ARTICLE

Testicular Torsion and Risk Factors for Orchiectomy

Jonathan M. Mansbach, MD; Peter Forbes, MA; Craig Peters, MD

Objective: To determine risk factors for testicular loss due to testicular torsion. Design and Participants: Medical records of patients aged 1 to 25 years with a principal diagnosis of testicular torsion were extracted from the 1998 Nationwide Inpatient Sample. Population-based rates of testicular torsion and orchiectomy were determined. Logistic regression was used to create a predictive model for orchiectomy. For comparison, medical records of patients aged 1 to 25 years with a principal diagnosis of testicular neoplasm were extracted. Results: The sample comprised 436 participants. The

benign and malignant testicular tumors is 1.2 cases per 100 000. Of the estimated 2248 males diagnosed nationally in 1998 with testicular torsion, 762 (34%) had an orchiectomy. In the final multivariate model estimating the probability of orchiectomy, only age was significant.
Conclusions: For males aged 1 to 25 years, testicular torsion is more common than testicular tumors, and increasing age is the sole identifiable risk factor for orchiectomy. We suggest that health care professionals educate prepubertal male patients about testicular torsion and the necessity of seeking timely care to reduce the risk of orchiectomy and of possible subsequent reduced fertility.

estimated incidence of testicular torsion for males aged 1 to 25 years in the United States is 4.5 cases per 100 000 male subjects per year, and the estimated incidence of

Arch Pediatr Adolesc Med. 2005;159:1167-1171 nography is a helpful tool to differentiate torsion from other causes of an acutely painful scrotum.5 Further delays in diagnosis or treatment may be caused by individual patient factors. Appendicitis is a similar acute surgical condition in which delayed diagnosis or delayed surgery may lead to morbidity, specifically rupture of the appendix. In this condition, differences in the individual patient factors, including insurance status and race, have been associated with the risk of rupture of the appendix.6,7 The objectives of this study were to determine by using a national database if there are identifiable risk factors for testicular loss due to testicular torsion and to place the epidemiology of testicular torsion in the context of the more commonly discussed condition of testicular neoplasm.
METHODS The 1998 Nationwide Inpatient Sample (NIS) is part of the Healthcare Cost and Utilization Project, sponsored by the Agency for Healthcare Research and Quality.8 The NIS is a database of hospital inpatient stays, containing data from approximately 7 million hospital stays. The 1998 NIS contains all discharge data from

Author Affiliations: Divisions of Adolescent/Young Adult Medicine (Dr Mansbach) and Urology (Dr Peters) and Clinical Research Program (Mr Forbes), Childrens Hospital Boston, Harvard Medical School, Boston, Mass.

urologic emergency. There is approximately a 4- to 8-hour window from the onset of torsion symptoms until surgical intervention is required to save the affected testis.1 Delays in care may necessitate orchiectomy, which has been associated with reduced fertility.2 One study3 found that 57% of patients had low sperm counts a median of 5 years after unilateral testicular loss from torsion. Providing the necessary medical and surgical services for a patient with testicular torsion requires 3 steps, namely, timely presentation, rapid diagnosis, and curative intervention. The surgical procedure performed would be orchiectomy for those patients with a nonviable testicle and septopexy for those with viable testes. One potential barrier to providing ideal care is delayed presentation. In fact, male subjects may be hesitant to seek medical attention for conditions involving their genitals, even for torsion.4 Fortunately, once a patient presents to a health care professional, the diagnosis of testicular torsion can usually be made from his history and physical examination. However, when the clinical diagnosis is uncertain, color Doppler ultraso-

ESTICULAR TORSION IS A

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400 Cancer (n = 120) Torsion (n = 436)

300

200

100

0 1 5 10 15 20 25

Age, y

Figure 1. Cumulative number of patients with testicular torsion and with testicular cancer.

