- Email: [email protected]
Variation in the evaluation of testicular conditions across United States pediatric emergency departments
Accepted Manuscript Variation in the evaluation of testicular conditions across United States pediatric emergency departments
Lois K. Lee, Michael C. Monuteaux, Joel D. Hudgins, John J. Porter, Susan C. Lipsett, Florence Bourgeois, Bartley G. Cilento, Mark I. Neuman PII: DOI: Reference:
S0735-6757(17)30626-5 doi: 10.1016/j.ajem.2017.07.078 YAJEM 56864
To appear in: Received date: Revised date: Accepted date:
26 May 2017 22 July 2017 25 July 2017
Please cite this article as: Lois K. Lee, Michael C. Monuteaux, Joel D. Hudgins, John J. Porter, Susan C. Lipsett, Florence Bourgeois, Bartley G. Cilento, Mark I. Neuman , Variation in the evaluation of testicular conditions across United States pediatric emergency departments, (2017), doi: 10.1016/j.ajem.2017.07.078
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Variation in the Evaluation of Testicular Conditions across United States Pediatric Emergency Departments (Evaluation of Testicular Conditions in Pediatric Emergency Departments)
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Lois K. Lee, MD, MPH, 1 Michael C. Monuteaux, ScD, 1 Joel D. Hudgins, MD, 1 John J. Porter, MBA,1 Susan C. Lipsett, MD, 1 Florence Bourgeois, MD, MPH, 1 Bartley G. Cilento Jr., MD, MPH 2 and Mark I. Neuman, MD, MPH1 1
Abstract word count: 241 Manuscript word count: 2453
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Corresponding author: Lois K. Lee, MD, MPH Division of Emergency Medicine Boston Children’s Hospital 300 Longwood Ave. Boston, MA 02115 Phone: 617-355-5089 Fax: 617-730-0335 Email: [email protected]
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Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA 2 Department of Urology, Boston Children’s Hospital, Boston, MA
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Funding source: none The authors have no financial or other conflicts of Interest to disclose.
ABSTRACT
Objectives: To explore the variation in diagnostic testing and management for males diagnosed with three testicular conditions (testicular torsion, appendix testis torsion, epididymitis/orchitis) using a large pediatric health care database. Diagnostic testing is
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frequently used in evaluation of the acute scrotum; however, there is likely variability in the use of these tests in the emergency department setting. Methods: We conducted a cross-sectional study of males with the diagnoses of testicular torsion, appendix testis torsion, and epididymitis/orchitis. We identified
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emergency department patients in the Pediatric Health Information Systems (PHIS)
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database from 2010-2015 using diagnostic and procedure codes from the International
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Classification of Diseases Codes 9 and 10. Frequencies of diagnoses by demographic characteristics and of procedures and diagnostic testing (ultrasound, urinalysis, urine
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culture and sexually transmitted infection testing) by age group were calculated. We
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analyzed testing trends over time.
Results: We identified 17,000 males with the diagnoses of testicular torsion (21.7%),
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appendix testis torsion (17.9%), and epididymitis/orchitis (60.3%) from 2010-2015.
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There was substantial variation among hospitals in all categories of testing for each of the diagnoses. Overall, ultrasound utilization ranged from 33.1-100% and urinalysis
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testing ranged from 17.0-84.9% for all conditions. Only urine culture testing decreased
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over time for all three diagnoses (40.6% in 2010 to 31.5 in 2015). Conclusions: There was wide variation in the use of diagnostic testing across pediatric
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hospitals for males with common testicular conditions. Development of evaluation guidelines for the acute scrotum could decrease variation in testing. Key words Scrotum Testicular Torsion Epididymitis
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Abbreviations ED: emergency department HCUP: Healthcare Cost and Utilization Project ICD: International Classification of Diseases KID: Kids’ Inpatient Database STI: sexually transmitted infection US: ultrasound U.S.: United States VCUG: voiding cystourethrogram
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1. INTRODUCTION
Acute scrotal pain and swelling—often referred to as “the acute scrotum”--are important urologic complaints encountered in males presenting to the emergency department (ED).1 The diagnosis of testicular torsion must always be considered and excluded in a timely fashion, although this is present in a minority of boys and adolescent males presenting with an acute scrotum relative to other conditions such as epididymitis and torsion of the appendix testis.1–7 The prevalence of these diagnoses among males less
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than 18 years old presenting with an acute scrotum range from 8-16% for testicular torsion, 1-75% for appendix testis torsion, and 4%-39% for epididymitis; however, these studies varied in the use of diagnostic testing or surgical exploration to make the diagnosis.3,5–8 A study using the Healthcare Cost and Utilization Project (HCUP) Kids’
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Inpatient Database (KID) estimated the yearly incidence of testicular torsion for males
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less than 18 years old was 3.8/100,000.9 Prompt diagnosis of testicular torsion is
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paramount as the risk of testicular salvage decreases substantially after more than 6
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hours of symptoms due to the development of testicular ischemia and necrosis.3
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Although certain physical examination findings can be helpful in distinguishing males with and without testicular torsion, scrotal ultrasound is considered the gold standard to
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establish the diagnosis.1,5,8 A clinical scoring system10,11 and clinical decision rule7 have
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been described for the evaluation of testicular torsion; however, their use has not been widely adopted due to suboptimal test characteristics and lack of external validation.
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The objective of our study was to explore the variation in diagnostic test utilization,
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including US, urinalysis, and sexually transmitted infection (STI) testing, and management for males diagnosed with testicular conditions using a large pediatric
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health care database. Understanding this type of variation in care can help inform future guidelines to standardize the use of diagnostic testing among pediatric males presenting with acute scrotal complaints to provide more efficient and effective care.
2. MATERIALS AND METHODS 2.1 Study Design and Setting
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This is a cross-sectional study of ED visits of males with 3 common testicular diagnoses: testicular torsion, torsion of the appendix testis, and epididymitis/orchitis. Data for this study were obtained from the Pediatric Health Information System (PHIS), an administrative database that contains inpatient, ED, ambulatory surgery, and
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observation encounter-level data from over 49 not-for-profit, tertiary care pediatric
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hospitals in the United States. These hospitals are affiliated with the Children’s Hospital
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Association (Overland Park, KS). Data quality and reliability are assured through a joint effort between the Children’s Hospital Association and participating hospitals. Portions
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of the data submission and data quality processes for the PHIS database are managed
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by Truven Health Analytics (Ann Arbor, MI). For the purposes of external benchmarking, participating hospitals provide discharge/encounter data including
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demographics, diagnoses, and procedures. Nearly all of these hospitals also submit
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resource utilization data (e.g. pharmaceuticals, imaging, and laboratory) into PHIS. Data are de-identified at the time of data submission, and data are subjected to a
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number of reliability and validity checks before being included in the database. For this
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study, data from 38 hospitals were included, as 11 hospitals did not have complete data available. This study was granted exemption from human subjects approval by our
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Institutional Review Board. 2.2 Study Population
Males 0-17 years old diagnosed with these three testicular conditions from January 1, 2010 to December 31, 2015 were eligible for inclusion. Patients were identified using the following ICD-9-CM and ICD-10-CM codes: 1) testicular torsion:608.20-608.22, N44.00-N44.02; 2) torsion of the appendix testis: 608.23, N44.03; and 3)
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Epididymitis/orchitis: 016.4, 095.8, 098.0, 099.54, 125.9, 604.0-604.99, A18.40, A52.73, A52.76, A52.79, A54.00, A54.02, A54.09, A56.11, A56.19, B74.9, N45.1-N45.4. The diagnosis of testicular torsion additionally required a procedure code for orchiectomy, orchipexy, reduction of torsed testicle, or other testicular procedure
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(supplementary Table). Children who had been transferred from another hospital were
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excluded, as they may have had imaging or testing performed at the referring hospital.
