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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Velasquez J, Boniface MP, Mohseni M. Acute Scrotum Pain: StatPearls Publishing, Treasure Island (FL); 2022. Review/Other-Dx N/A To review the evaluation and management of acute scrotum pain and highlights the role of the interprofessional team in caring for patients affected by it. No results stated in abstract. 4
2. Schick MA, Sternard BT. Testicular Torsion: StatPearls Publishing, Treasure Island (FL); 2022. Review/Other-Dx N/A To highlight the role of the interprofessional team in recognizing and treating testicular torsion. No results stated in abstract. 4
3. Bourke MM, Silverberg JZ. Acute Scrotal Emergencies. [Review]. Emergency Medicine Clinics of North America. 37(4):593-610, 2019 Nov. Review/Other-Dx N/A To explain how to diagnose and manage scrotal emergencies such as testicular torsion, Fournier gangrene, and testicular trauma. No results stated in abstract. 4
4. Kyaw L, Choo CSC, Ong LY, Yap TL, Teo HJ, Nah SA. Management of acute testicular pain in children: changing trends with improvements in scrotal ultrasonography over 18 years. Singapore Medical Journal. 64(4):249-254, 2023 04. Observational-Dx 519 boys To evaluate the performance of scrotal US in diagnosing testicular torsion over the past 18 years in our institution and determine the factors contributing to the length of wait times for it. Of these, 438 (84.4%) boys had undergone initial scrotal US; of these scrotal US cases, 28 were surgically explored, with 23 confirmed to have torsion. Another five cases were explored without prior US, and all were confirmed to have torsion. Performance analysis of US showed a sensitivity of 100% and a specificity of 98.8%. There was no significant difference between wait times of operated and non-operated patients. Time to US (P < 0.0001, r = 0.96) and time to OT (P < 0.0001, r = 0.64) correlated significantly with the total time from presentation to surgery. 3
5. 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
6. Cassar S, Bhatt S, Paltiel HJ, Dogra VS. Role of spectral Doppler sonography in the evaluation of partial testicular torsion. J Ultrasound Med 2008;27:1629-38. Review/Other-Dx 8 cases To evaluate the role of spectral Doppler and color flow Doppler sonography in the evaluation of partial testicular torsion. Testicles with partial testicular torsion showed variable spectral Doppler patterns, including increased, similar, or decreased amplitude of the arterial waveform relative to the contralateral testicle. Two cases showed reversal of arterial diastolic flow, and 1 case showed diastolic flow variability within the same testicle. Decreased blood flow was observed on color flow Doppler sonography in 7 of the 8 patients. 4
7. Carter CT, Brown A. Genitourinary Emergencies. In: Stone CK, Humphries RL, eds. CURRENT Diagnosis &amp; Treatment: Emergency Medicine, 8e. New York, NY: McGraw-Hill Education; 2017. Review/Other-Dx Book To present concise, easy-to-read, practical information on the diagnosis and treatment of a wide spectrum of conditions that present to the emergency department. The chapters emphasize the immediate management of life-threatening problems then present the evaluation and treatment of specific disorders. We trust that this text will aid all practitioners of emergency medicine in providing care to their patients. No results stated in abstract. 4
8. Dogra V, Bhatt S. Acute painful scrotum. Radiol Clin North Am 2004;42:349-63. Review/Other-Dx N/A To familiarize the reader with new technology and provide new insights into the sonographic diagnosis of painful scrotum. No results stated in abstract. 4
9. Trojian TH, Lishnak TS, Heiman D. Epididymitis and orchitis: an overview. Am Fam Physician 2009;79:583-7. Review/Other-Dx N/A To help differentiate epididymitis and orchitis from testicular torsion, which is a surgical emergency. No results stated in abstract. 4
10. NAMCS/NHAMCS - Ambulatory Health Care Data.  Available at: https://www.cdc.gov/nchs/ahcd/index.htm. Review/Other-Dx N/A To collect data on the utilization and provision of ambulatory care services in hospital emergency and outpatient departments and ambulatory surgery locations. No results stated in abstract. 4
11. Al-Taheini KM, Pike J, Leonard M. Acute epididymitis in children: the role of radiologic studies. Urology 2008;71:826-9; discussion 29. Observational-Dx 16 patients To assess the role of radiologic studies in the detection of significant urologic anomalies in boys with acute epididymitis. Fifteen of 16 patients had upper tract imaging (13 renal ultrasound and 2 intravenous pyelogram [IVP]). All upper tract imaging studies were normal. VCUG was performed in 13 of 16 patients, and was normal in 12 of 13 patients. One patient had reflux to right seminal vesicle, which resolved spontaneously on a follow-up study. The follow-up period ranged from 1 month to 11 years (median 2 months). None of the patients had recurrent epididymitis, except the individual who had reflux to seminal vesicle. 4
12. Van Glabeke E, Khairouni A, Larroquet M, Audry G, Gruner M. Acute scrotal pain in children: results of 543 surgical explorations. Pediatr Surg Int 1999;15:353-7. Observational-Dx 543 patients To describe the findings of pre-surgical examination and surgical exploration in 543 children. A total of 543 boys suffering from acute scrotal pain underwent emergency surgery. Of these, 91 had a testicular torsion (TT) (16.8%) and 250 had an appendage torsion (AT) (46%). The cause varied with patient age, with most TTs in newborns and boys of 15 years and most ATs in 10±11- year-olds; 21.5% were operated upon within 6 h of the onset of pain and 69.2% within 24 h. Most stayed in hospital for less than 24 h. 4
13. Noske HD, Kraus SW, Altinkilic BM, Weidner W. Historical milestones regarding torsion of the scrotal organs. J Urol 1998;159:13-6. Review/Other-Dx N/A To describe the historical development of diagnosis of torsion. No results stated in abstract. 4
