Three Part Question
[In patients with testicular pain] is [ultrasound better than clinical examination] at [ruling out testicular torsion]
A 15 year old boy presents to the emergency department with gradual onset testicular pain which has been present for the last six hours. On examination he has marked tenderness on the left side with normally placed testicles. There is some moderate left sided swelling and mild erythema and he describes some recent dysuria. You wonder if colour doppler ultrasound can help you accurately rule-out torsion and thus prevent this boy going for surgery unnecessarily?
Medline 1966 – March week 4 2005
Embase 1980- week 13 2005
Cochrane Library Issue 1 2005
Medline: (exp spermatic cord torsion/ OR testi$ adj torsion.mp) OR (exp testis/ AND torsion.mp). AND (exp ultrasonography/ OR ultraso$.mp.). Limit to Human and English Language - 223 articles
Embase:[(exp testis torsion/ OR testi$ adj torsion.mp.).)] AND [(exp echography/ OR exp Doppler Flowmetry/ or exp Doppler Echography/ or exp Color Ultrasound Flowmetry/ OR ultraso$.mp.)] Limit to Human and English Language – 284 papers found.
Cochrane Library Issue 1 2005
[torsion (mesh this term only) AND testis (mesh explode) OR spermatic cord torsion (mesh explode)] AND (ultrasonograpy (mesh explode)) 4 articles found.
263 papers found overall of which 7 relevant papers were relevant and of sufficient quality for inclusion.
|Author, date and country
||Study type (level of evidence)
|Stehr M and Boehm R,|
| 132 children with acute scrotum||Diagnostic cohort||% of torsions reported normal by ultrasound in a group with clinically suspected torsion||3.8%|| Indirect comparison of clinical examination versus ultrasound|
|Kravchick et al,|
|38 boys with scrotal pain and borderline clinical findings.||Diagnostic cohort||Correct diagnosis of torsion||Ultrasound 88.9% sensitive, 90% specific; clinical assessment 47.4% accuracy||No sensitivity or specificity for clinical assessment|
|Baker et al,|
|130 patients with equivocal clinical suspicion of torsion||Diagnostic cohort||Correct diagnosis of torsion by ultrasound||Sensitivity 88.9%, Specificity 98.8%||No direct comparison of clinical versus ultrasound|
|Hendrikx et al,|
|215 patients with scrotal complaints||Diagnostic cohort||38% of torsions missed||Clinical examination 7.6%; Ultrasound 7.6%||No direct comparison of clinical versus ultrasound|
|Schwaibold et al,|
|31 Patients with painful scrotums||Diagnostic cohort||Correct diagnosis of testicular torsion||Definitive diagnosis in 83%||Results from 1988 – 91|
|Yuan et al,|
|17 pre-op acute scrotums, 17 normal scrotums||Diagnostic cohort||Correct diagnosis of testicular torsion||48% accuracy at torsion pick up||Small study number. No direct comparison of clinical versus ultrasound|
|Dewire et al,|
|20 patients separated clinically into 3 groups (trauma, inflammation, ischaemia)||Diagnostic cohort||Correct diagnosis of torsion||Correctly predicted the need for surgery in 89%||Small study numbers
Data 12 years old|
Some of the studies found are over 10 years old and the technology available for ultrasound has changed considerably in that time. New techniques of ultrasound which attempt to identify a twisted cord as opposed to blood flow to the testicle appear promising. The results presented do not suggest that ultrasonography alone can rule out testicular torsion. It may be that it can perform this function in cases with low or even moderate clinical suspicion – but this question has not been addressed.
Clinical Bottom Line
Ultrasound examination is a useful addition to clinical examination and experience but should not over-rule clinical suspicion
- Stehr M, Boehm R Critical validation of colour Doppler ultrasound in diagnostics of acute scrotum in children European Journal of Pediatric Surgery 13(6):386-92, 2003 Dec.
- Kravchick S, Cytron S, Leibovici O, Linov L, London D, Altshuler A, Yulish E. Color Doppler sonography: its real role in the evaluation of children with highly suspected testicular torsion. European Radiology 11(6):1000-5, 2001.
- Baker LA, Sigman D, Mathews RI, Benson J, Docimo SG. An analysis of clinical outcomes using colour doppler testicular ultrasound for testicular torsion. Pediatrics 105(3 Pt 1):604-7, 2000 Mar.
- Hendrikx AJ, Dang CL, Vroegindeweij D, Korte JH. B-mode and colour-flow duplex ultrasonography: a useful adjunct in diagnosing scrotal diseases? British Journal of Urology 79(1):58-65, 1997 Jan.
- Schwaibold H, Fobbe F, Klan R, Dieckmann K-P. Evaluation of acute scrotal pain by color-coded duplex sonography. Urologia Internationalis Vol. 56(2)(pp 96-99), 1996.
- Yuan Z, Luo Q, Chen L, Zhu J, Zhu R. Clinical study of scrotum scintigraphy in 49 patients with acute scrotal pain: A comparison with ultrasonography. Annals of Nuclear Medicine Vol. 15(3)(pp 225-229), 2001.
- Dewire DM. Begun FP. Lawson RK. Fitzgerald S. Foley WD. Color Doppler ultrasonography in the evaluation of the acute scrotum. Journal of Urology Vol. 147(1)(pp 89-91), 1992.