984 hospitals located in 22 states, approximating a 20% sample of US community hospitals. The overall goal for the NIS is to create a sample of hospitals that is generalizable to hospitals in the entire United States. The NIS data set includes a weight variable for each observation so that a weighted analysis can produce national estimates, with confidence intervals, of total cases and rates of procedures of interest. The Childrens Hospital Boston Institutional Review Board approved this study. Medical records of patients aged 1 to 25 years with the principal diagnosis of testicular torsion (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD9-CM] code 608.2) in 1998 were extracted. The ICD-9-CM code 608.2 includes torsion of the testicle and torsion of the appendix testis and appendix epididymis. We compared the group of patients who received neither orchiectomy nor orchiopexy (n=65) with the group who had a procedure (n=436); the mean ages for the groups were 11.9 vs 15.0 years (P .001). We excluded the 65 patients who did not have a surgical procedure, as these youth most likely had torsion of the appendix testis. All 436 patients who had a surgical procedure were included in the analysis. Age-specific census estimates of the US male population were used to compute rates of testicular torsion and orchiectomy per 100 000 male subjects. The July 1998 US male population aged 1 to 25 years was extrapolated from census estimates for this population at July 1, 2000, and July 1, 2001. For comparison, medical records of patients aged 1 to 25 years with a principal diagnosis of testicular neoplasm (ICD-9-CM codes 186.9 and 222.0) were also extracted. Statistical analyses were performed using SAS software version 9 (SAS Institute Inc, Cary, NC). In univariate analyses, t tests and Wilcoxon signed rank tests were used for continuous variables, and Fisher exact tests were used for categorical variables. Analyses were conducted to determine the effect of different patient- and hospital-specific variables on the risk for orchiectomy. The patient-specific variables included age (treated categorically and continuously), race (white, black, or other), insurance status (Medicaid, self-pay, or private insurance), and annual household income (low income vs other, based on the median income of the patients ZIP code of residence). Hospitalspecific variables included census region (4 levels) and hospital location (urban or rural, in which urban is within a census statistical metropolitan area). Logistic regression was used to model orchiectomy rates controlling for the effects of hospital and patient covariates and to compute adjusted odds ratios. Because of the stratified and clus-

tered sample design used by the NIS, the SAS Proc SurveyMeans was used to compute variances for totals and confidence intervals for torsion, orchiectomy, and testicular neoplasm. Logistic regressions accounted for clustering and stratification using SAS Proc SurveyLogistic. Patients with missing covariate levels ( 4% of the total) were included in logistic regression models by assigning them to the majority covariate level. The missing data from the race variable were analyzed 3 ways, namely, with the missing data treated as a separate covariate level, with the missing data removed from the analysis, and with the missing data assigned to the majority covariate level (white race). Race was not significantly associated with orchiectomy no matter how the missing values were assigned. As a result, in the final analyses, missing covariates were assigned to the majority covariate level. The ICD-9-CM code 608.2 includes torsion of the testicle, appendix testis, and appendix epididymis. It is possible, therefore, that some patients, most likely the younger ones who had an orchiopexy, did not have torsion of the testicle but rather torsion of the appendix testis or appendix epididymis. If patients with torsion of the appendix testis or appendix epididymis had an orchiopexy, these misclassified patients would erroneously lower the percentage of younger males requiring orchiectomies. Therefore, a sensitivity analysis was performed to determine the potential effect of misclassification on our conclusions. Under the assumption that some of the youngest nonorchiectomy patients could be misclassified (ie, had an orchiopexy but not torsion of the testicle), random samples of 10%, 33%, and 50% of the nonorchiectomy patients in the youngest age category were removed, and the relationship between orchiectomy and age category (youngest vs oldest males) was reassessed. Although the correct proportion of the nonorchiectomy patients to be removed from the youngest age category is not known, we anticipate that much fewer than half of these patients, all of whom had a technically unnecessary surgical procedure, had torsion of the appendix epididymis or appendix testis. RESULTS