14. Jefferies MT, Cox AC, Gupta A, Proctor A. The management of acute testicular pain in children and adolescents. [Review]. BMJ. 350:h1563, 2015 Apr 02. Review/Other-Dx N/A To review the salient points in the history and clinical examination of acute scrotum to facilitate accurate diagnosis and prompt treatment of the most common presentations. No results stated in abstract. 4
15. Makela E, Lahdes-Vasama T, Rajakorpi H, Wikstrom S. A 19-year review of paediatric patients with acute scrotum. Scand J Surg 2007;96:62-6. Observational-Tx 388 consecutive boys under 17 years of age To compare incidence, symptoms and signs of spermatic cord torsion to those of other conditions causing acute scrotum. Scrotal explorations revealed 100 cases (26%) of spermatic cord torsion (SCT), 174 cases (45%) of torsion of the testicular appendage (AT), 38 cases (10%) of epididymitis (ED), 32 cases (8%) of incarcerated inquinal hernias and 44 (11%) other conditions. During the first year of life SCT was the most common cause of acute scrotum, another peak incidence being in adolescence. Almost half of the boys with AT were nine to 12 years of age (median 11). Except for infants, the patients' acute symptoms were pain (SCT 88%, AT 94%, ED 76%). Swelling in the hemiscrotum was found in 44% of SCT, in 39% of AT and in 88% of ED cases. Epididymitis was also accompanied by erythema (37%), but infrequently with fever (in 16%). Erythema was found also in AT (32%), but the "blue dot sign" was found positive in only 17 (10%) of the boys with AT. Three quarters of the boys who were operated on within six hours from onset of symptoms had testicle torsion. All testicles were saved when detorsion was performed within six hours, but salvage was possible in only half of the cases when symptoms had lasted more than six but less than 12 hours. 3
16. Yang C Jr, Song B, Liu X, Wei GH, Lin T, He DW. Acute scrotum in children: an 18-year retrospective study. Pediatric Emergency Care. 27(4):270-4, 2011 Apr. Observational-Dx 1215 patients To compare clinical manifestations, physical examination findings, laboratory, and radiographic dates in pediatric patients with different pathological diagnoses of acute scrotum as well as to accurately establish the true incidence of various pathological diagnoses of acute scrotum. Duration of pain less than 6 hours, fever, vomiting, history of trauma or activities, absence of cremasteric reflex, and abnormal testicle direction were significantly associated with testicular torsion. Blue dot sign and tender nodule were found significantly associated with torsion of the testicular appendix. Ultrasound showed decreased or absent blood flow in 91.3% testicular torsion patients; enlarged epididymis was found in 91.1% and 91.3% patients with torsion of the testicular appendix and epididymitis, respectively; and scrotal wall edema and hydrocele were found significantly associated with tunica vaginalis inflammation. Our salvageability rate in testicular torsion was 30.1%. 3
17. Boettcher M, Bergholz R, Krebs TF, Wenke K, Aronson DC. Clinical predictors of testicular torsion in children. Urology. 79(3):670-4, 2012 Mar. Observational-Dx 138 patients To distinguish the prognostic factors that decrease the probability of a negative exploration for "acute scrotum." Of the 138 patients, 19 (13.8%) had TT. This group was compared with the boys without TT at exploration. The patients with TT were older on average (11 years, 1 month vs 9 years, 1 month, p = .035). Pain for <24 hours (OR 4.2, 95% CI 1.3-13.4), nausea and/or vomiting (OR 21.6, 95% CI 4.9-93.4), abnormal cremasteric reflex (OR 4.8 95% CI 0.7-35.2), and a high position of the testis (OR 18.0 95% CI 1.8-177.1) were associated with an increased likelihood of torsion. In the group of boys with = 2 of these findings present, 100% had TT at exploration, with 0% false-positive results. 3
18. Fujita N, Tambo M, Okegawa T, Higashihara E, Nutahara K. Distinguishing testicular torsion from torsion of the appendix testis by clinical features and signs in patients with acute scrotum. Res Rep Urol 2017;9:169-74. Review/Other-Dx 70 patients To evaluate the clinical features and signs that can help distinguish TT from TAT. Patients with TT were significantly older than those with TAT (p < 0.001). The ambient temperature at onset was significantly lower in patients with TT than in patients with TAT (p = 0.038). Testicular swelling, high-riding testes, onset during sleep, high leukocyte counts, and high creatine phosphokinase levels were significantly more common in patients with TT than with TAT (p = 0.021, 0.032, 0.006, 0.003, and 0.043, respectively). Multivariate analysis showed that age and onset during sleep were significant independent factors for detection of TT. Eight patients (16.3%) underwent preoperative CDUS evaluation, and an absent or decreased blood signal in the involved testes was significantly correlated with the presence of TT (p = 0.018). 4
19. Molokwu CN, Somani BK, Goodman CM. Outcomes of scrotal exploration for acute scrotal pain suspicious of testicular torsion: a consecutive case series of 173 patients. BJU International. 107(6):990-3, 2011 Mar. Observational-Tx 173 patients To determine the surgical outcome of all scrotal explorations performed on patients presenting with acute scrotal pain suspicious of testicular torsion. The median age of the patients was 14 (0-92) years. 51% (n = 89) had testicular torsion, 24% (n = 42) had torsion of testicular appendages, 9% (n = 16) had epididymo-orchitis, and other pathology made up 5%. No obvious pathology was seen in 10% (n = 17). Patients with Torsion of Appendages were significantly younger than other patients with scrotal pain (P < 0.0001). Age was not useful in discriminating between patients with Testicular Torsion from other patients with scrotal pain. 9% (n = 16) of all patients required an orchidectomy. Frequency of Testicular Torsion was higher during the colder half of the year (n = 0.02). 2
