Predictors of Spermatic Cord Torsion—Clinical Presentation and Intraoperative Findings

doi:10.4236/oju.2011.14017

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Open Journal of Urology, 2011, 1, 81-85

doi:10.4236/oju.2011.14017 Published Online November 2011 (http://www.SciRP.org/journal/oju)

Predictors of Spermatic Cord Torsion—Clinical

Presentation and Intraoperative Findings

Axel Hegele1*, Dirk Wappelhorst1*, Zoltan Varga2, Fabian Brüning1, Peter Olbert1,

Carsten Frohme1, Rainer Hofmann1

1Department of Ur ology and Pediatric Urology, University Medical Center, Marburg, Germany

2Department of Ur ology and Pediatric Urology, Kreisklinikum Sigmaringen, Germany

E-mail: [email protected]

Received July 21, 2011; revised August 30, 2011; accepted September 9, 2011

Abstract

Background: To evaluate aetiology of acute scrotum after surgical exploration suspicious for spermatic cord

torsion, to compare surgical with clinical findings and to support the clinician distinguishing spermatic cord

torsion from other diseases mimicking this emergency requiring surgical exploration. Methods: All men with

the diagnosis of an acute scrotum who underwent emergency scrotal exploration between January 1995 and

October 2009 were retrospectively evaluated. Results: 230 patients were analyzed. Torsion of the spermatic

cord (53%) was the most common cause followed by torsion of the testis appendages (25%). Patients with

spermatic cord torsion were significantly older (15.5 y) and haunted hospital faster than others (p < 0.001).

Statistical analysis revealed that high testicular position and reduced/missing blood flow using duplex sono-

graphy are associated with increased probability of spermatic cord torsion. A significant difference in sea-

sonal variation was not seen. Conclusions: Our data demonstrate that spermatic cord torsion is more common

in adolescent. Short pain duration and high intrascrotal position of the testicle are associated with higher

probability of spermatic cord torsion. Duplex sonography plays an important role in the diagnostic workup

but history and physical examination are the crucial parameters. In nebulous clinical cases emergency surgi-

cal exploration has to be recommended.

Keywords: Acute Scrotum, Spermatic Cord Torsion, Emerge n c y, Cli n i c a l Pr e di c t o r

1. Introduction

Acute scrotum represents an emergency situation, that

has to be diagnosed urgently. Also adequate therapy has

to take place without loss of time [1,2]. An acute painful

swelling of the scrotum is often accompanied with local

signs like reddening and general symptoms. The reasons

causing symptom complex of acute scrotum are manifold.

A lot of differential diagnoses have to be taken into ac-

count: spermatic cord torsion, torsion of the appendages

of testis, inflammatory diseases like acute epididym-

orchitis, incarcerated inguinal hernia or testicular tumors

[3,4]. Among these diverse aetiologies spermatic cord

torsion is of special clinical interest. Spermatic cord tor-

sion mainly affects infants/juveniles and requires imme-

diate surgical intervention [5]. The spermatic cord rotates

in longitudinal axis so blood flow is completely or par-

tially disabled. After 6h of complete isch emia the testis is

irreversible damaged. Therefore, efficient and accurately

diagnostic tools are essential for testicular salvage. In

clinical routine medical history, carefully clinical evalua-

tion and duplex sonography are performed. Physical exa-

mination is often not sufficient to form a diagnosis espe-

cially in infants. Duplex sonography is routinely used but

if investigations are not confidently surgical exploration

has to be performed following the principle “if in doubt

check it out”.

The aim of the present study was to evaluate aetiology

of acute scrotum after surgical exploration suspicious for

spermatic cord torsion, to compare surgical with clinical

findings and to support the clinician distinguishing sper-

matic cord torsion from other diseases mimicking this

emergency requiring s u r gi cal ex ploration.

2. Patient and Methods

All boys and men with the diagno sis of an acute scrotum

*These authors contribut e d e

uall

to this wor

A. HEGELE ET AL.

clinically suspicious for spermatic cord torsion who un-

derwent emergency scrotal exploration at the Department

of Urology and Pediatric Urology (Medical Center,

Philipps-University Marburg) between January 199 5 and

October 2009 were retrospectively reviewed.

Registered data included, beside medical history,

demographic data like patient age, pain duration until

haunting Department of Urology, affected side, swelling

and actual season. Both physical findings like erythema

of the scrotal region, tenderness of the scrotum, uplifted

testis, testicular and/or epididymal pain and results of

preopera tively performed duplex sonography wer e recor-

ded.

Statistical analyses were performed using the nonpa-

rametric Mann-Whitney U-test to compare the results

between different groups. The Kruskal-Wallis ANOVA

test was used to analyze the differences between the dif-

ferent groups and subgroups (Statistical Packages for

Social Sciences SPSS® for Windows, Version 17). Sta-

tistically significance was accepted when p-value reached

< 0.05.

