By Larry B. Mellick, MS, MD, FAAP, FACEP
Professor of Emergency Medicine and Pediatrics
Medical College of Georgia
Georgia Health Sciences University
Augusta, Georgia

Pearl: The condition of testicular torsion is very vulnerable to misdiagnosis or mismanagement because of three common myths or misunderstandings.

Presentation: A 19-year-old male presented with the sudden onset of right scrotal pain. Because the patient had moderate scrotal swelling and a cremasteric reflex, the emergency physician diagnosed epididymitis. After evaluation and treatment in the emergency department, the patient was discharged home on pain medication and oral antibiotics. The patient returned a week later with persistent and worsening scrotal pain and swelling. A color Doppler ultrasound demonstrated a reactive hydrocele and confirmed an absence of blood flow. Torsion of the testicle was diagnosed. At surgery, a necrotic testicle was confirmed and an orchiectomy was performed. A lawsuit followed, and the emergency physician and his insurance company settled the case.

Discussion: The misdiagnosis of testicular torsion is a common cause of malpractice lawsuits. In fact, it is the third most common cause of a lawsuit in males 12 to 17 years of age.¹ However, a little known fact is that the accepted experts in evaluating scrotal pain, the urology specialty, are apparently sued more commonly than any other specialty. A 2001 review of closed case files specifically involving testicular torsion between 1979 to 1997 found that urologists were named most frequently (48%), liabilities for paid claims were an error in diagnosis (74%), and epididymitis was the most common misdiagnosis.² So, while emergency medicine physicians are in good company, these facts would attest to the fact that the diagnosis of testicular torsion is much more difficult than is commonly understood.

A careful review of the literature confirms that the various causes of acute scrotal pain have a significant overlap in signs and symptoms. Consequently, it is not possible to consistently and accurately differentiate between the most common causes of acute scrotal pain, i.e., testicular torsion (TT), torsion of the testicular appendage (TAT), and epididymo-orchitis (EO). This warning has been stated frequently, albeit too quietly, in the literature during the past five decades.^{3,4,5,6,7,8,9}

If one carefully analyzes the problem, it becomes crystal clear that there are three common misperceptions about testicular torsion by healthcare providers that are putting testicles at risk. These myths are as follows.

Myth #1: The etiology of scrotal pain can be diagnosed by the physical examination alone.
The overlap between the various etiologies of scrotal pain is much more significant than commonly understood. For example, while the cremasteric reflex is commonly absent in patients with testicular torsion, it is also present in enough TT patients to make reliance on this physical finding quite dangerous. Furthermore, the cremasteric reflex is also absent in many normal males as well as in patients with torsion of the testicular appendage and epididymo-orchitis.^10,11,12 Scrotal erythema, edema, and testicular swelling are also commonly found in all three conditions.^{4,5, 13,14,15} A finding strongly suggestive of epididymitis, pain and swelling around the upper pole of the testicle or epididymis, may also be found with TT or TAT.>^7,16 While the torsed testicle often may be elevated or have a transverse lie¹⁷, it commonly doesn’t. A vertical orientation of the testicle is not uncommon in torsion patients.^5,6,18,19

Myth #2: The history is pathognomonic in testicular torsion.
Unfortunately, there is also significant overlap in the historical elements of the three most common conditions associated with scrotal pain. For example, while the rapid onset of pain may be common in testicular torsion, it can also occur with TAT and EO. Cass et al reported that a gradual onset of pain was noted in 16% of their patients with testicular torsion, and a sudden onset was reported in 51% of their patients with acute epididymitis.²⁰ Another paper reported sudden onset of pain in 60 of 62 (96%) TT patients, 121 of 168 appendix torsion patients (72%), and 12 of 24 (50%) EO patients.²¹ Additionally, while some strongly believe that nausea and vomiting are good predictors of TT,²² these symptoms also occur with the other conditions. Mushtaq et al reported vomiting in 33% of TT patients and 14% of the EO patients.¹⁴

Myth #3: After six hours of pain, the testicle is unsalvageable in patients with testicular torsion.
Even though some testicles have poor outcomes when the pain has been present for six hours or less,^5,23,24 the well-documented truth is that other torsed testicles survive for much longer periods of time. While there are many examples of prolonged survival of testicles reported in the literature, this article can only provide a few. Viable testis were described in 5 of 14 patients greater than 12 hours (36% salvage rate), and 2 of 7 patients greater than 24 hours (22% salvage rate) by Mushtaq et al.¹⁴ Another article by Corbett et al described 23 patients with confirmed TT, and all patients presenting in less than 12 hours had testicular survival, as did 2 of 3 patients at 12-20 hours, and one of two at 24 hours.⁸ Intermittent torsion and lower degrees of torsion allowing persistent blood flow are most likely explanations. In fact, color Doppler ultrasound at times will document persistent blood flow in some testicles that are torsed, causing the healthcare provider to mistakenly assume that it is normal or EO.^6,25,26

