Demographic, clinical, and socioeconomic factors associated with delayed diagnosis and management of pediatric testicular torsion in West China: a retrospective study of 301 cases in a single tertiary children’s hospital

Testicular torsion (TT) is an urological emergency and needs prompt management. The incidence rate of TT in pediatrics is about 3.8–5.9 per 100,000, TT is not common but a time dependent urgent event [1‐3]. Delay in diagnosis and management of TT is associated with a poor clinical outcome, which may lead to testicular atrophy or even totally loss of the affected testis [1]. To data, there is no controversy that the time between onset of symptoms and detorsion, and the degree of cord twisting are the two main determinants for testicular salvage [4, 5]. An early study from Greece reported that no atrophied testis was observed in TT patients with incomplete torsion (180°–360°) and symptom duration less than 12 h, while absent or severely atrophied testis was observed in all TT cases with complete torsion (> 360°) and duration more than 24 h [6].

A large number of studies reported that, worldwide, the delayed diagnosis and management of TT was quite common, and a relatively high proportion of TT patients proven to be delayed even in tertiary hospitals [7, 8]. Aaron P. Bayne et al. [1] and Christopher E. Bayne et al. [9], in the United States, and Ekici et al. [10] in Turkey, have investigated the clinical, socioeconomic and other factors associated with delayed management of TT, while there have no relevant reports among Chinese populations. Identifying the factors that cause delayed management of pediatric TT in China would help to establish targeted medical health-care plans, salvage affected testes, and eventually protect boys’ reproductive health.

The aim of this retrospective study is therefore to investigate the geographic, clinical, and socioeconomic factors associated with delayed management of pediatric TT in West China. This study consecutively investigated all the surgically confirmed TT cases regarding clinical and socioeconomic factors and delayed surgical repair at the largest children’s medical center in West China from November 2004 to December 2020, and gave further evidence on the correlation between the surgical findings and the duration of symptoms onset to surgery.

Among the potential candidates in this 16-year period, 301 surgically confirmed TT children were included in this study. The number of TT children referred to our center greatly increased in recent 10 years, while the percentage of TT patients received timely management was not improved obviously.

Only about 26.9% of TT boys received timely surgical management (within 12 h). From the univariate analysis of geographic, clinical, and socioeconomic factors associated with delayed surgical management of TT, laterality (P = 0.093), medical insurance (P = 0.318), identification (P = 0.692) and education degree of main guardians (P = 0.146) were not different significantly among those TT children who received delayed or timely repair (Table 1). Among the TT boys with delayed surgical management, the percentages of non-comorbidity (P = 0.020), with symptoms progress (P <0.001), a history of former treatment (P <0.001), a first-treat in a primary or secondary health-care unit (P <0.001), living in a poverty county (P = 0.002), and far away from the main city zones (P <0.001) were significantly higher than those percentages among the children who received timely surgical repair of TT. In addition, age was significantly different among TT children with delayed or timely management (P = 0.030), and our data indicated that the older the age was, the lower risk of delayed management the boys suffered (Table 1).

All of the variables that determined to be statistically significant by the univariate analysis between TT children who received delayed or timely management were included in the logistic regression analysis (Table 2). Boys with age less than 6 years (P = 0.001), with a history of symptoms progress (P = 0.001) or former treatment (P <0.001) were significantly more likely to receive a delayed surgical management than a timely one. Patients without other diagnosis (P = 0.011) and those boys living far away from the main city zones (P <0.001) also associated with a delayed repair.

In surgical findings, the direction of rotation and type of torsion were not significantly different between those boys who received a delayed repair or not (Table 3). However, the degree of cord twisting, the blood supply, and grade of Arda, and outcomes of detorsion were significantly much different among boys received delayed management or timely repair (P <0.001).

Our study investigated the possible geographic, clinical, and socioeconomic factors that may cause delayed surgical management of pediatric TT, which was rarely reported in Chinese population. This study concerned the correlation between age, identification and education degree level of guardians, former treatment, absence of extra-scrotal symptoms, and whether a progress of symptoms and the time of duration from symptoms onset to surgery, which was also rarely reported in literatures. The definition of delayed surgical management of TT was still not well established, 12 h and 24 h were the most two discussed boundary [12, 13], and whether less than 12 h was more accepted in latest EAU guidelines pediatric urology 2020. We concerned both time intervals.

The surgical findings in this study furtherly confirmed the delayed management of TT would lead to less activity, insufficient blood supply, and poor outcome of torsed testes after adequate detorsion and supportive treatment. These conditions were all directly associated with subsequent poor clinical outcomes and ability of testicular salvage, consistent with literature findings [1, 14].

According to our study, the misdiagnosis rate of TT in primary, secondary and tertiary hospital was 93.8, 71.1, and 8.9%, respectively (Table 1). The misdiagnosis rate of TT was high, especially in primary and secondary levels-of-healthcare units. There were more than 30% boys with acute scrotum firstly treated not in a tertiary hospital, which led to a delayed surgical management of TT. And in addition, these boys transferred from primary and secondary healthcare units were much more likely to suffer an orchiectomy. Our findings indicated that it was very important to strengthen the public awareness of TT, and effects must be conducted to continuously re-educate and update physicians working at primary and secondary healthcare units. This finding was consistent with two latest similar studies from India and Brazil [7, 8], which indicated that improvement of accurate diagnosis of TT in primary and secondary healthcare units was greatly needed around the world.

Age less than six years was more likely to have delayed management of TT than those elder boys, this may be because small children wouldn’t judge the severity of scrotal uncomfortableness and express themselves. The same way, TT children without other diagnosis (mainly hydrocele) may suffer less pain, reddness and swelling, and this may further delay the treatment. About 52.5% of children lived far away from the Chongqing main city zone, these boys were apt to have their first consultant in the local healthcare units, while the local hospitals were suffering lack of experience on the identification and diagnosis of TT, thus made the delayed surgical management of TT.

Though this study had a relatively large participants in pediatric TT, there still existed several limitations. First, our results were limited by the retrospective observational design nature of the analysis. Some clinical and socioeconomic factors that may be related to delayed surgery, such as family history of TT, family economic conditions, guardians’ work, traffic conditions, were not available. Although our analysis was not full-scale, few studies have concerned these factors in such population and few studies have participants more than 300. Second, all data were drawn from the largest child specialist medical center in West China, some selective bias could not be avoided. In addition, the general public has a preference for treating in tertiary hospitals regardless of the severity of disease [15]. Third, those TT boys who were diagnosed and detorsed not in our hospital were not included into analysis, which may not completely represent the general condition.

Only approximately 26.9% of TT children received timely surgical management (within 12 h from symptoms onset to surgery) in West China. Delayed surgical management for TT was more likely for boys with age less than 6 years, the absence of other diagnosis, with a history of former treatment or symptoms progress, and those living far away from the main city zone. The misdiagnosis rate of TT in primary and secondary healthcare units was very high. It is vital to strengthen the public awareness of TT and conduct continuously re-education and update physicians working at primary and secondary healthcare units to maximize the possibility of timely surgical management for TT.