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Accurate and early diagnosis of acute scrotum is of the utmost importance to avoid testicular loss and/or needless surgery. The aim of this study is to analyze the clinical presentation and physical examination parameters together with the results of imaging studies in order to find out predictors for the differential diagnosis of acute scrotum with special emphasize on testicular torsion (TT). Patients who were treated for acute scrotum in our unit from 1970 up to and including 2000 were reviewed retrospectively. The study group was subdivided into three groups: "testicular torsion (TT)", "torsion of testicular appendage (TTA)", and "epididymoorchitis (EO)" group according to the diagnosis confirmed by radiologic and surgical findings. Presence and/or absence of various parameters related to clinical presentation, physical examination, and results of imaging studies were analyzed by statistical means in each group. One hundred and sixty children with a mean age of 12.2 years formed the study group. The mean duration of symptoms was 15 hours. No significant difference was noted between the three groups with regard to mean age and duration of symptoms. Nuclear scintigraphy and Doppler ultrasound were used as diagnostic aids in 50 and 66 children, respectively. Clinical presentation parameters including the presence of a) previous trauma, b) pain attacks, and c) nausea and vomiting, had the highest sensitivity, specificity, positive and negative predictive values in the TT group and the lowest values in the EO group. In contrast, the EO group had the highest statistical values with regard to presence of dysuria and micturition disorders. Physical examination parameters consisting of a) elevation, b) transverse location of testis, c) anterior rotation of epididymis, and d) absence of cremasteric reflex had the highest statistical values in the TT group. Contrary to this, imaging studies had the highest specificity and positive predictive values in the TTA group and the lowest values in the TT group. Previous history of trauma and pain attacks, presence of nausea and vomiting, and absence of urinary complaints are the main predictors of TT. Elevation and transverse location of testis with an anteriorly rotated epididymis associated with loss of ipsilateral cremasteric reflex strongly indicate TT. Although accuracy of imaging studies is higher for the differential diagnosis of TTA and EO, there is a considerable risk of misdiagnosis. Therefore, differential diagnosis of acute scrotum, particularly TT, still remains a clinical diagnosis, and clinical parameters deserve more importance in surgical decision making.

The decrease in blood flow due to the activation of sympathetic system has been suggested to play a role in contralateral testicular deterioration associated with unilateral testicular torsion. Sympathetic nerve discharges (SND) from the genitofemoral nerve were evaluated before and during unilateral testicular torsion. Under urethane anesthesia, arterial blood pressure and SND from splanchnic and right genitofemoral nerves were recorded in 12 male Sprague-Dawley rats, 8 of which were included in subsequent analyses. After control recordings of basal discharges for 2 min the left testis was twisted 720 degrees counterclockwise, and recording was resumed for an additional 30 min. Changes in nerve activity were calculated by measuring the area under the autospectrum curve, and alterations were compared. Following testicular torsion no significant changes were obtained for splanchnic SND, but the amplitude of SND from contralateral genitofemoral nerve showed an overall increase of 21.20+/-7.03% in six rats. This increase lasted about 10-15 min and activities returned to pretorsion levels. In two other rats no significant change was observed in either splanchnic or genitofemoral SND. Ipsilateral testicular torsion results in a transient increase in genitofemoral SND. A possible autonomic reflex mechanism may exist, and it may be activated by noxious stimuli from contralateral side. This reflex mechanism may initiate a series of events that lead to the injury of contralateral testis.

Objective: To evaluate the effect of afferent nerve blockage by administration of capsaicin on apoptotic changes in the contralateral testis in rats undergoing ipsilateral testicular torsion., Materials and Methods: Twenty male albino rats were randomly divided into four groups. In groups 1 and 2, rats underwent a sham operation and testicular torsion, respectively, after the intraperitoneal administration of 0.9% NaCl. Similarly, in groups 3 and 4 the rats underwent a sham operation and testicular torsion, respectively, after an intraperitoneal capsaicin injection. The testes were untwisted 24 h later and the contralateral testes harvested. Apoptosis was assessed in paraffin-embedded sections stained for nuclear DNA fragmentation. Fifteen cells were counted in each seminiferous tubule and the apoptotic cells recorded. A score was calculated for each group and the results compared using the Kruskal-Wallis analysis of variance and Mann Whitney U-tests, with P<0.05 considered to be significant., Results: The mean apoptotic score of group 2 was significantly higher than that of the other groups. There was no difference between the apoptotic scores of groups 1 and 3, 1 and 4, and 3 and 4., Conclusion: Capsaicin effectively prevented apoptosis in the contralateral testes of rats that had undergone testicular torsion.