20. Lee LK, Monuteaux MC, Hudgins JD, et al. Variation in the evaluation of testicular conditions across United States pediatric emergency departments. American Journal of Emergency Medicine. 36(2):208-212, 2018 Feb. Review/Other-Dx 17,000 males To explore the variation in diagnostic testing and management for males diagnosed with three testicular conditions (testicular torsion, appendix testis torsion, epididymitis/orchitis) using a large pediatric health care database. There was substantial variation among hospitals in all categories of testing for each of the diagnoses. Overall, ultrasound utilization ranged from 33.1-100% and urinalysis testing ranged from 17.0-84.9% for all conditions. Only urine culture testing decreased over time for all three diagnoses (40.6% in 2010 to 31.5 in 2015). 4
21. Zhao LC, Lautz TB, Meeks JJ, Maizels M. Pediatric testicular torsion epidemiology using a national database: incidence, risk of orchiectomy and possible measures toward improving the quality of care. Journal of Urology. 186(5):2009-13, 2011 Nov. Review/Other-Tx 2,443 boys and 152 newborns To determine the modern incidence of testicular torsion as well as the current rates of orchiectomy and attempted testicular salvage, and identified the risk factors for testicular loss. The overall mean age ± SD at presentation was 10.6 ± 5.8 years. The estimated yearly incidence of testicular torsion for males younger than 18 years old was 3.8 per 100,000. Orchiectomy was performed in 41.9% of boys undergoing surgery for torsion. The adjusted odds ratio for orchiectomy was highest for children in the youngest age quartile (younger than 10 years old, OR 1.58, 95% CI 1.25-2.00). Additional independent predictors of orchiectomy included Medicaid insurance (OR 1.39, 95% CI 1.14-1.69), black race (OR 1.33, 95% CI 1.04-1.71), nonemergency room admission source (OR 1.97, 95% CI 1.60-2.42) and surgery at a children's hospital or unit (OR 1.64, 95% CI 1.36-1.98). 4
22. Mellick LB, Sinex JE, Gibson RW, Mears K. A Systematic Review of Testicle Survival Time After a Torsion Event. Pediatric Emergency Care. 35(12):821-825, 2019 Dec. Review/Other-Tx N/A To provide a more accurate understanding of reported time frames of testicle survival after a torsion event. No results stated in abstract. 4
23. Barbosa JABA, de Freitas PFS, Carvalho SAD, et al. Validation of the TWIST score for testicular torsion in adults. International Urology & Nephrology. 53(1):7-11, 2021 Jan. Observational-Dx 68 patients To validate the TWIST Score applied by non-expert physicians for the diagnosis of testicular torsion in an adult population. Of 68 patients, 34 had TT (50%). Median age was 24.9 years. According to the original cutoffs of TWIST, 23 patients had a score = 2 among which none had TT. Fifteen patients had a score of 3-4, among which seven had TT. Thirty patients had a score = 5, among which 27 had TT. All 18 patients with a score of 6 or greater had TT (100% PPV). ROC curve revealed an AUC of 0.95. 2
24. Barbosa JA, Tiseo BC, Barayan GA, et al. Development and initial validation of a scoring system to diagnose testicular torsion in children. Journal of Urology. 189(5):1859-64, 2013 May. Observational-Dx 338 patients in prospective phase including 116 cases of acute scrotum for retrospective analysis. To create a scoring system to diagnose testicular torsion, decreasing the indication for ultrasound. The scoring system consisted of testicular swelling (2 points), hard testicle (2), absent cremasteric reflex (1), nausea/vomiting (1) and high riding testis (1). Cutoffs for low and high risk were 2 and 5 points, respectively. Ultrasound would be indicated only for the intermediate risk group. In the prospective data set 69% of patients had low, 19% intermediate and 11.5% high risk. Negative and positive predictive values were 100% for cutoffs of 2 and 5, respectively (specificity 81%, sensitivity 76%). Retrospective validation in 1 data set showed 66% of patients at low, 16% intermediate and 17% high risk. Negative and positive predictive values for cutoffs of 2 and 5 were 100% (specificity 97%, sensitivity 54%). The second retrospective data set included only torsion cases, none of which was misdiagnosed by the scoring system. 2
25. Cabo J, Graham K, Chen H, et al. Increasing utilization of the TWIST score in workup of patients with acute scrotal pain: Role in diagnosis and risk stratification. Journal of pediatric urology. 18(6):845.e1-845.e8, 2022 12. Observational-Dx 103 patients To achieve 100% compliance in TWIST utilization among urology and ED residents and to assess for score concordance between ED and urology assessments. Secondary goals were correlation of TWIST components with need for orchiectomy. As compared to our retrospective cohort, the documentation rate of complete TWIST score components on exam rose from 9% to 98% (P < 0.001) on ED evaluation and 16%-66% on urology evaluation (P < 0.001). Rates of repeat ultrasound for patient's transferred between facilities was similar (58% vs. 63%; p = 0.66) as was median time to OR (160 min vs. 145 min; p = 0.5). Using TWIST cutoff of >5 yielded a specificity of 94.5% for diagnosis of torsion, with corresponding strong correlation between ED and urology scores (rho = 0.71). A firm testicle was noted on urology evaluation in 100% of orchiectomy patients (vs. 61% of salvage patients) with persistent association after controlling for duration of symptoms (OR 28.1; P = 0.016). 3
26. Sheth KR, Keays M, Grimsby GM, et al. Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score. Journal of Urology. 195(6):1870-6, 2016 06. Observational-Dx 128 patients To assess the usefulness of the TWIST score when determined by nonurological nonphysician providers, mirroring emergency room evaluation of acute scrotal pain. TWIST score cutoff values of 0 and 6 derived from ROC analysis identified 31 high, 57 intermediate and 40 low risk cases (positive predictive value 93.5%, negative predictive value 100%) 2
