsion

of epididymis clearly required surgical treatment. In addition, another 76 patients

underwent unnecessary surgery. Although the symptoms in patients with torsion of

appendix testis (51 patients) or appendix epididymis (5 patients) resolved spontaneously,

resection improved the symptoms by considerably reducing local inflammation [3].

Moreover, Murphy et al. reported that prompt surgical operation in all patients with AS

can minimize testicular loss, and the surgical treatment of twisted appendages is safe,

allowing accurate diagnosis and pain relief with minimal morbidity [10]. Because we

agree with some of the study by Murphy et al., we tolerate false-positive results and

11
unnecessary surgical procedure to never miss the diagnosis of TT.

Consistent with the findings of previous studies, the findings of 38 patients of TT

with surgical procedure in our study indicate that age 12–15 years is one of the risk

factors for TT and that the condition often occurs in the left testis [18]. For

distinguishing TT from AS, our results indicates that both age (older than 12 years),

WBC count (12,000 cells/mm3) and laterality (left side) were significant factors.

Previous studies have shown an association between seasonal variations and the

occurrence of TT, with the highest incidence found to be associated with cold weather

[9,19]. For example, Srinivasan AK et al. reported that seasons with lower temperature

such as spring and winter are associated with increased incidences of TT [19]. However,

in our study, no significant differences were observed regarding to the seasonal

occurrence of TT. Furthermore, we believe that large numbers of patients are necessary

to determine such an effect with the consideration of factors, including outside

temperature, indoor temperature, staying time, time of symptom onset and type of

clothes.

The duration of symptoms was significantly longer in the patients with

non-salvageable testis than in those with salvageable testis. Degree of torsion was

significantly higher in the patients with non-salvageable testis than in those with

12
salvageable testis. A longer duration of symptoms and greater degree of torsion can lead

to a more severe onset of ischemia, but the degree of torsion can rarely be determined

without surgical exploration [5]. Previous studies reported that salvage rate largely

depended on the duration of symptoms and the degree of torsion [5,8,11,12,18].

At our hospital, the average duration from admission to surgery is 3.1 h (range, 1–8

h). For the testis to be salvaged, patients with TT must visit a hospital within 3 h of

experiencing testicular pain; however, 3 h are insufficient for the diagnosis of TT and

preparation for surgical treatment. The condition can deteriorate in patients who endure

the pain, do not diagnosed, and do not get accurate information. Earlier diagnosis and

treatment can be achieved by educating pediatric physicians, house staff, triage staff,

residents and other medical staff [7,11,20]. Friedman et al. reported that only 34% of

parents whose children experienced TT had heard of the term TT [21]. Therefore, it is

important to educate parents and patients about the problems related to TT [3,7,13,21].

Conclusion

Our results indicate that age (older than 12 years), WBC count (12,000 cells/mm3) and

laterality (left side) are significant factors to distinguish TT from AS. In comparison

with non-salvageable testis group or salvageable testis group in TT, the level of CRP,

13
duration of symptoms and degree of torsion were significantly different. The testicular

salvage rate largely depends on the duration of symptoms and degree of torsion. Salvage

rate of testis can be improved by educating pediatricians, parents, patients and medical

staff about the early diagnosis and treatment of torsion.

Complicate with ethical standards

Funding The authors received no financial support for this work.

Conflict of interest The authors have no conflicts of interest.

Ethical approval All procedures performed in studies involving human participants

were in accordance with the ethical standards of the institutional research committee

and with the 1964 Helsinki declaration and its later amendments or comparable ethical

standards.

Informed consent Informed consent was obtained from all individual participants

included in the study.