Objective: To evaluate the effect of capsaicin, a powerful neurotoxin selective to afferent nerves, on contralateral testicular damage in ipsilateral testicular torsion., Methods: Forty male albino rats were randomly allocated into five groups. No operation was performed in group one. After intraperitoneal administration of 0.9% NaCl, rats underwent a sham operation in group 2 and testicular torsion in group 3. In groups 4 and 5 rats underwent sham operation and testicular torsion, respectively after intraoperitoneal capsaicin injection. Contralateral testes were harvested on the fifteenth day of the experiment and mean seminiferous tubular diameters and mean testicular biopsy scores were recorded for each testis. The values were compared through analysis of variance (ANOVA) with Turkey-Kramer multiple comparisons test and p values less than 0.05 were considered to be significant., Results: Mean testicular biopsy scores and mean seminiferous tubular diameters of group 5 was significantly higher than the group 3. There was no difference between the groups 1, 2, 4, and 5 when these two parameters are concerned., Conclusion: Capsaicin effectively prevents contralateral testicular damage encountered following ipsilateral testicular torsion. The inhibition of afferent impulses from the ipsilateral testis under distress prevents contralateral testicular injury, and provides additional data to support the role of an autonomic reflex arc in contralateral testicular injury.

Objective: To evaluate if various conditions affecting the ipsilateral testis which also damage the contralateral testis share a common pathway for their effects., Materials and Methods: The study comprised five groups of 10 adult rats which underwent surgery to produce (on their left sides); group 1, a sham operation (control); group 2, testicular torsion; group 3, vas deferens obstruction; group 4, an intra-abdominal testis; and group 5, venous obstruction. The ipsilateral and contralateral testes were harvested 4 weeks after surgery. The relative proportions of haploid cells, the mean seminiferous tubular diameter (MSTD), mean testicular biopsy scores (MTBS), and lactate and hypoxanthine levels were determined and compared., Results: The proportions of haploid cells in the ipsilateral and the contralateral testes of groups 2-5 were significantly lower than those of the corresponding testes of the control group. The MSTD and MTBS of the ipsilateral testes in groups 2-5 were also significantly lower than the ipsilateral testes of controls and the contralateral testes within the same groups. While the MSTD and MTBS of the contralateral testes of groups 1 and 5 were not significantly different, those of the contralateral testes of groups 2-4 were significantly less than that of group 1. The lactic acid and hypoxanthine levels of the ipsilateral and contralateral testes were significantly increased in groups 2 and 3. While only the hypoxanthine level of group 5 increased significantly, both variables were not significantly different between the ipsilateral testes of groups 1 and 4., Conclusions: These four treatments damaged both the ipsilateral and contralateral testes. As the lactic acid and hypoxanthine levels within the contralateral testis were greater than in the controls, testicular torsion and vas deferens obstruction seem to share a common pathway (which may be a reflex decrease in contralateral testicular blood flow) for their effects on the contralateral testis.

Objective: To determine the changes occurring during ipsilateral spermatic cord torsion either in the presence or absence of the ipsilateral testis and epididymis, by evaluating noradrenaline and nitrite-nitrate concentrations in the contralateral testes., Materials and Methods: Forty male albino rats were allocated randomly to one of four equal groups undergoing: group 1, a sham operation; group 2, ipsilateral spermatic cord torsion; group 3, epididymo-orchidectomy only; and group 4, spermatic cord torsion after epididymo-orchidectomy. The contralateral testes were harvested after 24 h and the noradrenaline and nitrite-nitrate contents determined. The levels in each group were compared using the Kruskal-Wallis and Mann-Whitney U-tests., Results: The noradrenaline content of testes from group 2 was significantly lower than in those of groups 1 and 3, but there were no significant differences in content between groups 1 and 3, 1 and 4, and 2 and 4. The content in group 4 was significantly less than that in group 3. There were no significant differences in nitrite-nitrate contents among any of the groups., Conclusion: Spermatic cord torsion for 24 h, either in the presence or absence of a testis and epididymis, significantly decreased the noradrenaline content in the contralateral testis. This finding supports the suggestion that the sympathetic system is activated by exposure to noradrenaline in the contralateral testis during ipsilateral spermatic cord torsion, with no dependency on the presence of a testis and epididymis. As the nitrite-nitrate concentrations were unaffected, nitric oxide seems to have no role in contralateral testicular deterioration.

