








































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2023 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

SIUJ.ORG SIUJ  •  Volume 4, Number 4  •  July 2023

Key Words Competing Interests Article Information

Orchidectomy, testis, testicular torsion,  
rural health

None declared. Received on December 20, 2022 
Accepted on February 19, 2023 
This article has been peer reviewed.

Soc Int Urol J. 2023;4(4):257–264

DOI: 10.48083/ WKFE4169

257

ORIGINAL RESEARCH

Testicular Torsion: An Analysis of Rural Geography 
and Socioeconomic Status

Kevin Tree,1,2 Benjamin Charles Buckland,2,3 Roy Huynh,1,4 Sris Baskaranathan,1  
Dean Fisher,1 Balasubramaniam Indrajit1,4

1 Department of Surgery, Dubbo Base Hospital, New South Wales, Australia 2 University of Newcastle, New South Wales, Australia 3 Central Coast Local Health District, 
New South Wales, Australia 4 University of Sydney, New South Wales, Australia

Abstract

Objectives Testicular torsion is a time-critical, organ-threatening diagnosis requiring prompt surgical intervention 
for successful salvage of the organ. In Australia, 28% of individuals live in rural and remote areas and face barriers 
to health care such as greater distance, lower socioeconomic status, (SES), and limited health infrastructure. We 
hypothesize that these barriers would delay intervention and access to surgical care, and lead to higher orchidectomy 
rates.

Objectives A 12-year retrospective audit was conducted at a large rural referral center in Australia, focusing 
on patients undergoing scrotal exploration for testicular torsion. Primary outcomes were orchidectomy rate, time 
to operation, and ultrasound (US) and their relationship with patient distance, SES, age, and peripheral hospital 
attendance. Data on SES for geographic postcodes was obtained from the Australian Government Socio-Economic 
Indexes for Areas 2016. Statistical analysis was performed using IBM SPSS Statistics software, and a P value < 0.05 was 
considered significant.

Results The study involved 107 patients, of whom 46% had left-sided pathology. The median age of the patients 
was 14 years. Median SES was in the 37% to 41% centile range, median distance from travelled was 62 kilometers, 
and median time to operation from triage was 194 minutes. Of the patients, 34 attended a peripheral hospital. No 
significant risk factors for orchidectomy were identified. US was used in 65% of cases, with torsion detected in 50% of 
those cases, and orchidectomy performed in 11 patients. US had a sensitivity of 86.1% and specificity of 52.9%.

Conclusion Despite significant differences in geographical distance, SES, age, and access to health care, patients in 
rural and remote areas of Australia experienced equivalent outcomes in testicular torsion management. Testicular 
torsion was safely managed at a central referral center using a peripheral hospital catchment in rural and remote areas 
of Australia, despite significant time delays due to greater distance or lower SES.

Introduction
Testicular torsion is a medical emergency, requiring prompt surgical intervention within 6 hours to salvage the 
affected organ[1]. International guidelines such as those from the European Association of Urology (EAU) and British 
Association of Urological Surgeons (BAUS) endorse urgent scrotal exploration as the mainstay of treatment[2,3].

In Australia, 7 million people (28% of the population) live in rural and remote areas, with higher health morbid-
ity and mortality due to poor access and use of primary health care services compared with metropolitan areas[4].  
Socioeconomic status (SES) plays a crucial role in determining health outcomes, and rural geography is a risk factor 
for low SES[5–7].

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https://orcid.org/0000-0001-7125-6423


Statistical analysis
IBM SPSS Statistics version 28[12] and Microsoft Excel 
were used for statistical analysis. The Shapiro-Wilk test 
was performed, along with data histogram, to determine 
normality. Independent t tests + chi-square tests were 
performed to compare baseline characteristics with 
normal distribution, and the non-parametric Mann-
Whitney test was performed if the data distribution was 
not normal. Univariate regression and bivariate Pearson 
correlation were performed to compare outcomes 
of subgroups for dichotomous and continuous data, 
respectively. Multivariate regression was performed 
when significant results were found in the univariate 
regression to correct for potentia l confounding 
variables. A P value of < 0.05 was considered statistically 
significant.

