Sahel Medical Journal

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

Differentiating acute epididymitis from testicular torsion using scrotal scintigraphy


Zabah Muhammad Jawa1, Onyedika Okoye2,  
1 Department of Nuclear Medicine, National Hospital Abuja, Abuja, Nigeria
2 Department of Surgery, National Hospital Abuja, Abuja, Nigeria

Correspondence Address:
Dr. Zabah Muhammad Jawa
Department of Nuclear Medicine, National Hospital Abuja, Abuja
Nigeria

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.



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 2020 Nov 25 ];20:89-92
Available from: https://www.smjonline.org/text.asp?2017/20/3/89/223171


Full Text



 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 [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



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}{Figure 2}

 Results



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



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 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



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.

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