Date Published: November 29, 2011
Publisher: Hindawi Publishing Corporation
Author(s): Abdullatif Al-Terki, Talal Al-Qaoud.
Pertinent history taking and careful examination often taper the differentials of the acute scrotum; congruently the ability to diagnose acute spermatic cord torsion (SCT) when radiological adjuncts are not available is highly imperative. This observational study serves to present a series of 46 cases of spermatic cord torsion whereby we hypothesize the identification of a clinical knot on scrotal examination as an important clinical aid in making a decision to surgical exploration in patients with acute and subacute SCT, especially in centers where imaging resources are unavailable.
Reaching the confluence between clinical findings and imaging adjuncts remains a difficult task in diagnosing spermatic cord torsion (SCT) . Awaiting a radiological diagnosis of SCT in a young patient with a high index of suspicion may lead to unnecessary delay especially in patients presenting in the intermediate stage of torsion, hence rapid assessment is mandatory, and salvaging the affected testis is the ultimate goal within the time window available and the present facilities. Previous studies have demonstrated loss of the cremasteric reflex to be 99% sensitive in patients with suspected torsion [2, 3], however, in the young patient in extreme pain and discomfort, eliciting such sign can be cumbersome.
Available data from January 2009 to June 2011 on cases of acute scrotal pain presenting to our emergency department at Al-Amiri Hospital, Kuwait, was reviewed. Data on age (in years), duration of symptoms (in hours), site of pain, ultrasound use, presence of clinical knot on exam, and operative findings were extracted. The primary outcome was the presence of the spermatic cord knot on examination. Descriptive statistics of the series including frequency and percentages is presented stratified by diagnosis. Chi-squared test for trend tests was used to look for an association between age, site of torsion, the operative findings of degrees of rotation of the cord, and the primary outcome. Statistical analysis was conducted using STATA .
In total, data was available on 114 patients (Table 1): 46 cases of suspected torsion (40%), 32 cases of epididymitits/orchitis (28%), 18 cases of varicocele (16%), 8 cases of inguinal hernia (7%), and 10 cases of undiagnosed pain (9%). The spermatic cord knot sign was seen amongst 40 (87% sensitivity) of the patients with SCT (Table 1), and amongst none of the other patients presenting with other diagnoses.
Our modest series points to the potential aid the clinical knot sign adds to the emergency, pediatric, surgical, and urological staff attending to the case of acute scrotum presenting in the acute and subacute stage, when imaging is unavailable or delays action. Diagnosing SCT can be difficult, and distinction of the scrotal contents is necessary while paying particular attention to identifying the epididymis and delineating the cord from the epididymal head. A common clinical diagnostic dilemma in patients with acute scrotal pain is the inability to differentiate SCT from epididymitis and/or orchitis . We demonstrated that one could help differentiate that by identifying clinical knot sign that was not present in other cases of acute scrotal pain, without delaying surgical exploration.
We claim the identification of the clinical knot sign on examination helps to reassure the examining doctor of his/her suspicion of SCT in the acute and subacute stage, most importantly avoiding delay in awaiting imaging findings and decision to surgical exploration. The description of this clinical sign is particularly important to rural centers of limited resources, and in centers where Doppler and MRI studies are not readily available to aid diagnosis. However, as a result of the small number of cases, an inherent limitation of this descriptive series is our inability to reach a firm inference yet, and despite advocating the identification of this sign as a strong suspicion to proceed to scrotal exploration, a larger prospective study would enrich statistical power and serve to calculate more robust estimates of incidence, sensitivity, and specificity, and further facilitating exploration of factors associated with the spermatic cord knot while simultaneously accounting for possible confounders.