LES URGENCES A L'INSTITUT ARNAULT TZANCK Réunion du 20 Mai 1999

URGENCE EN UROLOGIETORSION DU TESTICULE
Dr Hervé QUINTENS Urologie

ACUTE SCROTUM H. QUINTENS
Acute scrotum in the childDubois R, Dodat H Arch Pediatr 1998 Aug;5(8):916-22 
Torsion of the spermatic cord is the most common etiology of acute scrotum in children.
only early surgical treatment, within 6 hours of the onset of symptoms, may ensure the preservation of the testis.
Spermatic cord torsionMalossini G, Curti P,Arch Esp Urol 1992 Jan-Feb;45(1):5-10 
surgical correction within 12 hours permitted testicular salvage.
over 12 hours, testicular atrophy was observed in 46%
detorsion must be performed as soon as possible.
Immunological and clinical study of patients after spermatic cord torsion.Mastrogiacomo I Andrologia 1982 Jan-Feb;14(1):25-30
25 pts spermatic cord torsion after puberty.
number of spermatozoid was lower
atrophic testis
torsion for more than 2 years
sterility after spermatic cord torsion is correlated with an autoimmune mechanism.
Acute scrotum in pediatric age: analysis of 265 consecutive cases CampobassoP,, Belloli G Pediatr Med Chir 1996 Sep-Oct;18
47% torsion of the appendix of testis,
26% torsion of testis
26% acute orchiepididymitis.
under 1 year torsion of testis (67%),
in the older patients the torsion of appendix of testis (50%). 
Etiology of acute scrotum in 100 boys with regard to age distribution.Melekos MD, J Urol 1988 May;139(5):1023-5 .
less than 15 years old with an acute scrotum causes
torsion of the spermatic cord (42 %)
torsion of the appendages (32 %).
the remaining 26 % of the cases
idiopathic scrotal edema (8 %),
epididymitis and orchitis (6 % each
incarcerated hernia and acute hematocele (3 % each).
Etiology of acute scrotum at surgical exploration in children, adolescents and adults.Goldwasser B Eur Urol 1992;21(1):45-7 
Torsion of testis
children 34%.
adolescent 86%
adults 88%
We therefore suggest using radionuclear scans and/or Doppler ultrasound to facilitate clinical diagnosis in the children group. 
Acute scrotum in childhood: considerations on 457 casesAbbate , Pampaloni A Pediatr Med Chir 1993 Jan-Feb;15(1)
the surgical approach is the correct treatment for the acute scrotum .
the surgical treatment present no problem
all the post-operatives were uneventful.
under 2 years = inguinal incision,
above 2 years = scrotal incision.
The controlateral orchiopexy, in case of torsion of the funicle, wasperformed in the same session
Critical analysis of the clinical presentation of acute scrotum: a 9-yearexperience at a single institution.Jefferson RH, Perez LM, Urol 1997 Sep;158(3 Pt 2):1198-200 
CONCLUSIONS
We believe that any boy 11 years old or older
with scrotal pain less than 12 hours in duration
that is associated with nausea or vomiting
should be considered to have torsion of the spermatic cord.
it is not necessary to perform imaging in this subset of boys before surgical exploration.
The importance of the cremasteric reflex in acute scrotal swelling in children.Rabinowitz R J Urol 1984 Jul;132(1):89-90 
in a 7-year evaluation of 245 boys with acute scrotal swelling
The correlation between the presence of the ipsilateral cremasteric reflex and the absence of testicular torsion was 100 per cent
the absence of this reflex increased the suspicion of testis torsion.
Manual derotation of the twisted spermatic cord.Cornel EB, Karthaus HF Br J Urol 1999 Apr;83(6):672-674 
successful manual derotation =
the immediate relief of all symptoms and
normal findings at physical examination.
subsequent elective bilateral orchidopexy.
No testicular atrophy was detected during the follow-up