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Children with complex chronic conditions,12,13 and those with a subsequent ED visit with the same ICD-9-CM or ICD-10 codes within 30 days were also excluded from the study
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cohort, as these patients may require different evaluations from healthy patients or
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those with a first-time presentation for testicular complaints. 2.3 Outcome Measures
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The primary outcome measure for this study was the hospital-level variation in scrotal
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ultrasound use in the evaluation of these testicular diagnoses. Secondary outcomes included the use of urinalysis and STI testing and performance of orchiectomy and
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orchipexy for children with testicular torsion.
2.4 Data Analysis
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Patient-level covariates included age, race, ethnicity, and insurance payer. In addition, data on the U.S. census region of the hospital, laboratory testing (UA, urine culture, STI testing), ultrasound use, and procedures were collected. STI testing for gonorrhea and chlamydia included codes for nucleic acid amplification tests and culture. Frequencies of these covariates by testicular diagnoses were calculated. For ultrasound and laboratory testing, frequencies were calculated and stratified by age group and by
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specific testicular diagnosis. We also searched for all patients with a diagnosis of testicular torsion and no code for scrotal ultrasound to determine if these patients had associated procedure codes of orchiectomy, orchiopexy, or reduction of testicular torsion. We compared the distribution of diagnostic and laboratory testing across the
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PHIS hospitals. We also calculated rates of ED visits for these testicular diagnoses
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over time and analyzed linear trends over time. To compare demographic
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characteristics for the three diagnoses, we performed univariate logistic regression modelling. All statistical tests were 2-tailed with α set at 0.05. All analyses were
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performed using Stata 13.0 (College Station, TX).
3 THEORY
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Given there is not a universally adopted clinical decision tool used to evaluate males
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presenting with an acute scrotum, there is likely substantial variation in care among hospitals. Understanding the variation in the use of diagnostic testing for males
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presenting with an acute scrotum may help develop guidelines to provide more
4 RESULTS
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standardized care, which could potentially decrease unnecessary testing.
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The study population included 17,000 ED visits for pediatric males with testicular diagnoses of testicular torsion (21.7%), torsion of the appendix testis (17.9%), and epididymitis/orchitis (60.3%) (Table 1), which represents 0.22% of all ED visits (n=7,786,929) during the study period. The median age for males with these testicular diagnoses was 11 years old (IQR 8, 13). Among males with testicular torsion, the majority (75%) were older than the median age. In contrast, for the diagnosis of torsion
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of the appendix testis the majority (75%) were below the median age, which was similar for epididymitis/orchitis (63%). The odds of testicular torsion were higher in black males (OR 2.89, 95% CI 2.36, 3.54) and Asians (OR 1.38, 95% CI 1.03, 1.85) compared to white males. Of the males diagnosed with testicular torsion, 35.3% (1,305/3,695) had a
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procedure code for orchiectomy, 90.4% (3,341/3/695) had a code for orchiopexy, 9.7%
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(358/3,695) had a code for testicular torsion reduction, and 5.6% (207/3,695) had other
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testicular procedures. Of note, orchiopexy could be for the contralateral testis, and not necessarily for the torsed testis, as this distinction could not be made in the dataset.
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The frequency of having both procedures for an individual patient with testicular torsion
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by age group was: 67.5% for < 1 year, 50.4% for 1-9 years, 29.7% for 10-13 years, and 22.1% for 14-17 years old (Table 2).
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4.1 Ultrasound and Urine Testing Utilization
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There was substantial variation in the use of scrotal ultrasound, urinalyses, and STI testing for each of the three testicular diagnoses (Figure 1). Use of scrotal ultrasound
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was common for all diagnoses (Table 2). When considering males with a diagnosis of
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testicular torsion and no code for scrotal ultrasound, all of these patients had associated procedure codes of orchiectomy, orchiopexy and/or reduction of testicular torsion. The
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use of urinalysis and urine culture varied by diagnosis and age, with urine cultures sent about half as often as urinalyses across all age groups. STI testing was low among all three testicular diagnoses with an overall rate of 0.68%. Across the individual PHIS hospitals, the proportion of testing utilized for males with testicular diagnoses varied from 17.0% to 84.9% for UA and 33.1% to 100% for US (Figure 2). 4.2 Trends in Test Utilization over Time
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During the study period of 2010-2015 there was minimal change in test utilization over time, with the exception of urine culture.. For urine culture, there was a steady decline that was statistically significant in all three diagnoses in the proportion of males tested, with an overall decrease in testing from 40.6% in 2010 to 31.5% in 2015. The tests for
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linear trend for urine culture for each diagnosis were: testicular torsion OR 0.93 (95% CI
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0.86, 1.00); appendix testis torsion OR 0.87 (95% CI 0.82, 0.93); and for
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5 DISCUSSION
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epididymitis/orchitis 0.93 (95% CI 0.89, 0.98).
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We describe the characteristics of 17,000 males with testicular diagnoses cared for in U.S. children’s hospitals, and demonstrate wide variation in the use of scrotal
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ultrasound and laboratory testing across individual hospitals. Most variation in the use
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of scrotal ultrasound occurred among children diagnosed with torsion of the appendix testis, and the greatest variation in urinalyses was observed among children with
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testicular torsion and appendix testis torsion. These findings support the need for more
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standardized guidelines for the management of pediatric males with testicular complaints presenting to U.S. ED’s to decrease variation in care and minimize
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unnecessary testing.
The evaluation of the acute scrotum in males presenting with testicular pain and/or swelling is focused on the timely identification of potential testicular torsion, since a missed or delayed diagnosis can lead to infarction and an unviable testicle. 3,14 Testicular Doppler ultrasound is safe, noninvasive, and has high sensitivity and positive
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and negative predictive values,15 8,16 for testicular torsion. It is therefore commonly used in the evaluation of the acute scrotum.7 While clinical tools have been developed to risk stratify males presenting with the acute scrotum to aid in identifying those at high risk for testicular torsion and obviate the need for further testing, 7,10,11 these clinical tools are
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not routinely used. Our study adds to the growing body of literature demonstrating the
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high rate of evaluation with ultrasound for children with testicular complaints.8,16
We observed wide variation (30%-100%) in the use of ultrasound across pediatric
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hospitals for these common testicular diagnoses. Further refinement of a clinical
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decision rule could potentially improve the more timely identification of testicular torsion while using a more standardized evidence-based approach for the evaluation of non-
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surgical conditions including appendix testis torsion and epididymitis/orchitis. In
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addition to scrotal ultrasound, urinalyses were performed in the majority of males with a diagnosis of appendix testis torsion and epididymitis/orchitis, which is similar to previous
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studies. 17,18, 3 In contrast, about one-third of males with a diagnosis of testicular torsion
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had a urinalysis performed, likely due to the emergent nature of this condition and the unnecessary need to diagnose an infectious etiology for testicular torsion. Urinalysis is
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often part of the evaluation of the acute scrotum to identify potential infectious causes of epididymitis. Retrograde flow of infected urine (e.g. bacterial urinary tract infection or STI) from the urethra through ejaculatory ducts, the vas deferens, and then into the epididymis has been described as a cause of infectious epididymitis.1,2 Studies evaluating the correlation of bacterial urinary tract infections and pyuria with epididymitis have had mixed results.1,4,18,17 In general, the recommendation is for males presenting
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with an acute scrotum to have urinalysis and urine culture as part of their evaluation. 1–3,5 One study compared boys with acute epididymitis with healthy controls and found those with epididymitis had an increased prevalence of positive bacterial and viral cultures and concluded epididymitis could be a result of a post-infectious inflammatory condition
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or from a viral infection. 19 Another study of 160 patients with a diagnosis of
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epididymitis/orchitis reported 9 (7%) patients had a positive urinalysis and/or culture,
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leading the authors to recommend urine cultures be sent on all patients with epididymitis and that antibiotics covering urinary pathogens be prescribed for those with
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positive urinalyses and positive urine cultures. 17
In prepubertal boys epididymitis/orchitis is most commonly idiopathic,2 and no specific
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treatment may be indicated, especially with a negative urine culture. Infants with
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epididymitis may have an underlying genitourinary abnormality that some recommend further evaluation by ultrasound and voiding cystourethrogram (VCUG).4, 3,20 In sexually
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active males, STIs are a common cause of epididymitis/orchitis, although this may be
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less common in adolescents compared to adults.17,18 Thus, testing by culture or nucleic acid amplification and treatment for C. trachomatis and N. gonorrhea is recommended
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for sexually active adolescent males presenting with an acute scrotum.2,17 In our sample of pediatric hospitals, STI testing was rarely performed, consistent with previous studies.17 Future research evaluating the prevalence and any other associated signs or symptoms of STIs in adolescent males presenting with an acute scrotum may help inform recommendations for STI testing in this age group.
