Reference
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1. Kapoor S. Testicular torsion: a race against time. Int J Clin Pract. 2008;62(5):821-827. Review/Other-Dx N/A A review on torsion of the testis. No results stated in abstract. 4
2. Pogorelic Z, Mustapic K, Jukic M, et al. Management of acute scrotum in children: a 25-year single center experience on 558 pediatric patients. Can J Urol. 23(6):8594-8601, 2016 Dec. Observational-Tx 558 patients To analyze management and outcomes of treatment in patients with acute scrotum. Scrotal explorations revealed 142 cases (25%) of spermatic cord torsion, 344 (62%) torsion of the testicular appendage, 54 (10%) epididymitis, 10 (2%) testicular trauma and 8 cases (1%) of other conditions. Two peaks of incidence of spermatic cord torsion were found, the first during first year of life and the second between 13 and 15 years of life. In patients with spermatic cord torsion, median duration of symptoms in the group of salvaged testes was 6 hours; while in the group of patients who underwent orchiectomy was 46 hours. Of the total number of patients with spermatic cord torsion 40 patients (28%) underwent orchiectomy while 102 testicles (72%) were saved. There were no major complications. Acute scrotum is significantly more common in the winter. Torsion of the testis has the highest incidence in January and August. 3
3. Lorenzo L, Rogel R, Sanchez-Gonzalez JV, et al. Evaluation of Adult Acute Scrotum in the Emergency Room: Clinical Characteristics, Diagnosis, Management, and Costs. Urology. 94:36-41, 2016 Aug. Review/Other-Dx 669 cases To evaluate the clinic characteristics, diagnosis, management, and costs of the adult acute scrotum in the emergency room (ER). A total of 669 cases of acute scrotum were analyzed. The mean age at presentation was 40.2 +/- 17.3 years. The most presented diagnoses were orchiepididymitis (28.7%), epididymitis (28.4%), symptoms of uncertain etiology (25.1%), and orchitis (10.3%). Diagnostic tests were carried out in 57.8% of cases. Most cases were treated as outpatients (94.2%), with 5.83% admitted and 1% undergoing surgical treatment. Overall, 13.3% of patients represented to the ER. Abnormal results in blood and urine tests were more common among older patients and infectious pathologies. The average cost generated by an acute scrotum ER consult was 195.03euro. 4
4. Karmazyn B, Steinberg R, Livne P, et al. Duplex sonographic findings in children with torsion of the testicular appendages: overlap with epididymitis and epididymoorchitis. J Pediatr Surg. 2006;41(3):500-504. Review/Other-Dx 29 patient cases reviewed To determine if US can differentiate torsion of testicular appendage from epididymoorchitis. Overlap in findings. Extratesticular nodule found in only 31%. Accompanying findings also seen in epididymoorchitis. 4
5. Sanguesa Nebot C, Llorens Salvador R, Pico Aliaga S, Garces Inigo E. Perinatal testicular torsion: ultrasound assessment and differential diagnosis. Radiologia. 59(5):391-400, 2017 Sep - Oct. Review/Other-Dx N/A To review the ultrasonographic appearance of neonatal testicular torsion for each presentation, the differential diagnosis with other causes of increased scrotal volume in neonates, and its treatment. No results stated in abstract. 4
6. Graumann LA, Dietz HG, Stehr M. Urinalysis in children with epididymitis. Eur J Pediatr Surg. 2010;20(4):247-249. Review/Other-Dx 151 consecutive patients Retrospective analysis to examine the diagnostic and therapeutic yield of urine tests in epididymitis in children. Results of urine examinations were available in 93 cases (62%). Urine cultures were done in 6/97 patients treated in hospital (6%), and all cultures were sterile. Surgical exploration was performed in 7 patients (5%); in 6 of them epididymal cultures were taken intraoperatively with negative microbiological results. Almost all urine tests (urinalysis, urine culture) were negative. Epididymitis in prepubertal boys seems to be mostly idiopathic, and positive microbiological findings are rare. Antibiotic treatment in this age group should only be done in cases with positive urine tests. 4
