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Emergency scrotal exploration in children: Is it time for a change in mindset in the UK?

Published:December 01, 2020DOI:https://doi.org/10.1016/j.jpurol.2020.11.029

      Summary

      Introduction

      Acute scrotal pain is a common problem in children. Amongst the various causes, only testicular torsion (TT) needs urgent, and arguably any, surgical intervention. However TT accounts for only approximately 25% of cases. The diagnosis of TT is currently based mainly on history and clinical examination in the UK.

      Objective

      We sought to find the incidence of finding TT during emergency scrotal exploration in four paediatric surgical centres in the UK. We also assessed the preoperative utilisation of clinical risk scores and Doppler ultrasound (DUS) to aid in the diagnosis.

      Patients and methods

      A retrospective review of 50 consecutive scrotal explorations done for acute scrotal pain at four tertiary pediatric surgical centres in 2019, including the preoperative utilisation of DUS, was analysed. Additionally an online survey was also sent out to consultant members of the British Association of Paediatric Urology to gauge their threshold for exploration, use of preoperative investigations and incidence of finding TT in their practice.

      Results

      In the four UK centres reviewed, TT was found in 24.5% (SD = 8.54) of explorations. The overall utilisation of preoperative DUS was 10%. The online survey revealed a low threshold for exploration. However 72% of respondents recalled finding TT in <50% of explorations, with just over a third reporting finding TT in only 10% of explorations. There was low utilisation of preoperative DUS and clinical risk scores.

      Discussion

      The incidence of finding TT during exploration in this cohort is the same as the incidence of TT in a population of children presenting with acute scrotal pain. We hypothesise that this is due to low accuracy of clinical assessment, low utilisation of preoperative clinical and radiological aids and the practice of exploring torted testicular appendages. Improving awareness and training in these modalities will increase diagnostic accuracy, limiting emergency scrotal explorations to those children with a higher risk of testicular torsion. A care pathway for children presenting with acute scrotal pain is suggested ()

      Conclusions

      Fig. 1
      Graphical AbstractCare pathway for children presenting with acute scrotal pain. Abbreviations: TT-Testicular torsion; DUS-Doppler ultrasound; POCUS-Point of care ultrasound; TWIST-Testicular Workup for Ischemia and Suspected Torsion. ∗ DUS evaluation should include blood flow within the testis, twisting of the spermatic cord, redundant spermatic cord within the scrotum and abnormal lie of the testis.

      Keywords

      Abbreviations:

      TT (Testicular torsion), TAT (Torsion of appendage of testis), DUS (Doppler ultrasound)
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      References

        • Lewis A.G.
        • Bukowski T.P.
        • Jarvis P.D.
        • Wacksman J.
        • Sheldon C.A.
        Evaluation of acute scrotum in the emergency department.
        J Pediatr Surg. 1995; 30: 277
        • Murphy F.
        • Fletcher L.
        • Pease P.
        Early scrotal exploration in all cases is the investigation and intervention of choice in the acute paediatric scrotum.
        Pediatr Surg Int. 2006; 22: 413-416
        • Caldamone A.A.
        • Valvo J.R.
        • Altebarmakian V.K.
        • Rabinowitz R.
        Acute scrotal swelling in children.
        J Pediatr Surg. 1984; 19: 581-584
        • Mansbach J.M.
        • Forbes P.
        • Peters C.
        Testicular torsion and risk factors for orchiectomy.
        Arch Pediatr Adolesc Med. 2005; 1591167e71
        • Anderson J.
        • Williamson R.
        Testicular torsion in Bristol: a 25 year review.
        Br J Surg. 1988; 75: 988-992
        • Visser A.J.
        • Heyns C.F.
        Testicular function after torsion of the spermatic cord.
        BJU Int. 2003 Aug; 92: 200-203
        • Thomas W.E.G.
        • Crane G.A.
        • Cooper M.J.
        • Lee G.
        • Williamson R.C.N.
        Testicular exocrine malfunction after torsion.
        Lancet. 1984; 2: 1357-1360
        • Tryfonas G.
        • Violaki A.
        • G Tsikopoulos
        • et al.
        Late postoperative results in males treated for testicular torsion during childhood.
        J Pediatr Surg. 1994; 29: 553-556
        • DaJusta D.G.
        • Granberg C.F.V.C.
        • LA B.
        Contemporary review of testicular torsion: new concepts, emerging technologies and potential therapeutics.
        J Pediatr Urol. 2013; 9: 723-730
      1. Barbosa J, Tiseo B, Barayan G RB& NH. Development and initial validation of a scoring system to diagnose testicular torsion in children. J pf Pediatr Urol. 189(5):1859–1864.