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5.1 Limitations Our study has several limitations. With the use of an administrative database, there is potential for misclassification bias as diagnoses and tests may be miscoded; however, given the large size of the study dataset, misclassification is most likely random and
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non-differential. The focus of our study was the use of ultrasound and urine testing in
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the evaluation of three common testicular diagnoses; however, we were unable to
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ascertain if these tests may have been obtained prior to presentation at the pediatric ED. We excluded patients who were transferred from other hospitals to minimize the
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inclusion of such patients, but cannot account for children who received this testing in
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an outpatient setting prior to arrival. Detailed clinical information is not available in the PHIS database, and thus, we were unable to determine any clinical reasons for specific
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testing or the results of testing. Although our intent was to evaluate children presenting
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with a testicular complaints, due to the limitations in the dataset, we relied on the use of diagnosis codes to establish our study cohort. Thus, testing patterns may not reflect
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actual rates of testing for all children with presenting signs and symptoms referable to
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the scrotum. Finally, as this database is comprised of data from free-standing pediatric hospitals, our results may not be generalizable to males evaluated at non-pediatric
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specific hospitals
5.2 Conclusions In this study of males with common testicular diagnoses, we observed wide variation in the use of diagnostic testing across pediatric hospitals. This variation may lead to increased healthcare costs and disparate outcomes. Additional research on the utility of
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urinalysis, urine culture, and STI testing is needed to develop better guidelines for laboratory testing for males presenting with an acute scrotum. Furthermore, refinement of clinical decision support tools to identify males at high risk for testicular torsion may
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aid in a more timely diagnosis, while decreasing use of testing for those at lowest risk.
Diaz EC, Kimball D, Gong EM. Acute Scrotal Pain in Pediatric Emergency
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1.
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REFERENCES
Medicine: Assessment, Diagnosis, Management, and Treatment. Clin Pediatr
Jefferies MT, Cox AC, Gupta A, Proctor A. The management of acute testicular
PT
2.
ED
Emerg Med. 2014;15(3):248-260. doi:10.1016/j.cpem.2014.08.002.
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pain in children and adolescents. BMJ. 2015;350(apr02_5):h1563. doi:10.1136/bmj.h1563. Lewis a G, Bukowski TP, Jarvis PD, Wacksman J, Sheldon C a. Evaluation of
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3.
acute scrotum in the emergency department. J Pediatr Surg. 1995;30(2):277-812. doi:0022-3468(95)90574-X [pii]. 4.
Gkentzis A, Lee L. The aetiology and current management of prepubertal epididymitis. Ann R Coll Surg Engl. 2014;96(3):181-183. doi:10.1308/003588414X13814021679311.
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5.
Yang C, Song B, Liu X, Wei G, Lin T, He D. Acute scrotum in children: an 18-year retrospective study. Pediatr Emerg Care. 2011;27(4):270-274. doi:10.1097/PEC.0b013e318213144e. Boettcher M, Bergholz R, Krebs TF, Wenke K, Aronson DC. Clinical predictors of
IP
testicular torsion in children. Urology. 2012;79(3):670-674.
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doi:10.1016/j.urology.2011.10.041. 7.
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6.
Shah MI, Chantal Caviness A, Mendez DR. Prospective pilot derivation of a
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decision tool for children at low risk for testicular torsion. Acad Emerg Med.
8.
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2013;20(3):271-278. doi:10.1111/acem.12086.
Liang T, Metcalfe P, Sevcik W, Noga M. Retrospective review of diagnosis and
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treatment in children presenting to the pediatric department with acute scrotum.
ED
Am J Roentgenol. 2013;200(5):W444-9.
PT
http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=2361751 2&retmode=ref&cmd=prlinks\npapers3://publication/doi/10.2214/AJR.12.10036. Zhao LC, Lautz TB, Meeks JJ, Maizels M. Pediatric Testicular Torsion
CE
9.
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Epidemiology Using a National Database: Incidence, Risk of Orchiectomy and Possible Measures Toward Improving the Quality of Care. J Urol. 2011;186(5):2009-2013. doi:10.1016/j.juro.2011.07.024. 10.
Barbosa J a., Tiseo BC, Barayan G a., et al. Development and initial validation of a scoring system to diagnose testicular torsion in children. J Urol. 2013;189(5):1859-1864. doi:10.1016/j.juro.2012.10.056.
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11.
Sheth KR, Keays M, Grimsby GM, et al. Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score. J Urol. February 2016. doi:10.1016/j.juro.2016.01.101.
12.
Feudtner C, Christakis DA, Connell FA. Pediatric deaths attributable to complex
IP
T
chronic conditions: a population-based study of Washington State, 1980-1997.
13.
CR
Pediatrics. 2000;106(1 Pt 2):205-209. doi:10.1542/peds.106.1.S1.205. Feudtner C, Feinstein JA, Zhong W, Hall M, Dai D. Pediatric complex chronic
US
conditions classification system version 2: updated for ICD-10 and complex
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medical technology dependence and transplantation. BMC Pediatr. 2014;14(1):199. doi:10.1186/1471-2431-14-199. Vasdev N, Chadwick D, Thomas D, N. V, D. C, D. T. The acute pediatric scrotum:
M
14.
ED
Presentation, differential diagnosis and management. Curr Urol. 2012;6(2):57-61.
15.
PT
doi:10.1159/000343509.
Cokkinos DD, Antypa E, Tserotas P, et al. Emergency ultrasound of the scrotum:
CE
a review of the commonest pathologic conditions. Curr Probl Diagn Radiol.
16.
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2011;40(1):1-14. doi:10.1067/j.cpradiol.2009.07.011. Yagil Y, Naroditsky I, Milhem J, et al. Role of Doppler ultrasonography in the triage of acute scrotum in the emergency department. J Ultrasound Med. 2010;29:11-21. 17.
Santillanes G, Gausche-Hill M, Lewis RJ. Are antibiotics necessary for pediatric epididymitis? Pediatr Emerg Care. 2011;27(3):174-178.
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doi:10.1097/PEC.0b013e31820d647a. 18.
Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics.
Somekh E, Gorenstein A, Serour F. Acute epididymitis in boys: evidence of a
IP
19.
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1998;102(1 Pt 1):73-76. doi:10.1542/peds.102.1.73.
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post-infectious etiology. J Urol. 2004;171(1):391-4; discussion 394.
Siegel A, Snyder H, Duckett JW. Epididymitis in infants and boys: underlying
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urogenital anomalies and efficacy of imaging modalities. J Urol. 1987;138(4 Pt 2):1100-1103. http://www.ncbi.nlm.nih.gov/pubmed/3309376. Accessed February
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1, 2016.
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20.
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doi:10.1097/01.ju.0000102160.55494.1f.
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Figure Legends
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Figure 1.
Figure 2.
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Distribution of urinalysis and scrotal ultrasound testing across hospitals by diagnosis. Figure represents median with shaded box as 25th to 75th percentiles and lines representing 10th and 90th percentiles.
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Distribution of testing of urinalysis and scrotal ultrasound by individual hospital.