In summary, some myths and misunderstandings about the diagnosis of testicular torsion result in the ongoing misdiagnosis of the condition. An awareness of the myths as well as a cautious reliance on the diagnostic trinity of history, physical examination, and an imaging study is essential. And, because the history, examination, and imaging studies still may give unreliable results, if any doubt remains, the patient should undergo surgical exploration.^27,28

References:

1. Selbst SM, Friedman MJ, Singh SB. Epidemiology and etiology of malpractice lawsuits involving children in US emergency departments and urgent care centers.  Pediatr Emerg Care 2005;21(3):165-169. 
2. Matteson JR, Stock JA, Hanna MK, et al.  Medicolegal aspects of testicular torsion. Urology 2001;57(4):783-786; discussion 786-787.
3. McAndrew HF, Pemberton R, Kikiros CS, et al. The incidence and investigation of acute scrotal problems in children. Pediatr Surg Int 2002;18(5-6):435-437. Epub 2002 Jul 12.
4. Leape LL. Torsion of the testis. Invitation to error. JAMA 1967;200(8):669-672.
5. Murphy FL, 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(5):413-416. Epub 2006 Apr 7. 
6. Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics1998;102(1 Pt 1):73-76.
7. Karmazyn B, Steinberg R, Kornreich L, et al. Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys. Pediatr Radiol2005;35(3):302-310. Epub 2004 Oct 16.
8. Corbett HJ, Simpson ET. Management of the acute scrotum in children. ANZ J Surg 2002;72(3):226-228.
9. Watkin NA, Reiger NA, Moisey CU. Is the conservative management of the acute scrotum justified on clinical grounds? Br J Urol 1996;78(4):623-627.
10. Caldamone AA, Valvo JR, Altebarmakian VK, et al. Acute scrotal swelling in children. J Pediatr Surg 1984;19(5):581-584.
11. Bingöl-Koloğlu M, Tanyel FC, Anlar B, et al. Cremasteric reflex and retraction of a testis. J Pediatr Surg 2001;36(6):863-867.
12. Caesar RE, Kaplan GW. The incidence of the cremasteric reflex in normal boys. J Urol1994;152(2 Pt 2):779-780.
13. Mäkelä E, Lahdes-Vasama T, Rajakorpi H, et al. A 19-year review of paediatric patients with acute scrotum. Scand J Surg 2007;96(1):62-66.
14. Mushtaq I, Fung M, Glasson MJ. Retrospective review of paediatric patients with acute scrotum. ANZ J Surg 2003;73(1-2):55-58.
15. Lyronis ID, Ploumis N, Vlahakis I, et al. Acute scrotum-etiology, clinical presentation and seasonal variation. Indian J Pediatr 2009;76(4):407-410. Epub 2009 Feb 10. 
16. Van Glabeke E, Khairouni A, Larroquet M, et al. Acute scrotal pain in children: Results of 543 surgical explorations. Pediatr Surg Int 1999;15(5-6):353-357.
17. McCombe AW, Scobie WG. Torsion of scrotal contents in children. Br J Urol 1988;61 (2): 148-150.
18. Ciftci AO, Senocak ME, Tanyel FC, et al. Clinical predictors for differential diagnosis of acute scrotum. Eur J Pediatr Surg 2004;14:333-338.
19. Eaton SH, Cendron MA, Estrada CR, et al. Intermittent testicular torsion: Diagnostic features and management outcomes. J Urol 2005;174(4 Pt 2):1532-1535; discussion 1535.
20. Cass AS, Cass BP, Veeraraghavan K. Immediate exploration of the unilateral acute scrotum in young male subjects. J Urol 1980;124(6):829-832.
21. Waldert M, Klatte T, Schmidbauer J, et al. Color Doppler sonography reliably identifies testicular torsion in boys. Urology 2010;75(5):1170-1174. Epub 2009 Nov 13.
22. Jefferson RH, Pérez LM, Joseph DB. Critical analysis of the clinical presentation of acute scrotum: A 9-year experience at a single institution. J Urol 1997;158(3 Pt 2):1198-1200.
23. Sessions AE, Rabinowitz R, Hulbert WC, et al. Testicular torsion: Direction, degree, duration and disinformation. J Urol 2003;169(2):663-665.
24. Anderson JB, Williamson RC. Testicular torsion in Bristol: A 25-year review. Br J Surg1988;75(10):988-992.
25. Lewis AG, Bukowski TP, Jarvis PD, et al. Evaluation of acute scrotum in the emergency department. J Pediatr Surg 1995;30(2):277-281; discussion 281-282.
26. Elsaharty S, Pranikoff K, Magoss IV, et al. Traumatic torsion of the testis. J Urol 1984;132(6):1155-1156.
27. Abul F, Al-Sayer H, Arun N. Acute scrotum: A review of 40 cases. Med Princ Pract 2005;14:177-181.
28. Bentley DF, Ricchiuti DJ, Nasrallah PF, et al. Spermatic cord torsion with preserved testis perfusion: Initial anatomical observations. J Urol 2004;172(6 Pt 1):2373-2376.

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