Cumulative No. of Patients

The final sample comprised 436 eligible participants from 231 hospitals in 22 states. The number of torsion cases nationally, estimated using a weighted analysis of the data, was 2248 cases (95% confidence interval [CI], 19502547 cases). Using census results, we estimated the total male population aged 1 to 25 years in 1998 to be 50.25 million. Using these 2 results, the incidence of testicular torsion is 4.5 cases (95% CI, 3.9-5.1 cases) per 100 000 male subjects per year in the United States. Within the age range considered, testicular torsion is most common in males aged 10 to 19 years, with an incidence of 8.6 cases (95% CI, 7.1-10.1 cases) per 100 000 male subjects per year. For comparison, the database contained 120 patients with benign or malignant testicular tumors. Using a weighted analysis, the number of such cases nationally was estimated to be 621 cases (95% CI, 300912 cases). Using the population estimate, the estimated incidence of benign and malignant testicular tumors is 1.2 cases (95% CI, 0.7-1.8 cases) per 100 000 male subjects per year, and the disorder is most common in males aged 16 to 24 years, with an incidence of 2.8 cases (95% CI, 1.4-4.2 cases) per 100 000 male subjects per year. Figure 1 shows that 86% of testicular torsion cases occur in males older than 10 years (median age, 15 years),
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Table 1. Comparison of Males Aged 1 to 25 Years With Testicular Torsion Having vs Not Having an Orchiectomy*
Orchiectomy (n = 149) 8 (5.4) 89 (59.7) 52 (34.9) 47 (31.5) 38 (25.5) 34 (22.8) 30 (20.1) 34 (22.8) 27 (18.1) 86 (57.7) 2 (1.3) 133 (89.3) 11 (7.4) 5 (3.4) 41 (27.5) 27 (18.1) 51 (34.2) 30 (20.1) 133 (89.3) 14 (9.4) 2 (1.3) No Orchiectomy (n = 287) 34 (11.8) 179 (62.4) 74 (25.8) 97 (33.8) 68 (23.7) 72 (25.1) 50 (17.4) 58 (20.2) 42 (14.6) 187 (65.2) 0 244 (85.0) 31 (10.8) 12 (4.2) 102 (35.5) 43 (15.0) 91 (31.7) 51 (17.8) 253 (88.2) 34 (11.8) 0

Table 2. Multivariate Predictors of Orchiectomy for Males Aged 1 to 25 Years With Testicular Torsion*
Odds Ratio (95% Confidence Interval) 1.08 (1.03-1.13) Reference 1.22 (0.74-2.02) 1.00 (0.54-1.86) 1.42 (0.84-2.39) 1.16 (0.66-2.01) Reference Reference 0.56 (0.23-1.36) 0.73 (0.36-1.45) 1.16 (0.51-2.64) 1.03 (0.50-2.12) Reference Reference 0.75 (0.39-1.41)

Variable Age, y 1-9 10-17 18-25 Race White Black Other Missing Insurance status Medicaid Self-pay Private Missing Annual household income, $ 25 000 25 000 Missing Census region Northeast Midwest South West Hospital location Urban Rural Missing

Variable Age Race White Black Other Insurance status Medicaid Self-pay Private Annual household income, $ 25 000 25 000 Census region Northeast Midwest South West Hospital location Urban Rural

P Value .003

.43 .99 .19 .61

.20 .37 .72 .94

.37

*Odds ratios greater than 1 indicate increased likelihood of having an orchiectomy. For categorical variables, the levels of the categories are compared with each categorys reference level. The odds ratio indicates the increase in the odds of having an orchiectomy per each 1-year increase in age.

