Testicular torsion is an emergent condition and timely recognition by almost all physicians, such as pediatricians, pediatric surgeons, urologist, neonatologist, emergency medicine physicians, and primary care physicians, is of paramount importance for early diagnosis and management to prevent testicular loss [31, 46].

There is currently no diagnostic test to unequivocally establish the diagnosis of torsion. The most important aspect in discerning the correct diagnosis is the history and physical examination. Information such as the duration of symptoms, character and quality of pain, time of onset of symptoms, activity at the time of initial symptoms, and the patient response to the symptoms are all important. Genital, inguinal, and abdominal examination should be done carefully. Testicular examination should include for lie (low or high) and axis (vertical or horizontal), comparing the torsione and untorsione side. Tender, elevated, transversely located testis with loss of cremasteric reflex are important in the diagnosis [64-66]. Laboratory examination should include a complete blood count and urinalysis which are usually normal. Rarely pyuria may be seen. Leukocytosis and pyuria are more common in infectious diseases, such as epididymitis or epididymoorchitis [1, 31].

Good imaging studies, however, can certainly be helpful in diagnosis. Gray-scale imaging, color Doppler, power Doppler and pulsed Doppler ultrasound, scintigraphy, nuclear magnetic resonance imaging (MRI), and computed tomography (CT) evaluate anatomy and perfusion. The ultrasound results differ depending on the duration and degree of the torsion. Ultrasonographic diagnosis is established by color or power Doppler, when there is not a detectable flow within the testicular parenchyma and cannot evaluate the duration of torsion and cannot predict testicu-lar viability. Color Doppler ultrasound has a sensitivity of 88.9% and a specificity of 98.8 and 1% false positive results [67, 68], but is technically difficult in infants. Ideally, both pulsed and color Doppler ultrasound should be used. In complete torsion, the blood flow is completely absent on Doppler imaging. In incomplete torsion, the blood flow may still be seen. Color Doppler is less sensitive from power Doppler ultrasound. In addition, ultrasound can also be used to diagnose prenatal torsion [69-74].

In the diagnosis of testicular torsion, nuclear MRI can also be used [75, 76]. MRI has a sensitivity rate of 93% and a specificity rate of 100% in diagnosis of testicular torsion [77]. Nuclear MRI has also been used to diagnose torsion and to differentiate torsion from other acute scrotum conditions. Its use, however, is limited, because of the need for sedation in young children and the fact that other, less expensive imaging modalities are available [29]. CT scans provide detailed anatomical information; on the other hand, contains the risk of exposure to radiation and gives no information on blood flow to the testes. Testicular radionuclide scintigraphy, using Tc-99m, Xe-133, and RP-30A, has been reported to have sensitivity of 100%, while specificity varies from 80 to 100%. Spermatic cord torsion is associated with poor radionuclide uptake and appears as cold spots on the sintigram. Radionuclide scin-tigraphy requires an intravenous process and this procedure usually takes a longer time compared with ultrasound imaging [31, 64, 78, 79].

Interestingly, the effectiveness of using infrared thermography [80, 81], testicu-lar oximetry [82], or the testis rigidity tester [83] for the noninvasive diagnosis of testicular torsion has been reported.

The procalcitonin assay is an easy, fast, noninvasive, inexpensive, and useful diagnostic maker for infectious disease; its level in healthy humans is 0.1 ng mL-1. During infections, it rises to over 0.5 ng mL-1. Yamis et al. [84] used this assay in differential diagnosis of torsion and epididymoorchitis. The increase in the epididymoorchitis group could help investigator to differentiate the epididymoorchi-tis from testicular torsion, and patients with high levels of procalcitonin should be accepted as epididymoorchitis and treated primarily by suitable antibiotics.

Ischemia-modified albumin is a new and sensitive biomarker of ischemia and oxidative stress. The U.S. Food and Drug Administration (FDA) recently licensed it for diagnostic use in suspected myocardial ischemia. Kutlu et al. [85] compared with sham and I/R testis tissue in terms of the malondialdehyde (MDA), glutathione (GSH), and myeloperoxidase (MPO) levels. They determined a high level of ischemia-modified albumin in testis torsion, indicating a potential value for testicular torsion diagnosis.

Inhibin B, a gonadal peptide regulating follicule-stimulating hormone (FSH) secretion, is an established marker of Sertoli cell function and spermatogenesis in adults. In contrast to the other hormones of the hypothalamo-pituitarygonadal axis, inhibin B is also secreted in detectable amounts during childhood. Inhibin B secretion depends on the interaction between Sertoli cells and germ cells [86] . Reduced levels of inhibin B have been described in adolescent boys after testicular torsion, particularly after orchidectomy [87]. Ozkan et al. [88] compared serum inhibin B levels to histopathologic parameters (Johnsen's score) on contralateral testicular damage after unilateral testicular torsion. They suggest that measurement of inhibin B levels to evaluate contralateral testicular damage after unilateral testicular torsion is more effective than histopathologic examination and this parameter evaluates complete testicular function.

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