27. Jakobsen JA. Ultrasound contrast agents: clinical applications. Eur Radiol 2001;11:1329-37. Review/Other-Dx N/A To discuss the clinical application of ultrasound contrast agent. No results stated in abstract. 4
28. Tang C, Fang K, Guo Y, et al. Safety of Sulfur Hexafluoride Microbubbles in Sonography of Abdominal and Superficial Organs: Retrospective Analysis of 30,222 Cases. J Ultrasound Med 2017;36:531-38. Review/Other-Dx 30,222 patients To investigate the safety of the sulfur hexafluoride microbubble contrast agent SonoVue (Bracco SpA, Milan, Italy) and to implement precautions with the intent of further improving the safety of this contrast agent. No patient died as a result of any adverse reaction. Six patients (0.020%) had adverse reactions of varying degrees, including 2 patients (0.007%) who had signs of early anaphylactic shock (chest tightness, palpitations, sweating, and rapid and weak pulse, followed by cyanosis, a disappearing pulse, and a drop in blood pressure) that improved after active rescue. The remaining 4 patients developed the following: redness and a rash on the arm above the injection site, nasal bleeding and nausea, nausea and vomiting, and back pain with numbness of the lips and limbs. Symptoms in these 4 patients self-resolved after a period of rest. 4
29. Appis AW, Tracy MJ, Feinstein SB. Update on the safety and efficacy of commercial ultrasound contrast agents in cardiac applications. Echo Res Pract 2015;2:R55-62. Review/Other-Dx N/A To focus on the use of UCAs in today's clinical practice, including the approved indications, a variety of off-label uses, and the most recent data, which affirms the safety and efficacy of UCAs. No results stated in abstract. 4
30. Piscaglia F, Bolondi L, Italian Society for Ultrasound in M, Biology Study Group on Ultrasound Contrast A. The safety of Sonovue in abdominal applications: retrospective analysis of 23188 investigations. Ultrasound Med Biol 2006;32:1369-75. Review/Other-Dx 23,188 investigations To assess the incidence of adverse events (AE) of a second-generation ultrasound contrast agent in real clinical practice. A total of 23,188 investigations were reported. No fatal event occurred. AEs were reported in 29 cases, of which only two were graded as serious; the rest, 27, were nonserious (23 mild, three moderate and one severe). The overall reporting rate of serious AE was 0.0086%. Overall, only four AEs required treatment (two serious, two nonserious including one moderate and one severe AEs). 4
31. Tenuta M, Sesti F, Bonaventura I, et al. Use of contrast enhanced ultrasound in testicular diseases: A comprehensive review. [Review]. Andrology. 9(5):1369-1382, 2021 09. Review/Other-Dx N/A To perform a nonsystematic review of the current literature to highlight the strength and flaws of performing CEUS and to provide a critical overview of current research evidence on this topic. No results stated in abstract. 4
32. Cantisani V, Bertolotto M, Weskott HP, et al. Growing indications for CEUS: The kidney, testis, lymph nodes, thyroid, prostate, and small bowel. [Review]. European Journal of Radiology. 84(9):1675-84, 2015 Sep. Review/Other-Dx N/A To present updated knowledge on CEUS application in the following fields: urogenital system (kidney, prostate and testicle), thyroid, small bowel and lymph nodes. No results stated in abstract. 4
33. Malferrari G, Pulito G, Pizzini AM, et al. MicroV Technology to Improve Transcranial Color Coded Doppler Examinations. J Neuroimaging 2018;28:350-58. Review/Other-Dx N/A To provide an update on technology related to Transcranial Color Coded Doppler Examinations. No results stated in abstract. 4
34. Visalli C, Mormina E, Tessitore A, et al. Acute scrotal pain in pediatric patients: diagnosis with an innovative Doppler technique (MicroV). Emerg Radiol 2021;28:209-14. Review/Other-Dx 1 patient To report a case of a pediatric patient suffering from acute scrotal pain assessed ultrasonographically with this innovative Doppler technique (MicroV) that may give more confidence in detecting testicular vascular signals if compared with traditional Doppler techniques. No results stated in abstract. 4
35. Turna O, Alis D. A comparative study of shear wave elastography in the evaluation of undescended and retractile testes in a pediatric population. J Med Ultrason (2001). 46(2):231-237, 2019 Apr. Observational-Dx 37 undescended testes (UDT) To evaluate the diagnostic value of shear wave elastography (SWE) in the evaluation of undescended and retractile testes (RT) in a pediatric population. The mean stiffness values of the UDT (13.80 ± 4.14 kPa, 2.14 ± 0.29 m/s) were higher than the mean SWE values of the normal testes (7.44 ± 2.11 kPa, 1.57 ± 0.21 m/s) (p < 0.0001). The mean stiffness values of the RT (9.64 ± 3.71 kPa, 1.75 ± 0.35 m/s) exceeded those of the normal testes (p = 0.004 for elasticity and p = 0.02 for speed). The mean stiffness value of the UDT was higher than the retractile ones (p < 0.0001 for elasticity and speed). 3
36. Xue E, Yu Y, Lin L, Li Z, Su H. Application value of real-time shear wave elastography in differential diagnosis of testicular torsion. Medical Ultrasonography. 22(1):43-48, 2020 03 01. Observational-Dx 30 patients and 20 healthy volunteers To evaluate the clinical value of real-time shear wave elastography (SWE) in differential diagnosis of testicular torsion and acute orchiditis. Emax value of the testicular capsule in the torsion group was higher than in the acute inflammation group (138.76±58.27 vs 16.40±4.71 kPa, p=0.0001). Emax value in the middle parenchyma of the testis showed no statistically significant difference between groups (p=0.053). Emax value in the twisted spermatic segment was higher than that in the lower spermatic segment with acute inflammation (166.61±60.07 vs 14.14±4.93, p=0.0001). In the torsion group, 12 testicular capsule areas showed "stiff ring sign" and all twisted segments of spermatic cord showed "stiff knot sign" but no signs were found in the inflammatory group. 3