Results
Patient characteristics
During the study period, 145 patients were identified, 
but only 107 were included in the analysis due to 
38 patients having incomplete data or meeting the 

exclusion criteria. The most common reason for 
exclusion was cryptorchidism. Median age was 14 
years, with 46% presenting with left-side symptoms 
(Table 1). All patients were from rural areas under the 
Modified Monash Model MM3-7. Torsion was present 
in 50% of cases, with left-sided torsion observed in 
49%. Orchidectomy was performed in 12 patients, with 
median age of 13.5 years, and 83% of the cases were 
left sided. The degree of torsion was documented in 18 
patients, and all 3 patients who underwent orchidectomy 
had rotation greater than 360 degrees. Of the 54 patients 
without torsion, 12 (22.2%) patients had torsion of the 
appendix testis and 10 (18.5%) had epididymitis. No 
cases of repeat scrotal exploration were identified. The 
median time to operation was 194 minutes from triage, 
but it was significantly longer (335 minutes) in patients 
who attended a peripheral health service. Upon arrival 
to emergency department of the operating hospital, 
median time between decision to operate and the actual 
operation was 32 minutes (interquartile range [IQR], 
35 minutes). In patients with testicular torsion, no 
significant association was found between time from 
triage to operation and orchidectomy rate (odds ratio 

TABLE 1.

Baseline characteristics 

All patients
Peripheral 

hospital 
attendance

Non-peripheral 
hospital 

attendance
P value

Patients 107 34 73

Age, years, median (IQR) 14 (8) 13.5 (9) 14 (9) 0.237

Side of pathology

Left, n (%) 49 (46) 21 (62) 28 (38) 0.024

Right, n (%) 58 (54) 13 (38) 45 (62)

Side in torsion 53 20 33

Left, n (%) 26 (49) 13 (65) 13 (39) 0.071

Right, n (%) 27 (51) 7 (35) 20 (61)

Distance, km, median (IQR) 62 (60) 122 (121) 11 (74) < 0.001

SES

IRSD, percentile, median (IQR) 39 (27) 17 (32) 40 (11) < 0.001

IRSAD, percentile, median (IQR) 37 (18) 22 (29) 38 (10) < 0.001

IER, percentile, median (IQR) 38 (14) 29 (9) 38 (3) <0.001

IEO, percentile, median (IQR) 41 (21) 21 (39.25) 41 (10.5) 0.044

Time to surgery from triage, minutes, median (IQR) 194 (220.5) 335 (191.25) 194 (223) <0.001

Ultrasound performed, n (%) 70 (65) 23 (68) 47 (64) 0.741

Torsion present, n (%) 53 (50) 20 (59) 33 (45) 0.19

Orchidectomy, n (%) 12 (11) 3 (9) 9 (12) 0.593

IEO: Index of Education and Occupation; IER: Index of Economic Resources; IQR: interquartile range; IRSAD: Index of Relative Socio-economic Advantage 
and Disadvantage; IRSD: Index of Relative Socio-economic Disadvantage; km: kilometers; SES socioeconomic status.

The Royal Australasian College of Surgeons (RACS) 
position statement on acute scrotal pain endorses the 
accreditation of general surgeons, pediatric surgeons, 
and urologists to manage and operate on suspected 
testicular torsion without transferring the patient[8]. 
However, rural and remote communities often lack 
adequate infrastructure or available surgeons, which can 
necessitate patient transfer and lead to potential delays 
to surgery and thus reduction in organ viability. The aim 
of this study was to examine the management of testicu-
lar torsion in rural areas and its relationship to distance, 
SES, or peripheral hospital attendance. Secondary 
outcomes included access to sonography and diagnos-
tic accuracy in testicular torsion. We hypothesize that 
delays in surgical intervention due to increased distance 
from rural areas, hospital transfers, and reduced access 
to health care infrastructure would result in higher 
orchidectomy rates.

Method
A retrospective audit was performed at Dubbo Base 
Hospital, a large rural referral center in New South 
Wales, Australia, from October 2010 to February 2022. 
The hospital has a 24-hour on-call surgical service, 
access to operating theaters and anesthesia, and 24-
hour on-call availability of ultrasonography and 
sonographers.

Electronic medical records from the Cerner applica-
tion were used to identify patients of all ages who under-
went scrotal exploration as a theater event. Baseline 
demographic information, residential postcode, time 
from triage to operation, age, laterality, ultrasonography 
usage, diagnosis at operation, and operative details were 
recorded. Patients with cryptorchidism, malignancy, 
and neonatal patients were excluded from the study.

