Emergency department management of acute scrotal pain in pediatric patients.

Testicular torsion is a urologic emergency, accounting for up to 15% of cases of acute scrotal pain. Rapid recognition and management are essential to ensure viability of the testis. Doppler ultrasound can be used to confirm the diagnosis of testicular torsion; however, recent studies suggest that a more judicious use of ultrasound may be safe, decrease delays in surgical management, and avoid unnecessary utilization of resources. This issue reviews the epidemiology and historical and physical examination findings of testicular torsion and other common causes of acute scrotal pain. The existing literature is reviewed and recommendations are provided to guide the emergency clinician in appropriate management and disposition of boys with acute scrotal pain.

The management of testicular torsion: A survey of Turkish pediatric surgeons and pediatric urologists.

BACKGROUND: This study aimed to evaluate the approaches of pediatric surgeons and pediatric urologists in Türkiye regarding the diagnosis and treatment of testicular torsion (TT) and their adherence to the European Association of Urology (EAU) pediatric urology guideline. METHODS: A survey consisting of 19 questions, accompanied by an annotation describing the objective of the study, was emailed to pediatric surgeons and pediatric urologists in June and July 2023. RESULTS: Of the 95 respondents, 62.1% had over 10 years of experience, and 48.4% treated more than five cases of TT annually. Of the participants, 87.4% stated that scrotal Doppler ultrasonography (US) was always used, and 12.6% stated that US was used in cases of doubtful diagnosis. Concerning treatment, 14.7% reported performing manual detorsion, 70.5% never did, and 14.7% did so only if the operating room was unavailable soon. A total of 92.6% of participants opted for emergency surgery. Among participants who perform manual detorsion, 71.4% perform surgery within 24 hours after successful manual detorsion. Regarding fixation of the contralateral testicle, 14.7% never performed it, and 27.4% did so only when they performed an orchiectomy on the torsion testicle. CONCLUSION: While most participants follow EAU pediatric urology guidelines by performing emergency surgery, the rate of manual detorsion is low. Few participants stated that emergency surgery may not be performed after manual detorsion. While all of the participants performed fixation of the torsion testicle in accordance with the guidelines, the same adherence was not observed in the contralateral testicle.

Comparison of the therapeutic effect of platelet-rich plasma and injectable platelet-rich fibrin on testicular torsion/detorsion injury in rats.

Testicular torsion is a common disorder in males and results in blockage of testicular circulation with subsequent damage of testicular germ cells. The current work aimed to compare the therapeutic effect of platelet-rich plasma (PRP) and injectable platelet-rich fibrin (i-PRF) on torsion/detorsion (T/D) injury in rats. Forty mature male Wister rats were arranged into 4 groups; (1) Control, (2) T/D, (3) T/D + PRP, and (4) T/D+ i-PRF. The right testis was twisting 1080° clockwise for 3 h in groups 2, 3 and 4, then 10 µl of PRP or i-PRF was injected intra-testicular 3 h after detorsion in groups 3 and 4, respectively. After 30 days postoperatively, the semen quality and hormonal assay were improved in PRP and i-PRF-treated groups with superiority of i-PRF (P < 0.001). High significance of Catalase, Glutathione Peroxidase (GPx), Superoxide Dismutase, Interleukin-1ß (IL-1ß), Caspase-3 and Tumor necrosis factor-α (TNF-α) was reported in treated rats with PRP and i-PRF (P < 0.001) with superiority to i-PRF-treated rats (P < 0.001). Testicular histoarchitectures were improved in PRP and i-PRF-treated rats with superiority of i-PRF-treated rats. It was concluded that PRP and i-PRF have regenerative efficacy on testicular damage after induced T/D injury with a superior efficacy of i-PRF.

Manual detorsion in pediatric testicular torsion: A narrative review of the literature.

Manual detorsion is infrequently performed in pediatric emergency medicine, particularly in centers with urology coverage. In no other emergency condition does an emergency physician not take immediate action to alleviate pain and damage, even if definitive care is close by. A small number of case reports exist in which pediatric emergency physicians have performed manual detorsion. This review the literature presents the case for routine manual detorsion prior to definitive orchiopexy.

Point-of-care ultrasonography for the diagnosis and manual detorsion of testicular torsion.

