Delayed Care Seeking and Outcomes of Testicular Torsion among Children during the COVID-19 Pandemic: A Systematic Review and Meta-Analysis

Introduction Since the onset of coronavirus disease 2019 (COVID-19), stay-at-home orders and fear caused by the pandemic have had a significant effect on the timing and outcomes of testicular torsion. However, the evidence was limited since the study results were inconsistent. This study aims to examine the hospitalization rates, timing, and outcomes of testicular torsion in children before and during the pandemic. Materials and Methods Using PubMed, Embase, and Google Scholar databases, we conducted a systematic search and meta-analysis of studies reporting the timing and outcomes of children admitted with testicular torsion before and during the COVID-19 pandemic. Subgroup analyses were conducted to explore possible sources of heterogeneity. Result The outcomes of 899 testicular torsion patients from eight studies were evaluated. Our study found an increased hospitalization rate for patients with testicular torsion (incidence rate ratio = 1.60, 95% confidence interval [CI]: 1.27-2.03;p = 0.001). Despite a significant increase in the duration of symptoms during the COVID-19 pandemic (weighted mean difference = 11.04, 95% CI: 2.75-19.33;p = 0.009), orchiectomy rates did not increase (odds ratio = 1.33, 95% CI: 0.85-2.10;p = 0.147). Conclusion During the COVID-19 pandemic, hospitalization rates for testicular torsion and the duration of symptoms among children increased significantly. Moreover, the rate of orchiectomy did not increase during the pandemic, indicating that pediatric emergency services have remained efficient and have prevented an increase in the number of orchiectomies performed despite pandemic-related closures and delays in transporting patients to medical care.

The Stochastic Ice-Sheet and Sea-Level System Model v1.0 (StISSM v1.0)

Introduction Since the onset of coronavirus disease 2019 (COVID-19), stay-at-home orders and fear caused by the pandemic have had a significant effect on the timing and outcomes of testicular torsion. However, the evidence was limited since the study results were inconsistent. This study aims to examine the hospitalization rates, timing, and outcomes of testicular torsion in children before and during the pandemic. Materials and Methods Using PubMed, Embase, and Google Scholar databases, we conducted a systematic search and meta-analysis of studies reporting the timing and outcomes of children admitted with testicular torsion before and during the COVID-19 pandemic. Subgroup analyses were conducted to explore possible sources of heterogeneity. Result The outcomes of 899 testicular torsion patients from eight studies were evaluated. Our study found an increased hospitalization rate for patients with testicular torsion (incidence rate ratio = 1.60, 95% confidence interval [CI]: 1.27-2.03;p = 0.001). Despite a significant increase in the duration of symptoms during the COVID-19 pandemic (weighted mean difference = 11.04, 95% CI: 2.75-19.33;p = 0.009), orchiectomy rates did not increase (odds ratio = 1.33, 95% CI: 0.85-2.10;p = 0.147). Conclusion During the COVID-19 pandemic, hospitalization rates for testicular torsion and the duration of symptoms among children increased significantly. Moreover, the rate of orchiectomy did not increase during the pandemic, indicating that pediatric emergency services have remained efficient and have prevented an increase in the number of orchiectomies performed despite pandemic-related closures and delays in transporting patients to medical care.

Presentations of the Acute Scrotum During the COVID-19 Pandemic: Experiences of a Non-urological Centre.

INTRODUCTION: Testicular torsion is a time-sensitive surgical emergency. Assessment of the acute scrotum warrants rapid surgical review and low threshold for surgical intervention.  Materials and methods: A retrospective cohort study was undertaken for a three-month period during the first wave of the 2020 COVID-19 pandemic and the corresponding period in 2019. Data were collected for all scrotal explorations undertaken at our non-urological centre during this time. RESULTS: Sixteen scrotal explorations were performed from April to June 2019, one had testicular torsion (6.25%). Forty-one explorations were performed from April to June 2020, nine had testicular torsion (21.95%). The most common diagnosis was epididymitis or epididymo-orchitis in 2019 and 2020 (27% and 37.5%, respectively). Sixty-two percent of patients presented within 12 hours in 2019 compared to only 37% during the first wave of the coronavirus disease 2019 (COVID-19) pandemic. CONCLUSION: This study found an increase in the number of patients presenting with acute scrotal pain triggering surgical intervention and the number of patients with testicular torsion. This is likely to reflect a decrease in patients able to access primary care assessment but may also be related to COVID-19. There was a marked delay in the presentation which has significant implications for testicular viability.