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Epididymitis -Orchitis N=10,258
Total N=17,000
Total ED Visits* N = 7,786,929
13 (11, 15) 114 (3.1) 534 (14.5) 1,385 (37.5) 1,662 (44.9)
10 (8, 12) 20 (0.7) 1,239 (40.6) 1,487 (48.8) 301 (9.9)
10 (8, 13) 150 (1.5) 3,775 (36.8) 4,155 (40.5) 2,178 (21.2)
11 (8, 13) 284 (1.7) 5,548 (32.6) 7,027 (41.3) 4,141 (24.4)
4 (1, 9) 1,373,995 (17.6) 4,678,027 (60.1) 1,000,040 (12.8) 734,867 (9.5)
1,848 (50.0) 1,151 (31.1) 85 (2.3) 431 (11.7) 180 (4.9)
1,957 (64.2) 296 (9.7) 67 (2.2) 383 (12.6) 344 (11.3)
6,460 (63.0) 1,516 (14.8) 212 (2.1) 1,633 (15.9) 437 (4.3)
10,265 (60.4) 3,831,166 (49.2) 2,963 (17.4) 2,198,008 (28.2) 364 (2.1) 155,387 (2.0) 2,447 (14.4) 1,182,093 (15.2) 961 (5.7) 420,275 (5.4)
687 (18.6) 2,586 (70.0) 422 (11,4)
906 (29.7) 1,903 (62.5) 238 (7.8)
2,650 (25.8) 6,435 (62.7) 1,173 (11.4)
4,243 (25.0) 2,024,247 (26.0) 10,924 (64.3) 4,933,206 (63.3) 1,833 (10.7) 829,476 (10.7)
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Torsion of the Appendix Testis N=3,047
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Age group Median (IQR) < 1 yr 1-10 yrs 10-13 yrs 14-17 yrs Race White Black Asian Other Missing Ethnicity Latino Non-Latino Unknown
Testicular Torsion N=3,695
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Characteristic
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Table 1. Characteristics of Patients with Testicular Diagnoses, PHIS Hospitals 2010-2015
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7,854 (46.2) 7,733 (45.5) 1,274(7.5)
5,055,332 (64.9) 2,149,103 (27.6) 518,463 (6.6)
1,240 (12.2) 4,525 (44.2) 2,035 (19.9) 2,427 (23.7)
2,003 (11.8) 7,905 (46.6) 3,336 (19.7) 3,725 (21.9)
619,991 (8.0) 3,599,210 (46.3) 2,058,261 (26.5) 1,490,668 (19.2)
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4,733 (46.1) 4,615 (45.0) 826 (8.0)
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Insurance payer Government 1,672 (45.2) 1,328 (43.6) Primary 1,749 (47.3) 1,490 (48.9) Other 241 (6.5) 207 (6.8) U.S. Census Region Northeast 404 (10.9) 359 (15.8) South 1,753 (47.4) 1,627 (53.4) North Central 796 (21.6) 505 (16.6) West 742 (20.1) 556 (18.2) *All diagnoses in PHIS hospitals, 2010-2015
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Table 2. Testing and Procedure Characteristics of Patients with Testicular Diagnoses, Stratified By Age Testicular Torsion N=3,695
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Test Performed
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Scrotal ultrasound < 1 yr (n=266) 1-9 yrs (n=5,607) 10-13 yrs (n=6,759) 14-17 yrs (n=3,404) Urinalysis < 1 yr (n=109) 1-9 yrs (n=4,043) 10-13 yrs (n=5,069) 14-17 yrs (n=2,594) Urine culture < 1 yr (n=121) 1-9 yrs (n=2,278) 10-13 yrs (n=2,685) 14-17 yrs (n=1,435)
2,586 (70.0) 91 (3.5) 436 (16.9) 944 (36.5) 1,115 (43.1) 1,129 (30.5) 14 (1.2) 156 (13.8) 412 (36.5) 547 (48.5) 543 (14.6) 13 (2.4) 86 (15.8) 186 (34.3) 258 (47.5)
Torsion of the Appendix Testis N=3,047 2,817 (92.5) 17 (0.6) 1,168 (42.5) 1,368 (48.5) 264 (9.4) 1,898 (62.3) 4 (0.2) 741 (39.0) 969 (51.1) 184 (9.7) 933 (30.6) 4 (0.4) 394 (42.2) 452 (48.4) 83 (8.9)
Epididymitis -Orchitis N=10,258
9,317 (90.8) 138 (1.5) 3,543 (38.0) 3,865 (41.5) 1,771 (19.0) 7,947 (77.5) 87 (1.1) 2,865 (36.1) 3,292 (41.4) 1,702 (21.4) 4,622 (45.1) 99 (2.1) 1,668 (36.1) 1,847 (40.0) 1,008 (21.8)
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1,011 (9.8) 6 (0.6) 18 (1.8) 113 (11.2) 874 (86.4) 23 (0.2) 2 (8.7) 5 (21.7) 8 (34.8) 8 (37.8) 12 (0.1) 1 (8.4) 3 (25.0) 4 (33.3) 4 (33.3)
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STI testing* 100 (2.7) 39 (1.3) < 1 yr (n=7) 1 (1.0) 0 (0.0) 1-9 yrs (n=20) 1 (1.0) 1 (2.5) 10-13 yrs (n=124) 7 (7.0) 4 (10.3) 14-17 yrs (n=999) 91 (91.0) 34 (87.2) Orchiopexy 3,341 (90.4) 125 (4.1) < 1 yr (n=100) 97 (2.9) 1 (0.8) 1-9 yrs (n=497) 477 (14.3) 15 (12.0) 10-13 yrs (n=1,276) 1,206 (37.7) 56 (44.8) 14-17 yrs (n=1,569) 1.507 (45.1) 53 (42.4) Orchiectomy 1,305 (35.3) 23 (0.7) < 1 yr (n=92) 9 (7.1) 1 (5.2) 1-9 yrs (n=297) 307 (23.5) 4 (21.1) 10-13 yrs (n=447) 473 (36.2) 8 (31.6) 14-17 yrs (n=409) 433 (33.2) 10 (42.1) *Includes testing for gonorrhea and chlamydia.
