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INTRODUCTION

Acute testicular pain represents about 0.5% of emergency department (ED) complaints.1 Causes of acute testicular pain include trauma, epididymitis, orchitis, tumor, and hernia; however, testicular torsion is the diagnosis of the greatest concern in the emergency setting.

The traditional teaching was that most patients presenting to an ED or urgent care with a complaint of acute testicular pain had testicular torsion.2 This misconception has been dispelled and it is now known that the most common etiology of acute testicular pain is epididymitis in adults, accounting for approximately 600,000 cases annually in the United States.3 The estimated annual incidence of testicular torsion is 3.8 per 100,000 (0.004%) for patients 1–18 years of age.4 It accounts for only 10–15% of cases of acute scrotum in children.5 However, the evaluation of acute testicular pain presents a considerable challenge for emergency providers, since 50% of patients presenting with testicular torsion delay seeking care for more than 6 hours and are at high risk of losing the torsed testicle.6

The issue of acute testicular pain is further complicated by the high potential for litigation associated with infertility after testicular loss due to torsion or disruption of the testicle from severe trauma. When the diagnosis of testicular torsion is missed, the majority of patients have been incorrectly diagnosed with epididymitis.7

CLINICAL CONSIDERATIONS

High-resolution color Doppler ultrasonography has become widely accepted as the test of choice for evaluating acute scrotal pain, replacing scintigraphy in most institutions.8 While scintigraphy requires less technical skill on the part of the radiologist consulted to evaluate the patient, there are major drawbacks to the technique. Scintigraphy is a time-consuming process that can add an hour or more to the evaluation of a patient who may already be several hours into the testicular torsion process.8 Furthermore, the resultant hyperemia of the scrotal skin during testicular torsion can mask a lack of blood flow to the testicle itself and lead to a misdiagnosis in less experienced hands.9 This nuclear medicine study also provides no information regarding testicular anatomy, which is a critical issue if pathology other than torsion is present. Magnetic resonance imaging (MRI) is a promising imaging modality for detecting acute scrotal problems, including ischemia caused by torsion. However, MRI is expensive and time consuming. Ultrasound contrast agents have been developed for the assessment of tissue perfusion. Contrast-enhanced ultrasonography (CEUS) is currently considered a reliable imaging modality for the evaluation of vascularity of various organs and its utility in the diagnosis of scrotal pathology is being explored. Preliminary reports on the use of CEUS in the evaluation of scrotal pathology suggest that it could be used to identify necrosis, ischemia, abscesses, and tumor vascularization. CEUS can potentially be used supplementarily with traditional Doppler ultrasound in cases where ultrasound findings are ambiguous and diagnosis remains inconclusive. It may provide a reliable and inexpensive ...

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