Is Doppler ultrasound superior to nuclear scintigraphy for diagnosing testicular torsion?
Date First Published:
August 27, 2026
Last Updated:
August 27, 2026
Report by:
Pericles Philippou, Resident Doctor (Blackpool Teaching Hospitals NHS Foundation Trust)
Search checked by:
Daniel Darbyshire, Consultant
Three-Part Question:
In [patients with suspected testicular torsion] is [Doppler ultrasound superior to nuclear scintigraphy] as a [first-line imaging modality]?
Clinical Scenario:
An 18-year-old man presents to the emergency department with a 4-hour history of sudden-onset severe left testicular pain associated with nausea and vomiting. On examination, the left testis is high-riding, swollen, and extremely tender, with an absent cremasteric reflex. You call the urology registrar, who is concerned about testicular torsion. The emergency department has immediate access to colour Doppler ultrasound, while nuclear scintigraphy is also available through the radiology department. You wonder whether Doppler ultrasound is superior to nuclear scintigraphy for diagnosing testicular torsion.
Search Strategy:
A structured literature search was conducted via Ovid using MEDLINE, EMBASE and Cochrane databases. A combination of MeSH terms and free-text keywords were included:
(exp spermatic cord torsion/ OR testicular torsion OR spermatic cord torsion OR acute scrotum) AND (exp ultrasonography/ OR ultrasound OR ultrasonograph* OR sonograph* OR doppler) AND (exp radionuclide imaging/ OR radionuclide OR scintigraph*)
In addition, forward citation tracking was performed using the Google Scholar “cited by” function on all included studies to identify any further relevant literature. Reference lists of selected papers were also screened to ensure no key studies were missed.
(exp spermatic cord torsion/ OR testicular torsion OR spermatic cord torsion OR acute scrotum) AND (exp ultrasonography/ OR ultrasound OR ultrasonograph* OR sonograph* OR doppler) AND (exp radionuclide imaging/ OR radionuclide OR scintigraph*)
In addition, forward citation tracking was performed using the Google Scholar “cited by” function on all included studies to identify any further relevant literature. Reference lists of selected papers were also screened to ensure no key studies were missed.
Outcome:
The search identified 146 papers, with no duplicates. After title and abstract screening, 125 papers were excluded. 21 papers underwent full-text review, and a further 15 were excluded: 4 were non-human studies, and 11 were not directly relevant to the three-part question.
6 papers were selected for final analysis: 4 prospective diagnostic cohort studies and 2 retrospective cohort studies. The key results are summarised in Table 1.
6 papers were selected for final analysis: 4 prospective diagnostic cohort studies and 2 retrospective cohort studies. The key results are summarised in Table 1.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Color Doppler sonography and scintigraphy of the testis: A prospective, comparative analysis in children with acute scrotal pain. Blask A.R.N.; Bulas D.; Shalaby-Rana E.; Rushton G.; Shao C.; Majd M. 2002 USA | 46 children presenting with acute scrotal pain (n=46, median age: 11) | Prospective comparative diagnostic cohort study (Level 2 evidence) | To compare colour Doppler sonography with testicular scintigraphy in differentiating surgical from non-surgical causes of acute scrotum, using surgical findings or clinical follow-up as the reference standard | • 14 surgical cases, including 12 surgically confirmed testicular torsions | • Small sample size (n=46) • Single-centre paediatric study limiting generalisability to adult populations • Ultrasound performance limited in younger prepubertal children due to difficulty detecting normal intratesticular blood flow • Colour Doppler examinations were performed and interpreted by experienced radiologists, limiting generalisability • Diagnostic performance metrics were calculated for differentiating surgical from non-surgical conditions, rather than for diagnosing testicular torsion alone |
| •Colour Doppler ultrasound correctly diagnosed 11/14 surgical conditions and 31/32 non-surgical conditions | |||||
| • Ultrasound sensitivity: 78.6% (95% CI, 66.7–90.5%) | |||||
| • Ultrasound specificity: 96.9% (95% CI, 94.3–99.5%) | |||||
| • Scintigraphy correctly diagnosed 11/14 surgical conditions and 29/32 non-surgical conditions | |||||
| • Scintigraphy sensitivity: 78.6% (95% CI, 66.7–90.5%) | |||||
| • Scintigraphy specificity: 90.6% [95% CI, 82.2–99.0%] | |||||
