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Three Part Question

In [male patients presenting with acute testicular torsion] does [delaying treatment longer than 8 hours] lead to [reduced testicular viability]

Clinical Scenario

A 20 year old gentleman presents to the Emergency department with a one hour history of an acute onset of severe testicular pain. On examintion the left testicle was found to be rather swollen and tender.

Search Strategy

Ovid MEDLINE 1966 to June Week 4 2006
EMBASE 1980 to 2006 Week 27
PUBMED
CINAHL - Cumulative Index to Nursing & Allied Health Literature 1982 to June Week 5 2006
The Cochrane Library
[testicular torsion.mp. or exp Spermatic Cord Torsion/] AND [exp Time Factors/ or 8 hours.mp.] OR [exp Time Factors/ or 8 hours.mp.] AND [exp Testis/ or exp Scrotum/ or exp Spermatic Cord Torsion/ or exp Testicular Diseases/] OR [testicular torsion.mp. or exp Spermatic Cord Torsion/] AND [exp Testis/ or exp Scrotum/ or exp Spermatic Cord Torsion/ or exp Testicular Diseases/
] OR [exp Time Factors/ or 8 hours.mp.] AND [testicular torsion.mp. or exp Spermatic Cord Torsion/] AND [exp Testis/ or exp Scrotum/ or exp Spermatic Cord Torsion/ or exp Testicular Diseases/] OR [exp Time Factors/ or 8 hours.mp.] AND [*Testis/ or *Scrotum/ or *Spermatic Cord Torsion/ or testicular viability.mp.] OR [testicular torsion.mp. or exp Spermatic Cord Torsion/] AND [exp Time Factors/ or 8 hours.mp.] AND [testicular viability.mp.] OR [exp Time Factors/ or 8 hours.mp.] AND [exp Testis/ or exp Scrotum/ or exp Spermatic Cord Torsion/ or exp Testicular Diseases/
] AND [testicular viability.mp.] OR [testicular torsion.mp. or exp Spermatic Cord Torsion/] AND [ exp Testis/ or exp Scrotum/ or exp Spermatic Cord Torsion/ or exp Testicular Diseases/] AND [testicular viability.mp.] OR [exp Time Factors/ or 8 hours.mp.] AND [testicular torsion.mp. or exp Spermatic Cord Torsion/] AND [exp Testis/ or exp Scrotum/ or exp Spermatic Cord Torsion/ or exp Testicular Diseases/] AND [testicular viability.mp.] OR [exp Time Factors/ or 8 hours.mp.] AND [testicular torsion.mp. or exp Spermatic Cord Torsion/] AND [exp Testis/ or exp Scrotum/ or exp Spermatic Cord Torsion/ or exp Testicular Diseases/] AND [testicular viability.mp.] OR [exp Time Factors/ or 8 hours.mp.] AND [*Testis/ or *Scrotum/ or *Spermatic Cord Torsion/ or testicular viability.mp.] AND [testicular viability.mp.]

Search Outcome

MEDLINE 14
EMBASE 11
CINAHL 0
PUBMED 211
The Cochrane Library Issue 2 2006
testicular torsion, ti.ab.kw OR spermatic cord torsion -[MeSH] 3 articles none relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Rampaul, M S. Hosking, S W. Poole May 1998 United Kingdom	All patients undergoing scrotal exploration for suspected testicular torsion over a 2 year period.	Retrospective hospital audit	Fifty patients underwent surgery of whom 22 (44%) had testicular torsion and six required orchidectomy.	All patients with a dead testicle presented more than 6 h after onset of symptoms. Of those presenting with 6, 24 or more than 24 h of symptoms, salvageable testes were found in 100%, 83% and 75%, respectively. The median duration of symptoms in patients with viable twisted testicle was 5.5 h compared with 42 h in those who underwent orchidectomy.	Small sample size which would introduce some elements of bias. It was not made imlicit that patient consent was gained or that they gained ethical approval for the study.
Dunne PJ, O'Loughlin BS. June 2000 Australia	1990-1995 99 patients underwent scrotal exploration for suspected testicular torsion.	Retrospective cohort study	Colour doppler ultrasonography, white blood count and urine microscopy results were documented, along with the patient's age and duration of testicular pain.	Testicular loss rate was 23%. Patients who experienced testicular pain for longer than 12 h had a testicular loss rate of 67%. Negative urine microscopy was suggestive of testicular torsion, but was not diagnostic. The white blood count did not aid in the diagnosis. CDS had three false negative results and a sensitivity of only 57%.	A small sample size was used and this introduces the room for bias. The study was not randomised which further contributes to bias. There was no statement made of the fact as to whether or not ethical approval was gained or not.

Comment(s)

The evidence available out there is somewhat limited. It is a key area that deserves some extensive reasearch. There needs to be clearly defined margins as per the 'window of opportunity' for salvaging the testicles following testicular torsion.

Clinical Bottom Line

All in all the earlier the the patient presents, is investigated and treated the better the prognosis for viable testicles.

References

1. Rampaul, M S. Hosking, S W. Poole Testicular torsion: most delay occurs outside hospital. Annals of the Royal College of Surgeons of England. May 1998; 80(3):169-72
2. Dunne PJ, O'Loughlin BS. Testicular torsion: time is the enemy. Australian and New Zealand Journal of Surgery June 2000; 70(6):441-2