The cremasteric reflex: a useful but imperfect sign in testicular torsion

doi:10.1016/S0022-3468(03)00280-X

Journal of Pediatric Surgery

Volume 38, Issue 8, August 2003, Pages 1248-1249

https://doi.org/10.1016/S0022-3468(03)00280-X Get rights and content

Abstract

The cremaster reflex has been reported to be absent in 100% of cases of testicular torsion, making it a useful sign in this difficult diagnosis. The authors report a case of surgically confirmed testicular torsion in which the cremasteric reflex clearly was present at presentation. The background of this sign and its utility in the evaluation of the acute scrotum are discussed.

Section snippets

Case report

A 4-year, 10-month-old boy was transferred from another hospital with an 18-hour history of testicular pain. At the first hospital, urinalysis and basic bloodwork results were normal, whereas Doppler ultrasonography reportedly showed decreased blood flow to both testes. The patient was afebrile but in moderate discomfort at our facility. Scrotal examination showed a normal 1.8-cm right testis and an indurated, exquisitely tender 3.5-cm left testis. The cremasteric reflex was present

Discussion

The significance of the cremasteric reflex in testicular torsion was reported by Rabinowitz1 in 1984. This report made the remarkable observation that the loss of the reflex is a 100% sensitive test for the presence of torsion. The specificity, however, was only 66%, because the cremasteric reflex can be absent in a number of other conditions as well as in normal individuals. One subsequent study quantified the value of the reflex in the acute scrotum in 26 patients.2 Together, these 2 series

References (8)

R. Rabinowitz
The importance of the cremasteric reflex in acute scrotal swelling in children
J Urol
(1984)
M.D. Melekos et al.
Etiology of acute scrotum in 100 boys with regard to age distribution
J Urol
(1988)
M.S. Feldstein
ReThe importance of the cremasteric reflex in acute scrotal swelling in children
J Urol
(1985)
A.M.R. Agur
Grant’s Atlas of Anatomy
(1991)

There are more references available in the full text version of this article.

Cited by (52)

Adjuvant pharmacological and surgical therapy for testicular torsion: Current state of the art
2020, Journal of Pediatric Urology
Although the consequences of testicular torsion (TT) have been recognized for centuries, little progress has been made to improve outcomes beyond those seen with timely scrotal exploration. Even with testicular salvage, ischemia/reperfusion injury cause significant atrophy and functional impairment. Recent efforts have sought to identify adjuvant pharmacological or surgical interventions that may attenuate these consequences. In this review, we assess the evidence supporting clinical use of these nascent interventions.
We conducted a review of the literature published from 2000 to 2020, using the search terms “torsion”, “testicular”, “reperfusion”, “ischemia”, and “injury”. Clinical and laboratory research focused on adjuvant pharmacological and surgical techniques mitigating torsion-associated injury in animal models and humans were identified. We recorded intervention timing/dose/route, and outcome timing/category through biomarkers of reperfusion injury, histology, and hormonal/reproductive function.
Fifty-four FDA-approved agents, plus 52 herbal/investigational drugs, were reported in animal TT models. In every study, the investigated agents showed beneficial effects on measured endpoints compared to controls. Despite these universally promising animal findings, no pharmacological trials in humans were reported. Surgical techniques studied in animal models included decompression (tunica albuginea incision, TAI), “ischemic conditioning”, and hypothermia. Only three human studies on surgical adjuvant maneuvers have been reported, all involving TAI; these showed potential benefit, but the level of evidence is low.
There is preliminary evidence that adjuvant treatments may mitigate the effects of ischemia/reperfusion injury. However, the pool of investigated pharmacological agents is wide, yet remarkably shallow; most compounds have been reported in a single animal study. To advance this field, a mechanism-based approach should be used to select promising agents that can be tested systematically. This will determine treatment parameters that maximize safety, efficacy, and tolerability. Only then is it possible to move toward human trials. Adjuvant surgical methods such as TAI show promise in humans but require more robust clinical evaluation.
Human cremaster muscle and cremasteric reflex: A comprehensive review
2020, Clinical Neurophysiology
Human research on the cremaster muscle (CM), cremasteric reflex (CMR) and genitofemoral nerve (GFN) and reports on their clinical applications using electrophysiological and histological techniques are rare. We aimed to present a detailed review of the human CM and CMR based on our earlier publications and relevant literature.
Electromyography (EMG) of the CM was recorded using disposable needle electrodes. CMR was obtained with tactile and/or electrical stimulation of the inner thigh. Transcranial magnetic stimulation (TMS) and magnetic stimulation of the upper lumbar roots were applied; GFN was stimulated using a surface electrode at the anterior superior iliac spine.
CM striated fibers comprised multiple motor end plates. CM needle EMG results were similar to those of the limb muscles in chronic neurogenic disorders. TMS produced clear-cut evoked motor responses from CM. GFN motor conduction time to CM was absent or delayed in patients with inguinal hernia. EMG of CM was abnormal in 40% of patients with premature ejaculation.
CM is different from other skeletal muscles both morphologically and physiologically. Intersegmental sacrolumbar reflexes are useful for evaluating ejaculatory dysfunction.
CM is an important muscle for testis thermoregulation and sexual reflexes. Neurophysiological techniques are available for physiological and clinical studies.
Acute and Chronic Scrotal Swelling
2018, Nelson Pediatric Symptom-Based Diagnosis
Acute and Chronic Scrotal Swelling
2017, Nelson Pediatric Symptom-Based Diagnosis
Diagnostic Imaging: Pediatrics
2017, Diagnostic Imaging: Pediatrics
Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score
2016, Journal of Urology
The TWIST (Testicular Workup for Ischemia and Suspected Torsion) score uses urological history and physical examination to assess risk of testis torsion. Parameters include testis swelling (2 points), hard testis (2), absent cremasteric reflex (1), nausea/vomiting (1) and high riding testis (1). While TWIST has been validated when scored by urologists, its diagnostic accuracy among nonurological providers is unknown. We assessed the usefulness of the TWIST score when determined by nonurological nonphysician providers, mirroring emergency room evaluation of acute scrotal pain.
Children with unilateral acute scrotum were prospectively enrolled in a National Institutes of Health clinical trial. After undergoing basic history and physical examination training, emergency medical technicians calculated TWIST score and determined Tanner stage per pictorial diagram. Clinical torsion was confirmed by surgical exploration. All data were captured into REDCap™ and ROC curves were used to evaluate the diagnostic usefulness of TWIST.
Of 128 patients (mean age 11.3 years) 44 (13.0 years) had torsion. TWIST score cutoff values of 0 and 6 derived from ROC analysis identified 31 high, 57 intermediate and 40 low risk cases (positive predictive value 93.5%, negative predictive value 100%).
TWIST score assessed by nonurologists, such as emergency medical technicians, is accurate. Low risk patients do not require ultrasound to rule out torsion. High risk patients can proceed directly to surgery, with more than 50% avoiding ultrasound. In the future emergency medical technicians and/or emergency room triage personnel may be able to calculate TWIST score to guide radiological evaluation and immediate surgical intervention at initial assessment long before urological consultation.

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Case reportThe cremasteric reflex: a useful but imperfect sign in testicular torsion

Abstract

Section snippets

Case report

Discussion

The importance of the cremasteric reflex in acute scrotal swelling in children

J Urol

Etiology of acute scrotum in 100 boys with regard to age distribution

J Urol

ReThe importance of the cremasteric reflex in acute scrotal swelling in children

J Urol

Grant’s Atlas of Anatomy

Case report
The cremasteric reflex: a useful but imperfect sign in testicular torsion