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Three Part Question

In [a patient with acute testicular pain and equivocal clinical findings] is [colour doppler ultrasonography better than emergency exploration] in [managing testicular torsion]

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
[exp ultrasonography, doppler, duplex/ or exp ultrasonography, doppler, color/ or exp ultrasonography, doppler, pulsed/] AND [exp Spermatic Cord Torsion/] OR [(colour doppler ultrasonography adj testicular torsion).mp. [mp=title, original title, abstract, name of substance word, subject heading word]] 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 [(colo?r adj2 ultrasonography).mp.] AND [(testicular adj torsion).mp.] OR [(colo?r adj2 ultrasonography).mp.] AND [(test#s adj torsion).mp. [mp=title, original title, abstract, name of substance word, subject heading word]] OR [(testicular adj torsion).mp.] And [(surg$4 adj explor$5).mp. [mp=title, original title, abstract, name of substance word, subject heading word]] OR [(colo?r adj2 ultrasonography).mp.] AND [(testicular adj torsion).mp.] AND [(surg$4 adj explor$5).mp. [mp=title, original title, abstract, name of substance word, subject heading word]] OR [(testicular adj torsion).mp.] AND [(surg$4 adj explor$5).mp. [mp=title, original title, abstract, name of substance word, subject heading word]] OR [(colo?r adj2 ultrasonography).mp.] AND [(testicular adj torsion).mp.] AND [(surg$4 adj explor$5).mp. [mp=title, original title, abstract, name of substance word, subject heading word]] AND [ limit 14 to (humans and english language)]

Search Outcome

MEDLINE 11
EMBASE 4
CINAHL 0
PUBMED 31
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
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 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.	The sample size used was very small which may have introduced some elements of bias to the study. There was no decllaration of the fact that they received ethical approval for the study they conducted.
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%.	The paper used a relatively small sample size and failed to implement randomisation. There was no declaration of ethical approval being gained.
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%.	The paper failed to randomise the process of which patients underwent surgical and which ones underwent colour doppler ultrasonography.
Pepe P, Panella P, Pennisi M, Aragona F. May 26 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.	The study did not state that it had gained ethicakl approval for the study. There was a small sample size, especially for the complexity of the study.

Comment(s)

These studies really illustrated the changing face of medicine as we aim to move towards a more conservative approach as opposed to jumping straight in with surgery. The evidence appears to show that no matter how close we get, the surgical need is always still going to be there, and at times will still overide any other means.

Clinical Bottom Line

As an entity on its own, colour doppler ultrasonography is inadequate. However, as an adjunct to clinical examination, and in the light of clinical expertise, it can drastically reduce the need for surgical exploration in suspected testicular torsion cases.

References

1. Suzer O, Ozcan H, Kupeli S, Gheiler EL. Color Doppler imaging in the diagnosis of the acute scrotum. European Urology 1997; 32(4):457-61.
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 June 2003;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 June 2005; 105(3 Pt 1):604-7.
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 Urology May 26 2006