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Electrophysiologic evaluation of cremasteric reflex in experimental orchitis
Journal of Pediatric Urology (2013) 9, 1098e1102
Electrophysiologic evaluation of cremasteric reflex in experimental orchitis b ¨ _ Tutku Soyer a,*, Elem Inal , Ozlem Boybeyi c, Mahi Balci d, ¨lu ¨mser Aydin b Mustafa Kemal Aslan c, Gu
a
Department of Pediatric Surgery, Hacettepe University, School of Medicine, Ankara, Turkey Department of Physical Medicine and Rehabilitation, Kirikkale University, School of Medicine, Kirikkale, Turkey c Department of Pediatric Surgery, Kirikkale University, School of Medicine, Kirikkale, Turkey d Department of Pathology, Kirikkale University, School of Medicine, Kirikkale, Turkey b
Received 5 February 2013; accepted 24 March 2013 Available online 6 May 2013
KEYWORDS Cremasteric reflex; Orchitis; Testicular torsion; Electrophysiology
Abstract Aim: Absent cremasteric reflex (CR) is a well known but not reliable sign of testicular torsion. We hypothesized that CR can also be altered in other causes of acute scrotum in children. An experimental study was performed to evaluate the clinical and electrophysiological features of CR in orchitis. Method: Eighteen Wistar albino rats were allocated into three groups: control (CG), sham (SG) and orchitis (OG). In CG, after anesthetization with ketamine hydrochloride, the medial site of the anterior superior iliac spine was stimulated to obtain CR electrophysiologically, and latency and duration were recorded with a needle electrode placed in the cremasteric muscle. Electrophysiologic evaluations were performed 24 h after injection of 0.1 ml of 106 cfu/ml Escherichia coli (0:6 strain) in 1 ml of physiologic saline into the right testicle in OG, and 1 ml of saline only in SG. All testicles were sampled to check for orchitis after the electrophysiologic evaluations. Results: CR was obtained in all rats in CG and in 83.3% and 66.6% in SG and OG respectively (p < 0.05). The latency of CR was significantly higher in OG (15.1 0.9 ms) and SG (15.5 1.2 ms) than CG (10.5 0.7 ms) (p < 0.017). The duration of CR was 15.1 3.2 ms in CG, 16.2 4.9 ms in SG and 18.5 3 ms in OG (p > 0.05). Histopathologic confirmation of orchitis was obtained in all testicle samples in OG, and number of neutrophils and total orchitis score was significantly higher in OG than the other groups (p < 0.05). Conclusion: Electrophysiologic parameters of CR may be altered in orchitis. Prolonged latency of CR in orchitis may be due to inflammation of the genitofemoral nerve or cremasteric muscle. ª 2013 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ90 532 6651960. E-mail address: [email protected] (T. Soyer). 1477-5131/$36 ª 2013 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jpurol.2013.03.014
Electrophysiologic evaluation of cremasteric reflex
Introduction The cremasteric reflex (CR) is a superficial reflex that is elicited by stroking the skin at the upper-inner aspect of the thigh, and results in elevation of the ipsilateral testes [1]. Among healthy children, CR was elicited in 48% of newborns and 100% of boys between 30 months and 12 years [2]. In 1984, Rabinowitz introduced the significance of CR in testicular torsion and suggested that CR is absent in cases of testicular torsion with 100% sensitivity and 66% specificity [3]. In response to his study, Feldstein reported a patient with an intact reflex in testicular torsion [4]. Later, Nelson et al. reported a case of testicular torsion with an 18-h history of testicular pain in a 4-year-old boy with an intact CR [5]. After these cases, we performed an experimental study to evaluate the latency and duration of CR in testicular torsion to evaluate the electrophysiologic parameters of CR [6]. Our findings revealed that although CR could not be detected clinically during testicular torsion, electrophysiologic parameters of the reflex did not differ in the early and late phases of torsion experimentally. Both clinical and experimental data about the use of CR in differential diagnosis of testicular torsion controvert the reliability of reflex loss in testicular torsion. Orchitis is the most common cause of acute scrotum in boys and requires prompt differential diagnosis to avoid unnecessary surgical exploration of affected testes. Although, intact CR is considered as a useful sign in differential diagnosis of testicular torsion, Kadish and Bolte reported an incidence of absent CR of 14% in orchitis [7]. Despite these clinical observations, there are no data about the electrophysiologic features of CR in orchitis. Therefore, an experimental study was performed to evaluate the clinical and electrophysiological features of CR in orchitis.