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Supplemental digital content
Supplemental Table. ICD* Procedure Codes for Testicular Procedures Codes
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ICD Version
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ICD-10
53.00;53.02;53.10;61.2;62.0;62.3;62.42;62.5;63.2;63.52;
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ICD-9
0V9900Z;0V990ZZ;0V9B00Z;0V9B0ZZ;0V9C00Z;0V9C0ZZ;0 VC90ZZ;0VC93ZZ;0VC94ZZ;0VCB0ZZ;0VCB3ZZ;0VCB4ZZ; 0VCC0ZZ;0VCC3ZZ;0VCC4ZZ;0VN90ZZ;0VN93ZZ;0VN94Z Z;0VNB0ZZ;0VNB3ZZ;0VNB4ZZ;0VNC0ZZ;0VNC3ZZ;0VNC 4ZZ;0VPD00Z;0VPD03Z;0VPD07Z;0VPD0JZ;0VPD0KZ;0VP D30Z;0VPD33Z;0VPD37Z;0VPD3JZ;0VPD3KZ;0VPD40Z;0V PD43Z;0VPD47Z;0VPD4JZ;0VPD4KZ;0VPD70Z;0VPD73Z;0 VPD77Z;0VPD7JZ;0VPD7KZ;0VPD80Z;0VPD83Z;0VPD87Z; 0VPD8JZ;0VPD8KZ;0VS90ZZ;0VS93ZZ;0VS94ZZ;0VSB0ZZ ;0VSB3ZZ;0VSB4ZZ;0VSC0ZZ;0VSC3ZZ;0VSC4ZZ;0VT90Z Z;0VT94ZZ;0VTB0ZZ;0VTB4ZZ;0VWD00Z;0VWD03Z;0VWD 07Z;0VWD0JZ;0VWD0KZ;0VWD30Z;0VWD33Z;0VWD37Z;0 VWD3JZ;0VWD3KZ;0VWD40Z;0VWD43Z;0VWD47Z;0VWD
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4JZ;0VWD4KZ;0VWD70Z;0VWD73Z;0VWD77Z;0VWD7JZ;0 VWD7KZ;0VWD80Z;0VWD83Z;0VWD87Z;0VWD8JZ;0VWD 8KZ;0YQ50ZZ;0YQ53ZZ;0YQ54ZZ;0YQ60ZZ;0YQ63ZZ;0YQ 64ZZ;0YQA0ZZ;0YQA3ZZ;0YQA4ZZ *International Classification of Diseases
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Figure 1. Distribution of Testing Across Hospitals
100%
80%
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60%
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40%
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Appendix Testis Torsion
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Urinalysis
Epididymitis/Orchitis
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Testicular Torsion
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Hospital-Level
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Ultrasound
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Figure 2. Ultrasound and Urinalysis Use by Individual Hospital
Rates of Ultrasound & Urinealysis in pediatric patients with testicular diagnosis across a sample of pediatric hospitals in the US from 2010-2015
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100%
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50%
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25%
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 Hospital
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Ultrasound
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% Received Test
75%
Urinalysis
Lois K. Lee, Michael C. Monuteaux, Joel D. Hudgins, John J. Porter, Susan C. Lipsett, Florence Bourgeois, Bartley G. Cilento, Mark I. Neuman PII: DOI: Reference:
S0735-6757(17)30626-5 doi: 10.1016/j.ajem.2017.07.078 YAJEM 56864
To appear in: Received date: Revised date: Accepted date:
26 May 2017 22 July 2017 25 July 2017
Please cite this article as: Lois K. Lee, Michael C. Monuteaux, Joel D. Hudgins, John J. Porter, Susan C. Lipsett, Florence Bourgeois, Bartley G. Cilento, Mark I. Neuman , Variation in the evaluation of testicular conditions across United States pediatric emergency departments, (2017), doi: 10.1016/j.ajem.2017.07.078
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Variation in the Evaluation of Testicular Conditions across United States Pediatric Emergency Departments (Evaluation of Testicular Conditions in Pediatric Emergency Departments)
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Lois K. Lee, MD, MPH, 1 Michael C. Monuteaux, ScD, 1 Joel D. Hudgins, MD, 1 John J. Porter, MBA,1 Susan C. Lipsett, MD, 1 Florence Bourgeois, MD, MPH, 1 Bartley G. Cilento Jr., MD, MPH 2 and Mark I. Neuman, MD, MPH1 1
Abstract word count: 241 Manuscript word count: 2453
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Corresponding author: Lois K. Lee, MD, MPH Division of Emergency Medicine Boston Children’s Hospital 300 Longwood Ave. Boston, MA 02115 Phone: 617-355-5089 Fax: 617-730-0335 Email: [email protected]
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Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA 2 Department of Urology, Boston Children’s Hospital, Boston, MA
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Funding source: none The authors have no financial or other conflicts of Interest to disclose.
ABSTRACT
Objectives: To explore the variation in diagnostic testing and management for males diagnosed with three testicular conditions (testicular torsion, appendix testis torsion, epididymitis/orchitis) using a large pediatric health care database. Diagnostic testing is
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frequently used in evaluation of the acute scrotum; however, there is likely variability in the use of these tests in the emergency department setting. Methods: We conducted a cross-sectional study of males with the diagnoses of testicular torsion, appendix testis torsion, and epididymitis/orchitis. We identified
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emergency department patients in the Pediatric Health Information Systems (PHIS)
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database from 2010-2015 using diagnostic and procedure codes from the International
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Classification of Diseases Codes 9 and 10. Frequencies of diagnoses by demographic characteristics and of procedures and diagnostic testing (ultrasound, urinalysis, urine
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culture and sexually transmitted infection testing) by age group were calculated. We
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analyzed testing trends over time.
Results: We identified 17,000 males with the diagnoses of testicular torsion (21.7%),
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appendix testis torsion (17.9%), and epididymitis/orchitis (60.3%) from 2010-2015.
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There was substantial variation among hospitals in all categories of testing for each of the diagnoses. Overall, ultrasound utilization ranged from 33.1-100% and urinalysis
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testing ranged from 17.0-84.9% for all conditions. Only urine culture testing decreased
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over time for all three diagnoses (40.6% in 2010 to 31.5 in 2015). Conclusions: There was wide variation in the use of diagnostic testing across pediatric
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hospitals for males with common testicular conditions. Development of evaluation guidelines for the acute scrotum could decrease variation in testing. Key words Scrotum Testicular Torsion Epididymitis
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Abbreviations ED: emergency department HCUP: Healthcare Cost and Utilization Project ICD: International Classification of Diseases KID: Kids’ Inpatient Database STI: sexually transmitted infection US: ultrasound U.S.: United States VCUG: voiding cystourethrogram
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1. INTRODUCTION
Acute scrotal pain and swelling—often referred to as “the acute scrotum”--are important urologic complaints encountered in males presenting to the emergency department (ED).1 The diagnosis of testicular torsion must always be considered and excluded in a timely fashion, although this is present in a minority of boys and adolescent males presenting with an acute scrotum relative to other conditions such as epididymitis and torsion of the appendix testis.1–7 The prevalence of these diagnoses among males less
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than 18 years old presenting with an acute scrotum range from 8-16% for testicular torsion, 1-75% for appendix testis torsion, and 4%-39% for epididymitis; however, these studies varied in the use of diagnostic testing or surgical exploration to make the diagnosis.3,5–8 A study using the Healthcare Cost and Utilization Project (HCUP) Kids’
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Inpatient Database (KID) estimated the yearly incidence of testicular torsion for males
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less than 18 years old was 3.8/100,000.9 Prompt diagnosis of testicular torsion is
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paramount as the risk of testicular salvage decreases substantially after more than 6
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hours of symptoms due to the development of testicular ischemia and necrosis.3
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Although certain physical examination findings can be helpful in distinguishing males with and without testicular torsion, scrotal ultrasound is considered the gold standard to
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establish the diagnosis.1,5,8 A clinical scoring system10,11 and clinical decision rule7 have
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been described for the evaluation of testicular torsion; however, their use has not been widely adopted due to suboptimal test characteristics and lack of external validation.
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The objective of our study was to explore the variation in diagnostic test utilization,
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including US, urinalysis, and sexually transmitted infection (STI) testing, and management for males diagnosed with testicular conditions using a large pediatric
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health care database. Understanding this type of variation in care can help inform future guidelines to standardize the use of diagnostic testing among pediatric males presenting with acute scrotal complaints to provide more efficient and effective care.
2. MATERIALS AND METHODS 2.1 Study Design and Setting
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This is a cross-sectional study of ED visits of males with 3 common testicular diagnoses: testicular torsion, torsion of the appendix testis, and epididymitis/orchitis. Data for this study were obtained from the Pediatric Health Information System (PHIS), an administrative database that contains inpatient, ED, ambulatory surgery, and
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observation encounter-level data from over 49 not-for-profit, tertiary care pediatric
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hospitals in the United States. These hospitals are affiliated with the Children’s Hospital
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Association (Overland Park, KS). Data quality and reliability are assured through a joint effort between the Children’s Hospital Association and participating hospitals. Portions
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of the data submission and data quality processes for the PHIS database are managed
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by Truven Health Analytics (Ann Arbor, MI). For the purposes of external benchmarking, participating hospitals provide discharge/encounter data including
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demographics, diagnoses, and procedures. Nearly all of these hospitals also submit
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resource utilization data (e.g. pharmaceuticals, imaging, and laboratory) into PHIS. Data are de-identified at the time of data submission, and data are subjected to a
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number of reliability and validity checks before being included in the database. For this
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study, data from 38 hospitals were included, as 11 hospitals did not have complete data available. This study was granted exemption from human subjects approval by our
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Institutional Review Board. 2.2 Study Population
Males 0-17 years old diagnosed with these three testicular conditions from January 1, 2010 to December 31, 2015 were eligible for inclusion. Patients were identified using the following ICD-9-CM and ICD-10-CM codes: 1) testicular torsion:608.20-608.22, N44.00-N44.02; 2) torsion of the appendix testis: 608.23, N44.03; and 3)
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Epididymitis/orchitis: 016.4, 095.8, 098.0, 099.54, 125.9, 604.0-604.99, A18.40, A52.73, A52.76, A52.79, A54.00, A54.02, A54.09, A56.11, A56.19, B74.9, N45.1-N45.4. The diagnosis of testicular torsion additionally required a procedure code for orchiectomy, orchipexy, reduction of torsed testicle, or other testicular procedure
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(supplementary Table). Children who had been transferred from another hospital were
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excluded, as they may have had imaging or testing performed at the referring hospital.