Quality Assessment of YouTube Videos as an Information Source for Testicular Torsion.

Background: Testicular torsion is an acute scrotal disease requiring urgent management, and the COVID-19 pandemic has been demonstrated to lead to poor outcomes for this disease. Presently, many people tend to seek health information via YouTube. This study aims to quantitatively assess the quality of English YouTube video content as an information source of testicular torsion. Methods: In this cross-sectional study, a search was performed with the search term "testicular torsion" on YouTube, and the first 100 videos listed by relevance were selected for our analysis. Duplicate, non-English, videos without audio and surgical videos were excluded. Video features (duration, number of days online, views, likes, comments), source of the video, and author's country were collected. Each video included in the study was assessed using DISCERN and Journal of the American Medical Association (JAMA) Benchmark Criteria. A correlation analysis was performed considering video features, video source, DISCERN scores and JAMA scores. Results: A total of 66 videos were included and analyzed. The most common video content was general information, including etiology, symptoms, and treatment. The majority of videos were from education and training websites (30%), physicians (23%), and independent users (21%). The mean DISCERN and JAMA scores were 36.56 and 2.68, respectively. According to DISCERN, the quality of video uploaded by physicians was relatively high (P < 0.001), and the quality of video uploaded by independent users was relatively low (P < 0.001). The JAMA score had no relevance to the video source (P = 0.813). The correlation between the video features, DISCERN and JAMA scores was controversial by different assessment methods. Conclusions: Despite most of the videos on YouTube being uploaded by medical or education-related authors, the overall quality was poor. The misleading, inaccurate and incomplete information may pose a health risk to the viewers, especially during the COVID-19 pandemic. Much effort needs to be undertaken to improve the quality of health-related videos regarding testicular torsion.

Testicular torsion during the COVID-19 pandemic: Results of a multicenter study in northern Italy.

INTRODUCTION: The literature reported an increased avoidance of the Emergency Department (ED) during COrona VIrus Disease 19 (COVID-19) pandemic, causing a subsequent increase of morbidity and mortality for acute conditions. Testicular torsion is a surgical emergency, which can lead to the loss of the affected testicle if a delayed treatment occurs. As testicular loss is time-related, outcome was hypothesized to be negatively affected by the pandemic. OBJECTIVE: The aim is to investigate whether presentation, treatment and outcomes of children with testicular torsion were delayed during COVID-19. STUDY DESIGN: Medical records of pediatric patients operated for testicular torsion of six Paediatric Surgical Units in Northern Italy between January 2019 and December 2020 were retrospectively reviewed. Patients were divided as for ones treated during (dC) or before the pandemic (pC). To reflect possible seasonality, related to lockdown restrictions, winter and summer calendar blocks were also analysed. For all cohorts, demographic data, pre-operative evaluation, operative notes and post-operative outcomes were reviewed. Primary outcomes were referral time, time from diagnosis to surgery and ischemic time, while secondary outcomes were orchiectomy and atrophy rates. Statistic was conducted as appropriate. RESULTS: A total of 188 patients with acute testicular torsion were included in the study period, 89 in the pre-COVID-19 (pC) period and 99 during COVID-19 (dC). Time from symptom onset to the access to the Emergency Department (T1) was not different among the two populations (pC: 5,5 h, dC: 6 h, p 0.374), and similarly time from diagnosis to surgery (pC: 2,5 h, dC: 2,5 h, p 0.970) and ischemic time (pC: 8,2 h, dC: 10 h, p 0.655). T1 was <6 h in 46/99 patients (46%) pC and 45/89 patients (51%) dC (p = 0.88, Fisher's exact test). Subgroup analysis accounting for different lockdown measures, confirm the absence of any difference. Orchiectomies rate was 23% (23/99) dC and 21% (19/89) pC (p = 0.861, Fisher's exact test) and rate of post-operative atrophy was 9% dC (7/76) and 14% pC (10/70), p = 0,44, Fisher's exact test. DISCUSSION: Despite worldwide pediatric ED accesses reduction, we reported that neither ischemic time nor the long-term outcomes in children with testicular torsion increased during the COVID-19 pandemic. In the available literature, few studies investigated the topic and are controversial on the results. Similarly to our findings, some studies found that timing and orchiectomy rates were not significantly different during the pandemic, while others reported a correlation to pandemic seasonality. Furthermore, in the recent pediatric literature it has been reported a delayed testicular torsion diagnosis due to shame in informing parents. Strengths of this study are the large numerosity, its multicentric design and a long study period. Its main limitation is being retrospective. CONCLUSIONS: We reported our large cohort from one of the most heavily COVID-19-affected regions, finding that referral, intra-hospital protocols and ischemic time in testicular torsion were not increased during to the pandemic, as well as orchiectomy rate and atrophy.