1099 hydrochloride (40 mg/kg, Ketelar, Pfizer Warner Lambert). Electrophysiologic evaluations were performed 24-h after injection of 0.1 ml of 106 cfu/ml Escherichia coli (0:6 strain) in 1 ml of physiologic saline into the right testicle in OG, and 1 ml of saline in SG. Clinical evaluation of CR was performed by eliciting the reflex in all groups before electrophysiologic evaluation by stroking the skin at the upper-inner thigh with a blunt object. Elevation of the ipsilateral testicle in an upward direction was considered as positive CR clinically. In order to confirm the histopathologic diagnosis of orchitis, all testicles were sampled after electrophysiological evaluation.
Electrophysiologic evaluation The electrophysiologic evaluation of CR was performed as described in our previous study [6]. After anesthetization, the cremasteric muscle was prepared for electrophysiological evaluation and a disposable concentric needle electrode (diameter 0.46 mm; recording area 0.07 mm2) was inserted into it. A ground electrode was placed on the skin (Fig. 1a and b). To elicit CR, an electrical stimulus was applied to the medial site of the anterior superior iliac spine using bipolar surface electrodes (Medelec Small, Ref. 16894T; Oxford Instruments Medical, Old Woking, UK), with 0.2 ms duration and varying intensity (50 Hze5 kHz band-pass filter, 200 mV per division amplifier display gain and 200 ms sweep time). Ten successive responses were recorded after applying stimuli at irregular intervals, with at least 3 s in between in order to avoid habituation, and minimum latency was measured after superimposition of these 10 responses. The onset latencies and durations of CR on superimposed signals were evaluated.
Histopathological evaluation
Materials and methods Eighteen Wistar albino rats were included in the study. Rats were allocated into three groups: control (CG), sham (SG) and orchitis (OG). In CG, electrophysiologic evaluations were performed after anesthetization with ketamine
Figure 1
Testicular samples were inflated and fixed with 10% formalin. Then all segments were embedded in paraffin. Tissues were sectioned in 4e5 mm pieces and stained with routine hematoxylin and eosin. The specimens were examined under a light microscope (Leica, Germany) by the same pathologist who was blind to the study.
(a,b) Detection of CR in electrophysiological evaluation.
1100
T. Soyer et al.
Figure 2
Histopathologic confirmation of orchitis in OG. PMNL infiltration of seminiferous tubules in OG (HE, 40).
Histopathologic findings including polymorphonuclear leucocytes (PMNL), edema, congestion and fibrosis were graded semiquantitatively for each parameter as follows: grade 0, normal; grade 1, mild; grade 2, moderate; and grade 3, severe. Total pathologic score defined by Cosentino was also evaluated [8]. Grade 1 showed normal testicular architecture with an orderly arrangement of germinal cells. Grade 2 injuries showed less orderly, noncohesive germinal cells, and closely packed seminiferous tubules. Grade 3 injury exhibited disordered, sloughed germinal cells with shrunken pyknotic nuclei and less distinct seminiferous tubule borders. Grade 4 injury defined seminiferous tubules that were closely packed with coagulative necrosis of the germinal cells.