| Prospective comparison of colour Doppler ultrasonography and testicular scintigraphy in acute scrotum. Karadeniz T.; Topsakal M.; Ariman A.; Eksioglu A.; Erton H.; Ozpacaci T.; Basak D. 1996 Hungary | 10 consecutive paediatric patients presenting with acute scrotal pain and/or swelling (n=10, mean age: 8) | Prospective comparative diagnostic cohort study (Level 2 evidence) | Diagnostic accuracy of colour Doppler ultrasonography and testicular scintigraphy for differentiating acute testicular ischaemia/torsion from inflammatory causes of acute scrotum, using surgical exploration or clinical follow-up as the reference standard | • 3/10 patients diagnosed with acute testicular ischaemia confirmed by surgical exploration | • Very small sample size (n=10) with only 3 torsion cases • Single-centre paediatric study limiting generalisability • Sensitivity and specificity were not formally calculated and only sensitivity could be derived from published raw data • Colour Doppler examinations were performed and interpreted by diagnostic radiologists, limiting generalisability • Ultrasound operators were aware of clinical history whereas scintigraphy was interpreted blindly, introducing potential interpretation bias |
| • Both colour Doppler ultrasound and scintigraphy correctly identified all 3 torsion cases (calculated sensitivity: 100% for both modalities) | |||||
| Acute scrotal disorders: Prospective comparison of color doppler US and testicular scintigraphy. Middleton W.D.; Siegel B.A.; Leland Melson G.; Yates C.K.; Andriole G.L. 1990 USA | 28 patients presenting with acute scrotal pain, swelling, or both (n=28, age range 1 day to 41 years, mean age: 24) | Prospective blinded comparative diagnostic cohort study (Level 2 evidence) | Diagnostic accuracy of colour Doppler ultrasonography and testicular scintigraphy for diagnosing testicular torsion, using surgical findings as the reference standard. | • 7/28 patients had surgically confirmed testicular torsion | • Small sample size (n=28) with only 7 torsion cases • Patients with clinically obvious torsion underwent immediate surgery and were excluded, introducing selection bias • Sensitivity and specificity were not formally calculated • Colour Doppler examinations were performed and interpreted by experienced radiologists, limiting generalisability • Initial scintigraphy interpretations were frequently performed by radiology residents with variable experience, potentially disadvantaging scintigraphy |
| • Colour Doppler ultrasound correctly identified all 7 torsion cases (calculated sensitivity: 100%) | |||||
| • Scintigraphy correctly identified 6/7 torsion cases (calculated sensitivity: 85.7%) | |||||
| • One false-negative scintigraphy occurred in a patient with 180° torsion | |||||
| • No false-positive diagnoses of testicular torsion occurred with either modality (calculated specificity: 100% for both modalities) | |||||
| Doppler ultrasound versus testicular scanning in the evaluation of the acute scrotum. Rodriguez DD; Rodriguez WC; Rivera JJ; Rodriguez S; Otero AA 1981 Mar USA | 47 patients aged ≤35 years presenting with acute scrotum over a 2-year period (n=47, mean age: 16) | Prospective comparative diagnostic cohort study (Level 2 evidence) | Diagnostic accuracy of Doppler ultrasonography and testicular scintigraphy for diagnosing testicular torsion, using surgical findings as the reference standard. | • 13/47 patients had surgically confirmed testicular torsion | • Very early Doppler technology (5.3 MHz Doppler stethoscope) with substantially lower diagnostic capability than modern colour Doppler ultrasound • Not all patients underwent both investigations, limiting direct comparison • Small sample size (n=47) with even smaller scintigraphy cohort (n=20, only 5 torsion cases) • High proportion of indeterminate Doppler examinations (19% overall) • Sensitivity and specificity were not formally calculated |
| • Doppler ultrasound correctly identified 8/13 torsion cases, with 4 indeterminate examinations and 1 false-negative result | |||||
| • Doppler ultrasound correctly identified 29/34 non-torsion cases and produced 5 indeterminate examinations | |||||
| • A subgroup of 20 patients underwent scintigraphy; 5/20 had torsion | |||||
| • Testicular scintigraphy correctly identified all 5 torsion cases and all 15 non-torsion cases | |||||
