We demonstrated in our cohort that the previous medical management was the only significant predictive factors of orchiectomy on multivariate analysis (p = 0.017). Our findings strengthen the conclusion of Bayne et al. [8] from the United States of America (USA). These authors reported that if the patient had previously been seen for the same symptomatology, this increased significantly the risk of orchiectomy. In developing countries, some missed diagnosis occurred in primary health-care centres. In these centres, there is sometimes a lack of qualified health agent who can recognize the signs of SCT. This situation results in diagnostic delay and therefore a delay in the patient’s transfer to a suitable health care facility.
The orchiectomy rate in patients who were referred vs. not referred was 62.5 % vs. 41.17 % respectively. However, that difference was not statistically significant (p = 0.08). Ramachandra et al. [11] in USA, did not find a significant correlation between the mode of hospital admission and the orchiectomy risk. Nevertheless, according to Ramachandra et al. [11], when the patient was referred, that increased the management delay, which was significantly related to the orchiectomy risk (p < 0.001). Therefore, the mode of hospital admission indirectly impacts the risk of orchiectomy by increasing the management delay. The Royal College of Surgeons in England recommends to perform surgical exploration in the hospital where the patient is seen for the first time [12]. The objective is to avoid transferring the patient in order to reduce the management delay. This approach is difficult to apply in our context because of a glaring lack of urologists and surgeons in these primary health care centres. Contrary to our cohort, the correlation between the surgical management delay and the risk of orchiectomy was significant in the series of Ramachandra et al. [11].
We found out a statistically significant correlation on univariate analysis between performing a scrotal ultrasound and the orchiectomy risk (P = 0.004). Indeed, performing a scrotal ultrasound may delay the patient’s transfer.
Zini et al. [13] showed that the delay between the patients’ arrival at the emergency department and the surgery was 2.6 times longer when an ultrasound was performed (p < 0.001). Preece et al. [14] made the same finding even though the correlation was not significant. Therefore, we agree with Sauvat et al. [15] and Zini et al. [13] that, if there is a slightest doubt, surgical exploration should immediately be carried out in order to reduce the management delay and hence the risk of orchiectomy. Surgical exploration remains the gold standard in the diagnosis of SCT [16]. This attitude is all the more justified in our context.
In our cohort, the orchiectomy rate was 44.44 % and 80.55 % respectively when the surgical management delay was less than 2 hours and more than 2 hours. However, this difference was not statistically significant (p = 0.06). It should be pointed out that the longer the management delay, the longer the ischemia lasts and the higher the risk of necrosis. It is therefore indispensable to avoid any factor that may lengthen the surgical management delay. It is important to avoid delay in surgical exploration because symptoms duration is already long. A duration of the symptoms more than 6 hours was a predictive factor for orchiectomy in our cohort on univariate analysis (p = 0.009). However, the duration of symptoms was no longer significant in multivariate analysis. This finding is contrary to what most authors report in the literature [5, 8, 11]. The delay in diagnosis when the patient arrives at the primary health-care centre is the determining factor in our context. This issue engage the responsibility of medical staff [5]. For some authors, in addition to symptoms duration, the severity of rotation is the main factor. Dias et al. [5] noted that the number of turns was significantly associated with a high orchiectomy rate, regardless of symptoms duration. Williamson [1] reported a case of orchiectomy after only 4 hours’ ischemia, and 2 viable testicles after 25 days of symptoms. He concluded that there is no absolute time beyond which one can assume that infarction is inevitable. Also Bentley et al. [16] asserted that testis perfusion can be maintained for a prolonged period in the presence of testicular torsion due to anatomical variability.
The patients’age was not a predictive factor of orchiectomy in our series (p = 0.69). There is a controversy concerning the role of age as a predictor of orchiectomy. Mansbach et al. [9], in a series of 436 patients under 25, found out a statistically significant correlation between the patient’s age and the occurrence of orchiectomy (p = 0.003). The more age increases, the more the risk of orchiectomy does. Also, for Ramachandra et al. [11], Zhao et al. [17] and Cost et al. [18], young age was significantly correlated with the risk of orchiectomy. The younger children’s inability to express scrotal pain might result in diagnosis and management delay.