Socioeconomic status
Socioeconomic status (SES) data was obtained from 
the publicly available Australian Bureau of Statistics: 
Socio-Economic Indexes for Areas 2016 (SEIFA)[9]. 

Abbreviations 
IEO Index of Education and Occupation
IER Index of Economic Resources
IQR interquartile range
IRSAD Index of Relative Socio-economic Advantage and 
Disadvantage
IRSD Index of Relative Socio-economic Disadvantage
SEIFA Socio-Economic Indexes for Areas
SES socioeconomic status
US ultrasound

Four categories of SES were assessed: Index of Relative 
Socio-economic Disadvantage (IRSD), Index of Relative 
Socio-economic Advantage and Disadvantage (IRSAD), 
Index of Education and Occupation (IEO), and Index 
of Economic Resources (IER). SEIFA 2016 ranks 
postcodes according to variables of both advantage and 
disadvantage including income, education, employment, 
housing, disability, and access to infrastructure. 
Postcodes are assigned a national centile, with 1 
indicating the lowest SES and 100 indicating the highest.

Peripheral hospital attendance and distance
The distance from the treating hospital was determined 
using Google Maps, considering road travel distance 
as all inter-hospital transfers were conducted by road 
transport. The distance was calculated from the center 
of the patient’s residential postcode to represent the 
patient’s local environmental resource and access to 
infrastructure[10].

Dubbo Base Hospital serves as a catchment for over 
20 multipurpose health services or peripheral hospitals, 
all located outside the Dubbo Base Hospital’s postcode. 
Peripheral hospitals did not have access to US but had a 
registered nurse or doctor available for clinical assess-
ment. They also lacked an operating theater or surgeon. 
The time to operation was calculated from time of the 
first triage at the attending health center within the 
catchment to the start of operation. Rural geographi-
cal classification was determined using the Australian 
Government Modified Monash Model[11], which cate-
gorizes based on geographic remoteness and town size 
from MM1 (highest) to MM7 (lowest).

Primary outcome
Primary outcome was to determine the association 
between socioeconomic status, road distance, or 
peripheral hospital attendance and orchidectomy 
rate. Patients with intraoperative findings of testicular 
torsion were considered true positive. Orchidectomy was 
performed when intraoperative assessment deemed the 
testicle non-viable despite re-assessment after de-torsion 
and a minimum 15 minutes of warming. Orchidopexy 
was performed for viable testes according to the BURST-
BAUS consensus guideline[2].

Secondary outcome
Secondar y outcomes included an assessment of 
ultrasonography usage and its sensitivity, specificity, 
positive predictive value, negative predictive value, 
and accuracy in a rural setting. Ultrasonography 
was performed with color Doppler, and a positive 
finding was considered low or absent blood flow, with 
suspicious findings considered positive. Furthermore, an 
assessment was performed to determine whether SES, 
distance, or peripheral hospital attendance influenced 
use of ultrasonography.

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 ORIGINAL RESEARCH Testicular Torsion: An Analysis of Rural Geography and Socioeconomic Status

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patients who underwent orchidectomy, 9 patients 
had preoperative ultrasonography, which correctly 
diagnosed the testicular torsion in all cases. Patients who 
underwent ultrasonography had significantly longer 
time to operation (349 minutes; standard deviation 
[SD], 348.8 minutes) compared to those without 
ultrasonography (176 minutes; SD, 131.5 minutes; 
P = 0.005), but there was no significant difference in the 
orchidectomy rate (P = 0.464).

Discussion
In Australia from 2020 to 2021, 1830 scrotal explorations 
were performed, as reported by the Australian Institute 
of Health and Welfare[13], an incidence of 1 per 50  000 
in a population of 25.74 million in 2021. Australia 
has a population density of 3.3 people per square 
kilometer[14], primarily due to population sparsity 
in rural and remote areas, where 7 million (28%) 
of Australians live. The combination of geographic 
isolation and a rare pathology exacerbate the time-
critical challenge of managing testicular torsion. The 
limited accessibility to healthcare infrastructure due to 
geographic distance acts as a major obstacle to achieving 
positive outcomes.