An experimental study was planned to evaluate if contralateral testicular deterioration following ipsilateral torsion requires the presence of a twisted ipsilateral testis and/or epididymis. Five groups, each containing 6 rats, were established. The groups underwent sham operation, epididymo-orchiectomy, testicular torsion, torsion following subepididymal orchiectomy and torsion following epididymo-orchiectomy. After 24 h, the contralateral testes were harvested and the percentage of haploid cells was determined by DNA flow cytometry. Ipsilateral torsion, in the presence and absence of testis and epididymis, significantly decreased the number of haploid cells compared to sham and epididymo-orchiectomy procedures. Torsion of only the ipsilateral spermatic cord and adjacent vasculature seemed to suffice to damage the contralateral testis. Since the presence of the ipsilateral testis and epididymis is not mandatory for this acquired damage, which occurs within 24 h, a role for a preexisting congenital defect and autoimmunity seems unlikely.

Objective: To evaluate the effects of vasodilator therapies and chemical sympathectomy on ipsilateral and contralateral testicular spermatogenetic activity after unilateral testicular torsion using DNA flow cytometry and thus determine whether contralateral testicular damage occurs through a reflexively decreased blood flow., Materials and Methods: The study comprised four groups of 20 rats each (groups 1-4) respectively receiving isotonic saline, verapamil, pentoxifylline and 6-hydroxy dopamine hydrobromide (6-OHD) intraperitoneally. Each group was further divided into two subgroups containing 10 rats which respectively underwent either a sham operation or 720 degrees clockwise torsion applied to the left testis. The testes were harvested after 24 h and the relative proportions of haploid, diploid and tetraploid cells determined by DNA flow cytometry for each testis. The proportion of haploid cells was used as an estimate of spermatogenesis. The mean proportions of haploid cells in the groups were compared using a one-way ANOVA and paired groups were compared using Student's t-test., Results: The proportions of haploid cells in the ipsilateral testes of rats undergoing torsion were significantly lower than in their contralateral testes and in the ipsilateral testes of the control groups. In group 4 (6-OHD) the proportion of haploid cells in the contralateral testes was significantly higher than those in the other groups after unilateral testicular torsion, but significantly lower than those in groups 1 and 4 after a sham operation. After unilateral testicular torsion the haploid cell proportions of the contralateral tests of groups 1-3 were not significantly different from each other., Conclusions: Because the spermatogenetic activity in the contralateral testis is depressed within 24 h of ipsilateral testicular torsion, contralateral testicular damage is an acquired effect: 6-OHD offers some protection and thus the damage seems to result from the involvement of the sympathetic system.

Contralateral testicular perfusion during unilateral testicular torsion was evaluated using simultaneous blood flow and O2 content determinations. Two groups, each consisting of 7 rats, were studied. Sham operation or 720 degrees clockwise twisting was performed on the left testes, and blood flow, O2 content and temperatures were monitored in the right testes for 180 min. An ultrasonic perivascular Doppler flowmeter system, an electronic thermometer and an O2 electrode were used for the monitoring. The contralateral testicular blood flow and relative O2 contents were stable in the control group. However, the initial and 180 min blood flow values decreased from 0.21 +/- 0.04 to 0.11 +/- 0.02 ml/min (p < 0.001), and the O2 contents from 0.857 +/- 0.123 to 0.319 +/- 0.037 (1.0 corresponds to 19.6 mm Hg pO2, p < 0.05) in the experimental group. Unilateral testicular torsion decreases the blood flow and O2 content of the contralateral testis. The contralateral testicular injury encountered following unilateral testicular torsion might result from hypoxia following the decrease in blood flow.