3. Results

In the mentioned time period a total of 237 men clini-

cally suspect for spermatic cord torsion were surgically

explored at the Department of Urology and Pediatric

Urology. 230 patients were evaluable (median age 12.5

years, range 1 day - 46 years).

All patients suffered testicular pain. Torsion of the

spermatic cord was the most common cause of acute

scrotum found in 122 pa tients (Group A: 53%), follo wed

by torsion of the testis appendages in 58 patients (Group

B: 25%), acute epididym-orchitis in 29 patients (Group C:

13%) and other aetiologies in 21 patients (Group D: 9%).

Patients with spermatic cord torsion (mean age 15.5

years, range 1 day - 43 years) were significantly older

than patients of Group B-D (p < 0.001, Figure 1).

Figure 1. Mean age of patients Group A - D (p < 0.001).

Patients with acute epididym-orchitis (Group C) displa-

yed the youngest age group (mean 6.9 years, range 2

months - 46 years).

Side location showed no significant differences: right

testis was affected in 104 (45.2%) and left testis in 126

patients (54.8%).

Group A had mean symptom duration until haunting

hospital of 6h (SD ± 1 14 h, range 1 - 28 days). No statis-

tical significant differences were found concerning left or

right side (53.3% vs. 46.7%). Swelling and reddening of

the scrotal area were documented in 77.1% of the pa-

tients. Scrotal uplifted testicle was found in 78% of the

cases. Duplex sonography revealed decreased or absent

blood flow in 54%.

Group B haunted hospital after 24h of painful symp-

toms (SD ± 35 h, range 1 h - 6.2 days). Left side was

affected in 58.6% of the cases. Swelling and reddening

were seen in 71% of the cases, uplifted testicle was

found in 32% and dup lex sonography showed no or lim-

ited testis perfusion in 19%.

Group C came to hospital after mean symptom dura-

tion of 24 h (SD ± 22h, range 3.5 h - 4 days), presentin g

swelling and reddening in 97%, uplifted testicle in 19%

and abnormal testicular blood flow in 17% of the cases.

Right side was affected in 55.2% of the patients.

Group D had mean symptom duration of 10 h (SD ±

20.1 h, range 1.5 h - 3 days), showing swelling and red-

dening in 70%, uplifted testicle in 18% and suspicious

duplex sonography in 20%. Left side was affected in

about two third of the cases (66.7% vs. 33.3%).

Statistical analysis revealed that high testicular posi-

tion is common in torsion of the spermatic cord with

significant difference compared to other aetiologies cau-

sing acute scrotum (p < 0.001). Swelling and reddening

showed no significant differences between the different

groups (p = 0.071). Duplex sonography revealed signifi-

cant reduced or totally missing testicular blood flow in

spermatic cord torsion compared to other aetiologies (p =

0.015). Additionally, patients with spermatic cord torsion

haunted hospital significant faster than others (p < 0.001,

Figure 2). No significant difference of affected side lo-

cation was detectable in the investigated cohort and the

subgroups. Patient characteristics, presented symptoms

and clinical findings of the different groups are summa-

rized in Table 1.

A significant difference in seasonal variation was not

seen: highest number of patients with acute scrotum and

need of emergency surgical intervention were found in

spring (n = 63) compared to summer, fall and winter (n =

56, n = 58, n = 53 resp.). Also no significant seasonal

differences were detectable within Group A-D (Figure

3).

A. HEGELE ET AL.

Table 1. Patient characteristics separated concerning intra-operative findings (Group A: spermatic cord torsion, Group B:

torsion of the testis appendages, Group C: ac ute e pididym-orchitis, Gr oup D: other s).

Affected side

Number Median age

(years) Median time dura-

tion (h ± SD) right left

High testicular

position Swelling/

reddening

Sonography

(no/reduced

blood flow)

Group A 122 15.5 6 (114) 57 65 77.9% 77.1% 54.4%

Group B 58 10.8 24 (34.8) 24 34 31.8% 71.2% 19.1%

Group C 29 6.9 24 (21.8) 16 13 19% 96.6% 16.7%

Group D 21 9.1 10 (20.1) 7 14 16% 65.1% 12,1%

total 230 12.7 104 126

Figure 2. Median time duration of pain until haunting

hospital (p < 0.001).

Figure 3. No seasonal significant variation was seen between

and within the different aetiologies causing acute scrotum.

