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Objective:
While testicular torsion is a common urologic emergency, clinical assessment can be challenging, particularly in children. Expedited ultrasound (US) diagnosis is essential to preserving the testis, but scrotal US orders do not convey the degree of clinical concern for any given patient. We created an expedited scrotal US pathway in our pediatric emergency department (ED) using a unique order labeled “hi-prob” for cases with high clinical suspicion. Physical examination by an attending ED physician was required prior to ordering the hi-prob exam, whereas routine exams could be ordered by any ED provider. After 16 months, we assessed frequency of testicular torsion and alternate diagnoses between the hi-prob and routine ED scrotal US exams.

Materials and Methods:
In this retrospective study, reports from ED scrotal US examinations dated March 2021 – June 2022 were coded for diagnosis by a pediatric radiology fellow and reviewed by a pediatric radiology attending (8 years experience). US examinations were grouped as hi-prob or routine and frequency of diagnosis was measured as a percentage of the total examinations in each category. Differences in frequency were assessed using chi-square and Fisher’s exact tests. Due to the large number of examinations, images were not reviewed.

Results:
Out of 693 scrotal US in our study, 161 (23%) were hi-prob examinations. The hi-prob group had a mean age of 10.0 years, compared to a mean age of 8.6 years in the routine group (p < 0.01). Testicular torsion or torsion/detorsion was diagnosed in 24% of hi-prob and 5% of routine exams (p < 0.001). Epididymitis and/or orchitis was present in 14% of hi-prob and 8% of routine exams (p < 0.05). Conversely, hydrocele was present in 13% of hi-prob and 20% of routine exams (p < 0.05). The frequencies of appendage torsion (12% hi-prob, 10% routine; p = 0.37), hernia (3% hi-prob, 5% routine; p = 0.38), and other findings (15% hi-prob, 20% routine; p = 0.135) were not significantly different between groups. Hi-prob examinations were normal 30% of the time, and routine examinations were normal 42% of the time (p < 0.01).

Conclusion:
Scrotal US examinations in the ED was significantly more likely to be positive for torsion when a hi-prob exam was ordered. Epididymitis/orchitis was also more likely among high-prob exams, which may expedite medical management and discharge of these patients. Nonemergent diagnoses such as hydrocele, hernia, and “other” including cellulitis, varicocele, and malignancy were less likely on hi-prob examinations, suggesting that ED attendings did not order them to simply expedite imaging. Future analysis will assess for differences in time to surgery between hi-prob and routine US groups. The concept of hi-prob exams may also be useful in other time sensitive diagnoses in the ED, such as ovarian torsion, stroke, sepsis, and critical trauma.