Statistical analysis and ethics The study was approved by the Local Ethical Committee of Kirikkale University. For statistical analysis SPSS 15.0 was used. Descriptive statistical variables were calculated to document the characteristics of all three groups. Comparisons of latency and duration of CR, and histopathologic grades of testicular samples between the CG, SG and OG groups were performed using the KruskaleWallis test. For data where a statistically significant difference was found with the KruskaleWallis test, the ManneWhitney U-test was used. Because three pairs of comparisons were studied,
Table 1
with Bonferroni adjustment, the error rate allowed in each significance testing was 0.016 (i.e. 0.05 divided by 3).
Results In histopathological evaluation, orchitis was confirmed in all experiments in OG (Fig. 2). When histopathologic parameters were evaluated, PMNL and Cosentino score were significantly higher in OG with respect to CG and SG (Table 1) (p < 0.05). CR was obtained in all of the rats in CG and in 83.3% and 66.6% in SG and OG respectively (p < 0.05). CR was evaluated electrophysiologically in all experiments in CG (n Z 6, 100%). Electrophysiologic detection of CR was significantly lower in SG (n Z 5, 83.3%) and OG (n Z 4, 66.6%) than CG (p < 0.05). The latency and duration of CR are shown in Table 2. Although duration of CR was prolonged in OG, no statistical difference was detected between groups (p Z 0.455). The latency of CR was statistically prolonged in OG and SG compared to CG (Fig. 3) (p Z 0.011 and p Z 0.017 respectively).
Discussion The cremasteric muscle is a striated muscle under involuntary control [9]. It is innervated by the genitofemoral nerve originating from L1eL2 spinal roots and presents a
Comparison of histopathologic grades of testicular inflammation.
PMNL Edema Congestion Fibrosis Cosentino’s score
CG (n Z 6) mean SD
SG (n Z 5) mean SD
OG (n Z 4) mean SD
0 1.7 0.8 2 0.6 0 3.8 1.4
0.3 0.5 2 2.2 0.4 0 4.5 0.5
2.5 2.5 2.7 0.3 8
0.5 0.5 0.5 0.5 1.3
pa
pb (CGeOG)
pb (CGeSG)
pb (SGeOG)
0.001 0.036 0.109 0.119 0.002
0.002 0.043 e e 0.003
0.138 0.317 e e 0.240
0.003 0.056 e e 0.003
CG: control group, SG: sham group, OG: orchitis group, ms: millisecond, SD: standard deviation. a KruskaleWallis test, the value of p < 0.05 was considered significant. b ManneWhitney test with Bonferroni adjustment, the value of p < 0.017 was considered significant.
Electrophysiologic evaluation of cremasteric reflex Table 2
1101
Mean latency and duration of CR between groups.
Latency (ms) Duration (ms)
CG (n Z 6) mean SD
SG (n Z 5) mean SD
OG (n Z 4)
pa
pb (CGeOG)
pb (CGeSG)
pb (SGeOG)
10.5 0.7 15.1 3.2
15.5 1.2 16.2 4.9
15.1 0.9 18.5 3
0.012 0.455
0.011 e
0.016 e
0.618 e
CG: control group, SG: sham group, OG: orchitis group, ms: millisecond, SD: standard deviation. a KruskaleWallis test, the value of p < 0.05 was considered significant. b ManneWhitney test with Bonferroni adjustment, the value of p < 0.017 was considered significant.