        • Mellick L.B.
        Torsion of the testicle: it is time to stop tossing the dice.
        Pediatr Emerg Care. 2012; 28: 80-86
        • Schmitz D.
        • Safranek S.
        Clinical inquiries. How useful is a physical exam in diagnosing testicular torsion?.
        J Fam Pract. 2009; 58: 433-434
        • Boettcher M.
        • Bergholz R.
        • Krebs T.F.
        • Wenke K.
        • Aronson D.C.
        Clinical predictors of testicular torsion in children.
        Urology. 2012; 79: 670-674
        • Soccorso G.
        • Ninan G.K.
        • RA& NS
        Acute scrotum: is scrotal exploration the best management?.
        Eur J Pediatr Surg. 2010; 20: 312-315
        • Srinivasan A.
        • Cinman N.
        • Feber K.
        • GJ& PL
        History and physical examination findings predictive of testicular torsion: an attempt to promote clinical diagnosis by house staff.
        J pf Pediatr Urol. 2011; 7: 470-474
        • Boettcher M.
        • Krebs T.
        • Bergholz R.
        • Wenke K Ad& Rk
        Clinical and sonographic features predict testicular torsion in children: a prospective study.
        BJUI. 2013; 112: 1201-1206
        • Sheth K.R.
        • Keays M.
        • Grimsby G.M.
        • Granberg C.F.
        • Menon V.S.
        • DaJusta D.G.
        • et al.
        Diagnosing testicular torsion before urological consultation and imaging: validation of the TWIST score.
        J Urol. 2016; 195: 1870-1876
        • Baker L.
        • Sigman D.
        • Mathews R.B.J.
        • S D.
        An analysis of clinical outcomes using color Doppler testicular ultrasound for testicular torsion.
        Pediatrics. 2000; 105: 604-607
        • Kalfa N.
        • Veyrac C.
        • Baud C.
        • Couture A AM& GR
        Ultrasonography of the spermatic cord in children with testicular torsion:impact on the surgical strategy.
        J Urol. 2004; 172: 1692-1695
        • Bandarkar A.
        • Blask A.
        Testicular torsion with preserved flow: key sonographic features and value-added approach to diagnosis.
        Pediatr Radiol. 2018; 48: 735-744
        • NHS East Midlands Clinical Network
        Commissioning guide: management of paediatric torsion.
        Royal College of Surgeons of England, London2016
        • Riccabona M.
        • Darge K.
        • Lobo M.
        • Ording-Muller L.
        • Augdal T.
        • Avni F.
        • et al.
        ESPR Uroradiology Taskforce—imaging recommendations in paediatric uroradiology, part VIII: retrograde urethrography, imaging disorder of sexual development and imaging childhood testicular torsion.
        Pediatr Radiol. 2015; 45: 2023-2028
        • Mustaq I.
        • Fung M.
        • Glasson M.J.
        Retrospective review of pediatric patients with acute scrotum.
        ANZ J Surg. 2003; 73: 55-58
        • Holland J.M.
        • Graham J.B.
        • Ignatoff J.M.
        Conservative management of twisted testicular appendages.
        J Urol. 1981 Feb; 125: 213-214
        • Lala S.
        • Price N.
        • Upadhyay V.
        Re-presentations and recurrent events following initial management of the acute paediatric scrotum: a 5 year review.
        ANZ J Surg. 2019 April; 89: E117-E121
      2. British association of paediatric urology statement: ‘recommendations for paediatric urology practice during the COVID-19 epidemic’; https://www.bapu.org.uk/news-and-events/news/recommendations-for- paediatric-urology-practice-during-covid-19-epidemic.

        • R J.
        An analysis of successful litigation claims in children in England.
        Arch Dis Child. 2011; 96: 838-840
        • Ben-Meir D.
        • Deshpande A.
        • Hutson J.M.
        Reexploration of the acute scrotum.
        BJU Int. 2006; 97: 364-366
        • Hart J.
        • Pastore G.
        • Jones M.
        • et al.
        Chronic orchalgia after surgical exploration for acute scrotal pain in children.
        J Pediatr Urol. 2016 Jun; 12: 168.e1-168.e6
        • Chan E.P.
        • Wang P.Z.T.
        • Myslik F.
        • Chen H.
        • Dave S.
        Identifying systems delays in assessment, diagnosis, and operative management for testicular torsion in a single-payer health-care system.
        J Pediatr Urol. Mar. 2019; 29: 30074e9
        • Friedman N.
        • Pancer J.
        • Savic R.
        • et al.
        Accuracy of point of care ultrasound by pediatric emergency physicians for testicular torsion.
        J Pediatr Urol. 2019; 15 (e1-e6): 608
        • Stolz L.
        • O'Brien K.M.
        • Miller M.L.
        • et al.
        A review of lawsuits related to point of care emergency ultrasound applications.
        West J Emerg Med. 2015 Jan; 16: 1-4
      3. Ryan K, Folkard S, Bastianpillai C, Green J. The management of testicular torsion in the UK: how can we do better? A national quantitative and qualitative analysis of the factors affected successful testicular salvage. J Pediatr Urol, http://doi.org/10.1016/j.jpurol.2020.08.018.