Testicular torsion is a medical emergency that neces-
sitates prompt surgical intervention, with the duration 
of symptoms being the primary predictor in the success 
of salvage procedures[15]. We hypothesized that barriers 
to healthcare such as geographical distance, peripheral 
hospital attendance, and low SES could delay interven-
tion and increase orchidectomy rates. Prompt surgical 
intervention plays a crucial role in reducing morbidity 
and mortality in emergency surgery[16], with patients 
residing in rural areas showing an association with 
equivocal or worse outcomes[17], particularly among 
transferred patients. Geographical remoteness is signifi-
cantly correlated with lower SES, and SES itself is asso-
ciated with worse outcomes in emergency surgery even 
when corrected for remoteness[18], suggesting that SES 
is the predominant risk factor for morbidity. In Austra-
lia, some patients who reside in rural or remote commu-
nities will elect to have surgical care closer to their 
homes despite being informed about the higher risks for 
morbidity and mortality[19]. As a result, the core curric-
ulum for both urology and general surgery trainees in 
Australia includes the competence to assess and perform 
scrotal explorations for testicular torsion at a patient’s 
initial presentation, regardless of their geographical 
location, without the need for transfer[8].

Limited literature exists on the impact of geographical 
location on testicular torsion outcomes from a distance 
and SES perspective, and the study findings are hetero-
geneous. A national study in Korea comparing metro-
politan and rural provinces demonstrated no significant 

difference in incidence or orchidectomy rates based on 
geographic region or SES[20]. The authors Choi et al. 
hypothesized that this is due to the ease of accessibility 
of public healthcare services in a relatively small coun-
try of 100 210 square kilometers. However, this contrasts 
the findings of the current study, conducted at a rural 
referral center with a catchment of 250 000 square kilo-
meters. A study in the United States conducted by Over-
holt et al.[21] demonstrated higher orchidectomy rates 
in patients who required transfer from peripheral health 
services, but did not find a significant correlation with 
distance or time delay. The authors acknowledged their 
study’s small sample size at only 23 patients, rendering the 
study underpowered and the findings nonsignificant.  
In contrast, our study, with a larger sample size (n = 107) 
and despite having patients who were geographically 
more distant (median 62 km vs. mean 38.3 km), did not 
find a significantly increased orchidectomy rate despite 
significantly longer time to operation. The Austra-
lian health care system, publicly funded by Medicare, 
relies on healthcare networks in rural areas, involving 
a catchment of multipurpose health services connected 
to a large rural referral hospital. This system ensures 
access to a 24-hour virtual doctor service at peripheral 
sites and facilitates inter-hospital transfers to a rural 
referral hospital where a surgeon is available on call  
24 hours a day. This timely access to clinical assessment 
allows for prompt review and escalation, thereby allevi-
ating disparities in rural and remote health care, in both 
surgical and medical care, to ensure patients from lower 
socioeconomic backgrounds receive optimal care. These 
initiatives by the Australian Government are part of the 
Stronger Rural Health Strategy[22], which aims to offset 
disadvantages related to access to and delivery of health 
care in rural and remote areas. This may explain why 
significant findings were found only in the SES category 
of IRSD, which measures variables related only to disad-
vantage, while IRSAD, IEO, and IER, which measure 
variables of advantage, such as higher education level, 
higher income brackets, and certain occupations, could 
mitigate or compensate for disadvantage.

Ultrasonography has seen increasing use for the 
assessment of possible testicular torsion, despite guide-
line recommendations that testicular torsion is a clin-
ical diagnosis[8]. The diagnostic ability of sonography 
for testicular torsion in adults has shown a sensitivity of 
86% and specificity 95%[23]. These results are aligned 
with our study findings, with a similar sensitivity but a 
much lower specificity. The low specificity could be due 
to a high false-positive rate, as “suspicious” findings 
were coded as positive, leading to scrotal exploration 
in all cases. There are numerous decision-making tools 
available, such as the TWIST score in all ages[24,25], 
reporting a high sensitivity of 98.4% to 100% in low-risk 
patients and safely ruling out testicular torsion prior to 

[OR], 0.999; P  =  0.584). Age was not associated with 
increased orchidectomy rate, ultrasound use, or time to 
operation (Table 2).