superficial reflex, requiring afferent, central and efferent components [1,10]. CR is elicited by stroking the skin at the upper-inner aspect of thigh, and results in retraction of the ipsilateral testes. CR is the most commonly mentioned reflex in pediatric surgical practice and is accepted as a significant diagnostic finding in testicular torsion. Loss of CR in testicular torsion was first described by Rabinowitz [3]. After his description, a limited number of clinical observations were reported of intact reflex in boys with testicular torsion. We then reported that CR could not be detected clinically, although the reflex arc was not disturbed electrophysiologically, in experimental testicular torsion [6]. However, the relation between absent CR and testicular torsion is well documented; the diagnostic accuracy of CR in other causes of acute scrotum has not been evaluated previously. Orchitis is the most common cause of acute scrotum in boys, and only 14% of cases had absent CR in one series [7]. In this study, we aimed to evaluate the electrophysiological features of CR in orchitis. In electrophysiological evaluations, the motor nerve depolarization of a peripheral nerve is tested with a single supramaximal stimulation along the course of the peripheral nerve and then by recording the composed muscle action potentials with a surface electrode from a muscle innervated by that nerve [11]. Electrophysiologically, the latency is the time to elicit a response from a muscle by stimulating a nerve, and the duration is the particular time interval of a compound muscle action. Previously, we demonstrated that the latency and duration of CR are not affected by testicular torsion [6]. In this study, we aimed to
Figure 3
evaluate the CR in rats with orchitis. We found significantly higher grades of PMNL infiltration and total pathologic score of Cosentino in OG. Histopathologic evaluations confirm that the rats developed orchitis after E. coli injection. In electrophysiologic evaluations, although CR was significantly prolonged in OG and SG when compared to CG, there was no significant difference in latency of CR between OG and SG. We suggest that prolonged latency in OG and SG may be explained by neuropraxia caused by compression of the injected materials (E. coli extract and saline) and/or bacterially induced inflammation in the cremasteric muscle and genitofemoral nerve. Also, duration of CR was prolonged in OG without any significant difference. This prolongation may also be caused by inflammation of the cremasteric muscle and/or genitofemoral nerve. Since, the cremasteric muscle and genitofemoral nerve were not sampled in this study, it was not possible to come to a firm conclusion about the cause of prolonged latency in orchitis. In order to support our suggestion, the genitofemoral nerve and cremasteric muscle should be sampled to evaluate the possible role of inflammation or neuropraxia due to compression. Since most of the cases with orchitis require antimicrobial treatment, the effect of such treatment on electrophysiologic features of CR should be further evaluated. In conclusion, our study demonstrates that electrophysiologic parameters of CR may be altered in orchitis. Therefore, we suggest that absent CR should not be considered as a reliable diagnostic tool for testicular torsion. Prolonged latency of CR in orchitis may be due to inflammation of the genitofemoral nerve or cremasteric
Examples of CR traces in electrophysiological studies.
1102 muscle. For more accurate comments, studies that involve detailed pathologic evaluations of the genitofemoral nerve and cremasteric muscle are needed.
Conflict of interest/Funding None.
References [1] Bingo glu M, Tanyel FC, Anlar B, Bu ¸u N. Cre¨l-Kolo ¨yu ¨kpamukc masteric reflex and retraction of a testis. J Pediatr Surg 2001; 36(6):863e7. [2] Bingo glu M, Demirci M, Bu ¸u N, Tanyel FC. ¨l-Kolo ¨yu ¨kpamukc Cremasteric reflexes of boys with descended, retractile and undescended testes: an electrophysiological evaluation. J Pediatr Surg 1999;34(3):430e4. [3] Rabinowitz R. The importance of the cremasteric reflex in acute scrotal swallowing in children. J Urol 1984;132:89e90. [4] Feldstein MS. Re: the importance of the cremasteric reflex in acute scrotal swallowing in children. J Urol 1985;133:488.
