| BACKGROUND AND OBJECTIVEBACKGROUND:Testicular torsion, also known as spermatic cord torsion, refers to the fact that one or both of the spermatic cords become(s) twisted, which leads to obstructed blood circulation of the spermatic cord, blocked testicular blood supply, thereby ischemia, hypoxia, and ultimately the infarction and permanently lose of testicle. It is the most common cause of teenagers’testicle lose. In 1840, Delasiauve first described the spermatic cord torsion, while, not until 1907 when Howard and Rigby published the article about testicular torsion on the Lancet was it recognized as an emergency disease by the medical community, being one of the common urological emergency diseases and requiring the intervention of emergency operation.There have not been any complete epidemiological statistics of testicular torsion incidence in our nation so far. It was reported that the incidence of the testicular torsion in young male under the age of 25 was 4.5 per 100,000 in the United States,1.4 per 100,000 in Brazil,2.9 per 100,000 in South Korea and 3.5 per 100,000 in Taiwan, respectively. The incidence of these countries and regions mentioned above were basically the same. There was about 25%(also reported as 1/3) patients were diagnosed as testicular torsion in the patients with acute scrotum in young male, and was approximately 9% in the children. Although spermatic cord torsion occurs mainly in young men, it can occur at any age from the neonatal to the old. The two peaks of the incidence, being the neonatal period and the adolescence, are coincidental in that they appear when the primary and secondary sexual characteristics develop respectively, and the highest incidence is 12-18 years old. Rare as the incidence of the elderly is, we should not ignore it anyway.It is not difficult to diagnose as spermatic cord torsion with unilateral scrotal persistent pain accompanying nausea, vomiting, and disappearance of cremaster reflex, swelled scrotum, tenderness in the physical examination. It can be further confirmed if color Doppler Sonography of scrotum show the blood signal of the testis reduces or disappears. However, in most of the patients with acute scrotum in the early stage, the symptoms are highly identical, and can not be differentiated by the history and physical examination. Even more unfortunately, some doctors, especially the community physicians, lack the capacity to distinguish the acute scrotum diseases as well as the vigilance of the testicular torsion, which usually leads to misdiagnosis as orchitis and epididymitis, resulting in mistreatment and prolonged ischemia of the testis. While the patients of testicular torsion need emergency surgical exploration, to perform detorsion and recovery of the normal anatomy, so that the testicular ischemia is promptly corrected. However, the time window for testis preservation is very narrow, only 6 to 8 hours since the torsion of spermatic cord. As a result, it is a race against time for urologists or emergency room physicians when encountering testicular torsion. However, the extremely high misdiagnosis rate results in many loss of the testicles in patients with testicular torsion. Therefore, for urologists, sufficient attention and vigilance should be attached to testicular torsion.OBJECTIVE:Patients with the acute scrotum show quite similar manifestation of onset. Most common acute scrotum diseases are acute epididymitis, acute orchitis, testicular torsion and testicular appendage torsion, all of which features clinical manifestations like sudden scrotal pain and swelling. The recognition and vigilance for testicular torsion of the clinicians, especially local physicians, should be improved. We collected clinical data of patients with testicular torsion, for clinical retrospective studying and discussion on the probable reasons of misdiagnosis, in order to improve the early diagnosis and surgical treatment of testicular torsion, as well as to avoid misdiagnosis and loss of testes.METHODS1. Screening of subjects for the research:Inpatients with spermatic cord torsion (all of them confirmed by surgery) from Urology Department of Nanfang Hospital were enrolled from February 2001 to March 2014, collecting their clinical data. There were 80 cases in total.2. General statistics:The patients were aged from 1 to 45 years old with a mean age of 19.06 ± 7.66 years old.66 cases were between 10 and 25 years old, accounting for 82.5%(66/80). All patients were hospitalized with unilateral torsion, with 61 cases on the left side and 19 cases on the right.53 patients had been treated in local hospital (including community hospital, primary grade hospital and middle grade hospital) before they were finally referred to our hospital (Nanfang Hospital), where 40 cases were misdiagnosed as acute orchitis or acute epididymitis,1 case as appendicitis and 1 as gastrointestinal