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Use of Doppler Ultrasound in the Evaluation of the Acute Scrotum: Diagnostic Aid or Unnecessary Delay?
Jonathan S. Ellison, MD, Sarah Hecht, MD, Julian Wan, MD, Kate Kraft, MD.
University of Michigan, Ann Arbor, MI, USA.

Introduction: Prompt evaluation of testicular torsion (TT) is critical to testicular salvage. Doppler ultrasound (DUS) has a higher sensitivity and specificity than standard physical exam alone but may delay treatment. We reviewed the use of DUS and management of acute scrotal pain within our emergency department (ED) to see if the use of DUS affected the time course of treatment.
Methods: An IRB-approved retrospective review of all urological consults from 2008-2012 was performed for patients presenting to the ED with acute scrotal pain. The presentation, lab tests, imaging, operative findings, and final diagnoses were analyzed and patients presenting with and without torsion, presenting with or without a viable testicle or presenting to our ED or another ED primarily were compared. Time course from symptom onset to final ED disposition or operative evaluate was also assessed for each patient.
Results: The records of 104 patients were reviewed. DUS was performed in 100 visits (92%). Epididymitis was the most common diagnosis (N =25, 31%) followed by TT (N = 20, 19%). Sixteen these patients presenting with TT had a viable testicle on exploration (70%). False positive and negative rates for DUS were 5% and 16%, respectively. The timeline points of ED evaluation for patients presenting with non-torsion etiology, TT with a viable testicle and TT with a non-viable testicle are noted in the Table. Patients presenting with a non-TT etiology had a significantly longer time from symptom onset to ED evaluation while those presenting with a non-viable TT had a trend towards a longer time course before presenting to the ED. Those with a non-viable TT did have a longer timeframe between ultrasound and urologic evaluation. There was no difference in the salvage rate for patients referred from an outside institution. 31 patients presented for follow-up ultrasound. A decrease in testicle volume was noted in 15 of 24 (63%) patients with complete testicular measurements noted on ultrasound, including 6 patients with TT and 5 patients with epididymititis. The degree of atrophy was greater for those patients with TT (52.6% vs 24.8%, p = 0.017)
Conclusion: DUS is a reliable adjunct for evaluation of acute scrotal pain but should not preclude surgical exploration in patients where clinical suspicion for TT is high. TT with a non-viable testicle was associated with longer time to ED presentation and also delayed urologic evaluation. The latter is an opportunity for improvement, while possibly affecting salvage. A decrease in testicle volume is common in those patients presenting for follow-up, even in cases where torsion is not present.
Median time course for evaluation of scrotal pain, from presentation to urologic management (hours,
Onset to
ED Check-in
ED Check-in to ED ExamED Exam to
Ultrasound
Ultrasound to
Uro Exam
Uro Exam to OR
No Torsion29.6
(p = 0.01)
0.40.9
(p = 0.05)
1.2N/A
TT with a viable testicle8.30.30.50.80.7
TT with a non-viable testicle29.10.20.12.2
(p=0.02)
1.2


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