Archives of Academic Emergency Medicine. 2022; 10(1): e9 OR I G I N A L RE S E A RC H Clinical Predictors of Testicular Torsion in Patients with Acute Scrotum; a Cross-Sectional Study Mohammad Sazgar1, Seyed Hossein Montazer2, Seyed Mohammad Hosseininejad3, Fatemeh Jahanian1, Behkam Rezaimehr4, Mohammad Behbohaninia5, Hamed Aminiahidashti1∗ 1. Department of Emergency Medicine, Mazandaran University of Medical Sciences, Sari, Iran. 2. Orthopedic Research Center, Mazandaran University of Medical Sciences, Sari, Iran. 3. Diabetes Research Center, Mazandaran University of Medical Sciences, Sari, Iran. 4. Department of Urology, Mazandaran University of Medical Sciences, Sari, Iran. 5. Student research Committee, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran. Received: December 2021; Accepted: December 2021; Published online: 11 January 2022 Abstract: Introduction: Testicular torsion is an important and critical issue in patients with acute scrotum referring to emergency department (ED). Early detection is very important to save the testicles. This study aimed to de- termine the diagnostic accuracy of clinical variables in predicting the presence of testicular torsion. Methods: This prospective cross-sectional study was done using the information of patients hospitalized from September 2015 to September 2020, with complaint of acute scrotum (ICD 10 code: N50.8), referring to ED for evaluation of the clinical predictors of testicular torsions, which were confirmed by surgery. Results: 81 patients with the mean age of 20.07 ± 9.64 (3- 45) years were studied. After surgical exploration, 70 patients (86.4%) had testicular torsion. Patients with torsion had lower age (p < 0.0001), lower time from symptom to ED visit (p < 0.0001), sud- den onset pain (p = 0.003), left side pain (p < 0.0001), and lower white blood cell (WBC) count (p = 0.001). The frequency of dysuria (p = 0.032), diarrhea/vomiting (p = 0.005), and fever (p = 0.002) was significantly lower in patients with torsion. The cremasteric reflex was absent in 57 (81.4%) cases who suffered from testicular torsion (p = 0.001). Based on the results of binary logistic regression analysis, age (B = -0.175, SE = 0.45; p < 0.0001) was the sole independent predictor of testicular torsion. The highest area under the receiver operating char- acteristics (ROC) curve in predicting the presence of torsion belonged to lower age [91.0 (95%CI: 83.2 – 98.7)], pain in left testis [0.931 (95%CI: 0.828-0.987)], and lower WBC count [0.805 (95%CI: 0.684-0.926)], respectively. Conclusion: It seems that clinical variables are not accurate enough to be considered as the sole predictor of testicular torsion and they should be used with caution and in combination with other available screening tools like Doppler ultrasonography in this regard. Keywords: Scrotum; Acute Pain; Spermatic Cord Torsion; Early Diagnosis; Emergency Service, Hospital Cite this article as: Sazgar M, Montazer S H, Hosseininejad S M, Jahanian F, Rezaimehr B, Behbohaninia M, Aminiahidashti H. Clini- cal Predictors of Testicular Torsion in Patients with Acute Scrotum; a Cross-Sectional Study. Arch Acad Emerg Med. 2022; 10(1): e9. https://doi.org/10.22037/aaem.v10i1.1484. 1. Introduction Acute scrotum or testicular pain is one of the most important problems in the emergency department (ED). Acute scro- tum is defined as a sudden onset scrotum pain with or with- ∗Corresponding Author: Hamed Aminiahidashti; Department of Emergency Medicine, Emam Khomeini Hospital, Amirmazandarani Bolivar, Sari, Mazan- daran province, Iran. Tell: +981133361700, ORCID: http://orcid.org/0000- 0002-2115-1903. out edema and tenderness, which is a true surgical emer- gency due to the possibility of testicular torsion (1, 2). There are a wide range of differential diagnoses for acute scro- tum, and early detection of testicular torsion is essential (3). Epididymo-orchitis, torsion of the appendix testis, and in- guinal herniation are some of the causes of presenting with acute scrotum symptoms (4). In some medical centers, all patients with acute scrotum are surgically explored to rule out testicular torsion (5, 6). There is clinical