Point of Care Ultrasound (POCUS) for the Diagnosis of Testicular Torsion: A Resident Education and Quality Improvement Initiative
Author: Leandra Stringer, Ernest Chan, Sara Cocco, Alex Jiang, Frank Myslik, Gary Brahm, Hassan Razvi, Sumit Dave, Peter Wang Date: September 27, 2019.
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I do not have an affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization.
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Delays in Testicular Torsion
1:4000 men <25 years old
Acute onset scrotal pain
80-100% salvage <6 hr <20% salvage at >12 hr
(Visser and Heyns, 2003)
• Scrotal doppler US can reduce the number of negative explorations.
• Can increase delay to definitive management.
• Use Doppler US to evaluate acute scrotum without delaying surgical exploration (GR: A, EAU 2016).
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Doppler Ultrasound
PPV 100% NPV 97.5%
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0 60 120 180 240In-hospital duration (minutes)
Triage to US Order US Order to US Performed US Performed to OR
Total time in hospital before surgical exploration: 235.8 minutes (3.93 hours)
Triage time 1.33 hrs
US acquisition 0.80 hrs (48mins)
Time to Surgery 1.80 hrs Pre-hospital
pain duration: 4 hours
Figure. Median in-hospital time intervals for the assessment, radiographic diagnosis, and surgical management of testicular torsion
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Role for Scrotal POCUS?
• POCUS for the diagnosis of testicular torsion in children with acute scrotum has a sensitivity of 100%.
• Specificity of 99.1% when performed by pediatric emergency physicians (Friedman et. al, 2019).
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Scrotal POCUS
• Develop and evaluate a scrotal POCUS curriculum for Urology and Emergency Medicine (EM) residents.
• Evaluate if Urology and EM residents can gain competence in scrotal POCUS.
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Objectives
• Experts from urology, emergency medicine, and radiology all collaborated in the Delphi method to design a curriculum.
• Pre/post design to assess for improvement and skill acquisition.
• An online survey was administered at baseline before curriculum intervention.
• Educational screencasts were sent out to participants.
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Methods
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• EM POCUS experts led a hands on training session.
• Participants were scored on OSAUS score to identify if gained competence in scrotal POCUS.
• Post test exam completed.
• Feedback on curriculum design, hands on session and future improvements.
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Methods
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OSAUS Score
• Twenty four participants included in the curriculum. Twelve urology and twelve EM residents.
• Twenty three of twenty four (95.8%) residents rated as competent at performing scrotal POCUS on OSAUS score.
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Results
• The hands on practice was deemed most beneficial.
• Smaller group sizes for hands on sessions.
• More pathology for hands on session.
• Practice on SP’s rated 4.5 (effective/very effective).
• Screencasts rated 3.6 (somewhat effective/effective).
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Results
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Outcome Pre Test Post Test Significance
Knowledge 72 83 P<.0001
Comfort 0.58 3.58 P<.0001
Confidence 1 2.09 P<.0001
Outcome Pre Test 3 month Post Significance
Knowledge 63 75 P=0.009
Comfort 0.8 3.2 P<.0001
Confidence 1.2 2.4 P=0.004
Figure 2: Comparing Pre to Post Curriculum
Figure 3: Comparing Pre to 3 Months Post
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Future Directions
Evaluative comparison of scrotal POCUS compared to standard doppler US for the assessment and diagnosis of testicular torsion at our institution.
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