Testicular torsion is a urological emergency caused by the loss of testicular tissue due to ischemic damage. Rapid diagnosis and urgent treatment play a crucial role in the management of testicular torsion. Manual detorsion can be performed at the bedside, thereby reducing the duration of ischemia. Recent studies have reported the use of point-of-care ultrasonography for diagnosing testicular torsion; however, no review article has focused on the ultrasonographic findings pertaining to manual detorsion. This review describes the diagnosis of testicular torsion and the ultrasonographic indications for manual detorsion. Spermatic cord twisting or the whirlpool sign, absence of or decreased blood flow within the affected testis, abnormal testicular axis, abnormal echogenicity, and enlargement of the affected testis and epididymis due to ischemia are the sonographic findings associated with testicular torsion. The following findings are considered indications for manual detorsion: direction of testicular torsion, i.e., inner or outer direction (ultrasonographic accuracy of 70%), and the degree of spermatic cord twist. The following sonographic findings are used to determine whether the treatment was successful: presence of the whirlpool sign and the degree and extent of perfusion of the affected testis. Misdiagnosis of the direction of manual detorsion, a high degree of spermatic cord twisting and insufficient detorsion, testicular compartment syndrome, and testicular necrosis were found to result in treatment failure. The success of manual detorsion is determined based on the symptoms and sonographic findings. Subsequent surgical exploration is recommended in all cases, regardless of the success of manual detorsion.

Pretreatment with remote ischemic conditioning attenuates testicular damage after testicular ischemia and reperfusion injury in rats.

Testicular torsion is a urological emergency. However, surgical detorsion of the torsed spermatic cord can cause testicular reperfusion injury. Although remote ischemic preconditioning (RIPC) has been convincingly shown to protect organs against ischemia/reperfusion (I/R) injury, little is known regarding the effect of RIPC on testicular torsion/detorsion-induced reperfusion injury. Therefore, we aimed to evaluate the effect of RIPC on testes after testicular I/R injury in a rat model in vivo. Male Sprague-Dawley rats were randomly classified into 4 groups: sham-operated (sham), testicular I/R (TI/R), or remote liver (RIPC liver) and limb (RIPC limb) ischemic preconditioning groups. Testis I/R was induced by 3 h of right spermatic cord torsion (720° clockwise), and reperfusion was allowed for 3 hours. In the RIPC group, four cycles of 5 min of ischemia and 5 min of reperfusion were completed 30 min prior to testicular torsion. The ERK1/2 inhibitor U0126 was administered intravenously at the beginning of reperfusion (1 mg/kg). The testes were taken for the oxidative stress evaluations, histology, apoptosis, immunohistochemical and western blotting analysis. Remote liver and limb ischemic preconditioning attenuated ipsilateral and contralateral testicular damage after testicular I/R injury. For example. RIPC reduced testicular swelling and oxidative stress, lessened structural damage, and inhibited the testicular inflammatory response and apoptosis. Furthermore, RIPC treatment enhanced testicular ERK1/2 phosphorylation postI/R. Inhibition of ERK1/2 activity using U0126 eliminated the protection offered by RIPC. Our data demonstrate for the first time that RIPC protects testes against testicular I/R injury via activation of the ERK1/2 signaling pathway.

Successful Outcome of Manual Testicular Detorsion Using Point-of-Care Ultrasound Guidance: A Clinical Experience.

ABSTRACT: Testicular torsion is a surgical emergency. It obstructs the blood supply to the testes, leading to testicular ischemia and necrosis. It presents with a sudden onset of severe unilateral testicular pain associated with nausea/vomiting, swollen scrotum, and high-riding testicles with an absent cremasteric reflex and negative Prehn sign. Prompt diagnosis of ischemic testicles using ultrasonography is challenging for emergency physicians. Color Doppler ultrasound may reveal a relative decrease or absence of blood flow in the affected testicle. The most specific ultrasonographic feature was the whirlpool sign of the spermatic cord. Manual detorsion should be performed as soon as possible before surgical intervention. However, manual detorsion may fail because of patient discomfort, incomplete torsion, and rotation of the testicle in a less common direction. We report a case demonstrating ultrasound-guided detorsion in a 14-year-old boy with right testicular torsion. The present case highlights the importance of incorporating ultrasound guidance into manual detorsion, which can improve the success rate of the procedure.

Comparison of hyperbaric oxygen and ozone treatment for ischemia/re-perfusion injury in an experimental testicular torsion model.