*Data are given as number (percentage). P = .03 for age, Fisher exact test. Other tests did not reach statistical significance. Missing value rows were not included in univariate tests for statistical association between individual risk factors and orchiectomy.

while 82% of testicular cancer cases occur in males older than 15 years (median age, 20 years). Of the 436 sample participants, 149 (34%) had an orchiectomy. Other characteristics of the sample are given in Table 1. Using the weighted data, of the estimated 2248 males diagnosed nationally as having testicular torsion in 1998, an estimated 762 (34%) had an orchiectomy. When age was grouped for descriptive purposes, the estimated percentage undergoing orchiectomy increased as age increased, namely, 19% among those aged 1 to 9 years, 33% among those aged 10 to 17 years, and 41% among those aged 18 to 25 years. In the weighted analysis, the rates were nearly the same, namely, 18% for those aged 1 to 9 years, 33% for those aged 10 to 17 years, and 41% for those aged 18 to 25 years. When the cutoff for the low annual household income group was changed from $25 000 to $35 000, the results were comparable. The final multivariate model estimating the probability of having an orchiectomy included adjustment for race, insurance status, annual household income, census region, and hospital location (Table 2). In the final model, only age was significant. For a 1-year increase in age, the adjusted odds of having an orchiectomy increased by 1.08 (95% CI, 1.03-1.13), or an increase of 8% in the odds per year. For each 10-year increase in age, the odds of having an orchiectomy doubles (1.0810 =2.2). Figure 2 shows

the raw data with an overlay of the modeled relationship between age and the proportion of patients with testicular torsion having an orchiectomy. To show the raw data at a finer level of detail, the figure displays more age categories than were used in the analysis. In the weighted analysis of the full data set, we observed orchiectomy rates among the youngest and oldest males of 18% and 41%, respectively (P .001). We conducted a sensitivity analysis to evaluate the potential effect of misclassification on this result. With a random 10% of the males who did not undergo orchiectomy from the youngest age category removed, the estimated orchiectomy rates for the youngest and oldest age categories were 20% and 41%, respectively (P .001). With a random 33% removed, the rates were 25% and 41%, respectively (P .001). With a random 50% removed, the rates were 31% and 41%, respectively (P=.02). Therefore, the effect of age remained strong even with moderate to large misclassification of the youngest nonorchiectomy subjects.
COMMENT

Testicular torsion is a treatable urologic emergency, with an incidence that is 3.75 times greater than the incidence of testicular tumors. The frequency of testicular torsion increases before puberty and the sole identifiable risk factor for orchiectomy due to testicular torsion is increasing age. We identified no differences in orchiectomy rates for other patient factors such as race, insurance status, or hospital location.
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0.6

Proportion Having Orchiectomy

0.5

0.4

0.3

0.2

0.1

0.0 1 5 10 15 20 25

Age, y

Figure 2. Estimated proportion of patients by age with testicular torsion having an orchiectomy. Error bars indicate 95% confidence intervals.

For a male with testicular torsion to save his testicle, he must recognize the symptoms of torsion, access health care, and have a timely surgical procedure. Unfortunately, male subjects may be hesitant to seek medical attention for conditions involving their genitals, even for torsion.4,9 One study9 found that 85% of male respondents did not think that it was necessary to seek attention for testicular swelling and that 36% did not think that it was necessary to seek attention for testicular swelling and pain. Despite this knowledge gap, we are not aware of a formal recommendation or an adolescent health guideline advising health care providers to discuss the signs and symptoms of testicular torsion with their male patients. Because the frequency of testicular torsion begins to increase when males are 10 years old, more than 5 years earlier than testicular tumors, it makes sense for health care professionals to educate prepubertal male patients about testicular disorders. Moreover, older adolescents have a documented knowledge deficit about testicular pathologic conditions10 and have fewer physician visits than preadolescents.11 To educate preadolescents about testicular disorders during health maintenance visits, health care professionals must not only believe that it is an important topic but also be comfortable discussing problems involving the testicle.12 The message to patients should be that scrotal pain, especially severe pain, requires immediate evaluation. In fact, any male in the peripubertal age group or older with scrotal pain should be presumed to have torsion until proven otherwise. Although testicular salvage has been reported with prolonged torsion symptoms,13 delayed presentation and age affect orchiectomy rates. In a 10-year retrospective study14 of 30 patients, males younger than 18 years had delayed presentation and had more orchiectomies than those 18 years and older. In contrast, a more recent 9-year retrospective study15 of 44 patients demonstrated that males aged 21 to 34 years had more orchiectomies than those aged 8 to 20 years. Although these data by Cummings et al15 confirm that delays in presentation increase orchiectomy rates, there was no statistically significant agerelated difference between the 2 age groups in the mean

