Introduction
Pre-pubertal testicular torsion remains a difficult-to-treat entity, with diagnosis often confounded and surgical treatment delayed. We sought to characterize the presentation of acute testicular torsion in this patient population in a large, tertiary care academic center.
Methods
We performed a retrospective chart review of all pre-pubertal (aged <=10 years) patients diagnosed with testicular torsion using billing codes over a 9-year study period (2015-2023). Data on demographics, duration of pain, clinical context, times of presentation to either an outside facility or one of our system Emergency Departments, time to surgical detorsion, findings at surgery, and all follow-up findings, including US when possible. Patients underwent surgical intervention by one of seven fellowship trained pediatric urologists over the study period.
Results
A total of 100 prepubertal patients were diagnosed with acute testicular torsion, including 6 (6%) neonatal torsions (aged <=1 month). Median (interquartile range [IQR]) age at index presentation was 4.2 (1.6-7.6) years, and 23 (23%) initially presented at outside hospital. Interestingly, 81 (86%) of non-neonatal patients had left sided torsion, while there was equal (50% each) distribution of laterality in neonatal patients. 14 (14%) had ipsilateral inguinal undescended testicle. Median (IQR) TWIST score, where available (n=78), was 5 (4-6): while 28 (35.9%) had intermediate risk score (3-4), 47 (60%) had high risk score (5-7). Median (IQR) Time from onset of symptoms to surgical intervention was 30 (8.7-66) hours.
Intraoperatively, 54 (54%) underwent ipsilateral orchiectomy. Amongst patients undergoing ipsilateral orchidopexy, 33 (71.7%) had follow up with urology postoperatively, including 22 (67%) with at-least 6-month follow-up. 18 (54%) had atrophy, including 5/6 (83%) of patients undergoing tunica vaginalis flap. Patients who had atrophy had higher TWIST scores (p=0.01, Figure 1), greater degrees of torsion (p=0.04, Figure 2) and longer duration of pain (median 26.1 [9.5-41.8] vs. 12.1 [8.1-30.5] hours), although the latter was not statistically significant.
Discussion
We noted an unusually high, and unexplained, preponderance of left-sided torsions (86%) in our cohort of pre-pubertal patients diagnosed with acute testicular torsion. More than 1/3rd of patients had intermediate risk TWIST score, underscoring the heterogeneity in presentation and scoring. While nearly half may undergo surgical salvage at initial presentation, the eventual testicular loss rate with longer follow up remains high (72% in our cohort), despite tunica vaginalis flaps. Likelihood of eventual atrophy may be associated with pre-operative (TWIST score) and intra-operative factors (degrees of torsion). These data can be used for optimal, individualized patient and family counseling and decision-making.