spasms.48 cases of 53 had a orchiectomy and lost the testis.27 cases had their initial diagnosis in our hospital, and 2 of them were misdiagnosed as acute epididymitis.22 cases occurred in Spring (February, March, and April), accounting for 27%(22/80),14 cases in Summer (May, June, and July) accounting for 18%(14/80),19 cases in Autumn (August, September, and October) accounting for 24%(19/80),25 cases in Winter (January, November, and December) accounting for 31%(25/80). It took 5 hours to 2 month from testicular pain onset to surgery, among which 9 cases less than 8 hours,9 cases 8 hours to 12 hours,6 cases 12 to 24 hours,15 cases 24 to 48 hours,41 cases more than 48 hours.3. Diagnostic methods:(1) History:Sudden testicular or hemiscrotal pain of the affected side, swelling, with or without nausea and vomiting. (2) Physical examination:Testicular swelling, scrotum with or without redness and/or fever, tenderness; hard testicle on palpation; Testicular elevation (Prehn’s sign) does not relieve the pain, unlike that in patients with orchitis. Compared with the contralateral, the spermatic cord was thickened and shortened, with transverse testis; (3) Auxiliary examination:Color Doppler sonography (CDS) showed blood flow signal of the testis decreased or disappeared.4. Surgical Methods:All of the patients were performed urgent scrotal exploratory surgery. Take the central transverse or longitudinal incision of scrotum, blunt dissection of the ipsilateral testis, detorsion of testicular and warm the testis 10-30 minutes with wet gauze, and then observe the testes color. If the color of the testis went ruddy, incise a small incision on the surface of the testicular albuginea with a scalpel, flow-out of bright red blood suggested preservation of the testis, and then fix both testis; if not, incise the ipsilateral testis, and fix contralateral testis conventionally.5. Statistical analysis:SPSS 13.0 (Statistic Package for Social Science 13.0) software is used for statistical analysis.x±s stands for the average age and seasonal incidence number. One-way ANOVA is used for analyzing mean onset incidence among seasons. LSD test is used for comparing the incidence between two seasons. Chi-square test is used for testing the relationship between the degree of testicular torsion, the time of ischemia and the testicular survival. Spearman rank correlation analysis is used for the correlation between the time of ischemia and the testicular survival rate. p<0.05 suggests statistical significance.RESULTS1. Result of the seasonal distribution of spermatic cord torsionAs the cases were collected by March 2014, we excluded the cases (4 cases) of 2014. We analyzed the incidence of each season from 2001 to 2013, and the results were as follows:the annual incidence of Spring (February, March, April) was 1.38 ± 1.19 people, Summer (May, June, July) 1.08 ± 1.38 people, Autumn (August, September, October) 1.46 ± 1.27 people, Winter (January, November, December) 1.92 ± 1.71 people. The result of One-way ANOVA between four seasons of the incidence:F= 0.81,p= 0.494> 0.05. There was no significant difference in seasonal incidence.2. Results of symptoms and physical examination78 cases out of 80 patients were admitted to the hospital because of sudden scrotum or testicles pain,2 patients with a sudden pain in groin area (with a history of cryptorchidism). Among them,73 cases suffered persistent pain that could not relieve spontaneously,7 cases with paroxysmal pain,9 patients with nausea, vomiting,1 case with low fever.3 cases reported a history of cryptorchidism, and 2 of them suffered a pain in groin area.78 patients had swelled testicle, while 2 patients showed no obvious signs of swelling. On palpation,42 patients had a hard testis,37 cases of which had red and warm skin of scrotum.32 patients had testicular elevation pain (Prehn’s sign),2 of which had a negative Prehn’s sign, and 48 of them had no records. There were 17 cases with a thicken, shorten spermatic cord, and the rest of them were not recorded.3. Results of Color Doppler sonography36 cases did not have CDS examination and 17 cases had among 53 patients who were admitted to local hospitals.9 out of 17 cases with results of CDS examination showed the reduction or disappeared blood signal of testicle, suggesting testicular torsion.8 cases showed a result of testicular parenchyma abnormal echo, considering inflammation of scrotum.27 patients were admitted in our hospital, and only one patient did not undergo CDS examination and misdiagnosed as acute orchitis, another case misdiagnosed as epididymitis, where the first CDS examination showed "enlarged testis and epididymis, visible blood flow signal, and there is heterogeneous echo around epididymis area, considering as epididymis". The rest of the 25 cases had CDS examination, all of which showed reduced or disappeared ipsilateral testicular