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Children with complex chronic conditions,12,13 and those with a subsequent ED visit with the same ICD-9-CM or ICD-10 codes within 30 days were also excluded from the study
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cohort, as these patients may require different evaluations from healthy patients or
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those with a first-time presentation for testicular complaints. 2.3 Outcome Measures
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The primary outcome measure for this study was the hospital-level variation in scrotal
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ultrasound use in the evaluation of these testicular diagnoses. Secondary outcomes included the use of urinalysis and STI testing and performance of orchiectomy and
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orchipexy for children with testicular torsion.
2.4 Data Analysis
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Patient-level covariates included age, race, ethnicity, and insurance payer. In addition, data on the U.S. census region of the hospital, laboratory testing (UA, urine culture, STI testing), ultrasound use, and procedures were collected. STI testing for gonorrhea and chlamydia included codes for nucleic acid amplification tests and culture. Frequencies of these covariates by testicular diagnoses were calculated. For ultrasound and laboratory testing, frequencies were calculated and stratified by age group and by
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specific testicular diagnosis. We also searched for all patients with a diagnosis of testicular torsion and no code for scrotal ultrasound to determine if these patients had associated procedure codes of orchiectomy, orchiopexy, or reduction of testicular torsion. We compared the distribution of diagnostic and laboratory testing across the
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PHIS hospitals. We also calculated rates of ED visits for these testicular diagnoses
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over time and analyzed linear trends over time. To compare demographic
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characteristics for the three diagnoses, we performed univariate logistic regression modelling. All statistical tests were 2-tailed with α set at 0.05. All analyses were
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performed using Stata 13.0 (College Station, TX).
3 THEORY
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Given there is not a universally adopted clinical decision tool used to evaluate males
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presenting with an acute scrotum, there is likely substantial variation in care among hospitals. Understanding the variation in the use of diagnostic testing for males
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presenting with an acute scrotum may help develop guidelines to provide more
4 RESULTS
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standardized care, which could potentially decrease unnecessary testing.
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The study population included 17,000 ED visits for pediatric males with testicular diagnoses of testicular torsion (21.7%), torsion of the appendix testis (17.9%), and epididymitis/orchitis (60.3%) (Table 1), which represents 0.22% of all ED visits (n=7,786,929) during the study period. The median age for males with these testicular diagnoses was 11 years old (IQR 8, 13). Among males with testicular torsion, the majority (75%) were older than the median age. In contrast, for the diagnosis of torsion
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of the appendix testis the majority (75%) were below the median age, which was similar for epididymitis/orchitis (63%). The odds of testicular torsion were higher in black males (OR 2.89, 95% CI 2.36, 3.54) and Asians (OR 1.38, 95% CI 1.03, 1.85) compared to white males. Of the males diagnosed with testicular torsion, 35.3% (1,305/3,695) had a
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procedure code for orchiectomy, 90.4% (3,341/3/695) had a code for orchiopexy, 9.7%
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(358/3,695) had a code for testicular torsion reduction, and 5.6% (207/3,695) had other
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testicular procedures. Of note, orchiopexy could be for the contralateral testis, and not necessarily for the torsed testis, as this distinction could not be made in the dataset.
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The frequency of having both procedures for an individual patient with testicular torsion
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by age group was: 67.5% for < 1 year, 50.4% for 1-9 years, 29.7% for 10-13 years, and 22.1% for 14-17 years old (Table 2).
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4.1 Ultrasound and Urine Testing Utilization
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There was substantial variation in the use of scrotal ultrasound, urinalyses, and STI testing for each of the three testicular diagnoses (Figure 1). Use of scrotal ultrasound
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was common for all diagnoses (Table 2). When considering males with a diagnosis of
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testicular torsion and no code for scrotal ultrasound, all of these patients had associated procedure codes of orchiectomy, orchiopexy and/or reduction of testicular torsion. The
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use of urinalysis and urine culture varied by diagnosis and age, with urine cultures sent about half as often as urinalyses across all age groups. STI testing was low among all three testicular diagnoses with an overall rate of 0.68%. Across the individual PHIS hospitals, the proportion of testing utilized for males with testicular diagnoses varied from 17.0% to 84.9% for UA and 33.1% to 100% for US (Figure 2). 4.2 Trends in Test Utilization over Time
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During the study period of 2010-2015 there was minimal change in test utilization over time, with the exception of urine culture.. For urine culture, there was a steady decline that was statistically significant in all three diagnoses in the proportion of males tested, with an overall decrease in testing from 40.6% in 2010 to 31.5% in 2015. The tests for
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linear trend for urine culture for each diagnosis were: testicular torsion OR 0.93 (95% CI
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0.86, 1.00); appendix testis torsion OR 0.87 (95% CI 0.82, 0.93); and for
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5 DISCUSSION
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epididymitis/orchitis 0.93 (95% CI 0.89, 0.98).
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We describe the characteristics of 17,000 males with testicular diagnoses cared for in U.S. children’s hospitals, and demonstrate wide variation in the use of scrotal
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ultrasound and laboratory testing across individual hospitals. Most variation in the use
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of scrotal ultrasound occurred among children diagnosed with torsion of the appendix testis, and the greatest variation in urinalyses was observed among children with
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testicular torsion and appendix testis torsion. These findings support the need for more
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standardized guidelines for the management of pediatric males with testicular complaints presenting to U.S. ED’s to decrease variation in care and minimize
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unnecessary testing.
The evaluation of the acute scrotum in males presenting with testicular pain and/or swelling is focused on the timely identification of potential testicular torsion, since a missed or delayed diagnosis can lead to infarction and an unviable testicle. 3,14 Testicular Doppler ultrasound is safe, noninvasive, and has high sensitivity and positive
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and negative predictive values,15 8,16 for testicular torsion. It is therefore commonly used in the evaluation of the acute scrotum.7 While clinical tools have been developed to risk stratify males presenting with the acute scrotum to aid in identifying those at high risk for testicular torsion and obviate the need for further testing, 7,10,11 these clinical tools are
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not routinely used. Our study adds to the growing body of literature demonstrating the
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high rate of evaluation with ultrasound for children with testicular complaints.8,16
We observed wide variation (30%-100%) in the use of ultrasound across pediatric
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hospitals for these common testicular diagnoses. Further refinement of a clinical
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decision rule could potentially improve the more timely identification of testicular torsion while using a more standardized evidence-based approach for the evaluation of non-
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surgical conditions including appendix testis torsion and epididymitis/orchitis. In
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addition to scrotal ultrasound, urinalyses were performed in the majority of males with a diagnosis of appendix testis torsion and epididymitis/orchitis, which is similar to previous
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studies. 17,18, 3 In contrast, about one-third of males with a diagnosis of testicular torsion
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had a urinalysis performed, likely due to the emergent nature of this condition and the unnecessary need to diagnose an infectious etiology for testicular torsion. Urinalysis is
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often part of the evaluation of the acute scrotum to identify potential infectious causes of epididymitis. Retrograde flow of infected urine (e.g. bacterial urinary tract infection or STI) from the urethra through ejaculatory ducts, the vas deferens, and then into the epididymis has been described as a cause of infectious epididymitis.1,2 Studies evaluating the correlation of bacterial urinary tract infections and pyuria with epididymitis have had mixed results.1,4,18,17 In general, the recommendation is for males presenting
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with an acute scrotum to have urinalysis and urine culture as part of their evaluation. 1–3,5 One study compared boys with acute epididymitis with healthy controls and found those with epididymitis had an increased prevalence of positive bacterial and viral cultures and concluded epididymitis could be a result of a post-infectious inflammatory condition
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or from a viral infection. 19 Another study of 160 patients with a diagnosis of
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epididymitis/orchitis reported 9 (7%) patients had a positive urinalysis and/or culture,
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leading the authors to recommend urine cultures be sent on all patients with epididymitis and that antibiotics covering urinary pathogens be prescribed for those with
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positive urinalyses and positive urine cultures. 17
In prepubertal boys epididymitis/orchitis is most commonly idiopathic,2 and no specific
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treatment may be indicated, especially with a negative urine culture. Infants with
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epididymitis may have an underlying genitourinary abnormality that some recommend further evaluation by ultrasound and voiding cystourethrogram (VCUG).4, 3,20 In sexually
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active males, STIs are a common cause of epididymitis/orchitis, although this may be
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less common in adolescents compared to adults.17,18 Thus, testing by culture or nucleic acid amplification and treatment for C. trachomatis and N. gonorrhea is recommended
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for sexually active adolescent males presenting with an acute scrotum.2,17 In our sample of pediatric hospitals, STI testing was rarely performed, consistent with previous studies.17 Future research evaluating the prevalence and any other associated signs or symptoms of STIs in adolescent males presenting with an acute scrotum may help inform recommendations for STI testing in this age group.