7. Boettcher M, Krebs T, Bergholz R, Wenke K, Aronson D, Reinshagen K. Clinical and sonographic features predict testicular torsion in children: a prospective study. BJU Int. 112(8):1201-6, 2013 Dec. Observational-Dx 104 patients To test the clinical and sonographic predictors of testicular torsion (TT) with the aim of reducing negative exploration rates. A total of 104 patients were included in the 16-month period of the study.• No single finding excluded TT. The clinical features (pain <24 h, nausea/vomiting, abnormal cremasteric reflex, high position of the testis) appeared predictive (100% sensitivity) and the clinical scoring system was proven to be reliable, reducing the negative exploration rate by >55%. • Ultrasound predictors alone were not able to identify all boys with TT. 2
8. Frohlich LC, Paydar-Darian N, Cilento BG Jr, Lee LK. Prospective Validation of Clinical Score for Males Presenting With an Acute Scrotum. Acad Emerg Med. 24(12):1474-1482, 2017 Dec. Observational-Dx 258 males To validate the Testicular Workup for Ischemia and Suspected Torsion (TWIST) score among pediatric emergency medicine providers for the evaluation of pediatric males presenting with testicular pain and swelling (acute scrotum). During the study period 258 males were enrolled in the study; 19 (7.4%) had testicular torsion. The mean (+-SD) age was 9.8 (+-0.3) years. The high-risk TWIST score of 7 had 100% specificity (95% confidence interval [CI] = 98%–100%) with 100% positive predictive value (95% CI = 40%–100%) for testicular torsion. Thearea under the curve was 0.82. The kappa statistic for the overall TWIST score was fair at 0.39. 3
9. Lemini R, Guana R, Tommasoni N, Mussa A, Di Rosa G, Schleef J. Predictivity of Clinical Findings and Doppler Ultrasound in Pediatric Acute Scrotum. Urol. j.. 13(4):2779-83, 2016 Aug 25. Observational-Dx 1091 patients To evaluate the role of Doppler ultrasonography (DUS) in diagnosing pediatric testicular torsion (TT), and its diagnostic accuracy, and helping clinicians increase specificity and decrease negative exploration rates. We analyzed 1091 patients, with a mean age of 9 years. DUS was performed in 498 patients (40.8%); 107 patients (8.8%) underwent surgery and 41 patients (3.3%) had a TT. The following clinical findings were collected: presence of scrotal pain, erythema and swelling, spermatic cord pain and abnormal cremasteric reflex. The clinical findings significantly associated with TT were spermatic cord pain (OR = 37, 95% CI: 11.9-111.1, P &lt; .001) and abnormal cremasteric reflex (OR = 47.6, 95% CI: 13.5-166.6, P &lt; .001); the presence of swelling resulted confounding (OR = 2.3, 95% CI: 0.7-8.4, P &lt; .001). Scrotal pain was not significantly associated with TT (P = .9), while erythema made TT unlikely (OR = 0.22, 95% CI: 0.07-0.7, P = .0445). In all cases the DUS significantly increased the predictivity. 3
10. Riccabona M, Darge K, Lobo ML, et al. ESPR Uroradiology Taskforce--imaging recommendations in paediatric uroradiology, part VIII: retrograde urethrography, imaging disorder of sexual development and imaging childhood testicular torsion. Pediatr Radiol. 45(13):2023-8, 2015 Dec. Review/Other-Dx N/A To outline effective imaging algorithms to optimize diagnostic accuracy and to harmonize diagnostic imaging among institutions and practitioners. No results stated in abstract. 4
11. Lam WW, Yap TL, Jacobsen AS, Teo HJ. Colour Doppler ultrasonography replacing surgical exploration for acute scrotum: myth or reality? Pediatr Radiol. 2005;35(6):597-600. Observational-Dx 626 patients Retrospective review to evaluate the improved accuracy in clinical diagnosis with color Doppler US added to normal clinical assessment. US had a sensitivity of 69.2% (95% CI, 38.9-89.5), specificity of 100% (95% CI, 98.5-100), PPV of 100% and NPV of 97.5%. Number of cases of testicular torsion was 8% in primary exploration and 3% US first group. 1.2% with normal flow had torsion. US is cost minimizing. 3