blood flow signal, corresponding to imaging diagnosis of testicular torsion. Except 2 patients who had been diagnosed as testicular torsion definitely, all of the patients who had their initial diagnosis at their local hospitals and later referred to our hospital were examined with CDS. The results suggested decreased or disappeared blood flow signal of testicle, corresponding to testicular torsion.4. Results of misdiagnosisThe first misdiagnosis rate was 55%(44/80) in our study among 80 cases of testicular torsion.53 cases of them were referred to local hospital at first, and 40 cases of them were misdiagnosed as orchitis or epididymitis,1 as appendicitis, and 1 as gastrointestinal spasms, with a high rate of misdiagnosis up to 79.25%(42/53).27 cases were admitted to our hospital since onset of scrotum pain, and 2 of them were misdiagnosed as orchitis or epididymitis.5. Results of surgeryAll of the testicles were seen with color of dark red, black and most of which were dark purple, as well as swelled and hard testicles during operation. All of the cases were intravaginal testicular torsion,61 on the left side, the rest on the right side. On the left side,21 cases were clockwise, while 18 cases were counterclockwise. On the right side,9 cases were clockwise, while 5 cases were counterclockwise. All the 28 cases having preserved the testicles underwent orchidopexy on the ipsilateral side, 26 cases of which underwent contralateral orchidopexy. Among the 52 cases having orchiectomy, only 8 patients did not udergo contalateral orchidopexy, and the rest of them had contralateral testicular fixation. The removed testicles were sent to Pathology Department for further study. The results showed ischemia and necrosis, matching the diagnosis of testicular torsion. The angle of torsion is between 180 to 720 degrees.64 cases in total had a torsion angle between 180 to 720 degrees,19 cases with an angle of 180 degrees,22 cases with an angle of 360 degrees,9 cases with an angle of 540 degrees and 12 cases with an angle of 720 degrees.6. Results of statistics between the ischemic time of testicle, torsion degree and the testicular survival rate.Spearman rank correlation analysis was used for the correlation between the time of ischemia and the testicular survival rate. Spearman correlation coefficient rs =-1, P<0.01, a negative correlation between them with statistical significance. The testicular survival rate was 88.89%(16/18) with the ischemic time less than 12 hours, and 19.35%(12/62) with the ischemic time more than 12 hours,χ2= 29.65, p<0.05, statistically significant. The relationship between the degree of twist and testicular survival:testicular survival was 50%(10/20) for the degree less than or equal to 270, 25.6%(11/43) for the degree 360 to 720, χ2= 3.876, p< 0.05, had statistical significance.CONCLUSION1. Testicle loss is closely related to ischemic time and the degree of torsion.2. CDS can differentiate and diagnose testicular torsion quickly. It is necessary to undergo CDS examination to exclude testicular torsion, even when clinical evidences may strongly suggest acute orchitis or epididymitis. As for the pre-pubertal and pubertal patients, negative result of CDS examination for the first time does not guarantee anything and reviewing CDS is necessary in the short term.3. The professional, acumen and experienced surgeons are requested in Emergency Department, in order to accelerate acute scrotum triage. For patients with clear or unclear testicular torsion diagnosis, timely surgical exploration is needed, to buy time for testicle preservation.4. We should consider testicular torsion as possible when encountering acute scrotum, in order to improve the vigilance of this disease. The key to preserve testicle is early diagnosis and early surgical intervention. The lack of understanding of testicular torsion and the inadvertence of history inquiry usually lead to misdiagnosis and testicular loss. We should strengthen our understanding and pay more attention to it, especially for local physicians.5. Orchiopexy is necessary for both the ipsilateral and the contralateral. We recommend the novel method of scrotal orchidopexy:eversion of the edges of the parietal layer of the tunica vaginalis, and the sutures are placed into the dartos of the posterior scrotal wall with non-absorbable sutures. As for the patients with long term intermittent testicular torsion, it is better to selectively perform the prophylactic bilateral testicular fixation.6. Compared with healthy men, the patients with testicular torsion, either orchiopexy or orchiectomy, show no statistical difference in sperm count, motility and hormonal function. Testicular torsion is not an important reason for male infertility, and the relationship between male infertility and testicular torsion needs further study. |
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