Clinical predictors for differential diagnosis of acute scrotum

Accurate and early diagnosis of acute scrotum is of the utmost importance to avoid testicular loss and/or needless surgery. The aim of this study is to analyze the clinical presentation and physical examination parameters together with the results of imaging studies in order to find out predictors for the differential diagnosis of acute scrotum with special emphasize on testicular torsion (TT). Patients who were treated for acute scrotum in our unit from 1970 up to and including 2000 were reviewed retrospectively. The study group was subdivided into three groups: "testicular torsion (TT)", "torsion of testicular appendage (TTA)", and "epididymoorchitis (EO)" group according to the diagnosis confirmed by radiologic and surgical findings. Presence and/or absence of various parameters related to clinical presentation, physical examination, and results of imaging studies were analyzed by statistical means in each group. One hundred and sixty children with a mean age of 12.2 years formed the study group. The mean duration of symptoms was 15 hours. No significant difference was noted between the three groups with regard to mean age and duration of symptoms. Nuclear scintigraphy and Doppler ultrasound were used as diagnostic aids in 50 and 66 children, respectively. Clinical presentation parameters including the presence of a) previous trauma, b) pain attacks, and c) nausea and vomiting, had the highest sensitivity, specificity, positive and negative predictive values in the TT group and the lowest values in the EO group. In contrast, the EO group had the highest statistical values with regard to presence of dysuria and micturition disorders. Physical examination parameters consisting of a) elevation, b) transverse location of testis, c) anterior rotation of epididymis, and d) absence of cremasteric reflex had the highest statistical values in the TT group. Contrary to this, imaging studies had the highest specificity and positive predictive values in the TTA group and the lowest values in the TT group. Previous history of trauma and pain attacks, presence of nausea and vomiting, and absence of urinary complaints are the main predictors of TT. Elevation and transverse location of testis with an anteriorly rotated epididymis associated with loss of ipsilateral cremasteric reflex strongly indicate TT. Although accuracy of imaging studies is higher for the differential diagnosis of TTA and EO, there is a considerable risk of misdiagnosis. Therefore, differential diagnosis of acute scrotum, particularly TT, still remains a clinical diagnosis, and clinical parameters deserve more importance in surgical decision making.