Peripheral hospital attendance and distance
Of the total patients, 34 (31.8%) attended a peripheral 
hospital, with median age of 13.5 years. The majority of 
these patients (62%) had left-sided pathology, in contrast 
to those with non-peripheral hospital attendance, 
with 62% exhibiting right-sided pathology. However, 
no significant difference in laterality was identified 
(P  =  0.071) in patients with diagnosis of torsion. The 
median distance from hospital was 122 kilometers 
(km) for patients attending a peripheral hospital, which 
was significantly further than that for non-peripheral 
hospital patients. Additionally, the time to operation was 
significantly longer for peripheral hospital attendees, 
at 335 minutes, compared to non-peripheral hospital 
attendees, at 194 minutes. There was no significant 
difference in torsion rate (59%) and orchidectomy 
rate (9%) between these 2 patient groups (P = 0.19 and 
P  =  0.593, respectively). Increased distance from the 
hospital was not a significant risk factor for orchidectomy 
or ultrasonography use (Table 2). Similarly, peripheral 
hospital attendance was also not a significant risk factor 
for orchidectomy or ultrasonography use (Table 2). 
However, increased distance was significantly associated 
with increased time to operation (P < 0.001).

Socioeconomic status
The median IRSD was 39, IRSAD was 37, IEO was 38, 
and IEO was 41, with all patients falling within the 
lower 50% of Australia’s national SES bracket. Patients 

TABLE 2.

Regression analysis for risk factors 

Orchidectomy Ultrasound use Time to operation

OR 95% CI P value OR 95% CI P value Pearson correlation 
coefficient

95% CI P value

Distance 1.001 0.996–1.006 0.665 1.001 0.997–1.004 0.671 0.474 0.313–0.609 < 0.001

Age 1.008 0.95–1.07 0.787 1.022 0.977–1.067 0.341 0.033 -0.157–0.222 0.732

IRSD 0.994 0.955–1.033 0.748 0.991 0.964–1.018 0.5 -0.199 0.374–0.009 0.040

IRSAD 0.996 0.953–1.04 0.853 0.989 0.96–1.019 0.483 -0.169 -0.347–0.022 0.082

IER 1.006 0.971–1.043 0.743 0.993 0.97–1.017 0.584 -0.178 -0.356–0.012 0.067

IEO 1.012 0.957–1.07 0.676 0.981 0.944–1.019 0.32 -0.065 -0.251–0.127 0.508

Peripheral 
hospital 
attendance 

0.688 0.174–2.722 0.594 1.157 0.488–2.743 0.741 1.004 1.001–1.006 0.002

CI: confidence interval; IEO: Index of Education and Occupation; IER: Index of Economic Resources; IRSAD: Index of Relative Socio-economic Advantage 
and Disadvantage; IRSD: Index of Relative Socio-economic Disadvantage; OR: odds ratio.

TABLE 3.

Ultrasonography diagnosis 

Sensitivity 86.1%

Specificity 52.9%

Positive predictive value 66%

Negative predictive value 78.3%

Accuracy 70%

who attended peripheral hospitals had a significantly 
lower median IRSD, IRSAD, IER, and IEO compared 
to those who presented directly—(IRSD 17 vs. 40, 
respectively), IRSAD (22 vs. 38, respectively), IER (29 
vs. 38, respectively), and IEO (21 vs. 41, respectively). 
Of those patients who presented directly, 46 lived in the 
same suburb as the operating hospital. No significant 
association was identified between the 4 SES categories 
and orchidectomy rate or ultrasound use. IRSD, a 
measure of only SES disadvantage, correlated with 
increased time to operation (P = 0.04); however, IRSAD, 
IER, and IEO did not show a significant correlation.

Ultrasonography
U ltrasound was per formed in 65% of pat ients 
preoperatively, with a sensitivity of 86.1%, specificity 
of 52.9%, positive predictive value of 66%, negative 
predictive value of 78.3%, and accuracy 70% (Table 3). 
Five patients had false-negative ultrasound results, 
and 16 patients had false-positive results. Of the 12 

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 ORIGINAL RESEARCH Testicular Torsion: An Analysis of Rural Geography and Socioeconomic Status

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References

1. Mellick LB, Sinex JE, Gibson RW, Mears K. A systematic review 
of testicle sur vival time af ter a torsion event. Pediatr Emerg 
Care.2019;35(12):821–825. doi: 10.1097/PEC.0000000000001287. 
PMID: 28953100

2. Clement KD, Light A, Asif A, Chan VW, Khadhouri S, Shah TT, et al.; 
FIX-IT collaborators. A BURST-BAUS consensus document for best 
practice in the conduct of scrotal exploration for suspected testicular 
torsion: the Finding Consensus for Orchidopexy in Torsion (FIX-IT) 
study. BJU Int.2022;130(5):662–670.