12. Sparano A, Acampora C, Scaglione M, Romano L. Using color power Doppler ultrasound imaging to diagnose the acute scrotum. A pictorial essay. Emerg Radiol. 2008;15(5):289-294. Review/Other-Dx 768 cases Pictorial essay to illustrate the various causes of acute nontraumatic scrotum by using color power Doppler US imaging based on a retrospective analysis of 768 cases performed at a Level I trauma center between January 2005 and June 2006. The differential diagnosis of acute nontraumatic scrotum is the domain of color power Doppler. It often allows the establishment of diagnosis, supporting clinical management to an appropriate treatment. The authors conclude that the dramatically important job is not to miss testicular torsion to assess a quick treatment. 4
13. Kalfa N, Veyrac C, Lopez M, et al. Multicenter assessment of ultrasound of the spermatic cord in children with acute scrotum. J Urol. 2007;177(1):297-301; discussion 301. Observational-Dx 919 patients from 11 hospitals To assess the validity and reproducibility of high resolution US based management of acute scrotum in children. 208 had torsion. Intratesticular vascularization was absent in 158 cases (76%). Cord twist seen in 199 (96%). Linear cord (705/711, 99% specificity) found in patients without torsion. High resolution US based management of acute scrotum is reliable and reproducible. Thanks to its high sensitivity and specificity for the diagnosis of spermatic cord torsion, high resolution US can significantly improve the management of acute scrotum in children. 3
14. Munden MM, Williams JL, Zhang W, Crowe JE, Munden RF, Cisek LJ. Intermittent testicular torsion in the pediatric patient: sonographic indicators of a difficult diagnosis. AJR Am J Roentgenol. 201(4):912-8, 2013 Oct. Review/Other-Dx 15 patients To determine whether intermittent testicular torsion, defined as the sudden onset of unilateral scrotal pain of short duration with spontaneous resolution, has sonographic indicators that can be used to establish the diagnosis. Analysis was performed on two separate categories for intermittent testicular torsion: total patient episodes (n = 19) and surgical cases (n = 10), with a total of 15 patients with 1.26 episodes per patient. Of the 19 episodes of intermittent testicular torsion, 63% (12) had either absent flow followed by normal to increased flow (n = 6, p = 0.18) or increased testicular flow (n = 6), 26% (5) had normal flow, and 10.5% (2) had decreased flow. Of the total episodes of intermittent testicular torsion, 79% (15) had a whirlpool sign or pseudomass, 10.5% (2) had neither a whirlpool sign or pseudomass but a "boggy" thickened cord, and 10.5% (2) had a normal appearance of the spermatic cord with no pseudomass. 4
15. 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. Review/Other-Dx 221 patients To prospectively investigate the role of high-resolution and color Doppler US in the differential diagnosis of acute scrotum and testicular torsion in particular. US revealed features of torsion of testicular appendages in 23 patients and AISE in 19. US of acute scrotum should include study of the spermatic cord. The US real-time whirlpool sign is the most specific and sensitive sign of torsion, both complete and incomplete. Intermittent testicular torsion is a challenging clinical condition with a spectrum of clinical and US features. 4
16. Yagil Y, Naroditsky I, Milhem J, et al. Role of Doppler ultrasonography in the triage of acute scrotum in the emergency department. J Ultrasound Med. 29(1):11-21, 2010 Jan. Observational-Dx 620 consecutive patients To examine the triage role of scrotal Doppler US as the primary preoperative diagnostic tool in patients presenting to the emergency department with acute scrotum. Doppler US for the diagnosis of testicular torsion had 94% sensitivity, 96% specificity, 95.5% accuracy, an 89.4% PPV, and a 98% NPV. Doppler US for the diagnosis of testicular malignancy had 92% sensitivity, 95% specificity, 94% accuracy, a 78.5% PPV, and a 98% NPV. Scrotal Doppler US is a highly sensitive preoperative diagnostic tool, thereby validating its routine use in the initial triage of patients with acute scrotum presenting to the emergency department. 3