T. Soyer et al. [5] Nelson CP, Williams JF, Bloom DA. The cremasteric reflex: a useful but imperfect sign in testicular torsion. J Pediatr Surg 2003;38(8):1248e9. [6] Soyer T, Tosun A, Somuncu S, Aydin G, Akman H, Inal E, et al. Electrophysiological evaluation of cremasteric reflex in experimental testicular torsion. Eur J Pediatr Surg 2007;17: 261e5. [7] Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion and torsion of testicular appendages. Pediatrics 1998;102:73e6. [8] Cosentino MJ, Nishida M, Rabinowitz R, Cockett AT. Histopathology of prepubertal rat testes subjected to various durations of spermatic cord torsion. J Androl 1986;7:23e31. [9] Ertekin C, Bademkıran F, Yıldız N, Ozdedeli K, Altay B, Aydogdu I, et al. Central and peripheral motor conduction of cremasteric muscle. Muscle Nerve 2005;31:349e54. [10] Zempoalteca R, Martinez-Gomez M, Hudson R, Cruz Y, Lucio RA. An anatomical and electrophysiological study of the genitofemoral nerve and some of its targets in the male rat. J Anat 2002;201:493e505. [11] Oh SJ. General concepts of electrophysiological studies in neuromuscular disease. In: Oh SJ, editor. Clinical electromyography. nerve conduction studies. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2003. p. 14e24.
Electrophysiologic evaluation of cremasteric reflex in experimental orchitis b ¨ _ Tutku Soyer a,*, Elem Inal , Ozlem Boybeyi c, Mahi Balci d, ¨lu ¨mser Aydin b Mustafa Kemal Aslan c, Gu
a
Department of Pediatric Surgery, Hacettepe University, School of Medicine, Ankara, Turkey Department of Physical Medicine and Rehabilitation, Kirikkale University, School of Medicine, Kirikkale, Turkey c Department of Pediatric Surgery, Kirikkale University, School of Medicine, Kirikkale, Turkey d Department of Pathology, Kirikkale University, School of Medicine, Kirikkale, Turkey b
Received 5 February 2013; accepted 24 March 2013 Available online 6 May 2013
KEYWORDS Cremasteric reflex; Orchitis; Testicular torsion; Electrophysiology
Abstract Aim: Absent cremasteric reflex (CR) is a well known but not reliable sign of testicular torsion. We hypothesized that CR can also be altered in other causes of acute scrotum in children. An experimental study was performed to evaluate the clinical and electrophysiological features of CR in orchitis. Method: Eighteen Wistar albino rats were allocated into three groups: control (CG), sham (SG) and orchitis (OG). In CG, after anesthetization with ketamine hydrochloride, the medial site of the anterior superior iliac spine was stimulated to obtain CR electrophysiologically, and latency and duration were recorded with a needle electrode placed in the cremasteric muscle. Electrophysiologic evaluations were performed 24 h after injection of 0.1 ml of 106 cfu/ml Escherichia coli (0:6 strain) in 1 ml of physiologic saline into the right testicle in OG, and 1 ml of saline only in SG. All testicles were sampled to check for orchitis after the electrophysiologic evaluations. Results: CR was obtained in all rats in CG and in 83.3% and 66.6% in SG and OG respectively (p < 0.05). The latency of CR was significantly higher in OG (15.1 0.9 ms) and SG (15.5 1.2 ms) than CG (10.5 0.7 ms) (p < 0.017). The duration of CR was 15.1 3.2 ms in CG, 16.2 4.9 ms in SG and 18.5 3 ms in OG (p > 0.05). Histopathologic confirmation of orchitis was obtained in all testicle samples in OG, and number of neutrophils and total orchitis score was significantly higher in OG than the other groups (p < 0.05). Conclusion: Electrophysiologic parameters of CR may be altered in orchitis. Prolonged latency of CR in orchitis may be due to inflammation of the genitofemoral nerve or cremasteric muscle. ª 2013 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ90 532 6651960. E-mail address: [email protected] (T. Soyer). 1477-5131/$36 ª 2013 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jpurol.2013.03.014
Electrophysiologic evaluation of cremasteric reflex
