Scrotal US diagnosis testicular torsion has improved in past years: study

The past 18 years in Singapore have seen an improvement in the diagnosis of testicular torsion with scrotal ultrasonography (US), which has demonstrated satisfactory results in sensitivity and negative predictive value over the past decades, according to a study.

However, the researchers found that US has led to increases in wait time for patients presenting with testicular pain at KK Women’s and Children’s Hospital in Singapore.

“Although there are currently no clear criteria for determining the necessity of scrotal US, quality improvement projects should aim to reduce wait times for both US and surgery while we await new evidence,” they said. [Singapore Med J 2023;64:249-254]

Boys presenting with acute scrotal pain from 2014 to 2015 were included in this retrospective review. The researchers then collected US reports, operative findings, final diagnosis, and key time points of the patients’ journey (time to emergency department consultation, time to admission, time to US, and time to operating theatre [OT]).

Performance results of US were compared with those observed in a historical cohort from 1998 to 2004. Likewise, wait times were compared between patients who underwent surgery and those who did not.

A total of 519 boys (mean age 9.15 years) had their data collected in this study. Of these, 438 (84.4 percent) had undergone initial scrotal US. Among these cases, 28 were surgically explored, with 23 confirmed to have torsion. In addition, five more cases were explored without prior US, and all of these were confirmed to have torsion.

Analysis of US performance revealed a 100-percent sensitivity and a 98.8-percent specificity. No significant difference was observed between wait times of operated and nonoperated patients. In addition, time to US (p<0.0001, r=0.96) and time to OT (p<0.0001, r=0.64) were significantly associated with the total time from presentation to surgery.

Testicular pain management

“Despite many studies documenting the usefulness of scrotal US in the evaluation of acute testicular pain, its role in routine management still remains controversial,” the researchers said. “The main argument centres on the time-sensitive nature of testicular torsion and the impact on testicular salvage.” [Int J Clin Pract 2008;62:821-827; Urology 2018;116:150-155; Eur J Pediatr Surg 2015;26:17-21]

However, published literature remains divided on the actual correlation between testicular salvage rate and symptom duration.

Some studies suggest that US leads to delays in the diagnosis and management of testicular torsion, but others see no significant difference in orchidectomy rates between paediatric patients with accelerated and normal workflows. [J Pediatr 2018;192:178-183; J Pediatr Urol 2016;12:233.e1-4]

“Our study looked at the key intrahospital time points and showed that the wait time for scrotal US indeed played a significant role in patients’ total wait time (p<0.0001, r=0.96), but we could not analyse the effects of symptom duration,” the researchers said.

“By contrast, there are clear advantages of US in reducing the negative exploration rate, reducing costs, and sparing both patients and caregivers surgical risk. However, we do acknowledge that the delay caused by scrotal US wait time may not be the same in every hospital system,” they added. [Semin Pediatr Surg 2013;22:129-133]