3. Radmayr C, Bogaert G, Dogan H, Kocvara R, Nijman J, Stein R, 
editors. EAU guidelines on paediatric urology. EAU Guidelines, edition 
presented at the annual EAU Congress Barcelona; 2019: EAU.

4. Australian Government. Australian Institute of Health and Welfare 
(AIHW). Welfare AIoHa. Rural and remote health. July 2, 2022. 
Accessed June 9, 2023. ht tps://w w w.aihw.gov.au/repor ts/
rural-remote-australians/rural-and-remote-health

5. Blumenthal SJ, Kagen J. The effects of socioeconomic status on health 
in rural and urban America. JAMA.2002;287(1):109. PMID: 11754719.

6. Beard JR, Tomaska N, Earnest A, Summerhayes R, Morgan G. Influence 
of socioeconomic and cultural factors on rural health. Aust J Rural 
Health.2009;17(1):10–15. doi: 10.1111/j.1440-1584.2008.01030.x. 
PMID: 19161494.

7. Shahar S, Vanoh D, Mat Ludin AF, Singh DK A, Hamid TA. Factors 
associated with poor socioeconomic status among Malaysian older 
adults: an analysis according to urban and rural settings. BMC Public 
Health.2019;19(Suppl 4):549. doi: 10.1186/s12889-019-6866-2. PMID: 
31196023; PMCID: PMC6565532.

8. Royal Australian College of Surgeons. RACo. Acute scrotal pain and 
suspected testicular torsion guidelines (2018). Accessed June 9, 
2023. https://www.surgeons.org/en/about-racs/position-papers/
acute-scrotal-pain-and-suspected-testicular-torsion-guidelines-2018

9. Australian Government. Australian Bureau of Statistics. Socio-
Economic Indexes for Areas (SEIFA). Accessed June 9, 2023. https://
www.abs.gov.au/websitedbs/censushome.nsf/home/seifa

10. Alexandrescu R, O’Brien SJ, Lyons RA, Lecky FE; Trauma Audit and 
Research Network. A proposed approach in defining population-based 
rates of major injury from a trauma registry dataset: delineation of 
hospital catchment areas (I). BMC Health Serv Res.2008;8:80. doi: 
10.1186/1472-6963-8-80. PMID: 18402693; PMCID: PMC2365946.

11. Australian Government. Department of Health and Aged Care. 
Care DoHaA. Modified Monash Model 2021. Accessed June 9, 
2023. https://www.health.gov.au/topics/rural-health-workforce/
classifications/mmm

12. IBM® SPSS® Statistics for Windows. Accessed June 9, 2023. https://
www.ibm.com/spss. Version 28.0.

13. Australian Government. Australian Institute of Health and Welfare 
(AIHW). Procedures data cubes. July 8, 2022. Accessed June 9, 2023. 
https://www.aihw.gov.au/reports/hospitals/procedures-data-cubes

14. Australian Government. Australian Bureau of Statistics – September 
2022. National, state and territory population. March 16, 2023. 
Accessed June 9, 2023. https://www.abs.gov.au/statistics/people/
population/national-state-and-territory-population/latest-release

15. Zvizdic Z, Aganovic A, Milisic E, Jonuzi A, Zvizdic D, Vranic S. 
Duration of symptoms is the only predictor of testicular salvage 
following testicular torsion in children: a case-control study. Am J 
Emerg Med.2021;41:197–200. doi: 10.1016/j.ajem.2020.11.023. PMID: 
33221112.

16. Meschino MT, Giles AE, Rice TJ, Saddik M, Doumouras AG, Nenshi 
R, et al. Operative timing is associated with increased morbidity 
and mortality in patients undergoing emergency general surgery: a 
multisite study of emergency general services in a single academic 
network. Can J Surg.2020;63(4):E321–E328. doi: 10.1503/cjs.012919. 
PMID: 32644317; PMCID: PMC7458678.

17. Wohlgemut JM, Ramsay G, Bekheit M, Scott NW, Watson AJM, 
Jansen JO. Emergency general surgery: impact of distance and rurality 
on mortality. BJS Open.2022;6(2):zrac032. doi: 10.1093/bjsopen/
zrac032. PMID: 35466374; PMCID: PMC9035437.

18. de Jager E, Chaudhary MA, Rahim F, Jarman MP, Uribe-Leitz T, 
Havens JM, et al. The impact of income on emergency general surgery 
outcomes in urban and rural areas. J Surg Res.2020;245:629–635. doi: 
10.1016/j.jss.2019.08.010. PMID: 31522036.