Introduction The cremasteric reflex (CR) is a superficial reflex that is elicited by stroking the skin at the upper-inner aspect of the thigh, and results in elevation of the ipsilateral testes [1]. Among healthy children, CR was elicited in 48% of newborns and 100% of boys between 30 months and 12 years [2]. In 1984, Rabinowitz introduced the significance of CR in testicular torsion and suggested that CR is absent in cases of testicular torsion with 100% sensitivity and 66% specificity [3]. In response to his study, Feldstein reported a patient with an intact reflex in testicular torsion [4]. Later, Nelson et al. reported a case of testicular torsion with an 18-h history of testicular pain in a 4-year-old boy with an intact CR [5]. After these cases, we performed an experimental study to evaluate the latency and duration of CR in testicular torsion to evaluate the electrophysiologic parameters of CR [6]. Our findings revealed that although CR could not be detected clinically during testicular torsion, electrophysiologic parameters of the reflex did not differ in the early and late phases of torsion experimentally. Both clinical and experimental data about the use of CR in differential diagnosis of testicular torsion controvert the reliability of reflex loss in testicular torsion. Orchitis is the most common cause of acute scrotum in boys and requires prompt differential diagnosis to avoid unnecessary surgical exploration of affected testes. Although, intact CR is considered as a useful sign in differential diagnosis of testicular torsion, Kadish and Bolte reported an incidence of absent CR of 14% in orchitis [7]. Despite these clinical observations, there are no data about the electrophysiologic features of CR in orchitis. Therefore, an experimental study was performed to evaluate the clinical and electrophysiological features of CR in orchitis.
1099 hydrochloride (40 mg/kg, Ketelar, Pfizer Warner Lambert). Electrophysiologic evaluations were performed 24-h after injection of 0.1 ml of 106 cfu/ml Escherichia coli (0:6 strain) in 1 ml of physiologic saline into the right testicle in OG, and 1 ml of saline in SG. Clinical evaluation of CR was performed by eliciting the reflex in all groups before electrophysiologic evaluation by stroking the skin at the upper-inner thigh with a blunt object. Elevation of the ipsilateral testicle in an upward direction was considered as positive CR clinically. In order to confirm the histopathologic diagnosis of orchitis, all testicles were sampled after electrophysiological evaluation.
Electrophysiologic evaluation The electrophysiologic evaluation of CR was performed as described in our previous study [6]. After anesthetization, the cremasteric muscle was prepared for electrophysiological evaluation and a disposable concentric needle electrode (diameter 0.46 mm; recording area 0.07 mm2) was inserted into it. A ground electrode was placed on the skin (Fig. 1a and b). To elicit CR, an electrical stimulus was applied to the medial site of the anterior superior iliac spine using bipolar surface electrodes (Medelec Small, Ref. 16894T; Oxford Instruments Medical, Old Woking, UK), with 0.2 ms duration and varying intensity (50 Hze5 kHz band-pass filter, 200 mV per division amplifier display gain and 200 ms sweep time). Ten successive responses were recorded after applying stimuli at irregular intervals, with at least 3 s in between in order to avoid habituation, and minimum latency was measured after superimposition of these 10 responses. The onset latencies and durations of CR on superimposed signals were evaluated.
Histopathological evaluation
Materials and methods Eighteen Wistar albino rats were included in the study. Rats were allocated into three groups: control (CG), sham (SG) and orchitis (OG). In CG, electrophysiologic evaluations were performed after anesthetization with ketamine
Figure 1
Testicular samples were inflated and fixed with 10% formalin. Then all segments were embedded in paraffin. Tissues were sectioned in 4e5 mm pieces and stained with routine hematoxylin and eosin. The specimens were examined under a light microscope (Leica, Germany) by the same pathologist who was blind to the study.
(a,b) Detection of CR in electrophysiological evaluation.
1100
T. Soyer et al.
Figure 2
Histopathologic confirmation of orchitis in OG. PMNL infiltration of seminiferous tubules in OG (HE, 40).