17. Yu KJ, Wang TM, Chen HW, Wang HH. The dilemma in the diagnosis of acute scrotum: clinical clues for differentiating between testicular torsion and epididymo-orchitis. Chang Gung Med J. 35(1):38-45, 2012 Jan-Feb. Observational-Dx 76 patients To determine the importance of different clinical clues to help differentiate the causes of this devastating condition. Testicular torsion was confirmed in 39 of the suspected 47 cases after surgical exploration. 21 of these 39 testicular torsion patients underwent orchiectomy, and 18 were rescued and underwent orchiopexy. The mean pain duration was significantly longer in the orchiectomy group than the orchiopexy group (38.05 hours vs 14.14 hours, P=0.009). In the testicular torsion group, fewer patients had elevated C-reactive protein levels no patients had pyuria, and the pain duration was shorter compared with the epididymo-orchitis group (5/11 vs 13/22 [P=0.045], 0/28 vs 8/28 [P=0.004] and 27.0 vs 74.5 hours [P=0.0003], respectively). The sensitivity of color Doppler US in diagnosing testicular torsion and epididymo-orchitis was 84.09% vs 92.59%. Logistic regression for multivariate analysis showed that left side manifestation and pain duration were significantly different between testicular torsion and epididymo-orchitis with ORs of 4.76, P=0.020 and 0.98, P=0.029, respectively. 3
18. Altinkilic B, Pilatz A, Weidner W. Detection of normal intratesticular perfusion using color coded duplex sonography obviates need for scrotal exploration in patients with suspected testicular torsion. J Urol. 189(5):1853-8, 2013 May. Observational-Dx 236 patients To assess the efficacy of color coded duplex US in predicting the need for scrotal exploration in patients with clinical suspicion of testicular torsion. Testicular torsion was the most common cause of impaired intratesticular blood flow (119 cases, 50.4%), followed by torsion of the testicular appendages (82, 34.8%), epididymoorchitis (18, 7.6%) and various other conditions (17, 7.2%). The sensitivity, specificity, and PPV and NPV of color coded duplex US for detecting testicular torsion were 100%, 75.2%, 80.4% and 100%, respectively. 2
19. Stehr M, Boehm R. Critical validation of colour Doppler ultrasound in diagnostics of acute scrotum in children. Eur J Pediatr Surg. 2003;13(6):386-392. Observational-Dx 132 consecutive cases To determine if accuracy of Doppler US for torsion is high enough in children. Majority of patients scanned (90%) had nonischemic cause of scrotal pain. It is easy to over diagnosis ischemic torsion on US. Highly dependent on operator and clinical situation. Even though color Doppler US is a very valuable diagnostic tool in this sense, this exclusion cannot be ensured in every case and is highly dependent on the expertise and technique of the investigator. Therefore, in cases with any doubts an operative exploration has to be performed to avoid the most dreaded complication in the treatment of acute scrotum. 3
20. Liang T, Metcalfe P, Sevcik W, Noga M. Retrospective review of diagnosis and treatment in children presenting to the pediatric department with acute scrotum. AJR Am J Roentgenol. 200(5):W444-9, 2013 May. Observational-Dx 342 children To evaluate US accuracy, findings, and clinical predictors in testicular torsion in boys presenting to the Stollery pediatric emergency department with acute scrotal pain. The false-positive rate for US was 2.6%, and there were no false-negative findings. Mean times from presentation at the emergency department to US and surgery were 209.4 and 309.4 minutes, respectively. Of the torsed testicles, 69% were salvageable. Sensitivity, specificity, and diagnostic accuracy of US for testicular torsion were 100%, 97.9%, and 98.1%, respectively. Sonographic heterogeneity was seen in 80% of nonviable testes at surgery and 58% of patients with viable testes (P=0.41). Sudden-onset scrotal pain (88%), abnormal position (86%), and absent cremasteric reflex (91%) were most prevalent in torsion patients. 3