19. Stewart GD, Long G, Tulloh BR. Surgical service centralisation in 
Australia versus choice and quality of life for rural patients. Med J 
Aust.2006;185(3):162–163. doi: 10.5694/j.1326-5377.2006.tb00507.x. 
PMID: 16893360.

20. Choi JB, Han KH, Lee Y, Ha US, Cho KJ, Kim JC, et al. The incidence of 
testicular torsion and testicular salvage rate in Korea over 10 years: a 
nationwide population-based study. Investig Clin Urol.2022;63(4):448–
4 5 4. doi: 10.4111/ icu.20 2 2012 2. PMID: 35 670 0 0 8; PMCID: 
PMC9262487.

21. Overholt T, Jessop M, Barnard J, Al-Omar O. Pediatric testicular 
torsion: does patient transfer affect time to intervention or surgical 
outcomes at a rural tertiary care center? BMC Urol. 2019;19(1):39. doi: 
10.1186/s12894-019-0473-5. PMID: 31101044; PMCID: PMC6525388.

22. Australian Government. Department of Health. Care DoHaA. 
Stronger Rural Health Strategy: improved access to Australian 
trained general practitioners. 2021. Accessed June 9, 2023. https://
a g e d c a r e . r o y al c o m mis sio n .g o v. au /s y s t e m / f ile s / 2 0 2 0 - 0 6 /
CTH.0001.1001.0585.pdf

23. Ota K, Fukui K, Oba K, Shimoda A, Oka M, Ota K, et al. The 
role of ultrasound imaging in adult patients with testicular 
torsion: a systematic review and meta-analysis. J Med Ultrason 
(2001).2019;46(3):325–334. doi: 10.1007/s10396-019-00937-3. PMID: 
30847624.

24. Barbosa JABA, de Freitas PFS, Carvalho SAD, Coelho AQ, Yorioka 
MAW, Pereira MWA, et al. Validation of the TWIST score for testicular 
torsion in adults. Int Urol Nephrol.2021;53(1):7-11. doi: 10.1007/s11255-
020-02618-4. PMID: 32844355.

ultrasonography. Thus, we recommend reserving sonog-
raphy for patients falling into the medium-risk groups as 
an adjunct to support clinician suspicion, and we suggest 
incorporating other scoring systems as decision-mak-
ing adjuncts. It is widely advocated in the literature 
that ultrasound should not delay scrotal exploration 
in high-risk patients due to increased rate of non-via-
ble testes due to in-hospital time delays[26]. However, 
in our study, we found much lower orchidectomy rates 
overall compared to the literature, despite there being 
significant in-hospital delays[26], indicating a poten-
tial underpowering to assess the relationship between 
ultrasonography and orchidectomy. Therefore, we agree 
with contemporary guidelines and advocate for scrotal 
exploration based on clinical findings, as ultrasonogra-
phy nearly doubled the time to definitive management 
in this study.

A limitation of this study is the inability to analyze 
the correlation between orchidectomy rates and symp-
tom onset or degree of torsion due to incomplete and 
heterogeneous documentation, prohibiting accurate 
data collection. The literature establishes that symptom 
onset followed by torsion rotation is the predominant 
established risk factor[27,28] and when symptom onset 
is < 24 hours, hospital transfer has been shown to signifi-
cantly increase orchidectomy rates[29]. However, in this 
study, we found no significant increase in orchidectomy 
rates associated with in-hospital delay to theaters, likely 
because the majority of patients underwent surgery 
within 4 hours of presentation. No manual de-torsion 
was performed and thus its role could not be assessed. 
Furthermore, the absence of network guidelines or 
protocols resulted in inconsistency in clinician deci-
sion-making, with a mix of registered nurses, general 
practitioners, general surgeons, and urologists making 
assessments and determining the need for transfer and 
surgery. In particular, this could explain the high rate of 
ultrasonography usage, but no significant differences in 
ultrasonography use were identified between peripheral 
and non-peripheral hospitals. The orchidectomy rate in 
this study for patients with torsion was 22.6%, which is 
lower than the rates described in the literature, which 

can rise up to 39%[27]. This difference suggests that 
the analysis may have been underpowered to appropri-
ately assess orchidectomy and its relationship with the 
variables described. We recommend future multicenter 
studies with sufficient samples sizes to further examine 
the relationships described in this study. Due to incom-
plete or unavailable data, follow-up was not assessed, 
predominantly due to barriers in rural health care, 
including limited patient access to health care follow-up 
or incomplete assessments performed by non-surgical 
healthcare providers at peripheral health sites.