BACKGROUND: This study aims to compare the effects of medical ozone (MO) therapy and hyperbaric oxygen (HBO) therapy in an experimental testicular torsion model by measuring the oxidant and antioxidant markers and examining the histopathological tissue damage findings. METHODS: Thirty-two Wistar rats are used and are divided into four groups; (1) sham group (SG), (2) only ischemia/reperfusion (I/R) by testicular torsion, (3) HBO administered group, and (4) MO administered group. No torsion was conducted in the SG. In all other groups, rats underwent testicular torsion followed by detorsion to create an I/R model. After I/R, HBO was injected in the HBO group, and in the MO group, intraperitoneal ozone was applied. At the end of 1 week, testicular tissues were obtained for biochemical analyzes and histopathological examinations. Biochemically, malondialdehyde (MDA) levels were measured for oxidant activity, and superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) levels were measured for antioxidant activity. Furthermore, the testicles were evaluated histopathologically. RESULTS: Both HBO and MO have significantly decreased MDA levels, compared with sham and I/R groups, resulting in decreased oxidation effects. The antioxidant GSH-Px levels in the HBO and MO groups were significantly higher than in the sham and I/R groups. In addition, the antioxidant SOD levels in the HBO group were significantly higher than sham, I/R, and MO groups. Therefore, the antioxidant effect of HBO was observed to be superior to MO, specifically considering SOD levels. Histopathologically, there was no significant difference between the groups (p>0.05). CONCLUSION: The study may extrapolate that both HBO and MO are antioxidant agents that can be used in testicular torsion. HBO treatment might improve the cellular antioxidant capacity due to increased antioxidant marker levels more than MO therapy. However, further studies are needed with a larger sample size.

High risk and low prevalence diseases: Testicular torsion.

INTRODUCTION: Testicular torsion is a serious condition that carries with it a high rate of morbidity. OBJECTIVE: This review highlights the pearls and pitfalls of testicular torsion, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: Testicular torsion is a urological emergency that occurs with rotation of the testicle along its supporting ligaments leading to obstruction of vascular flow. A key risk factor is the presence of a bell-clapper deformity. The most common population affected includes children in a bimodal distribution with the most cases occurring in the first year of life and between 12 and 18 years, although cases do occur in adults. Acute, severe, unilateral scrotal pain is the most common presenting symptom. Nausea and vomiting are common, but the presence or absence of a cremasteric reflex is not a reliable indicator of disease. The TWIST score may assist with clinical decision making in patients presenting with acute testicular pain but should not be used in isolation. If torsion is suspected or confirmed, consultation with the urology specialist should not be delayed, as outcomes are time sensitive. Ultrasound can be used for diagnosis, but a normal ultrasound examination cannot exclude the diagnosis. Treatment includes emergent urology consultation for surgical exploration and detorsion, as well as symptomatic therapy in the ED. Manual detorsion can be attempted in the ED while awaiting transfer or consultation. CONCLUSIONS: An understanding of testicular torsion can assist emergency clinicians in diagnosing and managing this disease.

The impact of bone marrow-derived mesenchymal stem cells on experimental testiculartorsion in rats.

BACKGROUND: The aim of this study was to investigate the healing effects of bone marrow-derived mesenchymal stem cells (BMMSCs) on experimental testicular torsion in rats. METHODS: Three groups consisting of 10 Wistar albino rats were created. In Group I, the left testicle was explored and relocated in the scrotum without any attempt to modify it. In Group II, the left testicle underwent torsion for three h and then was detorsed and relocated. In Group III, in addition to torsion and detorsion, BM-MSCs were administered intratesticularly. The rats were sacrificed on the seventh day, and the healing status of the testicles was investigated with histopathological and biochemical analyses. BM-MSC involvement was investigated by immunofluorescence microscopy. Statistical analysis was performed using SPSS 15.0. A p-value < 0.05 was considered statistically significant for all variables. RESULTS: Immunofluorescence microscopy showed that BM-MSCs were located around the Leydig cells in Group III. Under light microscopy, the mean Johnsen Score of Group III was significantly higher than that of Group II (p = 0.035). The interleukin-10 (IL-10) level was significantly higher in Group III compared to Group II (p = 0.003). While the malondialdehyde (MDA) values in Group I (the control group) were lower than in the other groups (p = 0.037), the superoxide dismutase (SOD) values were similar (p = 0.158). Although there was no statistically significant difference between Group II and Group III in terms of MDA, it was lower in Group III. Although the tissue SOD levels were higher in Group III than in Group II, the difference was not statistically significant. DISCUSSION: : This study has demonstrated that BM-MSCs significantly corrected the Johnsen Score and increased anti-inflammatory cytokine levels after testicular torsion. BM-MSCs can be used in testicular torsion as supportive therapy to minimize tissue damage.

Testicular torsion in children.

QUESTION: As a family physician caring for a large pediatric population, I evaluate numerous adolescents with testicular pain. Given the gravity of prognosis for late treatment of children with testicular torsion, what are best practices for its assessment and management? ANSWER: The Testicular Workup for Ischemia and Suspected Torsion (TWIST) score has been developed and validated to identify children at risk of testicular torsion. If the TWIST score is 0 and clinical suspicion is low in the office setting, a referral to urology for urgent consultation is not needed. If the TWIST score is 1 or higher or if the clinical presentation suggests torsion, manual detorsion should be attempted and the patient should be urgently sent to the nearest emergency department.

Role of ultrasound in manual detorsion for testicular torsion.