21. Bentley DF, Ricchiuti DJ, Nasrallah PF, McMahon DR. Spermatic cord torsion with preserved testis perfusion: initial anatomical observations. J Urol. 2004;172(6 Pt 1):2373-2376. Observational-Dx 61 patients To evaluate whether patients with specific anatomical configurations maintain testicular blood flow for prolonged periods, and, therefore, will have flow on US despite concurrent torsion. 4 patients had normal flow on color Doppler, but torsion. Authors speculate on anatomic abnormalities that may predispose false negative US. Testis perfusion can be maintained for a prolonged period in the presence of testicular torsion. Anatomical variability may account for differences in the duration of viability of the torsed testis. A high index of suspicion must be maintained to avoid missing the diagnosis of testicular torsion in these challenging cases. 3
22. Dogra VS, Rubens DJ, Gottlieb RH, Bhatt S. Torsion and beyond: new twists in spectral Doppler evaluation of the scrotum. J Ultrasound Med. 2004;23(8):1077-1085. Review/Other-Dx N/A To review the current status of acute scrotal imaging using Doppler. Analysis of the spectral waveform provides important additional information in various scrotal disorders with acute pain. Spectral waveform analysis is critical to diagnosing incomplete torsion when color and power Doppler examinations are indeterminate. 4
23. Pilatz A, Wagenlehner F, Bschleipfer T, et al. Acute epididymitis in ultrasound: results of a prospective study with baseline and follow-up investigations in 134 patients. Eur J Radiol. 82(12):e762-8, 2013 Dec. Observational-Dx 134 adults To perform a comprehensive follow-up analysis of US scrotal features and associated signs in patients with acute epididymitis. At first presentation, 61 patients (45.5%) had hydrocele, 63 (47.0%) concomitant orchitis, and 8 (5.9%) epididymal abscess. Epididymitis was predominantly located in 24 cases (17.9%) in the head, 52 cases (38.8%) in the tail, and 58 cases (43.3%) in both. On the affected side, testicular volume was 16.9 +/- 6.8 mL and peak systolic velocity of the testicular artery was 23.7 +/- 7.5 cm/s, compared to the healthy side with 12.3 +/- 4.4 mL and 9.5 +/- 3.6 cm/s respectively (P<0.001). Concomitant orchitis was associated with hydrocele, testicular enlargement and pain (P<0.01). Orchiectomy due to secondary testicular infarction was necessary in 4 cases, while in all other patients US parameters normalized. Only 16/90 patients (17.8%) showed a persistent epididymal swelling after 3 months. 3
24. Chang CD, Lin JW, Lee CC, et al. Acute Epididymo-orchitis-Related Global Testicular Infarction: Clinical and Ultrasound Findings With an Emphasis on the Juxta-epididymal String-of-Bead Sign. ULTRASOUND Q.. 32(3):283-9, 2016 Sep. Review/Other-Dx 6 patients with AEO-related GTI and 17 patients with torsion-related GTI 1. To report clinical and ultrasound findings of 6 patients with surgically proven Acute epididymo-orchitis (AEO)–related global testicularinfarction (GTI)2. Highlight the differences in the clinical and ultrasound features of AEO-related GTI and testicular torsion-related GTI All of the patients showed a juxta-epididymal string-of-bead pattern on color Doppler ultrasound, which was ascribed to patent arteries (5/6, 87%) and collateral vessels (1/6, 13%) in the tunica albuginea. There were no significant differences in age, laterality, leukocyte count, testicular volume ratio (infarcted/normal), frequencies of heteroechoic testicular parenchyma, scrotal skin thickening, and hydrocele between the 2 groups. However, the left testis was predominantly affected in both groups. Compared with torsion-related GTI, patients with AEO-related GTI had significantly longer duration from scrotal pain onset to surgery (13.5 +/- 5.2 vs 2.6 +/- 2.0 days, P < 0.001), a higher level of serum C-reactive protein (110.0 +/- 82.0 vs 41.2 +/- 35.9 mg/dL, P = 0.013), a higher frequency of the juxta-epididymal string-of-bead sign (100% vs 12%, P < 0.001), and a lower frequency of the whirlpool/knot sign (0% vs 88%, P = 0.002). 4
