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Three Part Question

In [patients presenting with acute unilateral testicular pain] is [an absent cremasteric reflex] an [accurate sign for diagnosis of testicular torsion]?

Search Strategy

Databases: Medline (1998-2021), Embase (1998-2022), Cochrane

Search terms:
(“Testicular Pain” OR “Scrotal Pain” OR “Acute Scrotum”).mp AND “Cremasteric Reflex”.mp AND ("Testicular Torsion" OR "Spermatic Cord Torsion" OR "twisted testis").mp

Search Outcome

Medline: 26 papers found
Embase: 51 papers found
Cochrane: 0 papers found

After duplications were removed, 51 papers remained; of these, 12 were relevant to the three-part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kadish and Bolte 1998 USA	90 children discharged in Utah, with TT, TAT or epididymo-orchitis, between 1994–1996.	Retrospective Review	Incidence	14.4% had TT. 100% of TT patients had an absent cremasteric reflex.	If data hadn’t been documented, it was interpreted as negative.
Mundell et al. 2021 England	81 patients aged 5-18, with acute testicular pain between 06/2015–03/2020.		29% had TT (another 4% had intermittent torsion). 70% of TT patients had an abnormal cremasteric reflex.		Excluded trauma patients.
Lyronis et al 2009 Greece	140 patients, up to 14-years-old, with acute scrotum between 01/1989–12/2006 in Crete.		25% had TT, 30% had TAT. 100% of TT patients had an absent cremasteric reflex. Everyone with TAT had a normal cremasteric reflex.		Small demographic (patients from one hospital)
Yang Jr. et al 2011 China	1228 patients discharged from China, between 01/1990–12/2008.		8.4% had TT. 74.8% had TAT. 91.3% of TT patients did not have a cremasteric reflex.		Small demographic (patients from one hospital)
Boettcher et al. 2013 Germany	104 patients treated for acute scrotum between 01/2001–04/2012 in two facilities in Germany		11.5% had TT; 68.3% had TAT. 50% of TT patients had an abnormal cremasteric reflex (OR 45.0; PPV 75%). 2.2% of non-TT patients had an abnormal cremasteric reflex.		Greater focus on USS than examination findings.
Ciftci et al. 2004 Turkey	160 children in Turkey, between 1970–2000 with TT, TAT or epididymo-orchitis.		Incidence	23% had TT; 31% had TAT. Absence of cremasteric reflex in TT had 92% sensitivity, 94% specificity, 83% PPV and 98% negative predicted value.	Only focused on 3 conditions (not all testicular pain)
Beni-Israel et al. 2009 Israel	492 patients with acute scrotum or testicular pain, between 01/2005–08/2007 in Israel.		3.3% had TT. An absent or reduced cremasteric reflex had OR 27.77 for TT.		Small number of patients with TT.
Boettcher et al. 2011 Germany	138 patients treated for acute scrotum in two facilities in Germany between 01/2008–12/2009.		13.8% had TT; 66.7% had TAT. 21.1% of TT patients had an abnormal cremasteric reflex (OR 4.8).		Small demographic (patients from one region of Germany)
Sazgar et al 2021 Iran	81 patients presenting to A&E with suspected TT in Iran, between 09/2015–09/2020.		86.4% had TT. 81.5% of TT patients had an absent cremasteric reflex. Absence of cremasteric reflex for TT had p-value 0.017		Only those with suspected TT were included – not everyone with testicular pain.
Lemini et al. 2016 Italy	1091 patients with acute testicular symptoms in Italy, between 01/2010–12/2013.		3.76% had TT; 29.6% had TAT. Abnormal cremasteric reflex had OR 47.6 for TT		Small demographic (patients from one region of Italy). Did not calculate the PPV for cremasteric reflex.
Liang et al. 2012 Canada	342 patients, aged 1-month to 17-years, with acute scrotum in Canada, between 07/2008–07/2011		10.2% had TT. 69% of torted testes were salvageable. 91% of TT patients had an abnormal cremasteric reflex (p-value <0.0001)		Small number of patients had TT. Some patient data was limited (retrospective study).
Yang et al 2011 China	118 patients with TT, in China between 01/1990–01/2010.		9.01% of acute scrotal presentations had TT. 94.9% of TT patients had an absent cremasteric reflex. A normal cremasteric reflex cannot exclude TT. Abnormal cremasteric reflexes were seen in non-TT patients.		Small sample set, given the long time-period.

Comment(s)

Over 4000 patients were assessed in this search, which found the cremasteric reflex to be abnormal in TT patients. The exact percentage affected differs between papers, with two studies (Kadeish and Bolte, and Lyronis et al.) reporting reflex absence in 100% of TT patients, whilst Boettcher et al. (2011) suggested it was closer to 21%. Despite this variation, the study by Ciftci et al found the absent reflex had 92% sensitivity and 94% specificity to TT, which suggests this examination finding is able to both rule in and rule out TT effectively. Although no single study investigated patients from multiple regions, the breadth of concurrent evidence globally suggests the conclusion can be extrapolated internationally.

Clinical Bottom Line

Patients presenting with testicular pain should have their cremasteric reflex assessed to aid TT diagnosis. Absence of the cremasteric reflex is common in TT, however, some patients with TT will have an intact reflex. Therefore, the presence of such reflex should not be used to rule out TT.

References

1. Kadish and Bolte A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages Pediatrics. 1998;102(1):73-76.
2. Mundell et al. A retrospective, five-year review of presentation, investigations and management of acute testicular pain in paediatric patients
3. Lyronis et al Acute scrotum -etiology, clinical presentation and seasonal variation
4. Yang Jr. et al Acute scrotum in children: An 18-year retrospective study
5. Boettcher et al. Clinical and sonographic features predict testicular torsion in children: A prospective study
6. Ciftci et al. Clinical predictors for differential diagnosis of acute scrotum
7. Beni-Israel et al. Clinical predictors for testicular torsion as seen in the pediatric ED
8. Boettcher et al. Clinical predictors of testicular torsion in children
9. Sazgar et al Clinical Predictors of Testicular Torsion in Patients with Acute Scrotum; a Cross-Sectional Study
10. Lemini et al. Predictivity of Clinical Findings and Doppler Ultrasound in Pediatric Acute Scrotum
11. Liang et al. Retrospective review of diagnosis and treatment in children presenting to the pediatric department with acute scrotum
12. Yang et al Testicular torsion in children: A 20-year retrospective study in a single institution