Testicular Torsion and Risk Factors for Orchiectomy

ARTICLE Testicular Torsion and Risk Factors for Orchiectomy Jonathan M. Mansbach, MD; Peter Forbes, MA; Craig Peters, MD Objective: To determine risk factors for testicular loss benign and malignant testicular tumors is 1.2 cases per due to testicular torsion. 100 000. Of the estimated 2248 males diagnosed nationally in 1998 with testicular torsion, 762 (34%) had an Design and Participants: Medical records of pa- orchiectomy. In the final multivariate model estimating tients aged 1 to 25 years with a principal diagnosis of tes- the probability of orchiectomy, only age was significant. ticular torsion were extracted from the 1998 Nation- wide Inpatient Sample. Population-based rates of testicular Conclusions: For males aged 1 to 25 years, testicular torsion and orchiectomy were determined. Logistic re- torsion is more common than testicular tumors, and in- gression was used to create a predictive model for orchi- creasing age is the sole identifiable risk factor for orchiectomy. For comparison, medical records of patients aged ectomy. We suggest that health care professionals edu- 1 to 25 years with a principal diagnosis of testicular neo- cate prepubertal male patients about testicular torsion plasm were extracted. and the necessity of seeking timely care to reduce the risk of orchiectomy and of possible subsequent reduced Results: The sample comprised 436 participants. The fertility. estimated incidence of testicular torsion for males aged 1 to 25 years in the United States is 4.5 cases per 100 000 male subjects per year, and the estimated incidence of Arch Pediatr Adolesc Med. 2005;159:1167-1171 ESTICULAR TORSION IS A nography is a helpful tool to differentiate urologic emergency. There torsion from other causes of an acutely is approximately a 4- to painful scrotum.5 8-hour window from the Further delays in diagnosis or treat- onset of torsion symptoms ment may be caused by individual pa- until surgical intervention is required to tient factors. Appendicitis is a similar acute T 1 save the affected testis. Delays in care may surgical condition in which delayed diag- necessitate orchiectomy, which has been nosis or delayed surgery may lead to mor- associated with reduced fertility.2 One bidity, specifically rupture of the appen- study3 found that 57% of patients had low dix. In this condition, differences in the sperm counts a median of 5 years after uni- individual patient factors, including in- lateral testicular loss from torsion. surance status and race, have been asso- Providing the necessary medical and ciated with the risk of rupture of the ap- surgical services for a patient with tes- pendix.6,7 The objectives of this study were ticular torsion requires 3 steps, namely, to determine by using a national data- timely presentation, rapid diagnosis, and base if there are identifiable risk factors for curative intervention. The surgical proce- testicular loss due to testicular torsion and dure performed would be orchiectomy to place the epidemiology of testicular tor- for those patients with a nonviable tes- sion in the context of the more com- ticle and septopexy for those with viable monly discussed condition of testicular testes. One potential barrier to providing neoplasm. ideal care is delayed presentation. In fact, male subjects may be hesitant to seek METHODS medical attention for conditions involv- Author Affiliations: Divisions ing their genitals, even for torsion.4 For- of Adolescent/Young Adult tunately, once a patient presents to a The 1998 Nationwide Inpatient Sample (NIS) Medicine (Dr Mansbach) and is part of the Healthcare Cost and Utilization Urology (Dr Peters) and health care professional, the diagnosis of Project, sponsored by the Agency for Health- Clinical Research Program testicular torsion can usually be made care Research and Quality.8 The NIS is a data- (Mr Forbes), Children’s from his history and physical examina- base of hospital inpatient stays, containing data Hospital Boston, Harvard tion. However, when the clinical diagno- from approximately 7 million hospital stays. Medical School, Boston, Mass. sis is uncertain, color Doppler ultraso- The 1998 NIS contains all discharge data from (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 159, DEC 2005 WWW.ARCHPEDIATRICS.COM 1167 ©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 tered sample design used by the NIS, the SAS Proc Sur- veyMeans was used to compute variances for totals and confi- 400 dence intervals for torsion, orchiectomy, and testicular neoplasm. Cancer (n = 120) Logistic regressions accounted for clustering and stratifica- Torsion (n = 436) tion using SAS Proc SurveyLogistic. 