37. Khatri G, Bhosale PR, Robbins JB, et al. ACR Appropriateness Criteria® Newly Diagnosed Palpable Scrotal Abnormality. J Am Coll Radiol 2022;19:S114-S20. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for newly diagnosed palpable scrotal abnormality, No results stated in abstract. 4
38. Schieda N, Oto A, Allen BC, et al. ACR Appropriateness Criteria® Staging and Surveillance of Testicular Cancer: 2021 Update. J Am Coll Radiol 2022;19:S194-S207. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for staging and surveillance of testicular cancer. No results stated in abstract. 4
39. Tsili AC, Argyropoulou MI, Dolciami M, Ercolani G, Catalano C, Manganaro L. When to ask for an MRI of the scrotum. [Review]. Andrology. 9(5):1395-1409, 2021 09. Review/Other-Dx N/A To summarize current research on when to ask for an MRI of the scrotum. No results stated in abstract. 4
40. Tsili AC, Bertolotto M, Turgut AT, et al. MRI of the scrotum: Recommendations of the ESUR Scrotal and Penile Imaging Working Group. [Review]. European Radiology. 28(1):31-43, 2018 Jan. Review/Other-Dx N/A To present recommendations for magnetic resonance imaging (MRI) of the scrotum. No results stated in abstract. 4
41. Gotto GT, Chang SD, Nigro MK. MRI in the diagnosis of incomplete testicular torsion. Br J Radiol 2010;83:e105-7. Review/Other-Dx 1 patient To present a case of subacute left testicular pain and enlargement. Scrotal Doppler ultrasound revealed an enlarged left testicle with symmetrical intra-testicular colour flow bilaterally. Contrast-enhanced MRI demonstrated incomplete testicular torsion which was verified at surgery. 4
42. Sanelli PC, Burke BJ, Lee L. Color and spectral doppler sonography of partial torsion of the spermatic cord. AJR Am J Roentgenol 1999;172:49-51. Review/Other-Dx N/A To present a case of partial torsion of the spermatic cord in which normal color Doppler flow pattern was observed in the testes. No results stated in abstract. 4
43. Cramer BM, Schlegel EA, Thueroff JW. MR imaging in the differential diagnosis of scrotal and testicular disease. Radiographics 1991;11:9-21. Review/Other-Dx 200 patients To describe our experience with magnetic resonance imaging in a series of 200 patients with suspected testicular abnormalities. 200 patients with testicular abnormalities were studied. For 74 of these patients, the diagnosis was cancer, based on clinical and US findings. MR imaging demonstrated malignant disease in 54 patients and benign disease in 20. All of the MR imaging findings were confirmed at surgical biopsy. 4
44. Mittal PK, Abdalla AS, Chatterjee A, et al. Spectrum of Extratesticular and Testicular Pathologic Conditions at Scrotal MR Imaging. [Review]. Radiographics. 38(3):806-830, 2018 May-Jun. Review/Other-Dx N/A To discuss the anatomy and MR imaging features of testicular and extratesticular neoplastic and nonneoplastic conditions and describes relevant MR imaging techniques. No results stated in abstract. 4
45. Muglia V, Tucci S, Jr., Elias J, Jr., Trad CS, Bilbey J, Cooperberg PL. Magnetic resonance imaging of scrotal diseases: when it makes the difference. Urology. 2002; 59(3):419-423. Observational-Dx 622 patients had US; 26 were selected for MRI To investigate the utility of MRI after inconclusive US in the evaluation of scrotal disease. MRI yielded additional and correct information (compared with US), coincident with the final diagnosis in 23 cases (82.1%). In regard to lesions suspected of malignancy at US (17 cases), MRI had a great concordance with the final diagnosis and was statistically significant (P<0.002, kappa test). Results indicate that MRI could help elucidate scrotal dilemmas found at US, although the small percentage of inconclusive sonograms confirms this technique as the first choice when imaging is required in scrotal diseases. 3
46. Parenti GC, Feletti F, Brandini F, et al. Imaging of the scrotum: role of MRI. Radiol Med (Torino). 114(3):414-24, 2009 Apr. Observational-Dx 801 patients; color Doppler US study followed by MRI in 46 patients To evaluate the usefulness of imaging for correct clinical and therapeutic management of patients with scrotal disease. Patients with suspected scrotal disease underwent color Doppler US. Color Doppler US revealed an inflammatory process in 277 patients (34.58%), testicular trauma in 112 (13.9%), funicular torsion or torsion of the vestigial remnant in 44 (5.4%), findings suggestive of testicular neoplasm in 35 (4.3%) and no abnormality in 41.5%. MRI, used to further investigate the color Doppler US findings in 46 cases, showed three cases of intraparenchymal haematoma, one of intrascrotal cavernous body rupture, one of testicular abscess with intrascrotal fistula, two of testicular infarction and 15 of neoplasm. MRI allowed the exclusion of focal abnormalities in ten patients with TM, in three with chronic orchitis and in four with atrophic involution. MRI confirmed the finding of inguinal hernia in three cases. Color Doppler US is irreplaceable as an initial approach to patients affected by scrotal disease, whereas MRI is an ideal second-line investigation. MRI offers useful, and in some cases decisive, information, as it is capable of revealing unexpected findings and elucidating complex aspects. MRI helps improve patient management, with an overall reduction in costs. 4
47. Parenti GC, Feletti F, Carnevale A, Uccelli L, Giganti M. Imaging of the scrotum: beyond sonography. [Review]. Insights Into Imaging. 9(2):137-148, 2018 Apr. Review/Other-Dx N/A To describe the role of second-level imaging techniques after an initial ultrasonography evaluation in the assessment of scrotal diseases. No results stated in abstract. 4
48. 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
49. Avery LL, Scheinfeld MH. Imaging of penile and scrotal emergencies. Radiographics. 33(3):721-40, 2013 May. Review/Other-Dx N/A To help radiologists accurately and rapidly diagnose time-sensitive infectious, inflammatory, and traumatic penile and scrotal emergencies. No results stated in abstract. 4