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5.1 Limitations Our study has several limitations. With the use of an administrative database, there is potential for misclassification bias as diagnoses and tests may be miscoded; however, given the large size of the study dataset, misclassification is most likely random and
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non-differential. The focus of our study was the use of ultrasound and urine testing in
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the evaluation of three common testicular diagnoses; however, we were unable to
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ascertain if these tests may have been obtained prior to presentation at the pediatric ED. We excluded patients who were transferred from other hospitals to minimize the
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inclusion of such patients, but cannot account for children who received this testing in
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an outpatient setting prior to arrival. Detailed clinical information is not available in the PHIS database, and thus, we were unable to determine any clinical reasons for specific
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testing or the results of testing. Although our intent was to evaluate children presenting
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with a testicular complaints, due to the limitations in the dataset, we relied on the use of diagnosis codes to establish our study cohort. Thus, testing patterns may not reflect
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actual rates of testing for all children with presenting signs and symptoms referable to
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the scrotum. Finally, as this database is comprised of data from free-standing pediatric hospitals, our results may not be generalizable to males evaluated at non-pediatric
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specific hospitals
5.2 Conclusions In this study of males with common testicular diagnoses, we observed wide variation in the use of diagnostic testing across pediatric hospitals. This variation may lead to increased healthcare costs and disparate outcomes. Additional research on the utility of
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urinalysis, urine culture, and STI testing is needed to develop better guidelines for laboratory testing for males presenting with an acute scrotum. Furthermore, refinement of clinical decision support tools to identify males at high risk for testicular torsion may
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aid in a more timely diagnosis, while decreasing use of testing for those at lowest risk.
Diaz EC, Kimball D, Gong EM. Acute Scrotal Pain in Pediatric Emergency
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REFERENCES
Medicine: Assessment, Diagnosis, Management, and Treatment. Clin Pediatr
Jefferies MT, Cox AC, Gupta A, Proctor A. The management of acute testicular
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2.
ED
Emerg Med. 2014;15(3):248-260. doi:10.1016/j.cpem.2014.08.002.
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pain in children and adolescents. BMJ. 2015;350(apr02_5):h1563. doi:10.1136/bmj.h1563. Lewis a G, Bukowski TP, Jarvis PD, Wacksman J, Sheldon C a. Evaluation of
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3.
acute scrotum in the emergency department. J Pediatr Surg. 1995;30(2):277-812. doi:0022-3468(95)90574-X [pii]. 4.
Gkentzis A, Lee L. The aetiology and current management of prepubertal epididymitis. Ann R Coll Surg Engl. 2014;96(3):181-183. doi:10.1308/003588414X13814021679311.
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5.
Yang C, Song B, Liu X, Wei G, Lin T, He D. Acute scrotum in children: an 18-year retrospective study. Pediatr Emerg Care. 2011;27(4):270-274. doi:10.1097/PEC.0b013e318213144e. Boettcher M, Bergholz R, Krebs TF, Wenke K, Aronson DC. Clinical predictors of
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testicular torsion in children. Urology. 2012;79(3):670-674.
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doi:10.1016/j.urology.2011.10.041. 7.
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6.
Shah MI, Chantal Caviness A, Mendez DR. Prospective pilot derivation of a
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decision tool for children at low risk for testicular torsion. Acad Emerg Med.
8.
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2013;20(3):271-278. doi:10.1111/acem.12086.
Liang T, Metcalfe P, Sevcik W, Noga M. Retrospective review of diagnosis and
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treatment in children presenting to the pediatric department with acute scrotum.
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Am J Roentgenol. 2013;200(5):W444-9.
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http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=2361751 2&retmode=ref&cmd=prlinks\npapers3://publication/doi/10.2214/AJR.12.10036. Zhao LC, Lautz TB, Meeks JJ, Maizels M. Pediatric Testicular Torsion
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9.
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Epidemiology Using a National Database: Incidence, Risk of Orchiectomy and Possible Measures Toward Improving the Quality of Care. J Urol. 2011;186(5):2009-2013. doi:10.1016/j.juro.2011.07.024. 10.
Barbosa J a., Tiseo BC, Barayan G a., et al. Development and initial validation of a scoring system to diagnose testicular torsion in children. J Urol. 2013;189(5):1859-1864. doi:10.1016/j.juro.2012.10.056.
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11.
Sheth KR, Keays M, Grimsby GM, et al. Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score. J Urol. February 2016. doi:10.1016/j.juro.2016.01.101.
12.
Feudtner C, Christakis DA, Connell FA. Pediatric deaths attributable to complex
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chronic conditions: a population-based study of Washington State, 1980-1997.
13.
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Pediatrics. 2000;106(1 Pt 2):205-209. doi:10.1542/peds.106.1.S1.205. Feudtner C, Feinstein JA, Zhong W, Hall M, Dai D. Pediatric complex chronic
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conditions classification system version 2: updated for ICD-10 and complex
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medical technology dependence and transplantation. BMC Pediatr. 2014;14(1):199. doi:10.1186/1471-2431-14-199. Vasdev N, Chadwick D, Thomas D, N. V, D. C, D. T. The acute pediatric scrotum:
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Presentation, differential diagnosis and management. Curr Urol. 2012;6(2):57-61.
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Cokkinos DD, Antypa E, Tserotas P, et al. Emergency ultrasound of the scrotum:
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a review of the commonest pathologic conditions. Curr Probl Diagn Radiol.
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2011;40(1):1-14. doi:10.1067/j.cpradiol.2009.07.011. Yagil Y, Naroditsky I, Milhem J, et al. Role of Doppler ultrasonography in the triage of acute scrotum in the emergency department. J Ultrasound Med. 2010;29:11-21. 17.
Santillanes G, Gausche-Hill M, Lewis RJ. Are antibiotics necessary for pediatric epididymitis? Pediatr Emerg Care. 2011;27(3):174-178.
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doi:10.1097/PEC.0b013e31820d647a. 18.
Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics.
Somekh E, Gorenstein A, Serour F. Acute epididymitis in boys: evidence of a
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post-infectious etiology. J Urol. 2004;171(1):391-4; discussion 394.
Siegel A, Snyder H, Duckett JW. Epididymitis in infants and boys: underlying
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urogenital anomalies and efficacy of imaging modalities. J Urol. 1987;138(4 Pt 2):1100-1103. http://www.ncbi.nlm.nih.gov/pubmed/3309376. Accessed February
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Distribution of urinalysis and scrotal ultrasound testing across hospitals by diagnosis. Figure represents median with shaded box as 25th to 75th percentiles and lines representing 10th and 90th percentiles.
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Distribution of testing of urinalysis and scrotal ultrasound by individual hospital.