guidance in this regard, but it is not accepted worldwide (7). Color Doppler ultrasonography of the testis is used as a fast method with This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem M. Sazgar et al. 2 high sensitivity and specificity in the diagnosis of testicular torsion (8, 9). However, false-negative results are possible in the early stage, incomplete torsion, and intermittent tor- sion; therefore, clinical signs should be considered (10). Nev- ertheless, differentiating testicular torsion from other causes of the acute scrotum in the emergency department is crucial (11) and diagnostic exploration should be performed if the diagnosis still remains in doubt (12). Based on the above- mentioned points, this study aimed to determine the diag- nostic accuracy of clinical variables in predicting the pres- ence of testicular torsion. 2. Methods 2.1. Study design and setting This prospective cross-sectional study was done using the in- formation of patients hospitalized from September 2015 to September 2020, with complaint of acute scrotum (ICD 10 code: N50.8), referring to the ED of Imam Khomeini Hospi- tal, Sari, Iran, affiliated to Mazandaran University of Medi- cal Sciences. The association between clinical characteris- tics and presence of testicular torsion (confirmed via surgery by urologist) was studied. This study was approved by the Ethics committee of Mazandaran University of Medical Sci- ences (IR.MAZUMS.REC.94-1313). The research team ad- hered to the ethical principles of the Helsinki Convention re- garding clinical studies. 2.2. Participants All patients referring to the ED with the complaint of acute scrotum, which was initially diagnosed as testicular torsion based on International Classification of Disease, version 10 (ICD10) code: N44) and underwent surgical exploration were included. Patients with incomplete information, those diag- nosed with conditions other than testicular torsion, and also cases with underlying testicular diseases, such as a testicular tumor, cryptorchidism, and history of surgery were excluded from the study. Informed consent was obtained from all eli- gible patients or their legal representatives. The executor has adhered to the all the principles of the Helsinki Declaration. 2.3. Data gathering Data regarding baseline characteristics, clinical examina- tions, history taking, and operating room reports of all pa- tients was extracted from patients’ profiles and collected in a data collection form. Variables such as age, type of pain, time from beginning of pain to ED presentation, dysuria, hema- turia, nausea and vomiting, side of pain, fever (T ≥ 38 ° C), cremasteric reflex, tenderness, erythema, and swelling were recorded for all cases. The data were collected by a trained emergency medicine resident under the direct supervision of an emergency medicine specialist. 2.4. Statistical analysis Considering sensitivity = 0.95 and specificity = 0.8 of red- ness and swelling of the scrotum and testicular pain (2, 13), 95% confidence interval, the maximum clinically acceptable width = 0.1, and prevalence = 0.25, the required sample size for this study was calculated to be 81 cases. Data were ana- lyzed using SPSS version 21.0 (SPSS Inc, Chicago, IL, USA). Quantitative variables were expressed using mean ± stan- dard deviation or frequency (%). The association between variables and presence of testicular torsion was studied us- ing Chi-square or student t test. Binary logistic regression analysis was done on variables with significant association to determine the independent predictors of torsion. Area un- der the receiver operating characteristics (ROC) curve of each variable in predicting the presence of testicular torsion was calculated and reported with 95% confidence interval. P < 0.05 was considered as an acceptable cut-off for statistical significance. 