50. 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
51. Kim W, Rosen MA, Langer JE, Banner MP, Siegelman ES, Ramchandani P. US MR imaging correlation in pathologic conditions of the scrotum. Radiographics 2007;27:1239-53. Review/Other-Dx N/A To present a pictorial review of sonographic finds of scrotal lesions correlated with their MR imaging appearances. No results stated in abstract. 4
52. 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
53. Sriprasad S, Kooiman GG, Muir GH, Sidhu PS. Acute segmental testicular infarction: differentiation from tumour using high frequency colour Doppler ultrasound. Br J Radiol 2001;74:965-7. Review/Other-Dx N/A To report a case of segmental testicular infarction presenting as a heterogeneous mass on B-mode ultrasound, confidently diagnosed as an area of infarction on high frequency colour Doppler ultrasound and proven on histology. No results stated in abstract. 4
54. Sweet DE, Feldman MK, Remer EM. Imaging of the acute scrotum: keys to a rapid diagnosis of acute scrotal disorders. [Review]. Abdominal Radiology. 45(7):2063-2081, 2020 07. Review/Other-Dx N/A To describe normal scrotal anatomy and a wide range acute scrotal disorders, with emphasis on the imaging and clinical features that can minimize the risk of misdiagnosis. No results stated in abstract. 4
55. Tsili AC, Bertolotto M, Rocher L, et al. Sonographically indeterminate scrotal masses: how MRI helps in characterization. [Review]. Diagnostic & Interventional Radiology. 24(4):225-236, 2018 Jul. Review/Other-Dx N/A To present how MRI helps in the characterization of sonographically indeterminate scrotal masses and to emphasize the key MRI features of benign scrotal masses. No results stated in abstract. 4
56. Mathur M, Mills I, Spektor M. Magnetic resonance imaging of the scrotum: pictorial review with ultrasound correlation. [Review]. Abdominal Radiology. 42(7):1929-1955, 2017 07. Review/Other-Dx N/A To showcase the added value of scrotal magnetic resonance imaging (MRI) in the workup of neoplastic and non-neoplastic entities. No results stated in abstract. 4
57. Parenti GC, Sartoni M, Gaddoni E, Zago S, Campioni P, Mannella P. Imaging of segmental testicular infarction: our experience and literature review. [Review]. Radiologia Medica. 117(7):1161-75, 2012 Oct. Observational-Dx 14 patients To evaluate the usefulness of the main methods of diagnostic imaging in patients with segmental testicular infarction (STI) for obtaining accurate clinical and therapeutic approaches. CDUS showed hypoechoic avascular areas suspicious for STI in 14 patients (1.75%). MRI confirmed the presence of predominantly hypointense lesions in T1- and T2-weighted sequences, with perilesional vasculature and no intrinsic contrast enhancement in 13 patients. In follow-up examinations, these abnormalities gradually decreased. This finding was confirmed in the five patients examined with CEUS. Only in one case did MRI reveal discrete intralesional contrast enhancement after injection of contrast medium, and the lesions appeared stable during the CDUS and MRI follow-up; this patient underwent orchiectomy, with a diagnosis of B-cell lymphoma. 3
58. 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
59. 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
60. Baliyan V, Das CJ, Sharma R, Gupta AK. Diffusion weighted imaging: Technique and applications. World J Radiol 2016;8:785-98. Review/Other-Dx N/A To provide insights in to the evolution of DWI as a new imaging paradigm and provides a summary of current role of DWI in various disease processes. No results stated in abstract. 4
61. Koh DM, Collins DJ. Diffusion-weighted MRI in the body: applications and challenges in oncology. AJR Am J Roentgenol 2007;188:1622-35. Review/Other-Dx N/A Review applications and challenges of DWI in the body. DWI derives its image contrast from differences in the motion of water molecules between tissues. Such imaging can be performed quickly without the need for the administration of exogenous contrast medium. The technique yields qualitative and quantitative information that reflects changes at a cellular level and provides unique insights about tumor cellularity and the integrity of cell membranes. Recent advances enable the technique to be widely applied for tumor evaluation in the abdomen and pelvis and have led to the development of whole-body DWI. 4
62. 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
63. Tokuda B, Kiba M, Yamada K, et al. The split sign: The MRI equivalent of the bell clapper deformity. British Journal of Radiology. 92(1095):20180312, 2019 Mar. Observational-Dx 9 patients To define the MRI findings in the bell clapper deformity (BCD) and to retrospectively evaluate its diagnostic ability. In one patient without hydrocele, readers were unable to evaluate the anatomy of the tunica vaginalis. Among seven patients with hydrocele, five had the split sign and all were surgically confirmed as BCD. In two patients with hydrocele but no split sign, one had normal scrotal anatomy and the other had a BCD with a necrotic testis adherent to the scrotal wall. 3
64. Nicola R, Menias CO, Dahiya N, Robinson K, Hara AK, Siegel CL. Review of paratesticular pathology: findings on ultrasound and MRI. [Review]. Abdominal Radiology. 42(2):585-601, 2017 02. Review/Other-Dx N/A To review the ultrasound and MR characteristics of various paratesticular pathologies. No results stated in abstract. 4
65. Parker RA 3rd, Menias CO, Quazi R, et al. MR Imaging of the Penis and Scrotum. [Review]. Radiographics. 35(4):1033-50, 2015 Jul-Aug. Review/Other-Dx N/A To review the basic anatomy of the penis and scrotum as seen at MR imaging and provide a basic protocol for penile and scrotal imaging, with emphasis on the advantages of MR imaging. No results stated in abstract. 4