Histopathologic findings including polymorphonuclear leucocytes (PMNL), edema, congestion and fibrosis were graded semiquantitatively for each parameter as follows: grade 0, normal; grade 1, mild; grade 2, moderate; and grade 3, severe. Total pathologic score defined by Cosentino was also evaluated [8]. Grade 1 showed normal testicular architecture with an orderly arrangement of germinal cells. Grade 2 injuries showed less orderly, noncohesive germinal cells, and closely packed seminiferous tubules. Grade 3 injury exhibited disordered, sloughed germinal cells with shrunken pyknotic nuclei and less distinct seminiferous tubule borders. Grade 4 injury defined seminiferous tubules that were closely packed with coagulative necrosis of the germinal cells.
Statistical analysis and ethics The study was approved by the Local Ethical Committee of Kirikkale University. For statistical analysis SPSS 15.0 was used. Descriptive statistical variables were calculated to document the characteristics of all three groups. Comparisons of latency and duration of CR, and histopathologic grades of testicular samples between the CG, SG and OG groups were performed using the KruskaleWallis test. For data where a statistically significant difference was found with the KruskaleWallis test, the ManneWhitney U-test was used. Because three pairs of comparisons were studied,
Table 1
with Bonferroni adjustment, the error rate allowed in each significance testing was 0.016 (i.e. 0.05 divided by 3).
Results In histopathological evaluation, orchitis was confirmed in all experiments in OG (Fig. 2). When histopathologic parameters were evaluated, PMNL and Cosentino score were significantly higher in OG with respect to CG and SG (Table 1) (p < 0.05). CR was obtained in all of the rats in CG and in 83.3% and 66.6% in SG and OG respectively (p < 0.05). CR was evaluated electrophysiologically in all experiments in CG (n Z 6, 100%). Electrophysiologic detection of CR was significantly lower in SG (n Z 5, 83.3%) and OG (n Z 4, 66.6%) than CG (p < 0.05). The latency and duration of CR are shown in Table 2. Although duration of CR was prolonged in OG, no statistical difference was detected between groups (p Z 0.455). The latency of CR was statistically prolonged in OG and SG compared to CG (Fig. 3) (p Z 0.011 and p Z 0.017 respectively).
Discussion The cremasteric muscle is a striated muscle under involuntary control [9]. It is innervated by the genitofemoral nerve originating from L1eL2 spinal roots and presents a
Comparison of histopathologic grades of testicular inflammation.
PMNL Edema Congestion Fibrosis Cosentino’s score
CG (n Z 6) mean SD
SG (n Z 5) mean SD
OG (n Z 4) mean SD
0 1.7 0.8 2 0.6 0 3.8 1.4
0.3 0.5 2 2.2 0.4 0 4.5 0.5
2.5 2.5 2.7 0.3 8
0.5 0.5 0.5 0.5 1.3
pa
pb (CGeOG)
pb (CGeSG)
pb (SGeOG)
0.001 0.036 0.109 0.119 0.002
0.002 0.043 e e 0.003
0.138 0.317 e e 0.240
0.003 0.056 e e 0.003
CG: control group, SG: sham group, OG: orchitis group, ms: millisecond, SD: standard deviation. a KruskaleWallis test, the value of p < 0.05 was considered significant. b ManneWhitney test with Bonferroni adjustment, the value of p < 0.017 was considered significant.
Electrophysiologic evaluation of cremasteric reflex Table 2
1101
Mean latency and duration of CR between groups.
Latency (ms) Duration (ms)
CG (n Z 6) mean SD
SG (n Z 5) mean SD
OG (n Z 4)
pa
pb (CGeOG)
pb (CGeSG)
pb (SGeOG)
10.5 0.7 15.1 3.2
15.5 1.2 16.2 4.9
15.1 0.9 18.5 3
0.012 0.455
0.011 e
0.016 e
0.618 e
CG: control group, SG: sham group, OG: orchitis group, ms: millisecond, SD: standard deviation. a KruskaleWallis test, the value of p < 0.05 was considered significant. b ManneWhitney test with Bonferroni adjustment, the value of p < 0.017 was considered significant.