4. Discussion

Acute scrotum represents one of the most difficult situa-

tions for the clinician. Especially spermatic cord torsion,

showing an incidence about 1:4000, is utmost impor-

tance. Delay of diagnosis and inadequate therapy may

result in loss of the testis. In view of manifold differen-

tial aetiologies causing an acute scrotum, despite careful

clinical evaluation and lack of time surgical exploration

will be performed in cases suspicious for spermatic cord

torsion [1,2]. Thus, some patients will be operated al-

though their disease could be treated conservatively. We

present our findings in 230 patients undergoing surgical

exploration to exclude spermatic cord torsion after clini-

cal evaluation. In our large cohort spermatic co rd torsion

was most common in 53% of patients, followed by tor-

sion of the testicular appendages in 25% and epidi-

dym-orchitis in 13%. Hegarty and co-workers presented

similar data of 100 patients finding spermatic cord tor-

sion most common (33%) [6]. Cavusoglu et al. found

spermatic cord torsion only in 29% but epididym-orchitis

in 37% of 165 surgically explored patients. Additionally

they reported that in neonatal period the most common

pathology was spermatic cord torsion and in prepubertal

period torsion of the appendages [7]. In contrast our data

of 230 consecutive patients showed that epididym-or-

chitis was most common in younger age group (median

6.9 years), patients suffering spermatic cord torsion were

significantly older (median 15.5 years). An explanation

for this findings maybe the ability of the older patien ts to

tell anamnestic details concerning typical clinical fea-

tures: i.e. sudden-onset p ain in sp ermatic cord to rsion.

Our findings were supported by data of Ben-Chaim

and co-workers. In 70% of 171 patients spermatic cord

torsion was present. Dividing their examined population

concerning age spermatic cord torsion was most common

found in adults, followed by adolescents and children

(88%, 86% and 34%, respectively) indicating the impor-

tance of a detailed anamnesis and the ability of the pa-

tients to tell typical clinical features [8]. Similar data

were published by Beni-Israel and co-workers from a

pediatric emergency department. Out of 523 patients

with a mean age of 10 years and 9 months presenting an

acute scrotum only 3.25% suffered spermatic cord tor-

sion [9]. Furthermore, our data concerning clinical pre-

dictors for spermatic cord torsion reveal that the uplifted

A. HEGELE ET AL.

testicle is significantly more existent in spermatic cord

torsion compared to other painful entities causing acute

scrotum. Additionally, patients with spermatic cord tor-

sion haunted hospital significantly faster. Other clinical

signs like reddening and swelling seem not to be suffi-

ciently reliable. Our clinical predictors associated with

higher likelihood of spermatic cord torsion are in line

with others [3,9,10,11]. These authors described also that

high position of testicle and short time duration until

haunting hospital are associated with existence of sper-

matic cord torsion.

Our data underline the impact of duplex sonography in

this emergency situation and in the diagnostic workup of

acute scrotum [1,12,13]. In our large cohort we found

significant reduction or loss of testicular perfusion in

spermatic cord torsion. However, the performance and

interpretation are operator-dependent and are supported

by history and physical findings thus in clinical unclear

cases surgical exploration is still indicated [14]. Some

authors described a seasonal variation of spermatic cord

torsion incidence. Lyronis and co-workers described a

significant increased appearance of spermatic cord tor-

sion during greek winter in 140 boys [15]. Srinivasan

and co-workers found, using multivariate analysis, a sig-

nificant correlation between spermatic cord torsion and

decreasing atmospheric temperature in 58 US children

[16]. Malakindiah and co-workers described an increased

occurrence from October to March in India [17]. Wil-

liams and co-workers did not see statistical relevant dif-

ferences between the different seasons but they also de-

scribed a trend to winter [18]. Our data showed that pa-

tients with acute scrotum are most common in spring.

Concerning spermatic cord torsion we found no signify-

cant seasonal differences, suggesting no aetiological role

for climatic conditions especially decreasing te mperature

in Germany. These different findings maybe explained

by the different locations Greek, US, India and Germany.

5. Conclusions

In conclusion our data demonstrate that in over 50% of

patient suffering an acute scrotum and demand for

emergency surgical exploration spermatic cord torsion

was found. Additionally spermatic cord torsion is more

common in adolescent. Short pain duration until haunt-

ing hospital and high intrascrotal uplifted position of the

testicle are associated with higher probability of a sper-

matic cord torsion. A seasonal variation in the incidence

of acute scrotum and especially spermatic cord torsion

with parallelism to d ecreasing temperature was not seen.

Duplex sonography plays an important role in the diag-

nostic workup but history and physical examination are

the crucial parameters in aetio logy evaluation of an acu te

scrotum. Therefore differential diagnosis of acute scrotum

still remains a diagnostic challenge. Our data underline

that in any case suspicious for spermatic cord torsion

emergency surgical exploration has to be performed im-

mediately.

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