3. Results 3.1. Baseline characteristics of studied patients Out of the 358 patients referring to the ED with acute scro- tum, 81 patients with the mean age of 20.07 ± 9.64 (range: 3- 45) years were suspected to have testicular torsion and were eligible for inclusion (Figure 1). The location of pain was the left testis in 67 (82.7%) cases, the right testis in 12 (14.8%), and on both sides in 2 (2.5%) patients. Testicu- lar pain was sudden onset in 64 (79.01%) and gradual in 17 (20.98%) cases. Dysuria, vomiting, and fever was detected in 17 (20.98%), 35 (43.20%), and 21 (25.92%) cases, respec- tively. The mean time from the onset of symptoms to ED visit was 6.41 ± 11.01 (range: 1-72) hours. In clinical examinations, 20 (24.69%) patients had cremasteric reflex, 62 (76.54%) ery- thema, 68 (83.95%) testicular swelling, and 73 (90.12%) pa- tients had testicular tenderness. Mean WBC count was 10700 ± 4400 cells/cubic millimeter. 20 (24.69%) patients under- went orchidectomy. 3.2. Screening characteristics of clinical findings After surgical exploration, 70 patients (86.4%) had testicu- lar torsion. Table 1 compares the baseline characteristics as well as signs and symptoms between cases with and without testicular torsion. Patients with testicular torsion had lower age (p < 0.0001), lower time from symptom to ED visit (p < 0.0001), sudden onset pain (p = 0.003), left side pain (p< 0.0001), and lower WBC count (p = 0.001). The frequency of dysuria (p = 0.032), diarrhea/vomiting (p = 0.005), and fever (p = 0.002) was significantly lower in patients with torsion. The cremasteric reflex was absent in 57 (81.4%) cases who suffered from testicular torsion (p = 0.001). Based on the re- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2022; 10(1): e9 Figure 1: The flow chart of patients’ enrollment to the study. sults of binary logistic regression analysis, age (B = -0.175, SE = 0.45; p < 0.0001) was the sole independent factor in predic- tion of testicular torsion. Figure 2 and table 2 show the area under the ROC curve of studied variables in predicting tes- ticular torsion. Accordingly, the highest area under the ROC curve value in this regard belonged to lower age [91.0 (95%CI: 83.2 – 98.7)], pain on the left side [0.931 (95%CI: 0.828-0.987)], and lower WBC count [0.805 (95%CI: 0.684-0.926)], respec- tively. 4. Discussion Based on the findings of present study, patients with testicu- lar torsion frequently presented with sudden onset pain in left testicle. The frequency of dysuria, diarrhea/vomiting, and fever, as well as WBC count was significantly lower in these cases. Age was the sole independent predictive factor of testicular torsion in this series. The maximum accuracy of studied variables in predicting torsion belonged to lower age, left side pain, and lower WBC count. Numerous studies have shown that pain, tenderness, and positive color Doppler ultrasound had the highest sensitiv- ity in diagnosis of testicular torsion. It has been shown that some clinical variables such as testicular swelling and stiff- ness, the lack of cremasteric reflex, and moving up of the tes- ticle had had a combined negative predictive value of 100% (specificity 81%, sensitivity 76%) in predicting testicular tor- sion (8). Age and involvement of the left testicle were inde- pendent factors in diagnosis of testicular torsion in Fabian et al. study (9), but in this study, age was the sole independent predictor of torsion. It has been shown that irreversible damage to the testis oc- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem M. Sazgar et al. 4 Figure 2: Area under the receiver operating characteristics (ROC) curve of different signs and symptoms in predicting the presence of testic- ular torsion (the values with 95% confidence interval are presented in table 2). Table 1: Comparison of baseline characteristics and clinical findings between cases with and without testicular torsion Variables Testicular torsion P Present (n = 70) Absent (n = 11) Age (year) 17.92 ± 7.85 33.72 ± 8.94 <0.0001 Time to ED visit (hour) 4.35 ± 4.72 19.45 ± 26.39 <0.0001 WBC (cells/mm3) 10039.28 ± 4278.19 14709.09 ± 3439.89 0.001 Type of pain Sudden 59 (84.3) 5 (45.5) 0.003 Gradual 11 (15.7) 6 (54.5) Signs and symptoms Dysuria 12 (17.1) 5 (45.5) 0.032 Diarrhea/vomiting 26 (37.1) 9 (81.8) 0.005 Fever 14 (20.0) 7 (63.6) 0.002 Hematuria 1 (1.4) 0 (0.0) 0.690 Erythema 54 (77.1) 8 (72.7) 0.748 Tenderness 64 (91.4) 9 (81.8) 0.321 Edema 54 (84.3) 8 (81.8) 