Testicular Torsion in Children. Diagnostic and Prognostic Potential of Ultrasonography

Introduction: Testicular torsion is the most urgent case in pediatric andrology that requires emergency care due to the high sensitivity of testicular tissue to hypoxia.

Objective: To determine statistically significant parameters indicating diagnostic significance of some ultrasonographic testicular torsion symptoms in children.

Materials and methods: Ultrasonography was performed in 202 children with testicular torsion (main group) and 449 patients (control group) aged from 2 months to 17 years 11 months and 28 days. During statistical processing we determined the mean values, their standard deviation, sampling errors, significance of differences in the mean values, correlation coefficient and did ROC analysis. For an objective ultrasonographic assessment of testicular shape, we implemented the coefficient of rounding – k_o = (testicular length – testicular thickness) / testicular length – and the parameter Δk_o calculated as the difference between k_o for the affected side and the contralateral one.

Results and discussion: Testicular torsion was more common in children above 12 years of age (84.7%). The k_o was 0.160 ± 0.007 in the group of children with testicular torsion and 0.037±0.003 in the control group (t = 16.92, p >> .001). The ROC analysis proved the Δk_o to be highly informative: AUC was 0.886. The Δk_o was 0.130 ± 0.008 for patients with favorable treatment outcomes and 0.19 ± 0.01 (p < 0.001) for those with unfavorable outcomes. In most cases (71), the whirlpool sign was visualized with preserved blood flow. In such a case, the probability of the favorable treatment outcome was 74.6%. The whirlpool sign visualization was significantly less common (31 cases) without Doppler ultrasonography; favorable treatment outcomes were achieved in 54.8%. Of 22 patients with the undetected whirlpool sign, favorable treatment outcomes were possible only in 40.9%.

Conclusions: The coefficient of rounding k_o can be used as an auxiliary criterion for the early diagnosis of testicular torsion. With Δk_o = 0.08, the sensitivity of the parameter in respect of testicular torsion is 79.2%, and specificity is 85.7%. With Δk_o = 0.16, the specificity of the parameter is almost 100% with a 45.0% decrease of the sensitivity. Whirlpool sign detection using color Doppler ultrasonography is a positive prognostic factor.

1. Olkhova EB, Topolnik MV, Rudin AYu, Runenko VI, Melnik IV. The role of gray-scale ultrasound in the diagnosis of postnatal testicular torsion in children. Radiology – Practice. 2021;(5):54–68. (In Russ.). https://doi.org/10.52560/2713-01182021-5-54-68

2. Olkhova EB, Borisov SYu, Topolnik MV, Tagirova AYu, Zhumasitov SV, Mukaseeva TV. The role of Doppler ultrasound in the diagnosis of postnatal testicular torsion in children. Radiology – Practice. 2021;(5):69–81. (In Russ.). https://doi.org/10.52560/2713-0118-2021-5-69-81

3. Abbas TO, Abdelkareem M, Alhadi A, et al. Suspected testicular torsion in children: diagnostic dilemma and recommendation for a lower threshold for initiation of surgical exploration. Res Rep Urol. 2018;10:241–249. PMID: 30584529. PMCID: PMC6287511. https://doi.org/10.2147/rru.s186112

4. Barbosa JA, Tiseo BC, Barayan GA, et al. Development and initial validation of a scoring system to diagnose testicular torsion in children. J Urol. 2013;189(5):1859–1864. PMID: 23103800. https://doi.org/10.1016/j.juro.2012.10.056

5. Burud IAS, Alsagoff SMI, Ganesin R, Selvam ST, Zakaria NAB, Tata MD. Correlation of ultrasonography and surgical outcome in patients with testicular torsion. Pan Afr Med J. 2020;36:45. PMID: 32774621. PMCID: PMC7388596. https://doi.org/10.11604/pamj.2020.36.45.21824

6. Kaye JD, Shapiro EY, Levitt SB, et al. Parenchymal echo texture predicts testicular salvage after torsion: potential impact on the need for emergent exploration. J Urol. 2008;180(4 Suppl):1733–1736. PMID: 18721947. https://doi.org/10.1016/j.juro.2008.03.104

7. Keays M, Rosenberg H. Testicular torsion CMAJ. 2019; 191(28):E792. PMID: 31308008. PMCID: PMC6629539. https:// doi.org/10.1503/cmaj.190158

8. Kumar V, Matai P, Prabhu SP, Sundeep PT. Testicular loss in children due to incorrect early diagnosis of torsion. Clin Pediatr (Phila). 2020;59(4–5):436–438. PMID: 32019340. https://doi.org/10.1177/0009922820903037

9. Roberts CE, Ricks WA, Roy JD, Hartin CW, Alemayehu H. Testicular workup for ischemia and suspected torsion in pediatric patients and resource utilization. J Surg Res. 2021;257: 406–411. PMID: 32892138. https://doi.org/10.1016/j.jss.2020.08.008

10. Shunmugam M, Goldman RD. Testicular torsion in children. Can Fam Physician. 2021;67(9):669–671. PMID: 34521708. https://doi.org/10.46747/cfp.6709669

11. Teurneau-Hermansson K, Zindovic I, Jakobsson J, et al. Doppler ultrasound improves diagnostic accuracy for testicular torsion. Scand J Urol. 2021;55(6):461–465. PMID: 34369846. https://doi.org/10.1080/21681805.2021.1962404

12. Tian XM, Tan XH, Shi QL, et al. Risk factors for testicular atrophy in children with testicular torsion following emergent orchiopexy. Front Pediatr. 2020;8. PMID: 33262963. PMCID: PMC7686235. https://doi.org/10.3389/fped.2020.584796

13. Vijayaraghavan SB. Sonographic differential diagnosis of acute scrotum: real-time whirlpool sign, a key sign of torsion. J Ultrasound Med. 2006;25(5):563–574. PMID: 16632779. https://doi.org/10.7863/jum.2006.25.5.563