66. Gupta R, Alobaidi M, Jafri SZ, Bis K, Amendola M. Correlation of US and MRI findings of intratesticular and paratesticular lesions: from infants to adults. Curr Probl Diagn Radiol 2005;34:35-45. Review/Other-Dx N/A To provide additional examples of the utility of MR in assessing intrascrotal disease, as well as illustrate some instances in which MR provided no significant benefit over ultra sound. No results stated in abstract. 4
67. O'Malley RB, Al-Hawary MM, Kaza RK, Wasnik AP, Liu PS, Hussain HK. Rectal imaging: part 2, Perianal fistula evaluation on pelvic MRI--what the radiologist needs to know. [Review]. AJR Am J Roentgenol. 199(1):W43-53, 2012 Jul. Review/Other-Dx N/A To provide an overview of pelvic MRI for the evaluation of perianal fistulas, with a description of the technique, illustration of relevant normal anatomy, and examples of various fistula types. No results stated in abstract. 4
68. 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
69. 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
70. 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
71. Lee FT, Jr., Winter DB, Madsen FA, et al. Conventional color Doppler velocity sonography versus color Doppler energy sonography for the diagnosis of acute experimental torsion of the spermatic cord. AJR Am J Roentgenol 1996;167:785-90. Observational-Dx 5 dogs To compare color Doppler velocity sonography and color Doppler energy sonography for the diagnosis of spermatic cord torsion in a canine model and determined the degree of torsion necessary to acutely halt testicular blood flow. Flow became undetectable by color Doppler velocity sonography and color Doppler energy sonography at 450 degrees in four of five cases and at 540 degrees in one of five cases. We found no significant difference between the velocity and the energy techniques for detecting this absence of flow (p > .05, Wilcoxon test). We found a significant difference in degree of flow for both techniques when comparing controls and all degrees of torsion combined (p < .006, Mann-Whitney test), but significance was achieved at lesser degrees of torsion with the velocity technique than with the energy technique (180 degrees and 360 degrees, respectively, Wilcoxon test). 2
72. Prando D. Torsion of the spermatic cord: the main gray-scale and doppler sonographic signs. Abdom Imaging 2009;34:648-61. Review/Other-Dx N/A To summarize the main clinical signs of the TSC and to illustrate and briefly discuss the US features of this entity, including gray-scale imaging, color Doppler with spectral analysis, and power Doppler sonography. No results stated in abstract. 4
73. 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
74. Gupta A, Dogra V. Role of color flow Doppler ultrasound in the evaluation of acute scrotal pain. [Review]. Andrology. 9(5):1290-1297, 2021 09. Review/Other-Dx N/A To review the role of color flow Doppler in the evaluation of acute scrotal pain, highlighting some of the most commonly seen pathologies such as epididymo-orchitis and testicular torsion. No results stated in abstract. 4
75. Sommers D, Winter T. The scrotum. In: Rumack CM, Levine D, eds. Diagnostic Ultrasound. 5th ed. Philadelphia, PA: Elsevier; 2018:chap 22. Review/Other-Dx Book chapter To provide complete and detailed information on the latest techniques for ultrasound imaging. No results stated in abstract. 4
76. Dogra VS, Gottlieb RH, Oka M, Rubens DJ. Sonography of the scrotum. Radiology 2003;227:18-36. Review/Other-Dx N/A To review the anatomy of the scrotum and the scanning protocol for scrotal US, as well as detailed descriptions of disease processes and their US appearances. No results stated in abstract. 4
77. Sung EK, Setty BN, Castro-Aragon I. Sonography of the pediatric scrotum: emphasis on the Ts--torsion, trauma, and tumors. [Review]. AJR. American Journal of Roentgenology. 198(5):996-1003, 2012 May. Review/Other-Dx N/A To review the different scrotal disease entities in the pediatric population, focusing on acute scrotum, traumatic injuries, and testicular tumors. No results stated in abstract. 4
78. Hamper UM, DeJong MR, Caskey CI, Sheth S. Power Doppler imaging: clinical experience and correlation with color Doppler US and other imaging modalities. Radiographics 1997;17:499-513. Observational-Dx 85 To present our clinical experience with power Doppler US, compare the technique with conventional color Doppler US, and discuss the limitations of power Doppler sonography. Power Doppler US was judged superior to color Doppler US in assessing blood flow in 59 cases (66%), equal in 28 cases (31%), and inferior in two cases (2%). However, the final diagnosis was altered in only four patients (5%). For ex-ample, active extravasation of blood from a pseudoaneurysm after a renal biopsy was detected with power Doppler US but not color Doppler US (Fig 6). Power Doppler US findings did not cause a change in diagnosis in 84 cases (94%). If used alone, power Doppler US would have led to misdiagnosis in one patient (1%). 4
79. Guo X, Sun L, Lei W, Li S, Guo H. Management of testicular torsion <360degree in children: a single-center, retrospective study. Journal of International Medical Research. 48(4):300060519895861, 2020 Apr. Review/Other-Dx 57 patients To summarize clinical manifestations, and physical examination, laboratory examination, and ultrasound results of children with testicular torsion <360°. Ultrasound showed low blood flow in 46 (80.8%) patients. The testis was retained in 41 (72.0%) patients and resected in 16 (28.0%). The testes appeared necrotic at 2 to 3 days after onset for patients with 270° torsion, appeared necrotic at 3 to 4 days after onset for those with 180° torsion, and were not necrotic at 4 to 5 days after onset for those with 90° torsion. The duration of symptoms in children decreased as the torsion angle increased. 4
80. 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