time to presentation. Because the time to presentation was similar between the 2 groups, the group aged 21 to 34 years was presumed to have a greater degree of spermatic cord twisting, causing the increased orchiectomy rate. Sessions et al16 reported greater median degrees of torsion in patients requiring orchiectomy (median, 540) compared with patients with salvaged testicles (median 360), but the range in both groups was identical and large (range, 180-1080). The national data in our study are consistent with the findings of the more recent study15 and identify a parallel between increasing age and increased orchiectomy rates. Misdiagnosed testicular torsion resulting in loss of a testicle has legal implications, but the actual scope of malpractice claims related to torsion is difficult to determine.17 Most concerning for patients, and the basis of some malpractice claims, is the potential association between unilateral testicular loss due to testicular torsion and reduced fertility and sperm counts.2,3 Although the true pathogenesis of reduced fertility remains unproven, experimental data indicate that the contralateral intact testis may be harmed by antisperm antibodies18 or by increased germinal epithelial apoptosis.19 Other reports have suggested the presence of a congenital testicular dysplasia as the basis for reduced fertility in torsion.20,21 The conclusions about the role of congenital pathologic conditions, however, were based on the lack of relationship between the histological changes in the contralateral testis and the duration of torsion or the interval since torsion.20,21 Because this observation might indicate that reduced fertility in torsion is not preventable, preservation of as much testicular tissue as possible would seem to be a priority. One limitation of this study is that these data are from 1998, but there have been no important changes in the management of patients with testicular torsion during this period.22,23 The database was not designed to address the possible explanations for the linear association between increasing age and the rate of orchiectomies. For example, there is no variable in the data set that permits adjustments for the duration of the torsion before presentation or for the degree of torsion. However, the lack of an explanation does not alter the message that males need to seek care quickly when they have scrotal pain. The study is also limited by the fact that the ICD-9-CM code 608.2 includes more diagnoses than torsion of the testicle, but our sensitivity analysis suggests that the major finding would remain significant even if half of the group aged 1 to 9 years did not have torsion of the testicle.
CONCLUSIONS

These data suggest that testicular torsion is more common than testicular neoplasm. Increasing age is a predictor of orchiectomy due to testicular torsion but not race, insurance status, or hospital location. We suggest that health care providers begin discussing testicular disorders, specifically testicular torsion, with prepubertal patients at the time of routine testicular examination. Moreover, national organizations may want to consider
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revising their male health guidelines to include earlier education about testicular health. Males should understand that acute or intermittent scrotal pain needs immediate medical evaluation and that delays may affect their fertility. Accepted for Publication: June 6, 2005. Correspondence: Jonathan M. Mansbach, MD, Division of Adolescent/Young Adult Medicine, Childrens Hospital Boston, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115 (Jonathan.Mansbach@childrens .harvard.edu). Funding/Support: This study was supported by a grant from the Novack Family Foundation, Boston (Dr Mansbach). Previous Presentation: This study was presented in part at the 2002 Annual Meeting of the Society for Adolescent Medicine; March 24, 2004; St Louis, Mo.
REFERENCES
1. Schneck FX, Bellinger MF. Abnormalities of the testes and scrotum and their surgical management. In: Walsh P, Retik A, Vaughan E, Wein A, eds. Campbells Urology. 8th ed. Philadelphia, Pa: WB Saunders Co; 2002:2379. 2. Schutte B, Becker H, Vydra G. Exocrine and endocrine testicular function following unilateral torsion: a retrospective clinical study of 36 patients [in German]. Urologe A. 1986;25:142-146. 3. Ferreira U, Netto Junior NR, Esteves SC, Rivero MA, Schirren C. Comparative study of the fertility potential of men with only one testis. Scand J Urol Nephrol. 1991;25:255-259. 4. Rampaul MS, Hosking SW. Testicular torsion: most delay occurs outside hospital. Ann R Coll Surg Engl. 1998;80:169-172. 5. Baker LA, Sigman D, Mathews RI, Benson J, Docimo SG. An analysis of clinical outcomes using color Doppler testicular ultrasound for testicular torsion. Pediatrics. 2000;105:604-607. 6. Braveman P, Schaaf VM, Egerter S, Bennett T, Schecter W. Insurance-related differences in the risk of ruptured appendix. N Engl J Med. 1994;331:444-449.