300 Patients with missing covariate levels (Ͻ4% of the total) were included in logistic regression models by assigning them to the majority covariate level. The missing data from the race vari- 200 able were analyzed 3 ways, namely, with the missing data treated as a separate covariate level, with the missing data removed from the analysis, and with the missing data assigned to the major- 100 Cumulative No. of Patients ity covariate level (white race). Race was not significantly associated with orchiectomy no matter how the missing values were assigned. As a result, in the final analyses, missing covar- 0 iates were assigned to the majority covariate level. 1510 15 20 25 The ICD-9-CM code 608.2 includes torsion of the testicle, Age, y appendix testis, and appendix epididymis. It is possible, therefore, that some patients, most likely the younger ones who had Figure 1. Cumulative number of patients with testicular torsion and with an orchiopexy, did not have torsion of the testicle but rather testicular cancer. torsion of the appendix testis or appendix epididymis. If patients with torsion of the appendix testis or appendix epididy- 984 hospitals located in 22 states, approximating a 20% sample mis had an orchiopexy, these misclassified patients would er- of US community hospitals. The overall goal for the NIS is to roneously lower the percentage of younger males requiring create a sample of hospitals that is generalizable to hospitals orchiectomies. Therefore, a sensitivity analysis was per- in the entire United States. The NIS data set includes a weight formed to determine the potential effect of misclassification on variable for each observation so that a weighted analysis can our conclusions. Under the assumption that some of the young- produce national estimates, with confidence intervals, of total est nonorchiectomy patients could be misclassified (ie, had an cases and rates of procedures of interest. The Children’s Hos- orchiopexy but not torsion of the testicle), random samples of pital Boston Institutional Review Board approved this study. 10%, 33%, and 50% of the nonorchiectomy patients in the Medical records of patients aged 1 to 25 years with the prin- youngest age category were removed, and the relationship be- cipal diagnosis of testicular torsion (International Classifica- tween orchiectomy and age category (youngest vs oldest males) tion of Diseases, Ninth Revision, Clinical Modification [ICD- was reassessed. Although the correct proportion of the nonor- 9-CM] code 608.2) in 1998 were extracted. The ICD-9-CM code chiectomy patients to be removed from the youngest age cat- 608.2 includes torsion of the testicle and torsion of the appen- egory is not known, we anticipate that much fewer than half dix testis and appendix epididymis. We compared the group of these patients, all of whom had a technically unnecessary of patients who received neither orchiectomy nor orchiopexy surgical procedure, had torsion of the appendix epididymis or (n=65) with the group who had a procedure (n=436); the mean appendix testis. ages for the groups were 11.9 vs 15.0 years (PϽ.001). We ex- cluded the 65 patients who did not have a surgical procedure, as these youth most likely had torsion of the appendix testis. RESULTS All 436 patients who had a surgical procedure were included in the analysis. Age-specific census estimates of the US male population were The final sample comprised 436 eligible participants from used to compute rates of testicular torsion and orchiectomy per 231 hospitals in 22 states. The number of torsion cases 100 000 male subjects. The July 1998 US male population aged nationally, estimated using a weighted analysis of the data, 1 to 25 years was extrapolated from census estimates for this was 2248 cases (95% confidence interval [CI], 1950- population at July 1, 2000, and July 1, 2001. For comparison, 2547 cases). Using census results, we estimated the total medical records of patients aged 1 to 25 years with a principal male population aged 1 to 25 years in 1998 to be 50.25 diagnosis of testicular neoplasm (ICD-9-CM codes 186.9 and million. Using these 2 results, the incidence of testicu- 222.0) were also extracted. lar torsion is 4.5 cases (95% CI, 3.9-5.1 cases) per 100 000 Statistical analyses were performed using SAS software ver- male subjects per year in the United States. Within the sion 9 (SAS Institute Inc, Cary, NC). In univariate analyses, t tests and Wilcoxon signed rank tests were used for continu- age range considered, testicular torsion is most com- ous variables, and Fisher exact tests were used for categorical mon in males aged 10 to 19 years, with an incidence of variables. 8.6 cases (95% CI, 7.1-10.1 cases) per 100 000 male sub- Analyses were conducted to determine the effect of differ- jects per year. For comparison, the database contained ent patient- and hospital-specific variables on the risk for or- 120 patients with benign or malignant testicular tu- chiectomy. The patient-specific variables included age (treated mors. Using a weighted analysis, the number of such cases categorically and continuously), race (white, black, or other), nationally was estimated to be 621 cases (95% CI, 300- insurance status (Medicaid, self-pay, or private insurance), and 912 cases).

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