Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
Home Print this page Email this page
Users Online:: 648

 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 20  |  Issue : 3  |  Page : 89-92

Differentiating acute epididymitis from testicular torsion using scrotal scintigraphy


1 Department of Nuclear Medicine, National Hospital Abuja, Abuja, Nigeria
2 Department of Surgery, National Hospital Abuja, Abuja, Nigeria

Date of Web Publication16-Jan-2018

Correspondence Address:
Dr. Zabah Muhammad Jawa
Department of Nuclear Medicine, National Hospital Abuja, Abuja
Nigeria
Login to access the Email id


DOI: 10.4103/1118-8561.223171

Rights and Permissions
  Abstract 


Introduction: In patients with acute scrotal pain, differentiating acute epididymitis from testicular torsion should be made promptly and accurately, to treat the underlying cause correctly. Acute epididymitis is treated with a simple course of antibiotics while testicular torsion requires emergency surgical exploration to salvage the testis. The assessment of patients with acute scrotal pain is done mainly using color Doppler ultrasonography, which, however, requires skills and has limitations of being highly operator-dependent and uncomfortable to patients with scrotal pains because it may take too long to perform and often involves probe compression. Scrotal scintigraphy using 99m Tc-pertechnetate may provide an alternative reproducible, quick noninvasive and reliable nuclear medicine functional imaging technique that could be used in the evaluation of patients with acute scrotal pain. The aim of this study is to document our clinical experiences with the use of scrotal scintigraphy in differentiating acute epididymitis from testicular torsion in patients with acute scrotal pain. Material and Method: All scrotal scintigraphy performed in our institution between 2007 and 2015 were included in this study. Scrotal scintigraphy was performed after intravenous administration of 99m Tc-pertechnetate radiotracer and images were acquired using MEDISO dual-headed gamma camera. Acute epididymitis is diagnosed when there is increased blood flow on dynamic images and increased uptake around the region of the epididymis, while testicular torsion as decreased blood flow and photopenic area in the testis on dynamic and static images, respectively. The final diagnosis was documented based on relief of symptoms after a course of antibiotics or surgical exploration. Results: All patients were examined by urologist and only patients in whom the differentiation between acute epididymitis and torsion could not be made clinically were include in this study. A total of 21 patients were studied. There were 16 patients diagnosed with acute epididymitis and five patients with testicular torsion. Conclusion: Our study demonstrates that scrotal scintigraphy is a simple, accurate, and effective functional imaging technique that can differentiate acute epididymitis from testicular torsion in selected patients presenting with acute scrotal pain.

Keywords: Acute epididymitis, scrotal scintigraphy, testicular torsion


How to cite this article:
Jawa ZM, Okoye O. Differentiating acute epididymitis from testicular torsion using scrotal scintigraphy. Sahel Med J 2017;20:89-92

How to cite this URL:
Jawa ZM, Okoye O. Differentiating acute epididymitis from testicular torsion using scrotal scintigraphy. Sahel Med J [serial online] 2017 [cited 2018 Feb 20];20:89-92. Available from: http://www.smjonline.org/text.asp?2017/20/3/89/223171




  Introduction Top


In patients with acute scrotal pain, differentiating acute epididymitis from testicular torsion should be made promptly and accurately, to treat the underlying cause correctly. Acute epididymitis is treated with a simple course of antibiotics [1],[2] while testicular torsion requires emergency surgical exploration to salvage the testis.[3],[4] The initial evaluation of patients with acute scrotal pain involves good history and clinical examination. Unfortunately, the overlapping signs and symptoms added by the difficulties in examining these patients because of pains and tenderness in the scrotum make this initial assessment difficult. The next stage of evaluation involves the use of color Doppler ultrasonography,[5],[6] which however, requires skills and has limitations of being highly operator dependent and uncomfortable to patients with scrotal pains because it may take too long to perform and often involves probe compression. Scrotal scintigraphy which has a high sensitivity and specificity using 99m Tc-pertechnetate Tc99m may provide an alternative reproducible, quick noninvasive, and reliable nuclear medicine functional imaging technique that could be used in the evaluation of patients with acute scrotal pain.[7],[8],[9]