Indications for conservative management of acute scrotal pain in children.Hastie KJ, Charlton CA Br J Surg 1990 Mar;77(3) 
This study suggested that urgent operation was unnecessary if :
a tender nodule was found (pathognomonic of a torted appendage)
after more than 24h of pain with scrotal erythema and oedema..
Evaluation of acute scrotum in the emergency department.Lewis AG, Bukowski TP J Pediatr Surg 1995 Feb;30(2):277 
A 2-year retrospective review of 238 cases of acute scrotal pain in a children's hospital emergency
The diagnostic error rate on first encounter was 7%,resulting in 10 negative scrotal explorations..
39% of the children with epididymitis who underwent investigation were found to have either structural or functional urinary tract abnormalities.
Spermatic cord torsion in adults.Kattan S. Scand J Urol Nephrol 1994 Sep;28(3)
20% of patients were misdiagnosed as epididymitis.
53% has history of similar previous attacks.
The average delay prior to presentation was 7 hours.
Absence of fever was the rule occurring in all patients.
Leucocytosis (33%) and significant pyuria (27%) were commonly encountered
the presence of significant pyuria even if associated with leucocytosis does not exclude spermatic cord torsion.
Acute scrotum without technologyMerenciano Cortina FJ, P Actas Urol Esp 1998 Jan;22(1):37-42 
Finally, an earlier intervention in the event of suspicious cord torsion remains the most important factor in the prognosis.
Our results, using no state-of-the-art diagnostic technologies, are similar to other series and we see no trend towards unnecessary surgical examination
A 25-year review of the acute scrotum in childrenSidler D, SS Afr Med J 1997 Dec;87(12):1696-8 
Diagnosis was made clinically in all cases.
Successful conservation of the testis = the time interval symptom / surgical derotation.
We advocate expedient surgical exploration and derotation with controlateral orchidopexy,
even with highly specialised investigation which may not be widely available
Do all children with an acute scrotum require exploration?Kass EJ, Stone KT, Cacciarelli AA, Mitchell B
the majority (71%) of children with an acute scrotum did not require immediate surgical exploration.
Color Doppler ultrasound can reliably identify those children
with an acute scrotum who require exploration
and spare the majority needless surgery.
Routine scrotal exploration is no longer necessary for all children with an acute scrotum. 
Testicular torsion versus epididymitis: a diagnostic challenge.Petrack EM, Cleveland, Ohio Pediatr Emerg Care 1992 Dec;8. 
When testicular torsion is strongly considered :
immediate exploratory surgery
immediate testicular radionuclide scanning
Doppler sonography
If these radiographic studies cannot be arranged and interpreted within one to two hours, scrotal exploration should be performed.
Acute scrotal disorders: prospective comparison of color Doppler US and testicular scintigraphy.Middleton WD, Radiology 1990 Oct;177(1):177-81 
There were no false-positive diagnoses of testicular torsion color Doppler US or scintigraphy
Color Doppler US is at least as accurate as testicular scintigraphy and can function as an effective means of evaluating patients with suspected testicular torsion. 
The value of radionuclide scrotal imaging in the diagnosis of acute testicular torsion.Melloul M, Br J Urol 1995 Nov;76(5):628-31 
Of the 87 patients, 44 underwent scrotal exploration and 42 patients were treated conservatively.
in diagnosing testicular torsion :
The specificity =100%
The sensitivity = 98%.
The RSI can clearly distinguish among testicular torsion, torsion of testicular appendages and epididymitis. 
Color Doppler ultrasound evaluation of the acute scrotum.Galejs LE, Kass EJ Tech Urol 1998 Dec;4(4):182-4 
Torsion was ruled out by ultrasound with 100% specificity verified on follow-up.
color Doppler ultrasound can
identify reliably those children with an acute scrotum who require exploration
and exclude those children without testis torsion who would otherwise undergo needless surgery. 





The use of color doppler sonography of the acute scrotum in childrenFernandez MS Cir Pediatr 1997 Jan;10(1):25-8 
72 consecutive cases of acute scrotum in children younger than 13 years old,
Doppler examination showed a
97.2% sensibility and 72.2% specificity in the diagnosis of epididymo-orchitis
88.88% sensibility and 100% specificity in the diagnosis of testicular torsion.
Color Doppler imaging in the diagnosis of the acute scrotum.Suzer O, Ozcan H Eur Urol 1997;32(4):457-61 
the 102 patients evaluated ages 11-44
CDI diagnosed 18 patients with testicular torsion and 78 patients with epididymorchitis.
testicular torsion = absent flow on CDI
epididymorchitis = normal or increased flow in all patients
All cases of torsion were confirmed on surgical exploration,
CDI = 100% sensitive and 100% specific in the diagnosis of the acute scrotum.
The acute scrotum.Kass EJ, Lundak B Pediatr Clin North Am 1997 Oct;44(5)
urgent surgical exploration =
duration of the pain brief +
history and physical examination suggest torsion
diagnostic imaging =
not possible to definitely diagnose or exclude testicular torsion
or the duration of pain > 12 hours =>
Color Doppler sonography is preferable to nuclear imaging
blood flow
normal or increased, =>scrotal exploration is not required.
decreased or does not provide a definite diagnosis=> scrotal exploration is recommended.