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Three Part Question

In [male patients presenting with acute testicular pain] is [colour doppler ultrasonography enough] to [differentiate torsion, rupture and epididymo-orchitis]

Clinical Scenario

A 20 year old gentleman presented to the Emergency Department with a one hour history of acute onset testicular pain. On examination the left testicle was found to be rather swollen and tender.

Search Strategy

Ovid MEDLINE(R) 1966 to July Week 1 2006
EMBASE 1980 to 2006 Week 27
CINAHL - Cumulative Index to Nursing & Allied Health Literature 1982 to July Week 1
PUBMED
[exp ultrasonography, doppler, duplex/ or exp ultrasonography, doppler, color/ or exp ultrasonography, doppler, pulsed/] AND [exp Spermatic Cord Torsion/] [(colour doppler ultrasonography adj testicular torsion).mp. [mp=title, original title, abstract, name of substance word, subject heading word]] [exp ultrasonography, doppler, duplex/ or exp ultrasonography, doppler, color/ or exp ultrasonography, doppler, pulsed/] AND [exp Testicular Diseases/ or exp Testis/ or testicular rupture.mp. or exp Scrotum/] [exp ultrasonography, doppler, duplex/ or exp ultrasonography, doppler, color/ or exp ultrasonography, doppler, pulsed/] AND [exp Epididymitis/ or exp Orchitis/ or epididymo-orchitis.mp.] [(colour doppler ultrasonography adj testicular rupture).mp. [mp=title, original title, abstract, name of substance word, subject heading word]] [(colour doppler ultrasonography adj epididymo-orchitis).mp. [mp=title, original title, abstract, name of substance word, subject heading word]] [[exp ultrasonography, doppler, duplex/ or exp ultrasonography, doppler, color/ or exp ultrasonography, doppler, pulsed/] AND [exp Spermatic Cord Torsion/]] OR [[exp ultrasonography, doppler, duplex/ or exp ultrasonography, doppler, color/ or exp ultrasonography, doppler, pulsed/] AND [exp Testicular Diseases/ or exp Testis/ or testicular rupture.mp. or exp Scrotum/]] OR [[exp ultrasonography, doppler, duplex/ or exp ultrasonography, doppler, color/ or exp ultrasonography, doppler, pulsed/] AND [exp Epididymitis/ or exp Orchitis/ or epididymo-orchitis.mp.]] [limit to (humans and english language)] OR [(colo?r adj2 ultrasonography).mp.] AND [(testicular adj torsion).mp.] AND [limit to (humans and english language)] OR [(test#s adj torsion).mp. [mp=title, original title, abstract, name of substance word, subject heading word]] OR [(colo?r adj2 ultrasonography).mp.] AND [(test#s adj torsion).mp. [mp=title, original title, abstract, name of substance word, subject heading word]]

Search Outcome

Ovid MEDLINE results 211
EMBASE results 347
CINAHL results 1
PUBMED results 117

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Suzer O. Ozcan H. Kupeli S. Gheiler EL. 1997 Turkey	102 consecutive patients referred with scrotal pain.	Cohort study	All patients were evaluated by physical examination, ultrasound with stethoscopic Doppler followed by (colour doppler ultrasonography)CDS. Patients diagnosed with testicular torsion by CDS underwent surgical exploration.	CDS was found to be 100% sensitive and 100% specific in the diagnosis of the acute scrotum. CDS is more accurate and reliable than physical examination in conjunction with gray-scale ultrasound and Doppler stethoscopic examination in the differential diagnosis of the acute scrotum. CDS is practical and can be performed in a rapid manner.	Evaluated clinical examination, ultrasound with stethoscopic Doppler followed by CDS, therefore futher studies would need to be carried out in order to establish the effectiveness of CDS alone in the differentiation of the the acute scrotum.
Zini L, Mouton D, Leroy X, Valtille P, Villers A, Lemaitre L, Biserte J. June 2003 France	January 1995-June 2001 168 patients admitted to the emergency department with an empirical diagnosis of torsion of the spermatic cord.	Retrospective Cohort study	Scrotal ultrasound was performed when there was a doubt about the diagnosis or in the presence of atypical clinical features. All patients underwent surgical exploration of the scrotum.	False-negatives were 10% of the cases with CDS. Sensitivity 79% and specificity 88%.	Failure to account for every single patient involved in the study. They did not state that they had ethical approval for the study or that they gained consent from their patients.
Lam WW, Yap TL, Jacobsen AS, Teo HJ June 2005 Singapore	January 1998-June 2004 626 patients presenting with acute scrotal pain	Retrospective Cohort study	Following history and physical examination, the patients either proceeded directly to surgery or underwent CDS examination. If clinical suspicion of testicular torsion persisted after CDS, the patients would still undergo surgical scrotal exploration.	For testicular torsion, CDS yielded a sensitivity of 69.2% (95% confidence interval (CI) =38.9-89.5), specificity of 100% (95% CI=98.5-100), positive predictive value of 100% and negative predictive value of 97.5%.	Although retrospective, there did not appear to be randomisation of which patients were used and therefore would undergo surgical exploration as opposed to CDS as the primary mode of diagnosis.
Pepe P, Panella P, Pennisi M, Aragona F. 26th May 2006 Italy	July 2000-July 2005 150 patients admitted with acute unilateral scrotal pain. Median age 17.2 years.	Cohort study	Sensitivity and specificity of Colour Doppler sonography (CDS) and clinical examination over surgical exploration, in differentiation of testicular torsion and epidiymo-orchitis.	CDS was found to have a lower sensitivity and specificity than clinical examination. CDS is an indispensable imaging modality for acute scrotum.	Did not declare that consent was gained from the patients involved. There was no statement of ethical approval gained.

Comment(s)

There is a wide and varied distribution as to the usefulness of colour doppler ultrasonography with debates as to its usefulness in helping to diagnose testicular torsion. Its effectiveness has been thought to be operator-dependent, but still avery useful tool even in the emergency setting.

Clinical Bottom Line

Colour doppler ultrasonography is a useful adjunct to clinical examination and is able help diagnose testicular torsion.

References

1. Suzer O. Ozcan H. Kupeli S. Gheiler EL. Color Doppler imaging in the diagnosis of the acute scrotum. European Urology. 32(4):457-61, 1997.
2. Zini L, Mouton D, Leroy X, Valtille P, Villers A, Lemaitre L, Biserte J. Should scrotal ultrasound be discouraged in cases of suspected spermatic cord torsion? Urology 13(3):440-4.
3. Lam WW, Yap TL, Jacobsen AS, Teo HJ Colour Doppler ultrasonography replacing surgical exploration for acute scrotum: myth or reality? Paediatric Radiology 2005 Jun;35(6):597-600.
4. Pepe P, Panella P, Pennisi M, Aragona F. Does color Doppler sonography improve the clinical assessment of patients with acute scrotum? European Journal of Radiology 2006 May 26;