Influence of COVID-19 pandemic on timing and outcomes of treatment for acute testicular torsion in adults: a single institution experience.

INTRODUCTION: The worldwide spread of SARS-COV2 had led to a delay in treatment of numerous urological pathologies, even in emergency conditions. We therefore sought to determine whether the timing of diagnosis and treatment and the postoperative outcome of patients with testicular torsion had been changed during the COVID pandemic. MATERIALS AND METHODS: We considered all patients evaluated in the emergency department (ED) for testicular torsion from February 2018 to August 2019 (pre-COVID period) and from February 2020 to August 2021 (during COVID pandemic). All patients underwent clinical and ultrasound evaluation and subsequently scrotal exploration. Primary outcomes were the time differences from pain onset to ED presentation and from ED presentation to surgical treatment. We also investigated whether the number or orchiectomies required changed during the pandemic. RESULTS: A total of 54 patients were divided in two groups: 40 patients in pre-COVID-19 group and 14 in the COVID-19 cohort. Mean time from symptoms onset to ED access was longer during the pandemic (4.2 ± 5.7 versus 39.6 ± 37.3 hours, p = 0.009). Mean time from ED access to surgery was similar (2.9 ± 1.1 versus 4.2 ± 2.3, p = 0.355). In addition, the number of orchiectomies was higher in COVID-19 group (2.5% versus 28.6%, p < 0.01), compared to a lower number of detorsions (97.5% versus 71.4%, p < 0.01). Elapsed time from pain onset to surgery was directly correlated with the increased white blood cell (WBC) count after surgery (r = 0.399, p = 0.002). DISCUSSION AND CONCLUSIONS: The current study identifies a significant delay in presentation of testicular torsion which resulted in a significant increase in orchiectomies with the expected decreased in detorsion/orchiopexy. In addition, there was an increase in the WBC at presentation associated with delayed presentation.

Comparison of the outcomes of testicular torsion among children presenting during the Coronavirus Disease 2019 (COVID-19) pandemic versus the pre-pandemic period: A systematic review and meta-analysis.

OBJECTIVE: To evaluate whether the Coronavirus Disease 2019 (COVID-19) pandemic resulted in a prolonged duration of symptoms, a delayed presentation to the medical facility, and consequently more orchiectomy procedures among children with testicular torsion compared to the pre-COVID-19 period. METHODS: Systematic search of four scientific databases was performed. The search terms used were (coronavirus OR novel coronavirus OR SARS-CoV-2 OR COVID-19) AND (testicular torsion OR orchidectomy OR orchiectomy OR orchidopexy OR orchiopexy). The inclusion criteria were all boys presenting with testicular torsion during the COVID-19 and pre-COVID-19 periods. A comparison of the average duration of symptoms, the proportion of children with delayed presentation (>24 h), and the proportion of children requiring orchiectomy was made among the two groups. The Downs and Black scale was used for methodological quality assessment. RESULTS: The present meta-analysis included six comparative studies (five retrospective studies). A total of 711 patients (473 during the COVID-19 period) were included. No significant differences in the average duration of symptoms (WMD: 2.6, 95% CI -6.78 to 11.99, P = 0.59), the proportion of children with delayed presentation (RR = 1.03, 95% CI 0.52-2.02, p = 0.94), and orchiectomy rate (RR = 1.23, 95% CI 0.82-1.84, p = 0.31) were observed among the two patient groups. All studies had a moderate risk of bias. CONCLUSION: The duration of symptoms, the proportion of children with delayed presentation, and orchiectomy rate did not significantly differ among the children with testicular torsion presenting during the COVID-19 and pre-COVID-19 periods. However, due to the moderate risk of bias, the level of evidence of the available comparative studies is limited.