PURPOSE: Manual detorsion can be performed for testicular torsion before scrotal exploration. Using sonographic findings, this study investigated the need for additional treatments after manual detorsion for testicular torsion. METHODS: This study evaluated 13 retrospective cases of testicular torsion subjected to manual detorsion. Manual detorsion was classified as failure or success based on residual spermatic cord twist. The following sonographic findings of the affected testis were compared using the Fisher exact test: whirlpool sign, horizontal or altered lie, and hypoperfusion. RESULTS: Manual detorsion failed in five patients. There was a significant difference in the incidence of the whirlpool sign between the two groups (present/absent sign in the failure vs. success groups: 4/1 vs. 0/8, p = 0.007). Horizontal or altered lie and hypoperfusion in the affected testis were not significantly different between groups (5/0 vs. 3/4, p = 0.07, one case excluded, and 5/0 vs. 4/4, p = 0.10, respectively). CONCLUSIONS: Ultrasound findings after manual detorsion, particularly, the whirlpool sign, were useful for planning subsequent treatment such as additional manual detorsion or surgical intervention. The testicular axis and the perfusion of the twisted testis may not recover to normal after successful manual detorsion, but if they recover, this procedure could be judged a success.

Effects of hypothermia and pentoxifylline on the adnexal torsion/detorsion injuries in a rat testis model.

This study was designed to investigate the effects of separate and combined administration of hypothermia and pentoxifylline to preserve the effects on the testicles in an experimental model of testicular torsion/ detorsion injuries in rats. Forty male adult Wistar rats were randomly divided into five groups, control, torsion/detorsion (TD), torsion/detorsion/hypothermia (TD+ICE), torsion/detorsion received of pentoxifylline (40mg/kg, ip) (TD+PTX) and torsion/detorsion/hypothermia/PTX (TD+ICE+PTX). Left testicular torsion (TT) was performed for 4 and half hours, and ice fragments have been used at the beginning of torsion. After the reperfusion period (a week), oxidative maker's serum levels, testosterone hormone, sperm parameters, and histopathological and gene expression evaluations have been performed. Significant adverse changes were observed in the TD group for histological variables, sperm count, oxidative marker, testosterone hormone, Bax, BCL2 and caspase-3 expression. The parameters studied in the group receiving PTX improved in comparison with the TD group, while macroscopical parameters of both the hypothermia and PTX+ICE groups were not different compared with the TD group. The results revealed that PTX, as an antioxidant component, was protective against testicular torsion, while hypothermia and hypothermia plus PTX did not exhibit this property, which may have been due to the duration of hypothermia (4 hr) or reperfusion period.

Combined melatonin-adipose derived mesenchymal stem cells therapy effectively protected the testis from testicular torsion-induced ischemia-reperfusion injury.

BACKGROUND: This study tested the hypothesis that combined melatonin (Mel) and adipose-derived mesenchymal stem cells (ADMSCs) treatment was superior to either one alone on protecting the testis against acute testicular torsion-induced ischemia-reperfusion (TTIR) injury. METHODS AND RESULTS: Male adult SD rats (n = 30) were equally categorized into group 1 (sham-operated control), group 2 [TTIR/by torsion of right/left testis (i.e., ischemia) with rotated 720° counterclockwise for 2 h, then detorsion (i.e., reperfusion) to the original position for 72 h], group 3 (TTIR + Mel/intraperitoneal administration/50 mg/kg at 30 min after ischemia, followed by 20 mg at 3 h and days 1/2/3 after TTIR), group 4 (TTIR + ADMSCs/1.2 × 106 cells/by tail-vein administration at 30 min after ischemia, followed by days 1/2 TTIR), and group 5 (TTIR + Mel + ADMSCs/tail-vein administration). The result showed that the protein expressions of oxidative-stress (NOX-1/NOX-2/oxidized-protein), apoptotic/mitochondrial-damaged (mitochondrial-Bax/cleaved-caspase3/cleaved-PARP/cytosolic-cytochrome C), and fibrotic (TGF-ß/Smad3) biomarkers as well as testicular damage scores were lowest in group 1, highest in group 2, and significantly higher in groups 3/4 than in group 5, but they showed no difference between groups 3/4, whereas the protein expressions of androgen receptor (AR) and vimentin showed an opposite pattern of oxidative stress (all p < 0.0001). The cellular levels of inflammation (MMP-9/MPO/CD68) exhibited an identical pattern, whereas the numbers of Sertoli cells, α-tubulin, AR and vimentin as well as thickness of seminiferous tubule exhibited an opposite pattern of oxidative stress among the groups (all p < 0.0001). CONCLUSION: Mel-ADMSCs effectively protected the testis against TTIR injury.