Objective: To evaluate contralateral testicular blood flow by histological examination of arterioles during ipsilateral testicular torsion., Materials and Methods: The study comprised two groups of 20 male albino rats (weight 250-270 g). The control group underwent a sham operation, while in the second group the left testes were twisted clockwise by 720 degrees. All rats underwent bilateral orchidectomy 24 h after the initial intervention. Three slides for each testis (n = 240) were evaluated randomly while unaware of treatment to determine the total number of arterioles, the percentage of collapsed and open arterioles, the diameter of open arterioles and the presence or absence of blood cells in the lumen. Differences were assessed using t-tests for paired and independent samples., Results: Very few arterioles were collapsed in both testes of the control group and in the ipsilateral testes of the torsion group, but half the arterioles in the contralateral testes of the torsion group were collapsed. The difference between the contralateral testes of the two groups and between the ipsilateral and contralateral testes in the torsion group were significant. The diameter of uncollapsed arterioles did not differ significantly among either testes of the control and torsion groups and either testes in each group. Both testes in the torsion group had significantly more arterioles containing blood cells than those in the control group. The difference between the testes in the torsion group was also significant, but was not in the control group., Conclusion: There was histological evidence of decreased blood flow in the contralateral testis during unilateral testicular torsion; contralateral testicular damage during unilateral testicular torsion may result from hypoxia caused by decreased blood flow.

Unilateral spermatic cord torsion in the presence or absence of ipsilateral testis causes hypoxia in the contralateral testis. An experimental study was conducted to find the most important structure that causes contralateral testicular hypoxia following ipsilateral twisting. In five groups each consisting of 10 rats sham operations, epididymoorchiectomy, spermatic cord torsion, spermatic cord torsion following subepididymal orchiectomy or spermatic cord torsion following epididymoorchiectomy were performed. Lactic acid, hypoxanthine and thiobarbituric acid reactive products of lipid peroxidation (TBAR) were determined in the contralateral testis. While lactic acid, hypoxanthine and TBAR values did not differ significantly following sham and epididymoorchiectomy procedures, evaluation of other groups revealed significantly increased values compared with sham and epididymoorchiectomy groups. Since torsion of only spermatic cord and testicular vasculature causes contralateral testicular hypoxia, testis and epididymis do not seem to be mandatory for occurrence of contralateral testicular hypoxia. Testicular artery under distress seems to be the most important structure that results in contralateral testicular hypoxia following torsion.

The effects of chemical sympathectomy on contralateral testicular histology, fertility and fecundity following unilateral testicular torsion were evaluated in rats. Four groups, placebo plus sham operation, 6-OH-dopamine plus sham operation, placebo plus torsion, and 6-OH-dopamine plus torsion, were established. When the placebo plus sham operation and placebo plus torsion groups were compared, it was found that contralateral testicular damage following unilateral testicular torsion occurred with significantly decreased values for mean seminiferous tubular diameter (MSTD), mean testicular biopsy score (MTBS) and fertility. The relatively normal values for MSTD, MTBS and fertility in the 6-OH-dopamine plus sham operation and 6-OH-dopamine plus torsion groups indicate the preventive role of chemical sympathectomy on contralateral testicular damage. Since chemical sympathectomy prevents contralateral histologic deterioration and preserves fertility in unilateral testicular torsion, the decreased blood flow in the reflex-activating sympathetic system may play a role in contralateral testicular damage.

Objective: To evaluate the effect of chemical sympathectomy on lactic acid and hypoxanthine concentrations in both testes during unilateral testicular torsion in a rat experimental model., Materials and Methods: Four groups, comprising 10 rats each, were studied. Group I was the control group, Group II rats received a placebo and underwent unilateral testicular torsion, Groups III and IV received guanethidine monosulphate and 6-OH-dopamine hydrobromide respectively, and underwent unilateral testicular torsion. The levels of lactic acid and hypoxanthine in both testes were measured., Results: In rats in Group II the levels of lactic acid and hypoxanthine in both testes were significantly elevated when compared to the control group. In the groups of rats that had undergone chemical sympathectomy, the levels of lactic acid and hypoxanthine were significantly decreased in the contralateral testes compared to rats in Groups I and II., Conclusion: Chemical sympathectomy prevents the elevation of lactic acid and hypoxanthine levels in the contralateral testis of rats with unilateral testicular torsion. Therefore, we conclude that contralateral testicular damage during unilateral testicular torsion may result through a reflex activating sympathetic system.