25. Karmazyn B, Steinberg R, Kornreich L, et al. Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys. Pediatr Radiol. 2005;35(3):302-310. Observational-Dx 172 total patients: 41 had testicular torsion; 131 had other diagnoses Retrospective study to define the clinical and US criteria that best predict testicular torsion. Stepwise regression analysis yielded 3 factors significantly associated with testicular torsion: duration of pain =6 hours; absent or decreased cremasteric reflex; and diffuse testicular tenderness. When children were scored by final diagnosis for the presence of these factors (0-3), none of the children with a score of 0 had testicular torsion, whereas 87% with a score of 3 did. US finding of decreased or absent testicular flow had sensitivity of 63% and specificity of 99%. Authors suggest that all children with acute scrotal pain and a clinical score of 3 should undergo testicular exploration, and children with a lower probability of testicular torsion (score 1 or 2) should first undergo diagnostic US. 3
26. Baldisserotto M, de Souza JC, Pertence AP, Dora MD. Color Doppler sonography of normal and torsed testicular appendages in children. AJR Am J Roentgenol. 2005;184(4):1287-1292. Observational-Dx 33 patients To determine the size and appearance of normal and torsed testicular appendages on US. Appendix >5.6 mm as the US diagnostic criterion for torsion of a testicular appendage, sensitivity was 68.2% and specificity was 100%. Low sensitivity, but high specificity may preclude need for surgery. 3
27. Harkness G, Meikle G, Craw S, Samalia K. Ultrasound appearance of scrotal fat necrosis in prepubertal boys. Pediatr Radiol. 2007;37(4):370-373. Review/Other-Dx 10 patients Retrospective studies to describe the US appearance of scrotal fat necrosis in pre-pubertal boys. The combination of specific imaging features of scrotal fat necrosis with the characteristic clinical presentation can confirm the diagnosis of scrotal fat necrosis. 4
28. Bilagi P, Sriprasad S, Clarke JL, Sellars ME, Muir GH, Sidhu PS. Clinical and ultrasound features of segmental testicular infarction: six-year experience from a single centre. Eur Radiol. 2007;17(11):2810-2818. Review/Other-Dx 24 patients To analyze the aetiology and US appearances of segmental testicular infarction. Segmental testicular infarction has US features, with reduced or absent vascularity. Awareness of the US features will allow for conservative management and avoid unnecessary orchidectomy. 4
29. Fernandez-Perez GC, Tardaguila FM, Velasco M, et al. Radiologic findings of segmental testicular infarction. AJR Am J Roentgenol. 2005;184(5):1587-1593. Review/Other-Dx 12 patients To describe segmental testicular infarction findings and establish a proper diagnosis that can avoid orchiectomy. 8/12 had acute pain and 3/12 chronic pain. 3/12 had antecedent epididymitis. Suggest US, followed by MRI when necessary. 4
30. Bertolotto M, Derchi LE, Sidhu PS, et al. Acute segmental testicular infarction at contrast-enhanced ultrasound: early features and changes during follow-up. AJR Am J Roentgenol. 2011;196(4):834-841. Observational-Dx 20 men To assess whether contrast-enhanced US is useful for characterization of acute segmental testicular infarction. 14/16 lesions examined within 24 hours were oval, and 2 were wedge shaped. 8 lesions were isoechoic to the testis, 6 were hypoechoic, and 2 had mixed echogenicity. 12 lesions were avascular and 4 were hypovascular at color Doppler examination. Contrast-enhanced US showed avascular parenchymal lobules in all cases and without perilesional rim enhancement in 12/13 studies. 2 to 17 days after the symptoms appeared, contrast-enhanced US showed avascular lobules in all cases and perilesional rim enhancement in 8 examinations. After 1 month or more, contrast-enhanced US depicted intralesional vascular spots in 12/14 infarcts. Perilesional enhancement was absent. 4
31. Valentino M, Bertolotto M, Derchi L, et al. Role of contrast enhanced ultrasound in acute scrotal diseases. Eur Radiol. 21(9):1831-40, 2011 Sep. Observational-Dx 50 patients To evaluate the efficacy of contrast-enhanced US in patients with acute scrotal pain not defined at US with color Doppler. 23 patients had a final diagnosis of testicular tumor, 3 abscess, 8 focal infarction, 7 trauma, 3 testicular torsion, 1 hematoma. 5 patients were negative. 35 patients were operated (23 testicular tumors, 6 trauma, 3 testicular torsion, 1 abscess, 1 focal infarction, and 1 hematoma) and 15 underwent medical treatment or were discharged. US provided a definitive diagnosis in 34/50 as compared to the 48/50 patients diagnosed at contrast-enhanced US. Sensitivity and specificity were 76% and 45% for US and 96% and 100% for contrast-enhanced US, respectively. 3
