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Three Part Question

Is the presence of [a positive cremsteric reflex] sufficient to [exclude testicular torsion] in [a patient with acute testicular pain]?

Clinical Scenario

An 18 years old gentleman presents to the Emergency department with a two hours history of an acute onset of severe left testicular pain. On examination, the left testicle is tender with absent ipsilateral cremasteric reflex.

Search Strategy

Ovid MEDLINE
EMBASE
PUBMED
The Cochrane Library
Ovid MEDLINE 502
EMBASE 7921
PUBMED 51
The Cochrane Library 0

Search Outcome

5 relevant papers were found.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Rabinowitz R 1984 USA	A consecutive case series evaluated 245 boys, newborn to 18 years of age, with acute scrotal swelling.	Case series.	None of the 125 subjects who had an intact cremasteric reflex had ipsilateral testicuiar torsion. The cremasteric reflex was absent in all 56 subjects with testicular torsion.	An absent cremasteric reflex in boys with acute scrotal swelling had a sensitivity of 100% (95% confidence interval (Cl], 91%-100%), a specificity of 66% (95% CI, 59%-72%), and a likelihood ratio of a negative test (presence of a cremasteric reflex) of 0.01 {95% CI, 0.001-0.21).	The study did not include patients older than 18 years.
Kadish H A et al 1988 USA	A retrospective review of patients with the diagnosis of epididymitis, testicular torsion, or torsion of appendix testis. Ninety patients were included in the study (64 with epididymitis, 13 with testicular torsion, and 13 with torsion of appendix testis).	Retrospective.	All 13 patients with testicular torsion had a tender testis with an absent cremasteric reflex.	Patients presenting with a tender testicle and an absent cremasteric reflex were more likely to have a testicular torsion rather than epididymitis or torsion of appendix testis.	Retrospective study. Limited number of cases.
			Fewer patients with epididymitis had a tender testicle (69%) or an absent cremasteric reflex (14%).	An absent cremasteric reflex was the most sensitive physical finding for diagnosing testicular torsion.
Hughes ME et al 2001 USA	A case of preserved cremasteric reflex in association with testicular torsion.	Case study	Original studies reported a 100% correlation between the presence of a cremasteric reflex with nontorsion of the testis. Conversely, the absence of a cremasteric reflex raises suspicion of, but is not reliable in the diagnosis of torsion.	This case represents the first reported instance in the emergency medicine literature of a normal cremasteric reflex in association with acute testicular torsion.	Case report
Nelson CP et al 2003 USA	A patient with preserved cremasteric reflex and a surgically confirmed testicular torsion.	Case study	The authors report a case of surgically confirmed testicular torsion in which the cremasteric reflex clearly was present at presentation.		Case report
Elliot M. Paul et al 2004 USA	358 boys presenting with acute scrotal pain and/or swelling between 1/1999–10/2002 (ages: 0–18 years) were evaluated.	Retrospective	Results were compared with final diagnoses as established from operative findings, office charts, and/or telephone contact. 211 charts were available for complete analysis. The presence of cremasteric reflex (CR) on the symptomatic side correlated with the absence of testicular torsion in 167 cases. The absence of CR correlated with surgically confirmed testicular torsion in 15 cases.	There were 27 cases of absent CR in non-torsed testes and two cases of present CR in surgically confirmed torsion.	Retrospective study. Not all patients charts were available for the study.
Yang, C et al 2011 China	A retrospective review of patients with a diagnosis of testicular torsion between January 1990 and January 2010 was performed. We included 118 cases in the study, accounting for 9.01% of all cases of acute scrotum.	Retrospective	Absence of cremasteric reflex presented in 112 (94.9%) patients.	Two of the other six patients with normal cremasteric reflex had testicular torsion and had their testes removed.	Retrospective study

Comment(s)

There is a limited number of studies evaluating the sensitivity of physical signs in diagnosing testicular torsion. Preserved ipsilateral cremasteric reflex in a patient with testicular pain is a sensitive sign in excluding testicular torsion. Few case studies reported preserved cremasteric reflex with surgically confirmed torsion therefore correlation with patient history and other physical signs is crucial. On the other hand, an absent ipsilateral cremasteric reflex is usually suspicious but might not be sufficient to diagnose testicular torsion in some cases especially if the reflex is bilaterally absent as it could be normally absent in some adults.

Clinical Bottom Line

The cremasteric reflex is one of the most important clinical signs in patients presenting with acute scrotum especially when correlated with history and other physical signs.

References

1. Rabinowitz R The Importance of the Cremasteric Reflex in Acute Scrotal Swelling in Children Journal of urology 1984;132(1):89-90
2. Kadish H A et al A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics 1998;102(1):73-76
3. Hughes ME et al Normal cremasteric reflex in a case of testicular torsion The American journal of emergency medicine 2001;19(3):241–242
4. Caleb P Nelson et al The cremasteric reflex: a useful but imperfect sign in testicular torsion Journal of pediatric surgery 2003;38(8):1248–1249
5. Elliot M. Paul et al How useful is the cremasteric reflex in diagnosing testicular torsion? Journal of the American College of Surgeons 2004;199(3):101
6. Yang, C et al Testicular torsion in children: a 20-year retrospective study in a single institution TheScientificWorldJournal 2011;11:362–368.