Objectives: An experimental study has been conducted to investigate testicular blood flow alterations through acute biochemical changes during unilateral testicular torsion and detorsion., Methods: One hundred twenty male albino rats were divided into 12 groups, each containing 10 rats. One group served to determine basal values of biochemical parameters, 4 groups were subjected to varying periods of unilateral testicular torsion (3, 6, 12, and 24 hours, respectively), 3 groups were subjected to detorsion following varying periods of torsion (6, 12, and 24 hours, respectively), and 4 groups underwent sham operations as controls. Levels of lactic acid, hypoxanthine, and lipid peroxidation products were determined in testicular tissues., Results: Values of these 3 parameters obtained from sham operation control groups did not differ significantly from basal values (p > 0.05). All 3 parameters were increased significantly in both ipsilateral torted and contralateral nontorted testes after unilateral testicular torsion when compared with basal values (p < 0.05). Detorsion did not cause significant changes in levels of lipid peroxidation products in both ipsilateral torted and contralateral nontorted testes when compared with values obtained after torsion (p > 0.05)., Conclusions: Ipsilateral testicular torsion causes a decrease not only in the ipsilateral torted but also in the contralateral nontorted testicular perfusion. The clues of reperfusion injury do not become evident following detorsion of testicular torsion lasting more than 6 hours.

Although deteriorating effects of unilateral spermatic cord torsion are generally accepted, the mechanism remains controversial. An experimental study was performed to evaluate the necessity of testicular and spermatogenetic material for contralateral testicular deterioration following unilateral spermatic cord torsion in rats. The animals were allocated to four groups: control, spermatic cord torsion, subepididymal orchiectomy, and spermatic cord torsion 14 days after subepididymal orchiectomy. The testes were removed on the 14th days and mean seminiferous tubular diameters and mean testicular biopsy scores were determined. Although contralateral testicular deterioration was more pronounced in the presence of testicular tissue, the absence of testicular tissue and/or spermatogenetic material did not prevent its occurrence. This is highly suggestive that autoimmune mechanism does not play a role in contralateral testicular damage following unilateral spermatic cord torsion.

Testicular blood flows during unilateral testicular torsion were measured by Xenon-133 clearance technique. Xenon-133 was injected via the left carotid artery into the heart. Measurements were performed in control and left-sided testicular torsion groups, each consisting of ten rats. Left and right testicular blood flows, which were 29.157 +/- 2.272 ml/100 g/min and 29.773 +/- 2.934 ml/100 g/min in the controls, were 11.983 +/- 3.655 ml/100 g/min and 16.098 +/- 3.757 ml/100 g/min in the experimental group and differed significantly. The decrease in contralateral testicular blood flow may play an important role in the contralateral testicular damage encountered following unilateral testicular torsion.

The ipsilateral and contralateral testes after unilateral incarcerated inguinal hernia were evaluated, and compared to the contralateral testis after unilateral testicular torsion in 30 prepubertal rats. Control, torsion and detorsion at 24 hours, and incarcerated inguinal hernia and reduction in the 24 hour groups, each consisting of ten rats were established. The testes were harvested after 15 days. Mean seminiferous tubular diameters (MSTD) and mean testicular biopsy scores (MTBS) were determined and compared. A decrease in MSTD and depression in MTBS, which was more prominent in the ipsilateral testes, were found in both ipsilateral and contralateral testes following unilateral incarcerated inguinal hernia. The testicular damage encountered after unilateral incarcerated inguinal hernia was similar to the contralateral testicular damage following unilateral testicular torsion with the utilized parameters.

Changes in contralateral testicular blood flow during unilateral testicular torsion were evaluated using an electromagnetic flowmeter in 13 adult male New Zealand White rabbits. There was an immediate and then a progressive decrease during torsion and a gradual increase following detorsion. A decrease in testicular blood flow over a critical period of time may be associated with contralateral testicular damage following unilateral testicular torsion.