32. Geiger J, Epelman M, Darge K. The fountain sign: a novel color Doppler sonographic finding for the diagnosis of acute idiopathic scrotal edema. J Ultrasound Med. 29(8):1233-7, 2010 Aug. Review/Other-Dx 10 patients To evaluate the relevance of color Doppler US in children presenting with AISE. Marked bilateral scrotal wall thickening and hyperemia resembling a fountain were detected in the transverse plane on color Doppler US in all patients. 4
33. Lee A, Park SJ, Lee HK, Hong HS, Lee BH, Kim DH. Acute idiopathic scrotal edema: ultrasonographic findings at an emergency unit. Eur Radiol. 2009;19(8):2075-2080. Observational-Dx 12 patients To identify diagnostic features that may help to avoid unnecessary surgical intervention. Easy compressibility was observed in all patients, and blood flow was increased in 11 patients. Enlargement and hypervascularity of the ipsilateral inguinal lymph nodes were observed in all patients. The mean long-axis diameter of the lymph node was 10.4 mm. The testis and epididymis of patients were normal in most cases. US may be a useful diagnostic tool to differentiate AISE from other acute diseases of the scrotum. 3
34. Makela E, Lahdes-Vasama T, Ryymin P, et al. Magnetic resonance imaging of acute scrotum. Scand J Surg. 100(3):196-201, 2011. Observational-Dx 17 boys or young men To evaluate the feasibility of dynamic contrast-enhanced MRI in the detection of testicular ischemia and its ability to differentiate testicle torsion from other causes of acute scrotum. All the normal testicles gave increasing ROI values meanwhile all 3 testicles with torsion gave constantly low values referring to no perfusion. Other causes of acute scrotum, such as epididymitis and torsion of testicular appendage seemed to be related with normal perfusion. Dynamic contrast-enhanced MRI seems to show reliably ischemia of testicle and thus it may be helpful in selecting patients with acute scrotum for urgent operation. 3
35. Terai A, Yoshimura K, Ichioka K, et al. Dynamic contrast-enhanced subtraction magnetic resonance imaging in diagnostics of testicular torsion. Urology. 2006;67(6):1278-1282. Observational-Dx 39 patients To retrospectively correlate MRI diagnosis with surgical findings and/or clinical outcomes in patients with an acute scrotum. Highly selected population, ie, “inconclusive differential diagnosis on physical examination and/or Doppler US.” MRI sensitivity 93%, specificity 100%. 3
36. Watanabe Y, Nagayama M, Okumura A, et al. MR imaging of testicular torsion: features of testicular hemorrhagic necrosis and clinical outcomes. J Magn Reson Imaging. 2007;26(1):100-108. Observational-Dx 14 patients To determine if emergency subtraction dynamic contrast-enhanced MRI and T2- and T2-weighted imaging of the testis is useful in the evaluation testicular torsion. In 10/14 patients MRI revealed total or partial necrosis of the affected. In the diagnosis of complete torsion, the sensitivities were 100% for dynamic contrast-enhanced MRI and 75% for T2- and T2-weighted imaging. In the detection of testicular necrosis, T2- and T2-weighted imaging showed the highest accuracy (100%), followed by 12-hour time from onset (93%), intraoperative findings (79%), and dynamic contrast-enhanced MRI (71%). 3
37. Maki D, Watanabe Y, Nagayama M, et al. Diffusion-weighted magnetic resonance imaging in the detection of testicular torsion: feasibility study. J Magn Reson Imaging. 34(5):1137-42, 2011 Nov. Observational-Dx 28 patients To investigate the feasibility and usefulness of diffusion-weighted magnetic resonance imaging in the detection of testicular torsion. Diffusion-weighted and ADC images with diagnostic quality were obtained in 23 out of the 28 patients (82%). In testicular torsion (n = 9), the mean ADC value of the twisted testes was significantly lower than that of the nonaffected testes (0.750 +/- 0.297 vs. 1.017 +/- 0.165 x 10(-3) mm(2)/sec, P < 0.05). In other scrotal disorders (n = 14), there was no significant difference in the mean ADC value of the testes between the affected and nonaffected side (P = 0.655). The affected-to-nonaffected ratio of ADC value was significantly lower in testicular torsion than that in other scrotal disorders (P < 0.05). 3
