Pediatric Urology Clinical Predictors of Testicular Torsion in Children Michael Boettcher, Robert Bergholz, Thomas F. Krebs, Katharina Wenke, and Daniel C. Aronson OBJECTIVE To distinguish the prognostic factors that decrease the probability of a negative exploration for “acute scrotum.” In some institutes, patients with “acute scrotum” undergo immediate explora- tion after clinical evaluation. Because testicular torsion (TT) accounts only for a fraction of these cases, most infants can be treated conservatively. METHODS We performed a retrospective study of all patients treated at our institute from January 2008 to December 2009 for the diagnosis of “acute scrotum.” Differences between groups were calculated using the chi-square test or analysis of variance and Mann-Whitney-Wilcoxon test for univariate or multivariate analysis, expressed as odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS The data from 138 patients were analyzed. The mean age was 9 years, 8 months. 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. CONCLUSION TT is uncommon among the group of boys treated for “acute scrotum.” In particular, a pain duration 24 hours, nausea or vomiting, a high position of the testis, and an abnormal cremasteric reflex had a positive prognostic value for TT. A clinical score might help to avoid unnecessary explorations. In the future, we intend to test the diagnostic set described combined with ultrasonography. UROLOGY 79: 670 – 674, 2012. © 2012 Elsevier Inc. T orsion, or rotation of the testis with twisting of the spermatic cord, is a surgical emergency. Late presentation or failure to diagnose and correctly manage this condition leads to loss of the testis on the affected side. The triggering reason for scrotal swelling, reddening, and pain without previous trauma is not al- ways obvious. However, testicular torsion (TT), torsion of the appendages of the testis, and epididymo-orchitis (EO) will account for 90% of cases. Other diagnoses that can rarely mimic torsion include idiopathic scrotal edema, hydrocele, scrotal hernia, testicular tumor, thrombosed varicocele, and Schoenlein-Henoch purpura. TT was first described by Hunter in 1776. 1 It can occur at any age but is most common in the adolescent age group, with a smaller peak in the neonatal age group. 2 This distribution results from the different types of tor- sion. TT in newborns results almost exclusively from extravaginal testicular torsion. Neonates present with swelling, discoloration of the scrotum on the affected side, and a firm painless mass in the scrotum. The testis is typically infarcted and necrotic at birth. 3 Pubertal boys develop intravaginal torsion that occurs within the tu- nica vaginalis. The predisposing factors include a long and narrow mesentery or a bell-clapper deformity. TT is defined as a rotation of the longitudinal axis of the spermatic cord, resulting in strangulation of testicular blood flow. The extent of testicular ischemia depends on the degree of torsion, varying from 180° to 720°. The testicular salvage rate hinges on the degree of torsion and the duration of ischemia. Almost all testes are savaged within the first 6 hours after the onset of symptoms. With later treatment, the salvage rates rapidly decrease. 4,5 Typically, TT presents with a sudden onset of severe pain followed by inguinal and/or scrotal swelling. Many patients also have gastrointestinal symptoms with nausea and vomiting. Often, a high riding testis with a transverse orientation is found. The absence of the cremasteric reflex in a patient with acute scrotal pain supports the diagnosis of TT. 6 Torsion of the appendix testis and appendix epididy- mis occurs usually in 7-14 year-old boys. Patients present From the Department of Pediatric Surgery, Hamburg University UKE-Medical School, University Children’s Hospital Altona, Hamburg, Germany Reprint requests: Michael Boettcher, M.D., Department of Pediatric Surgery, Uni- versity Children’s Hospital Altona, University Medical Center Hamburg-Eppendorf, Hamburg University, Bleickenallee 38, Hamburg 22763 Germany. E-mail: michboettcher@gmail.com Submitted: August 18, 2011, accepted (with revisions): October 21, 2011 670 © 2012 Elsevier Inc. 0090-4295/12/$36.00 All Rights Reserved doi:10.1016/j.urology.2011.10.041