14
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18
Table.1 Detail of patients with AS (N=165)
Age (yrs) 9.4 ± 0.6
Surgical
Conservativ
Final diagnosis treatmen
e treatment
t
Torsion of appendix
72 (43.6%) 51 21
testis
Epididymitis 44 (26.7%) 19 25
TT 38 (23.0%) 38 0

Torsion of appendix
5 (3.0%) 5 0
epididymis
Scrotal dermatitis 2 (1.2%) 0 2
Torsion of 1 (0.6%) 1 0
Tumor of spermatic
1 (0.6%) 1 0
cord
Acute hydrocele 1 (0.6%) 0 1
Trauma 1 (0.6%) 0 1
Total 165 (100%) 115 50
Laterality
Right side 66 (40.0%)
Left side 93 (56.4%)
Both sides 6 (3.6%)

First diagnosis
TT Not TT
TT 38 0
Final dignosis
Not TT 23 127

Sensitivity 38/38 (100%)

Specificity 127/150(84.7%)
AS: Acute scrotum
TT: Testicular torsion
Table. 2 Detail of patients with TT (N=38)
p Value
Age (yrs) 10.55 ±1.47
0-3 4
4-7 5
8-11 6
12-15 23 <0.01
Duration of 41.44 ± 29.35
symptoms (h) (range, 1-504)
Laterality
Right side 9 (23.7%)
Left side 29 (76.3%) <0.01
Salvageable 23 (60.5%)
Non-salvageable 15 (39.5%)
Season
Spring 8
Summer 8
Autum 8
Winter 14 NS
TT: Testicular Torsion
WBC: White Blood Cell
CRP: C-reactive protein
Table. 3 Comparison between TT and Not TT
TT Not TT p Value Adjusted OR (95% CI)
Patients 38 127
Age (yrs) 10.55 ±4.48 9.13 ±3.59 0.006
0-3 4 11 0.373 0.49 (0.15-1.67)
4-7 5 21 0.048 0.32 (0.11-0.95)
8-11 6 64 <0.001 0.13 (0.05-0.34)
12-15 23 31 1.0 (Reference)
WBC (cells/mm3) 10,105 ± 3,6838,131 ± 3,609 0.003
3
WBC >12,000 (cells/mm 14 12 <0.001 5.59 (2.33-13.41)
CRP (mg/dl) 0.55 ± 0.72 0.41 ± 0.52 0.719
CRP > 1.0 (mg/dl) 5 6 0.129 3.06 (0.93-10.08)
Laterality
Right side 9 57 0.014 0.35 (0.16-0.79)
Left side 29 64 1.0 (Reference)
Both sides 0 6 0.176 0.15 (0.00-1.48)
TT: Testicular Torsion
WBC: White Blood Cell
CRP: C-reactive protein
Table. 4 Comparison between non-salvageable testis group
and salvageable testis group in TT patients
Non-salvageable Salvageable pValue
Patient 15 23
Age (yrs) 9.53 ± 5.36 11.12 ± 3.78 0.412
3
WBC (cells/mm ) 10,500 ± 3,608 9,847 ± 3,788 0.622
CRP (mg/dl) 0.99 ± 1.01 0.27 ± 0.09 0.028
Duration of 84.3 ± 128.0 14.2 ± 19.9
<0.001
symptoms (h) (range, 2-504) (range, 1-96)
Torsion Degree
441.8 ± 259.1 168.3 ± 141.8 0.005
(degrees)
TT: Testicular torsion
WBC: White Blood Cell
CRP: C-reactive protein
Table. 5 Predictive factors of non-salvageable testis
Non-salvageable Salvageable p Value Adjusted OR (95% CI)
Patient 15 23
Age (yrs)
0-3 3 1 0.32 4.00 (0.46-31.9)
4-7 2 3 1.00 0.89 (0.15-5.61)
8-11 1 5 0.62 0.33 (0.04-2.78)
12-15 9 14 1.0 (Reference)
3
WBC > 12,000 (cells/mm ) 5 8 1.00 0.94 (0.30-3.59)
CRP > 1.0 (mg/dl) 5 0 0.006 24.6 (1.29-487.1)
Duration of symptoms > 6
13 13 0.08 5.00 (1.00-24.00)
h
Torsion degree > 180 ° 8 7 0.19 2.61 (0.70-9.81)
WBC: White Blood Cell
CRP: C-reactive protein