  Methods Top


All scrotal scintigraphy performed in our institution between 2007 and 2015 were included in this study. We included only patients who were examined by urologist and in whom the differentiation between acute epididymitis and torsion could not be made clinically. Scrotal scintigraphy was performed after intravenous administration of between 185 and 370 MBq of 99m Tc-pertechnetate Tc99m radiotracer, dynamic, and static images were acquired using MEDISO dual-headed gamma camera. Patients were imaged in the supine position with the penis taped out of the field of view of imaging. Dynamic images were acquired immediately postinjection with a sequence of 10 images of 5 s per image; this was followed by static images of 400 s per image. Acute epididymitis is diagnosed when there is increased blood flow on dynamic images and increased uptake around the region of the epididymis [Figure 1], while testicular torsion [Figure 2] as decreased blood flow and photopenic area in the testis on dynamic and static images, respectively. The final diagnosis was documented based on relieve of symptoms after a course of antibiotics or surgical exploration
Figure 1: Scrotal scintigraphy showing increased uptake of radiotracer in the right epididymis consistent with acute epididymitis

Click here to view
Figure 2: Scrotal scintigraphy showing large photopenic area within the left testis consistent with acute testicular torsion

Click here to view



  Results Top


A total of 21 patients were studied with age ranges between 11 and 45 years. There were 16 patients diagnosed with acute epididymitis and five patients with testicular torsion.

Out of the 16 patients diagnosed with acute epididymitis, 11 of them were aged between 19 and 31 years, only one patient in this age group was diagnosed with testicular torsion.

Among the five patients diagnosed with testicular torsion, 4 of them were aged between 11 and 15 years.


  Discussion Top


The major cause of acute scrotal pain is acute epididymitis and testicular torsion both of which are emergency conditions that often presents at emergency units.[10],[11] Urologists, Pediatricians, and Pediatric surgeons are faced with the task of differentiating these acute conditions, which unfortunately have overlapping signs and symptoms. Differentiation of acute epididymitis from testicular torsion has a great importance because of the major differences in treatment modalities.

Clinical evaluation combined with color Doppler ultrasonography or testicular scintigraphy is used in differential diagnosis.[5],[6]

Acute epididymitis is an inflammatory condition of the epididymis. The epididymis is located in the posterior aspect of the testis; it is responsible for storage, maturation, and transport of sperm and connects the efferent ducts of the testis to the vas deference. An inflammatory cause of epididymis is mainly due to  Escherichia More Details coli, chlamydia trachomatis, and occasional viral infection. The patients are usually young adolescent.[1],[2]

Testicular torsion is the twisting of the testis on the spermatic cord that will result to the strangulation of the blood supply and subsequent infarction of the testis. The predisposing factors to testicular torsion include congenital “bell clapper” deformity, injuries to the groin. Rarely, torsion can be associated with testicular malignancy and extremely cold weather.[3],[4],[12]

Differential diagnosis should be made between acute epididymitis and testicular torsion since torsion of the testicle is a true surgical emergency.

Ultrasonography with color Doppler has proved to be a valuable tool in the differential diagnosis of epididymis and torsion. This method uses visual color coding of flow velocities in blood vessels superimposed on the gray scale ultrasound to determine increases and decreases in blood flow. Studies show that ultrasonography has a sensitivity of 82% and specificity of 100% for torsion.[5],[6] In addition, the sensitivity and specificity for epididymis were found to be 70% and 88%, respectively.[5] Ultrasound is operator-dependent and requires skills and it also takes time to perform and often uncomfortable in patients with acute scrotal pains.[5],[6]

Radionuclide scrotal scintigraphy with 99m Tc-pertechnetate is the most accurate method of differentiating acute epididymitis from testicular torsion. Studies have shown scrotal scintigraphy to have a positive predictive value of 75%, a sensitivity of 90%, and specificity of 95%.[7],[8],[9],[13],[14]

Acute epididymitis is diagnosed on scrotal scintigraphy when there is increased blood flow on dynamic images and increased uptake around the region of the epididymis, while testicular torsion as decreased blood flow and photopenic area in the testis on dynamic and static images, respectively [Figure 1] and [Figure 2].

Of the 16 patients with acute epididymitis, 11 were aged between 19 and 31 years only one patient in this age group had testicular torsion. The high incidence of acute epididymitis at age range between 19 and 31 years is due to active sexual expose in this group.

Among the five patients with testicular torsion, four patients were aged between 11 and 15 years. Our result is similar to that in the literature.[1],[11],[14]

Our study demonstrates that scrotal scintigraphy has a 100% sensitivity and specificity in differentiating acute epididymitis from testicular torsion; these findings are slightly higher compared with similar studies in literature%.[7],[13],[14],[15],[16] The reason for this is because our patients were highly selected, i.e., only patients in whom acute epididymitis and testicular torsion could not be differentiated clinically were included in our studied.