superficial reflex, requiring afferent, central and efferent components [1,10]. CR is elicited by stroking the skin at the upper-inner aspect of thigh, and results in retraction of the ipsilateral testes. CR is the most commonly mentioned reflex in pediatric surgical practice and is accepted as a significant diagnostic finding in testicular torsion. Loss of CR in testicular torsion was first described by Rabinowitz [3]. After his description, a limited number of clinical observations were reported of intact reflex in boys with testicular torsion. We then reported that CR could not be detected clinically, although the reflex arc was not disturbed electrophysiologically, in experimental testicular torsion [6]. However, the relation between absent CR and testicular torsion is well documented; the diagnostic accuracy of CR in other causes of acute scrotum has not been evaluated previously. Orchitis is the most common cause of acute scrotum in boys, and only 14% of cases had absent CR in one series [7]. In this study, we aimed to evaluate the electrophysiological features of CR in orchitis. In electrophysiological evaluations, the motor nerve depolarization of a peripheral nerve is tested with a single supramaximal stimulation along the course of the peripheral nerve and then by recording the composed muscle action potentials with a surface electrode from a muscle innervated by that nerve [11]. Electrophysiologically, the latency is the time to elicit a response from a muscle by stimulating a nerve, and the duration is the particular time interval of a compound muscle action. Previously, we demonstrated that the latency and duration of CR are not affected by testicular torsion [6]. In this study, we aimed to
Figure 3
evaluate the CR in rats with orchitis. We found significantly higher grades of PMNL infiltration and total pathologic score of Cosentino in OG. Histopathologic evaluations confirm that the rats developed orchitis after E. coli injection. In electrophysiologic evaluations, although CR was significantly prolonged in OG and SG when compared to CG, there was no significant difference in latency of CR between OG and SG. We suggest that prolonged latency in OG and SG may be explained by neuropraxia caused by compression of the injected materials (E. coli extract and saline) and/or bacterially induced inflammation in the cremasteric muscle and genitofemoral nerve. Also, duration of CR was prolonged in OG without any significant difference. This prolongation may also be caused by inflammation of the cremasteric muscle and/or genitofemoral nerve. Since, the cremasteric muscle and genitofemoral nerve were not sampled in this study, it was not possible to come to a firm conclusion about the cause of prolonged latency in orchitis. In order to support our suggestion, the genitofemoral nerve and cremasteric muscle should be sampled to evaluate the possible role of inflammation or neuropraxia due to compression. Since most of the cases with orchitis require antimicrobial treatment, the effect of such treatment on electrophysiologic features of CR should be further evaluated. In conclusion, our study demonstrates that electrophysiologic parameters of CR may be altered in orchitis. Therefore, we suggest that absent CR should not be considered as a reliable diagnostic tool for testicular torsion. Prolonged latency of CR in orchitis may be due to inflammation of the genitofemoral nerve or cremasteric
Examples of CR traces in electrophysiological studies.
1102 muscle. For more accurate comments, studies that involve detailed pathologic evaluations of the genitofemoral nerve and cremasteric muscle are needed.
Conflict of interest/Funding None.
References [1] Bingo glu M, Tanyel FC, Anlar B, Bu ¸u N. Cre¨l-Kolo ¨yu ¨kpamukc masteric reflex and retraction of a testis. J Pediatr Surg 2001; 36(6):863e7. [2] Bingo glu M, Demirci M, Bu ¸u N, Tanyel FC. ¨l-Kolo ¨yu ¨kpamukc Cremasteric reflexes of boys with descended, retractile and undescended testes: an electrophysiological evaluation. J Pediatr Surg 1999;34(3):430e4. [3] Rabinowitz R. The importance of the cremasteric reflex in acute scrotal swallowing in children. J Urol 1984;132:89e90. [4] Feldstein MS. Re: the importance of the cremasteric reflex in acute scrotal swallowing in children. J Urol 1985;133:488.
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