RESULTS OF A PROSPECTIVE CLINICAL PATHWAY TO EXPEDITE CARE IN PEDIATRIC TESTICULAR TORSION
Robert DeFoor, MD.
Cincinnati Childrens Hospital, Cincinnati, OH, USA.
BACKGROUND: Torsion of the spermatic cord leading to testicular infarction demands prompt diagnosis and treatment to prevent testicular organ loss. For many years, rapid access to ultrasonography has been available in our institution on a 24-hour basis. In 2016, a collaboration among the ED, Radiology, and Urology was formed to establish a protocol for boys presenting with acute scrotal pain. Ultrasound results diagnostic of torsion prompt a direct call from Radiology to the Urology attending to expedite operative intervention.
METHODS: A prospective cohort study was performed to assess clinical outcomes for males evaluated in the Pediatric Emergency Department in our institution with a chief complaint of scrotal pain less than 24 hours in duration. Inclusion criteria included patients under 19 years of age with at least one month of follow-up. Data abstracted from the medical record included patient demographics, onset of pain, imaging, time from presentation in the ED to the operating room (OR), and rate of orchiectomy. Univariate analysis between means was performed with a two-tailed t-test.
RESULTS: A total of 144 patients presented with scrotal pain, 136 (94%) of which underwent a scrotal ultrasound. Of those, 21 (14.5%) were diagnosed with testicular torsion and underwent surgical repair, and 29 patients with testicular torsion served as a historical control in the immediate 12 months prior to the protocol. The mean age was 14.0 years in the study group and 14.5 years in the controls. The median time from presentation to the OR was 170 minutes in the study group and 191 minutes in the control group (p<0.01). The orchiectomy rate was 4/29 (14%) in the control group and 9/21 (43%) in the study group. Twelve patients undergoing orchiectomy had >18 hours of pain, and one patient had > 12 hours of pain prior to presentation to the ED. No patients with acute onset of pain less than 4 hours required orchiectomy.
CONCLUSIONS: A prospective protocol for assessing patients with acute scrotal pain is feasible in a pediatric ED setting. This resulted in faster time for patients with torsion reaching the operating room for intervention compared to historical control. While this did not result in higher testicular salvage rate during the study period, expediting care for ischemic organ resulted in 100% salvage rate in patients with early presentation of symptoms.
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