81. Burks DD, Markey BJ, Burkhard TK, Balsara ZN, Haluszka MM, Canning DA. Suspected testicular torsion and ischemia: evaluation with color Doppler sonography. Radiology 1990;175:815-21. Observational-Dx 32 patients To report the results of color doppler sonography in group of patients with scrotal pain in whom testicular ischemia was suspected as a result of possible torsion or of recent herniorrhaphy. Color Doppler sonography was performed in 32 patients with a painful scrotum in whom testicular ischemia from torsion or postherniorrhaphy was clinically suspected. Surgical correlation was available in 15 patients, and scintigraphic correlation was available in 17 patients. Seven of the 32 patients were diagnosed as having testicular ischemia from torsion. Color Doppler flow imaging demonstrated a lack of intratesticular flow in six of the seven testes with torsion and relatively normal intratesticular flow in one of the patients with acute torsion. Normal or increased intratesticular flow was demonstrated by color Doppler in all 57 of the nonischemic testes. Using the single criterion of presence or absence of identifiable intratesticular flow, the authors found that color Doppler was 86% sensitive, 100% specific, and 97% accurate in the diagnosis of torsion and ischemia in the painful scrotum. 4
82. 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
83. 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
84. 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
85. Baud C, Veyrac C, Couture A, Ferran JL. Spiral twist of the spermatic cord: a reliable sign of testicular torsion. Pediatr Radiol 1998;28:950-4. Observational-Dx 30 patients To determine if direct visualisation of the twisted spermatic cord using high resolution US is a reliable sign to assess testicular torsion. In 14 of the 23 cases of torsion, the diagnosis was based on the colour Doppler findings in the scrotum because blood flow was absent in the symptomatic testis and detectable without difficulty on the normal side. In nine cases, CDS was unreliable; in six cases intratesticular perfusion was present in a twisted testis and in three small boys, no colour signal was obtained in either testis. In all cases of torsion, the spiral twist of spermatic cord was detected at the external inguinal ring. The twist induced an abrupt change in spermatic cord course, size and shape below the point of torsion. It appeared in the scrotum as a round or oval, homogeneous or heterogeneous extratesticular mass with or without blood flow, that could be connected cephalad with the normal inguinal cord. In the other seven cases (three late torsions of the appendix testis, one epididymo-orchitis and three torsions with spontaneous reduction), no spiral twist was detectable. 4
86. 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
87. Kalfa N, Veyrac C, Baud C, Couture A, Averous M, Galifer RB. Ultrasonography of the spermatic cord in children with testicular torsion: impact on the surgical strategy. J Urol 2004;172:1692-5; discussion 95. Observational-Dx 44 patients We evaluate whether direct visualization of the twisted cord during emergency high resolution ultrasonography (HRUS) is a reliable sign to diagnose the torsion and whether its absence can dispense with unnecessary surgery. Spermatic cord torsion at surgery was confirmed in all 44 cases. The time lost by the examination was never more than 30 minutes. Intratesticular blood flow was absent in the affected testis in 31 cases, and color Doppler sonography (CDS) was unreliable in the others. In all cases, regardless of CDS findings, HRUS succeeded in detecting the twist as a snail shell-shaped mass measuring 11 to 33 mm. 3
88. Baker LA, Sigman D, Mathews RI, Benson J, Docimo SG. An analysis of clinical outcomes using color doppler testicular ultrasound for testicular torsion. Pediatrics 2000;105:604-7. Observational-Dx 110 patients To delineate the clinical outcomes of color Doppler ultrasound (US) in the equivocal torsion patient. After clinical and radiologic evaluation, torsion was excluded in 110 patients without surgical exploration. In 3 patients, intermittent testicular torsion was diagnosed and in 17 patients, emergent exploration was performed for US diagnosis of testicular torsion. Twenty-five patients (22.7%) were subsequently lost to follow-up. Follow-up of 85 patients with US negative for torsion (mean length of follow-up = 466.9 days) revealed no testicular atrophy in 83. Two patients underwent delayed orchiectomy/contralateral orchiopexy for missed testicular torsion. Of 17 patients with US positive for torsion, 9 underwent orchiectomy for a necrotic torsed testis, 7 viable torsed testes were found, and 1 torsed appendix testis was found. Therefore, color Doppler US for the equivocal acute scrotum yielded a 1% false-positive rate, sensitivity of 88.9%, and specificity of 98.8%. 3
89. 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
90. 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
91. Middleton WD, Siegel BA, Melson GL, Yates CK, Andriole GL. Acute scrotal disorders: prospective comparison of color Doppler US and testicular scintigraphy. Radiology 1990;177:177-81. Observational-Dx 28 patients To compare the results of color Doppler US and testicular scintigraphy in patients with acute scrotal pain. Findings from surgery confirmed testicular torsion in seven patients. All cases were correctly diagnosed with color Doppler US. Scintigraphy enabled correct diagnosis of six, but findings were false-negative in one patient with 180 degrees torsion. One patient had a surgically confirmed scrotal abscess that was correctly diagnosed with both color Doppler US and scintigraphy. Findings from clinical follow-up in the remaining 20 patients were consistent with epididymitis, orchitis, or torsion of an appendix testis. There were no false-positive diagnoses of testicular torsion by means of either color Doppler US or scintigraphy in any of these 20 patients. 2
92. 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 evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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