Rare case of a patient with testicular torsion complicated by acute pneumonia, requiring emergency surgery, during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic has been causing delay in patient arrival at hospital and starting surgery. We report a delay in a case of testicular torsion complicated by acute pneumonia during the COVID-19 pandemic in Japan. CASE PRESENTATION: A 17-year-old Japanese boy presented to our emergency room with acute left scrotum pain and fever in January 2021. It took 2.5 h to transfer him. Physical examination and color Doppler ultrasonography revealed left testicular torsion. Chest computed tomography indicated acute pneumonia. He successfully underwent surgical detorsion 7.5 h after symptom onset, with COVID-19 preventive measures in place. A negative polymerase chain reaction test result for COVID-19 was revealed after surgery. CONCLUSION: We experienced a rare case of testicular torsion complicated by acute pneumonia during the COVID-19 pandemic. Special attention should be paid to preventing infection and surgery delay to avoid testicular loss.

Surge in testicular torsion in pediatric patients during the COVID-19 pandemic.

BACKGROUND: Testicular torsion is a pediatric surgical emergency, and prompt diagnosis and treatment is imperative. During the COVID-19 pandemic, pediatric patients with symptoms of testicular torsion may be reluctant to seek medical care which increases the likelihood of delayed presentation and the need for an orchiectomy. This observational study sought to determine whether there was a higher number of testicular torsion cases during COVID-19. METHODS: As the first patient with COVID-19 was admitted to our facility on March 6, 2020, we identified male children ages 1-18 years with testicular torsion between March 1-December 31, 2020 (during COVID-19) compared to the same time period between 2015 and 2019 (prior to COVID-19). All patients were evaluated at our Institution's Emergency Department by a pediatric urologist. RESULTS: There were 38 cases of testicular torsion between March 1-December 31, 2020 compared to 15.8 cases on average during the same 10-month period between 2015 and 2019 (a total of 79 cases). There was a statistically significant increase in testicular torsion cases during the COVID-19 pandemic compared to equivalent time periods in 2015-2019 (38 vs. 15.8, p = 0.05). Patients with testicular torsion during the COVID-19 pandemic were younger, had a longer duration of symptoms, and had a higher number of orchiectomies (although not statistically significant). CONCLUSION: During the COVID-19 pandemic, an escalation in testicular torsion cases was observed. Timely assessment, diagnosis, and surgery are crucial to prevent testicular loss and potential infertility in the future. Further evaluation is needed to elucidate the surge in testicular torsion and possible mechanisms.

Is there an increased incidence of orchiectomy in pediatric patients with acute testicular torsion during COVID-19 pandemic?-A retrospective multicenter study.

INTRODUCTION: Testicular torsion is a real emergency condition which requires prompt diagnosis and surgical management to prevent testicular loss. During the coronavirus (COVID-19) pandemic, an increased avoidance of the emergency departments for non-COVID-19 illnesses has been reported in the medical literature. OBJECTIVE: The aim of this study was to investigate whether the COVID-19 pandemic caused increased number of orchiectomies in pediatric patients presenting with acute testicular torsion compared to pre-COVID-19 period. STUDY DESIGN: A total number of 119 pediatric patients who underwent surgery for acute testicular torsion from January 2019 to December 2020 were enrolled in retrospective multi-center study from six institutions in Croatia. The patients were divided in two groups. The first group (pre-COVID-19) consisted of the patients who underwent surgery before COVID-19 pandemic (n = 68), while the second group (COVID-19) consisted of the patients who underwent surgery during the COVID-19 pandemic (n = 51). Main outcomes of the study were orchiectomy rates and time from onset of the symptoms to emergency department presentation. RESULTS: During the COVID-19 pandemic period 43.1% (22/51) of the patients underwent orchiectomy while orchiectomy was performed in 16.2% (11/68) of the patients from the pre-COVID group (p = 0.001). Median time from onset of the symptoms to emergency department presentation during COVID-19 pandemic and pre-COVID-19 periods was 14h (IQR 5, 48) and 6h (IQR 3, 22) (p = 0.007), respectively. A higher proportion of patients waited over 24 h to present to emergency department during the COVID-19 pandemic compared to the pre-COVID-19 period (47% vs 8.8%, p = 0.007). CONCLUSION: During COVID-19 pandemic a significantly higher rates of orchiectomies and increase in delayed presentations for testicular torsion was found. More patient education during pandemic in regards to management of emergency conditions such as testicular torsion is required.

A multicenter study of acute testicular torsion in the time of COVID-19.