Conclusion
In conclusion, our findings indicate that for patients 
residing in rural-remote areas of Australia, geographical 
distance, SES, age, and peripheral hospital attendance 
were not significant risk factors for orchidectomy 
rate. Despite significant time delays associated with 
peripheral hospital attendance, geographic remoteness, 
and low SES, we suggest that testicular torsion can be 
managed safely in rural health care settings, particularly 
within a rural referral center with a peripheral hospital 
catchment. Future multicenter, prospective studies 
examining symptom onset and clinical decision-making 
rules, such as TWIST score, should be performed 
in rural health care settings to assess the diagnostic 
accuracy and the role and safety of ultrasonography in 
the management of this organ-threatening condition.

Acknowledgments
The research protocol (PID01054/ETH00931/STE01878) 
was approved by the Greater Western Human Ethics 
Research Committee as a negligible/low-risk project. 
The data were retrospectively collected and de-identified, 
eliminating the need for informed consent from each 
patient. This study did not involve any trials or animal 
experiments. The authors would like to disclose that 
they have not received any grant support and they 
declare no conf licts of interest. All the authors have 
reviewed and agree upon the content of the manuscript. 
The manuscript has not been previously published and it 
is not under consideration elsewhere.

263262 SIUJ.ORG SIUJ  •  Volume 4, Number 4  •  July 2023SIUJ  •  Volume 4, Number 4  •  July 2023 SIUJ.ORG

 ORIGINAL RESEARCH Testicular Torsion: An Analysis of Rural Geography and Socioeconomic Status

https://www.aihw.gov.au/reports/rural-remote-australians/rural-and-remote-health
https://www.aihw.gov.au/reports/rural-remote-australians/rural-and-remote-health
https://www.surgeons.org/en/about-racs/position-papers/acute-scrotal-pain-and-suspected-testicular-torsion-guidelines-2018
https://www.surgeons.org/en/about-racs/position-papers/acute-scrotal-pain-and-suspected-testicular-torsion-guidelines-2018
https://www.abs.gov.au/websitedbs/censushome.nsf/home/seifa
https://www.abs.gov.au/websitedbs/censushome.nsf/home/seifa
https://www.health.gov.au/topics/rural-health-workforce/classifications/mmm
https://www.health.gov.au/topics/rural-health-workforce/classifications/mmm
https://www.aihw.gov.au/reports/hospitals/procedures-data-cubes
https://www.abs.gov.au/statistics/people/population/national-state-and-territory-population/latest-release
https://www.abs.gov.au/statistics/people/population/national-state-and-territory-population/latest-release
http://SIUJ.org
http://SIUJ.org


25. Qin KR, Qu LG. Diagnosing with a TWIST: systematic review and meta-
analysis of a testicular torsion risk score. J Urol.2022;208(1):62–70. 
doi: 10.1097/JU.0000000000002496. PMID: 35238603.

26. Wright HG, Wright HJ. Ultrasound use in suspected testicular torsion: 
an association with delay to theatre and increased intraoperative 
finding of non-viable testicle. N Z Med J.2021;134(1542):50–55. PMID: 
34531583.

27. MacDonald C, Kronfli R, Carachi R, O’Toole S. A systematic review 
and meta-analysis revealing realistic outcomes following paediatric 
torsion of testes. J Pediatr Urol.2018;14(6):503–509. doi: 10.1016/j.
jpurol.2018.09.017. PMID: 30404723.

28. Howe AS, Vasudevan V, Kongnyuy M, Rychik K, Thomas LA, Matuskova 
M, et al. Degree of twisting and duration of symptoms are prognostic 
factors of testis salvage during episodes of testicular torsion. Transl 
Androl Urol.2017;6(6):1159–1166. doi: 10.21037/tau.2017.09.10. PMID: 
29354505; PMCID: PMC5760391.

29. Kwenda EP, Locke RA, DeMarco RT, Bayne CE. Impact of hospital 
transfer on testicular torsion outcomes: a systematic review and 
meta-analysis. J Pediatr Urol.2021;17(3):293.e1–293.e8. doi: 10.1016/j.
jpurol.2021.01.038. PMID: 33610457.

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