7. Guagliardo MF, Teach SJ, Huang ZJ, Chamberlain JM, Joseph JG. Racial and ethnic disparities in pediatric appendicitis rupture rate. Acad Emerg Med. 2003; 10:1218-1227. 8. Healthcare Cost and Utilization Project. 1998 Nationwide Inpatient Sample. Rockville, Md: Agency for Healthcare Research and Quality; 1998. 9. Nasrallah P, Nair G, Congeni J, Bennett CL, McMahon D. Testicular health awareness in pubertal males. J Urol. 2000;164:1115-1117. 10. Goldenring JM, Purtell E. Knowledge of testicular cancer risk and need for selfexamination in college students: a call for equal time for men in teaching of early cancer detection techniques. Pediatrics. 1984;74:1093-1096. 11. Marcell AV, Klein JD, Fischer I, Allan MJ, Kokotailo PK. Male adolescent use of health care services: where are the boys? J Adolesc Health. 2002;30:35-43. 12. Brenner JS, Hergenroeder AC, Kozinetz CA, Kelder SH. Teaching testicular selfexamination: education and practices in pediatric residents. Pediatrics [serial online]. 2003;111:e239-e244. 13. Jones DJ, Macreadie D, Morgans BT. Testicular torsion in the armed services: twelve year review of 179 cases. Br J Surg. 1986;73:624-626. 14. Barada JH, Weingarten JL, Cromie WJ. Testicular salvage and age-related delay in the presentation of testicular torsion. J Urol. 1989;142:746-748. 15. Cummings JM, Boullier JA, Sekhon D, Bose K. Adult testicular torsion. J Urol. 2002;167:2109-2110. 16. Sessions AE, Rabinowitz R, Hulbert WC, Goldstein MM, Mevorach RA. Testicular torsion: direction, degree, duration and disinformation. J Urol. 2003;169: 663-665. 17. Matteson JR, Stock JA, Hanna MK, Arnold TV, Nagler HM. Medicolegal aspects of testicular torsion. Urology. 2001;57:783-787. 18. Williamson RC, Thomas WE. Sympathetic orchidopathia. Ann R Coll Surg Engl. 1984;66:264-266. 19. Hadziselimovic F, Geneto R, Emmons LR. Increased apoptosis in the contralateral testes of patients with testicular torsion as a factor for infertility. J Urol. 1998; 160:1158-1160. 20. Dominguez C, Martinez Verduch M, Estornell F, Garcia F, Hernandez M, GarciaIbarra F. Histological study in contralateral testis of prepubertal children following unilateral testicular torsion. Eur Urol. 1994;26:160-163. 21. Hagen P, Buchholz MM, Eigenmann J, Bandhauer K. Testicular dysplasia causing disturbance of spermiogenesis in patients with unilateral torsion of the testis. Urol Int. 1992;49:154-157. 22. Kass EJ, Stone KT, Cacciarelli AA, Mitchell B. Do all children with an acute scrotum require exploration? J Urol. 1993;150:667-669. 23. Herbener TE. Ultrasound in the assessment of the acute scrotum. J Clin Ultrasound. 1996;24:405-421.

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