0.748 Side of pain Left 66 (94.3) 1 (9.1) <0.0001 Right 4 (5.7) 8 (72.7) Both 0 (0.0) 2 (18.2) Cremasteric reflex Yes 13 (18.6) 7 (63.6) 0.001 No 57 (81.4) 4 (36.4) ED: emergency department; WBC: white blood cell count. curs less frequently in patients with torsion referring to the ED within the first 6 hours of symptom onset and complete infarctions would occur in 90% of cases that present to ED af- ter 24 hours (13). In this study, lower time to ED visit was sig- nificantly associated with the presence of testicular torsion. Neutrophil to lymphocyte ratio (NLR) was found to have a sensitivity of 84% and specificity of 92% in predicting testic- ular torsion (10). Although an increase in white blood cell count has been shown to be an inflammatory marker in pa- tients with testicular torsion (5), it cannot be used as a marker for differentiating various causes of acute scrotum syndrome (14). Also, in this study, patients with testicular torsion had a significantly lower WBC count. It could be concluded that relying on clinical variables as the This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 5 Archives of Academic Emergency Medicine. 2022; 10(1): e9 Table 2: Area under the receiver operating characteristics (ROC) curve of different signs and symptoms in predicting the presence of testicular torsion Test Result Variable(s) Area 95% CI SE P-value Lower Upper Age 0.910 0.832 0.987 0.040 <0.0001 Side of pain 0.931 0.828 1.000 0.053 < 0.0001 White blood cell 0.805 0.684 0.926 0.062 0.001 Cremasteric reflex 0.725 0.549 0.902 0.090 0.017 Diarrhea/vomiting 0.723 0.571 0.875 0.078 0.018 Fever 0.718 0.542 0.895 0.090 0.021 Time to ED presentation 0.715 0.524 0.906 0.098 0.023 Type of pain 0.694 0.508 0.880 0.095 0.039 Dysuria 0.642 0.450 0.833 0.098 0.133 Tenderness 0.548 0.355 0.741 0.098 0.610 Erythema 0.522 0.335 0.709 0.096 0.815 Hematuria 0.493 0.310 0.676 0.093 0.940 Edema 0.488 0.301 0.674 0.095 0.896 CI: Confidence interval; SE: standard error; ED: emergency department. sole indicator of torsion and need for exploration surgery is not acceptable and decision in this regard should be made with caution and in combination with other findings. 5. Limitations The limitations of the study were the high number of pa- tients who did not consent to surgery after being a candidate for surgical exploration and those who were discharged from the emergency room against medical advice. Also, since the studied center did not have a pediatric ward, most of the pa- tients were adults. 6. Conclusion It seems that, clinical variables are not accurate enough to be considered as the sole predictor of testicular torsion and they should be used with caution and in combination with other available screening tools like Doppler ultrasonography in this regard. 7. Declarations 7.1. Acknowledgments The authors’ thanks emergency department staff for their as- sistance in conducting the study. 7.2. Authors’ contributions HA, SMM, BR contributed to the project development and study design. MB and HA contributed data collection and in- terpretation of the data. HA, MS, FJ contributed to data anal- ysis. HA, MS, SMH developed the manuscript. HA, MS, SMH, BR critically edited and revised the manuscript. All authors read and approved the final manuscript. 7.3. Funding and supports This study was extracted from a thesis project, which was fi- nancially supported by a grant (No: 1313) from Mazandaran University of Medical Sciences. 7.4. Conflict of Interest There are no conflicts of interest. References 1. Corbett HJ, Simpson ET. Management of the acute scro- tum in children. ANZ journal of surgery. 2002;72(3):226- 8. 2. Boettcher M, Bergholz R, Krebs TF, Wenke K, Aronson DC. Clinical predictors of testicular torsion in children. Urology. 2012;79(3):670-4. 3. Gatti JM, Patrick Murphy J. Current management of the acute scrotum. Seminars in pediatric surgery. 2007;16(1):58-63. 4. Burgher SW. Acute scrotal pain. Emergency medicine clinics of North America. 1998;16(4):781-809, vi. 5. Yang C, Jr., Song B, Liu X, Wei GH, Lin T, He DW. Acute scrotum in children: an 18-year retrospective study. 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