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Epididymitis -Orchitis N=10,258
Total N=17,000
Total ED Visits* N = 7,786,929
13 (11, 15) 114 (3.1) 534 (14.5) 1,385 (37.5) 1,662 (44.9)
10 (8, 12) 20 (0.7) 1,239 (40.6) 1,487 (48.8) 301 (9.9)
10 (8, 13) 150 (1.5) 3,775 (36.8) 4,155 (40.5) 2,178 (21.2)
11 (8, 13) 284 (1.7) 5,548 (32.6) 7,027 (41.3) 4,141 (24.4)
4 (1, 9) 1,373,995 (17.6) 4,678,027 (60.1) 1,000,040 (12.8) 734,867 (9.5)
1,848 (50.0) 1,151 (31.1) 85 (2.3) 431 (11.7) 180 (4.9)
1,957 (64.2) 296 (9.7) 67 (2.2) 383 (12.6) 344 (11.3)
6,460 (63.0) 1,516 (14.8) 212 (2.1) 1,633 (15.9) 437 (4.3)
10,265 (60.4) 3,831,166 (49.2) 2,963 (17.4) 2,198,008 (28.2) 364 (2.1) 155,387 (2.0) 2,447 (14.4) 1,182,093 (15.2) 961 (5.7) 420,275 (5.4)
687 (18.6) 2,586 (70.0) 422 (11,4)
906 (29.7) 1,903 (62.5) 238 (7.8)
2,650 (25.8) 6,435 (62.7) 1,173 (11.4)
4,243 (25.0) 2,024,247 (26.0) 10,924 (64.3) 4,933,206 (63.3) 1,833 (10.7) 829,476 (10.7)
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Age group Median (IQR) < 1 yr 1-10 yrs 10-13 yrs 14-17 yrs Race White Black Asian Other Missing Ethnicity Latino Non-Latino Unknown
Testicular Torsion N=3,695
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Table 1. Characteristics of Patients with Testicular Diagnoses, PHIS Hospitals 2010-2015
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7,854 (46.2) 7,733 (45.5) 1,274(7.5)
5,055,332 (64.9) 2,149,103 (27.6) 518,463 (6.6)
1,240 (12.2) 4,525 (44.2) 2,035 (19.9) 2,427 (23.7)
2,003 (11.8) 7,905 (46.6) 3,336 (19.7) 3,725 (21.9)
619,991 (8.0) 3,599,210 (46.3) 2,058,261 (26.5) 1,490,668 (19.2)
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Insurance payer Government 1,672 (45.2) 1,328 (43.6) Primary 1,749 (47.3) 1,490 (48.9) Other 241 (6.5) 207 (6.8) U.S. Census Region Northeast 404 (10.9) 359 (15.8) South 1,753 (47.4) 1,627 (53.4) North Central 796 (21.6) 505 (16.6) West 742 (20.1) 556 (18.2) *All diagnoses in PHIS hospitals, 2010-2015
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Table 2. Testing and Procedure Characteristics of Patients with Testicular Diagnoses, Stratified By Age Testicular Torsion N=3,695
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Scrotal ultrasound < 1 yr (n=266) 1-9 yrs (n=5,607) 10-13 yrs (n=6,759) 14-17 yrs (n=3,404) Urinalysis < 1 yr (n=109) 1-9 yrs (n=4,043) 10-13 yrs (n=5,069) 14-17 yrs (n=2,594) Urine culture < 1 yr (n=121) 1-9 yrs (n=2,278) 10-13 yrs (n=2,685) 14-17 yrs (n=1,435)
2,586 (70.0) 91 (3.5) 436 (16.9) 944 (36.5) 1,115 (43.1) 1,129 (30.5) 14 (1.2) 156 (13.8) 412 (36.5) 547 (48.5) 543 (14.6) 13 (2.4) 86 (15.8) 186 (34.3) 258 (47.5)
Torsion of the Appendix Testis N=3,047 2,817 (92.5) 17 (0.6) 1,168 (42.5) 1,368 (48.5) 264 (9.4) 1,898 (62.3) 4 (0.2) 741 (39.0) 969 (51.1) 184 (9.7) 933 (30.6) 4 (0.4) 394 (42.2) 452 (48.4) 83 (8.9)
Epididymitis -Orchitis N=10,258
9,317 (90.8) 138 (1.5) 3,543 (38.0) 3,865 (41.5) 1,771 (19.0) 7,947 (77.5) 87 (1.1) 2,865 (36.1) 3,292 (41.4) 1,702 (21.4) 4,622 (45.1) 99 (2.1) 1,668 (36.1) 1,847 (40.0) 1,008 (21.8)
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STI testing* 100 (2.7) 39 (1.3) < 1 yr (n=7) 1 (1.0) 0 (0.0) 1-9 yrs (n=20) 1 (1.0) 1 (2.5) 10-13 yrs (n=124) 7 (7.0) 4 (10.3) 14-17 yrs (n=999) 91 (91.0) 34 (87.2) Orchiopexy 3,341 (90.4) 125 (4.1) < 1 yr (n=100) 97 (2.9) 1 (0.8) 1-9 yrs (n=497) 477 (14.3) 15 (12.0) 10-13 yrs (n=1,276) 1,206 (37.7) 56 (44.8) 14-17 yrs (n=1,569) 1.507 (45.1) 53 (42.4) Orchiectomy 1,305 (35.3) 23 (0.7) < 1 yr (n=92) 9 (7.1) 1 (5.2) 1-9 yrs (n=297) 307 (23.5) 4 (21.1) 10-13 yrs (n=447) 473 (36.2) 8 (31.6) 14-17 yrs (n=409) 433 (33.2) 10 (42.1) *Includes testing for gonorrhea and chlamydia.
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Supplemental digital content
Supplemental Table. ICD* Procedure Codes for Testicular Procedures Codes
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ICD Version
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53.00;53.02;53.10;61.2;62.0;62.3;62.42;62.5;63.2;63.52;
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ICD-9
0V9900Z;0V990ZZ;0V9B00Z;0V9B0ZZ;0V9C00Z;0V9C0ZZ;0 VC90ZZ;0VC93ZZ;0VC94ZZ;0VCB0ZZ;0VCB3ZZ;0VCB4ZZ; 0VCC0ZZ;0VCC3ZZ;0VCC4ZZ;0VN90ZZ;0VN93ZZ;0VN94Z Z;0VNB0ZZ;0VNB3ZZ;0VNB4ZZ;0VNC0ZZ;0VNC3ZZ;0VNC 4ZZ;0VPD00Z;0VPD03Z;0VPD07Z;0VPD0JZ;0VPD0KZ;0VP D30Z;0VPD33Z;0VPD37Z;0VPD3JZ;0VPD3KZ;0VPD40Z;0V PD43Z;0VPD47Z;0VPD4JZ;0VPD4KZ;0VPD70Z;0VPD73Z;0 VPD77Z;0VPD7JZ;0VPD7KZ;0VPD80Z;0VPD83Z;0VPD87Z; 0VPD8JZ;0VPD8KZ;0VS90ZZ;0VS93ZZ;0VS94ZZ;0VSB0ZZ ;0VSB3ZZ;0VSB4ZZ;0VSC0ZZ;0VSC3ZZ;0VSC4ZZ;0VT90Z Z;0VT94ZZ;0VTB0ZZ;0VTB4ZZ;0VWD00Z;0VWD03Z;0VWD 07Z;0VWD0JZ;0VWD0KZ;0VWD30Z;0VWD33Z;0VWD37Z;0 VWD3JZ;0VWD3KZ;0VWD40Z;0VWD43Z;0VWD47Z;0VWD
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4JZ;0VWD4KZ;0VWD70Z;0VWD73Z;0VWD77Z;0VWD7JZ;0 VWD7KZ;0VWD80Z;0VWD83Z;0VWD87Z;0VWD8JZ;0VWD 8KZ;0YQ50ZZ;0YQ53ZZ;0YQ54ZZ;0YQ60ZZ;0YQ63ZZ;0YQ 64ZZ;0YQA0ZZ;0YQA3ZZ;0YQA4ZZ *International Classification of Diseases
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Figure 1. Distribution of Testing Across Hospitals
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Figure 2. Ultrasound and Urinalysis Use by Individual Hospital
Rates of Ultrasound & Urinealysis in pediatric patients with testicular diagnosis across a sample of pediatric hospitals in the US from 2010-2015
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