Introduction

Testicular torsion (TT) is a common urological emergency with the majority of cases occurring in adolescence, making this an important presentation to pediatric emergency departments (EDs). TT accounts for 10-15% of pediatric acute scrotum (1). Testicular torsion typically presents with acute onset, unilateral testicular pain, and may be associated with nausea and vomiting. The differential diagnosis of TT is broad and includes more common diagnoses such as epididymo-orchitis and torsion of the appendix testis (1). 

Cases that are highly suggestive of testicular torsion warrant immediate consultation with urology for de-torsion; however, in cases where the diagnosis is uncertain or at the request of the surgical team, doppler ultrasound is used to confirm the diagnosis prior to surgical intervention. 

 Certain clinical features are highly suggestive of the diagnosis of TT. The Testicular Workup for Ischemia and Suspected Torsion (TWIST) score (Table 1) was developed to help diagnose TT and decrease the use of ultrasound (2,3) . Low TWIST score (0-2) has a sensitivity 98% which allows ruling out TT and high TWIST (5-7) has specificity of 97% which allows ruling in the diagnosis. Ultrasound is helpful to confirm the diagnosis for the intermediate (2-4) risk group (2,4,5). 

 

Table 1. TWIST score for clinical suspicion of testicular torsion. 

Testicular swelling	2 points
Hard testis on palpation	2 points
Absent cremasteric reflex	1 point
High riding testis	1 point
Nausea or vomiting	1 point

 

Delayed diagnosis of TT is associated with loss of testis and infertility. Cases that are highly suggestive of testicular torsion warrant immediate surgical consultation. The European Associatione of Urology 2024 recommendations for pediatric TT include that the clinical decision should be based on physical examination and ultrasound can be used as an adjunct that should not delay definitive care (6). In confirmed cases of TT, early surgical exploration is warranted. 

 

Why PoCUS?

Studies consistently show that the most important factor for testicle viability is the duration of ischemia (7–9). Salvage of the testicle diminishes significantly after 6 hours, making early identification of this condition extremely important for improved patient outcomes (9). The median time from symptom onset to ED presentation for patients with possible TT is 4 hours – leaving only 2 hours for triage, ED physician assessment, work-up, urology consultation and transfer to the operating room to improve chances of testicular viability (7). Delays to definitive care in patients with TT are a preventable cause of orchiectomy in young men (7,10). PoCUS is an easily accessible bedside tool that can be used to expedite care for these patients. It can also help with resource allocation of our radiology performed ultrasounds, especially at centers where this is not readily available 24 hours a day. PoCUS can be used to rule in TT and has been shown to decrease time to OR for testicular torsion and decreased length of stay in ED (10,11). 

 

Testicular PoCUS skills can be acquired rapidly. Competency and skill confidence was achieved by urology and emergency resident following a curriculum which included three audio lectures followed by 1-hour of hands-on practice (12). The test characteristics of PoCUS vs RADUS are demonstrated in Table 2.   

 

Table 2: Test characteristics of radiology performed ultrasound vs. point-of-care ultrasound for testicular torsion (10) 

	Radiology US	Point of Care US
Sensitivity	100%	95%
Specificity	98%	93%
Positive predictive value	83%	46%
Negative predictive value	100%	100%
Median time for performing US	61 minutes	23 minutes

 

 

 

 

 

Author: Jade Seguin, MD, FRCPC

Secondary Author: Michelle Fric, MD, FRCPC

Reviewer(s): Christopher Chan, MD, FRCPC, Mark Bromley, MD, FRCPC, Melanie Willimann, MD, FRCPC, Colin Bell, MD, FRCPC, Omar Damji, MD, FRCPC, Julia Stiz, MSc, RDMS

References

1. Alrajhi K, Woo MY, Vaillancourt C. Test characteristics of ultrasonography for the detection of pneumothorax: a systematic review and meta-analysis. Chest 2012;141:703-8. doi:10.1378/chest.11-0131.

2. Seow et al. Comparison of Upright Inspiratory and Expieratory Chest Radiographs for Detecting Pneumothoraces. AJR 1996; 166:313-316. doi: 10.2214/ajr.166.2.8553937.

3. Murphy et al. CT and Chest Radiography are Equally Sensitive in the Detection of Pneumothorax After CTGuided Pulmonary Interventional Procedures. AJR 1990;154:45-46. doi: 10.2214/ajr.154.1.2104723.

4. Raimondi et al. Lung Ultrasound for Diagnosing Pneumothorax in the Critically Ill Neonate. J Pediatr 2016;175:74-8. doi:10.1016/j.jpeds.201.04.018

5. Cattarossi et al. Lung Ultrasound Diagnostic Accuracy in Neonatal Pneumothorax. Canad Resp J. 2016. doi 10.1155/2016/6515069

6. Liu et al. Lung ultrasonography to diagnose pneumothorax of the newborn. AJEM 2017;35:1298-1302. doi: 10.1016/j.ajem.2017.04.001.

7. Volpicelli et al. Semi-quantification of pneumothorax volume by lung ultrasound. Int Care Med 2016;40:14607. doi:10.1007/s00134-014-3402-9.

Conclusion

Congratulations on taking the first step towards adopting PoCUS as a part of your practice! The key concepts in this chapter can be revisited regularly to help you understand how to generate and interpret different scans. Orienting yourself to a 2D representation of a 3D object will take some time, so take any opportunity you have to reach for an US probe to hone your skills. Image generation is the most difficult skill to obtain with respect to PoCUS but with a systematic approach you will be able to reliably create high-quality scans that can enhance your clinical decision-making.

References

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2. Howard ZD, Noble VE, Marill KA, Sajed D, Rodrigues M, Bertuzzi B, Liteplo AS. Bedside ultrasound maximizes patient satisfaction. J Emerg Med. 2014 Jan;46(1):46-53. doi: 10.1016/j.jemermed.2013.05.044. Epub 2013 Aug 12. PubMedPMID: 23942153.
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9. Sivitz et al. Effect of Bedside Ultrasound on Management of Pediatric Soft Tissue Infection. J of Emerg Med. 2010; 39(5): 637-43. doi:10.1016/j.jemermed.2009.05.013.
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15. Barbaric D et al. In patients presenting to the emergency department with skin and soft tissue infections what is the diagnostic accuracy of point-of-care ultrasonography for the diagnosis of abscess compared to the current standard of care? A systematic review and meta-analysis. 2017. BMJ Open. Jan 10;7(1):e013688.
16. Dean AJ et al. Techniquefor emergency medicine bedside ultrasound identification of a radiolucent foreign body. 2003. J Emerg Med. Apr;24(3):303-8.
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Note: Videos and images thanks to Amanda Toney at Denver Health, Jon Orsborn at Children’s Hospital Colorado and personal images of the author Julia Brant from Children’s Hospital Co.

Summary

Bedside ultrasound is useful for diagnosing and managing many skin soft tissue conditions. It can help distinguish cellulitis from abscess more reliably than clinical exam alone as well as guide drainage. It also helps to identify and locate foreign bodies. In addition to adding diagnostic value, bedside ultrasound has also been shown to decrease length of stay in the emergency department, increase patient perception of emergency physician skill, and improve patient satisfaction with ED care. Mastering skin and soft tissue sonography will improve your clinical skills and enhance the care you provide to you patients.

 

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