Limitation

We are aware of the limitations of our study, which include highly selective patients' population and few number. A larger and more inclusion criteria of patients are required to validate this data.


  Conclusion Top


Scrotal scintigraphy is becoming a popular diagnostic tool among urologist and pediatric surgeons in differentiating acute epididymitis from testicular torsion in selected patients presenting with acute scrotal pain because the technique is simple, reproducible, accurate, and friendly to patients. In addition, the time required to carry out scrotal scintigraphy is between 10 and 15 min.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kaver I, Matzkin H, Braf ZF. Epididymo-orchitis: A retrospective study of 121 patients. J Fam Pract 1990;30:548-52.  Back to cited text no. 1
    
2.
Thrall JH, Ziessman HA. Nuclear Medicine: The Requisites. 2nd ed. Missouri: Mosby; 2001. p. 358-62.  Back to cited text no. 2
    
3.
Williams CR, Heaven KJ, Joseph DB. Testicular torsion: Is there a seasonal predilection for occurrence? Urology 2003;61:638-41.  Back to cited text no. 3
    
4.
Bartsch G, Frank S, Marberger H, Mikuz G. Testicular torsion: Late results with special regard to fertility and endocrine function. J Urol 1980;124:375-8.  Back to cited text no. 4
    
5.
Wilbert DM, Schaerfe CW, Stern WD, Strohmaier WL, Bichler KH. Evaluation of the acute scrotum by color-coded Doppler ultrasonography. J Urol 1993;149:1475-7.  Back to cited text no. 5
    
6.
Nussbaum Blask AR, Bulas D, Shalaby-Rana E, Rushton G, Shao C, Majd M. Color Doppler sonography and scintigraphy of the testis: A prospective, comparative analysis in children with acute scrotal pain. Pediatr Emerg Care 2002;18:67-71.  Back to cited text no. 6
    
7.
Beltran MR. Testicular imaging. In: Henkin RE, Boles MA, Dillehay CL, editors. Nuclear Medicine. Vol. II. New York: Mosby-Year Book, Inc.; 1996. p. 1110-21.  Back to cited text no. 7
    
8.
Wu HC, Sun SS, Kao A, Chuang FJ, Lin CC, Lee CC. Comparison of radionuclide imaging and ultrasonography in the differentiation of acute testicular torsion and inflammatory testicular disease. Clin Nucl Med 2002;27:490-3.  Back to cited text no. 8
    
9.
Holder LE, Melloul M, Chen D. Current status of radionuclide scrotal imaging. Semin Nucl Med 1981;11:232-49.  Back to cited text no. 9
    
10.
Schneck FX, Bellinger MF. Abnormalities of the testis and scrotum and their surgical management. In: Walsch PC, editor. Campbell's Urology. 8th ed., Vol. 3. Philadelphia, PA: WB Saunders Co.; 2002. p. 2353-94.  Back to cited text no. 10
    
11.
Mushtaq I, Fung M, Glasson MJ. Retrospective review of paediatric patients with acute scrotum. ANZ J Surg 2003;73:55-8.  Back to cited text no. 11
    
12.
Barthold JS. Abnormalities of the testis and scrotum and their surgical management. Urology. 10th ed. Philadelphia, PA: WB Saunders; 2012. p. 642-5.  Back to cited text no. 12
    
13.
Yasemin S, Isik A, Handa T, Oner S, Orhen Z, Sema C. Radionuclide imaging in differential diagnosis of torsion and infections of the testis and epididymis revised. Marmara Med J 2006;19:132-4.  Back to cited text no. 13
    
14.
Joyce JM, Grossman SJ. Scrotal scintigraphy in testicular torsion. Emerg Med Clin North Am 1992;10:93-102.  Back to cited text no. 14
    
15.
Yuan Z, Luo Q, Chen L, Zhu J, Zhu R. Clinical study of scrotum scintigraphy in 49 patients with acute scrotal pain: A comparison with ultrasonography. Ann Nucl Med 2001;15:225-9.  Back to cited text no. 15
    
16.
Levy OM, Gittelman MC, Strashun AM, Cohen EL, Fine EJ. Diagnosis of acute testicular torsion using radionuclide scanning. J Urol 1983;129:975-7.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
  Methods
  Results
  Discussion
  Conclusion
   References
   Article Figures

 Article Access Statistics
    Viewed133    
    Printed1    
    Emailed0    
    PDF Downloaded18    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]