How Useful Is a Physical Exam in Diagnosing Testicular Torsion?

Evidence Based Answers CLINICAL INQUIRIES from the Family Physicians Inquiries Network

David Schmitz, MD How useful is a physical exam Family Medicine Residency of Idaho, Boise in diagnosing testicular torsion? Sarah Safranek, MLIS University of Washington Health Sciences Library, Seattle Evidence-based answer It’sCopy useful, for evidence-based but imperfect, in answer ruling diagnosis, but occurs in fewer than 50% of out testicular torsion (strength of cases (SOR: C, case series). Other fi ndings recommendation [SOR]: C, expert opinion). are less reliable (SOR: C, case series). The cremasteric refl ex or a nontender The standard of care for diagnosing testicle usually excludes testicular torsion, testicular torsion relies on studies beyond but case reports have noted the opposite to the physical examination (SOR: C, expert be true (SOR: C, case series). An abnormal opinion). testicular lie can help establish the

❚ Evidence summary A retrospective study reviewed the Several studies have contrasted physical records of 90 hospitalized patients, 18 examination fi ndings associated with years or younger, who were discharged testicular torsion with fi ndings related with a diagnosis of testicular torsion, FAST TRACK to epididymitis and torsion appendix epididymitis, or torsion appendix testis. Neither the testis. Neither the presence nor absence The cremasteric refl ex was absent, and of any particular physical examination testicular tenderness present, in all 13 presence nor sign excludes the diagnosis of testicular patients with testicular torsion. The pres- absence of any torsion. ence or absence of other physical exam particular physical fi ndings—such as abnormal testicular lie, examination sign The cremasteric reﬂ ex tender epididymis, and scrotal erythema often rules out testicular torsion or edema—didn’t exclude testicular tor- conclusively A consecutive case series evaluated 245 sion (TABLE).2 rules out boys, newborn to 18 years of age, with testicular acute scrotal swelling. None of the 125 But cremasteric reﬂ ex and subjects who had an intact cremasteric testicular torsion can coexist torsion. refl ex had ipsilateral testicular torsion. Isolated case reports have demonstrated The cremasteric refl ex was absent in all the presence of the cremasteric refl ex 56 subjects with testicular torsion.1 An with an eventual diagnosis of testicular absent cremasteric refl ex in boys with torsion.3,4 All of these studies were lim- acute scrotal swelling had a sensitivity ited by a small number of patients and of 100% (95% confi dence interval [CI], their retrospective nature. 91%-100%), a specifi city of 66% (95% CI, 59%-72%), and a likelihood ratio of Recommendations a negative test (presence of a cremasteric When evaluating patients suspected to

IMAGE © BRIAN EVANS / PHOTO RESEARCHERS, INC. IMAGE © BRIAN EVANS refl ex) of 0.01 (95% CI, 0.001-0.21). have testicular torsion, the European

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433_JFP0809 433 7/17/09 9:38:02 AM TABLE INQUIRIES The patients all had testicular torsion, but how helpful were the exam ﬁ ndings?

PHYSICAL FINDING SENSITIVITY (95% CI) SPECIFICITY (95% CI) LR+ (95% CI) LR− (95% CI) CLINICAL Absent cremasteric reﬂ ex 96% 88% 7.9 0.04 (73%-100%) (79%-93%) (4.3-14.5) (0.003-0.62)

Tender testicle 96% 38% 1.6 0.09 (73%-100%) (28%-49%) (1.3-1.9) (0.006-1.46) Abnormal testicular lie 46% 99% 72 0.54 (24%-70%) (94%-100%) (4-1215) (0.33-0.88)

Tender epididymitis 23% 20% 0.29 3.95 (1%-50%) (12%-30%) (0.11-0.78) (2.29-6.8) Isolated tenderness 4% 83% 0.21 1.17 (superior pole of testis) (0%-27%) (73%-90%) (0.01-3.28) (1.01-1.35)

CI, confi dence interval; LR+, likelihood ratio of testicular torsion if the physical fi nding was present; LR−, likelihood ratio of testicular torsion if the physical fi nding was absent. Adapted from: Kadish HA, et al. Pediatrics. 1998.2

Society for Pediatric Urology (ESPU) ously prepare an operating room, there is recommends looking for absence of a ample evidence that fewer patients with cremasteric refl ex and abnormal testicu- infection will be operated on.”7 ■ lar position.5 The ESPU notes that “in many cases it is not easy to determine the References cause of acute scrotum based on history 1. Rabinowitz R. The importance of the cremasteric 5 refl ex in acute scrotal swelling in children. J Urol. and physical examination alone.” The 1984;132:89-90. FAST TRACK society recommends using Doppler ultra- 2. Kadish HA, Bolte RG. A retrospective review of pe- Radiologic sound as an adjunct to the history and diatric patients with epididymitis, testicular torsion, physical. and torsion of the testicular appendages. Pediat- evaluation should rics. 1998;102:73-76. UpToDate notes that “the diagnosis 3. Rabinowitz R. Re: The importance of the cremas- be undertaken if of testicular torsion can be made clinical- teric refl ex in acute scrotal swelling in children. J the diagnosis is in ly,” but states that “radiologic evaluation Urol.1985;133:488. (a color Doppler ultrasound or nuclear 4. Hughes ME, Currier SJ, Della-Giustina D. Normal question and the cremasteric refl ex in a case of testicular torsion. scan of the scrotum) should be under- Am J Emerg Med. 2001;19:241-242. performance of taken if the certainty of the diagnosis is 5. Acute scrotum in children. In: Tekgul S, Riedmiller H, Gerharz E, et al. Guidelines on Paediatric Urol- imaging studies in question and the performance of im- ogy. Arnhem, The Netherlands: European Asso- will not aging studies will not signifi cantly delay ciation of Urology, European Society for Paediat- treatment.”6 ric Urology; 2009:13-19. Available at: http://www. signiﬁ cantly delay ngc/gov/summary/summary.aspx?doc_id=12593. The American College of Radiology Accessed June 10, 2009. treatment. recommends color Doppler ultrasound 6. Brenner JS, Ojo A. Causes of scrotal pain in children and adolescents. In: Basow DS, ed. UpToDate (CDU) or radionuclide scrotal imaging [online database]. Version 17.1. Waltham, Mass: (RNSI) to evaluate testicular perfusion. UpToDate; 2009. The group notes that “although some 7. Remer EM, Francis IR, Baumgarten DA, et al, Ex- pert Panel on Urologic Imaging. Acute onset of authors still suggest immediate surgi- scrotal pain without trauma, without antecedent cal exploration in patients with a strong mass. Reston, VA: American College of Radiology; 2007. Available at: http://www.acr.org/Secondary clinical impression of testicular ischemia, MainMenuCategories/quality_safety/app_ if either CDU or RNSI is readily avail- criteria/pdf/ExpertPanelonUrologicImaging/ AcuteOnsetofScrotalPainWithoutTrauma able and can be performed within 30 to WithoutAntecedentMassDoc2.aspx. Accessed 60 minutes of the request to simultane- October 14, 2008.

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