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Three Part Question

[In patients with testicular pain] is [ultrasound better than clinical examination] at [ruling out testicular torsion]

Clinical Scenario

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?

Search Strategy

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.

Search Outcome

263 papers found overall of which 7 relevant papers were relevant and of sufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Stehr M and Boehm R, 2003, Germany	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, 2001, Israel	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, 2000, USA	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, 1997, Netherlands	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, 1996, Germany	31 Patients with painful scrotums	Diagnostic cohort	Correct diagnosis of testicular torsion	Definitive diagnosis in 83%	Results from 1988 – 91
Yuan et al, 2001, China	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, 1992, USA	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

Comment(s)

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

References

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.