38. Amini B, Patel CB, Lewin MR, Kim T, Fisher RE. Diagnostic nuclear medicine in the ED. [Review]. Am J Emerg Med. 29(1):91-101, 2011 Jan. Review/Other-Dx N/A To describe the indications and nuclear medicine techniques used for the evaluation of low-risk patients with chest pain, suspected pulmonary embolus, acute cholecystitis, gastrointestinal bleeding, acute scrotum, and the radiographically occult fracture. Myocardial perfusion imaging is the most exciting, useful, and underused class of nuclear medicine studies available to emergency physicians, in addition to other nuclear medicine studies that remain useful in the emergency department for more carefully selected patient populations. 4
39. Melloul M, Paz A, Lask D, Manes A, Mukamel E. The value of radionuclide scrotal imaging in the diagnosis of acute testicular torsion. Br J Urol. 1995;76(5):628-631. Observational-Dx 87 patients To assess the accuracy of radionuclide scrotal imaging in the diagnosis of testicular torsion and torsion of testicular appendages. Of the 87 patients, 44 underwent scrotal exploration and 42 patients were treated conservatively. One patient with a ‘missed torsion’ pattern on radionuclide scrotal imaging refused operation and was lost to follow-up. Of the 44 patients who underwent surgery, testicular torsion was found in 30 and torsion of testicular appendages in 14 patients. The specificity of the radionuclide scrotal imaging in diagnosing testicular torsion was 100% and the sensitivity was 98%. An area of increased tracer activity in the presence of a normal radionuclide angiogram was suggestive of torsion of testicular appendages with a specificity of 93%. Of the 42 patients who were treated conservatively, 19 had epididymitis, according to clinical and radionuclide scrotal imaging findings, 10 had torsion of testicular appendages, 2 had orchiepididymitis, 2 had hydrocele, 2 had haematocele and 7 patients had normal testes. At a follow-up examination, normal testicles were found in all 42 patients. 3
40. Paltiel HJ, Connolly LP, Atala A, Paltiel AD, Zurakowski D, Treves ST. Acute scrotal symptoms in boys with an indeterminate clinical presentation: comparison of color Doppler sonography and scintigraphy. Radiology. 1998;207(1):223-231. Observational-Dx 41 boys To compare the performance of color Doppler US and scintigraphy in assessing testicular perfusion in boys with clinically equivocal presentations. Color Doppler US demonstrated 9/11 cases of torsion and 23/30 cases of nontorsion, with 1 false-positive and 8 indeterminate studies. Scintigraphy demonstrated 10/11 cases of torsion and 29/30 cases of nontorsion, with 2 indeterminate studies (both in patients with inguinal testis). When indeterminate studies were considered positive for torsion, specificity was 77% for color Doppler US vs 97% for scintigraphy (P=.05). There were no other statistically significant differences between the sensitivities and specificities. 3
41. Hod N, Maizlin Z, Strauss S, Horne T. The relative merits of Doppler sonography in the evaluation of patients with clinically and scintigraphically suspected testicular torsion. Isr Med Assoc J. 2004;6(1):13-15. Observational-Dx 75 total patients: 27 with testicular torsion. Retrospective review to assess the diagnostic value of Doppler US in patients with acute scrotal pain and scintigraphic findings suggestive of testicular torsion. 27 patients had scintigraphic findings suggestive of testicular torsion. Doppler US was 95% specific and 86% sensitive for testicular torsion. Doppler US should be used as the first. Scintigraphy should be performed only in certain settings of equivocal US findings to prevent false negative US diagnosis. 3
42. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide guidelines on exposure of patients to ionizing radiation. No abstract available. 4