BACKGROUND: Testicular torsion is a surgical emergency, and time to detorsion is imperative for testicular salvage. During the COVID-19 pandemic, patients may delay emergency care due to stay-at-home orders and concern of COVID-19 exposure. OBJECTIVE: To assess whether emergency presentation for testicular torsion was delayed during the COVID-19 pandemic, and whether the rate of orchiectomy increased compared to a retrospective period. STUDY DESIGN: Patients were prospectively enrolled in a multicenter study from seven institutions in the United States and Canada. Inclusion criteria were patients two months to 18 years of age with acute testicular torsion from March through July 2020. The retrospective group included patients from January 2019 through February 2020. Statistical analysis was performed using Kruskal-Wallis tests, Chi-square tests, and logistic regression. RESULTS: A total of 221 patients were included: 84 patients in the COVID-19 cohort and 137 in the retrospective cohort. Median times from symptom onset to emergency department presentation during COVID-19 compared to the retrospective period were 17.9 h (IQR 5.5-48.0) and 7.5 h (IQR 4.0-28.0) respectively (p = 0.04). In the COVID-19 cohort, 42% of patients underwent orchiectomy compared to 29% of pre-pandemic controls (p = 0.06). During COVID-19, 46% of patients endorsed delay in presentation compared to 33% in the retrospective group (p = 0.04). DISCUSSION: We found a significantly longer time from testicular torsion symptom onset to presentation during the pandemic and a higher proportion of patients reported delaying care. Strengths of the study include the number of included patients and the multicenter prospective design during the pandemic. Limitations include a retrospective pre-pandemic comparison group. CONCLUSIONS: In a large multicenter study we found a significantly longer time from testicular torsion symptom onset to presentation during the pandemic and a significantly higher proportion of patients reported delaying care. Based on the findings of this study, more patient education is needed on the management of testicular torsion during a pandemic.

Timing and outcomes of testicular torsion during the COVID-19 crisis.

BACKGROUND: During the COVID-19 crisis, there has been widespread reporting that non-COVID-19-related medical care has been delayed, even for emergent conditions. Testicular torsion is an emergent condition with higher risk of testicular loss with longer ischemic times. We sought to investigate whether patients with testicular torsion had longer time from symptom onset to initial presentation, longer total ischemic time, and higher rate of orchiectomy during the pandemic. MATERIALS AND METHODS: Using billing data, we identified all patients age >1yo seen in our hospital from 1/1/2018 through 5/31/2020 who underwent emergent scrotal exploration for confirmed testicular torsion, comparing the COVID-19 crisis (3/1/2020-5/31/20) to the pre-COVID-19 period (1/1/2018-2/29/20). The primary outcome was time from symptom onset to initial presentation and secondary outcomes were ischemic time (time from symptom onset to entry of the OR) and orchiectomy rate. Parameters were compared with Mann-Whitney U and Fisher's exact tests; Poisson regression compared rates of torsion. RESULTS: Of 94 total cases, 77 occurred during the pre-COVID-19 period and 17 during the COVID-19 crisis. Median time from symptom onset to initial presentation was not significantly different (2.4 h [IQR 1.1 h-38.9] during COVID-19 vs. 5.6 h [IQR 1.6-16.9] during pre-COVID-19 period, p = 0.476). Time to presentation was >12 h in 5/17 patients (29%) during COVID-19 and 24/77 patients (31%) during pre-COVID-19 period (p = 1.00). Median ischemic time during COVID-19 was 7.5 h (IQR 4.7 h-45.5 h) compared to 9.4 h (IQR 5.4 h-22.5 h) during pre-COVID-19 period (p = 0.694). Incidence of orchiectomy in our center was 29% (5/17) during COVID-19 and 17% (13/77) during pre-COVID-19 period (p = 0.397). About half of patients were seen initially at outside facilities prior to arrival (47% [8/17] during COVID-19 vs. 49% [38/77] during pre-COVID-19 period, p = 1.00). The number of torsion case presentations per week to our facility increased from 0.7 cases/week in the pre-COVID-19 period to 1.3 cases/week during COVID-19 (p = 0.015); when comparing only the March 1 to May 31 calendar period, there were 0.6 cases/week during the pre-COVID-19 period and 1.3 cases/week during COVID-19 (p = 0.021). CONCLUSION: Time to presentation, ischemic times, and orchiectomy rates for testicular torsion at our center were not significantly different during the COVID-19 period compared to the preceding 2 year period. The number of torsion case per week presenting to our facility increased significantly.