| The relative merits of Doppler sonography in the evaluation of patients with clinically and scintigraphically suspected testicular torsion. Hod N.; Maizlin Z.; Strauss S.; Horne T. 2004 Israel | 27 patients presenting with acute scrotal pain with an intrascrotal photopenic lesion on scintigraphy suggestive of testicular torsion (n= 27, age range 1 to 49 years) | Retrospective comparative diagnostic cohort study (Level 3 evidence) | Diagnostic accuracy of Doppler sonography in patients with scintigraphic findings suggestive of testicular torsion, using surgical findings or clinical follow-up as the reference standard | • Final diagnosis confirmed testicular torsion in 7 patients and non-torsion pathology in 20 patients | • Small sample size (n=27) with only 7 torsion cases • Retrospective study design • Only those with scintigraphic findings suggestive of torsion were included, introducing significant selection bias. • Specificity/sensitivity of scintigraphy cannot be meaningfully compared with Doppler sonography because inclusion required a positive scintigraphic result |
| • Scintigraphy falsely suggested torsion in 20 non-torsion cases, resulting in poor specificity within this cohort | |||||
| • Doppler ultrasound correctly identified 6/7 torsion cases and 19/20 non-torsion cases | |||||
| • Ultrasound sensitivity: 86% | |||||
| • Ultrasound specificity: 95% | |||||
| Acute scrotal symptoms in boys with an indeterminate clinical presentation: Comparison of color Doppler sonography and scintigraphy. Paltiel H.J.; Connolly L.P.; Atala A.; Paltiel A.D.; Zurakowski D.; Treves S.T. 1998 USA | 41 boys (n=41, mean age: 9.4) presenting with acute scrotal pain and/or swelling with clinically equivocal acute scrotal symptoms | Retrospective comparative diagnostic cohort study (Level 3 evidence) | Diagnostic performance of colour Doppler ultrasonography and testicular scintigraphy for detecting testicular torsion, using surgical findings or clinical follow-up as the reference standard | • 11/41 patients had testicular torsion | • Retrospective study design • Small sample size (n=41) with only 11 torsion cases • Included only patients with clinically equivocal presentations, introducing selection bias • Colour Doppler examinations were performed by operators with varying levels of experience, including on-call radiology fellows after routine hours. • High proportion of indeterminate ultrasound examinations (20%) • Diagnostic performance varied substantially depending on how indeterminate studies were classified |
| • Colour Doppler ultrasound identified 9/11 torsions and 23/30 non-torsion cases, with 8 indeterminate examinations (all in prepubertal patients with small volume testes) and 1 false-positive result | |||||
| • Scintigraphy identified 10/11 torsions and 29/30 non-torsion cases, with 2 indeterminate examinations (both in patients with inguinal testes) | |||||
| • Indeterminate studies were treated as positive for torsion when calculating sensitivity and specificity (authors' preference) | |||||
| • Ultrasound sensitivity: 100% | |||||
| • Ultrasound specificity: 77% | |||||
| • Scintigraphy sensitivity: 100% | |||||
| • Scintigraphy specificity: 97% |
Author Commentary:
The available evidence demonstrates that both Doppler ultrasound and testicular scintigraphy have high diagnostic accuracy for testicular torsion, with neither modality consistently outperforming the other. Three comparative studies reported equivalent sensitivities for the two imaging techniques, with both achieving 100% sensitivity in several cohorts.1,2,6 However, one prospective blinded study found that Doppler ultrasound correctly identified all cases of surgically confirmed torsion, whereas scintigraphy missed one patient with incomplete (180°) torsion. This suggests ultrasound may be more sensitive in cases with residual testicular perfusion.3 Conversely, the earliest comparative study favoured scintigraphy, although it utilised a handheld Doppler stethoscope rather than modern colour Doppler ultrasound, substantially limiting its relevance to current clinical practice.4
The overall quality of the evidence is limited. All included studies were small, single-centre diagnostic cohort studies, with the largest including only 47 patients. These cohorts contained relatively few confirmed cases of testicular torsion, reducing the precision of reported diagnostic performance values.1–6 Several studies were conducted exclusively in paediatric populations, limiting generalisability to adult patients.1,2,6 Other studies included broad age ranges with insufficient subgroup analysis.3,4,5 Selection bias was also common, with one study excluding patients with clinically obvious torsion.3 Another study restricted inclusion to patients with positive scintigraphic findings, preventing meaningful comparison between the diagnostic modalities.5
Operator dependence is a key limitation of Doppler ultrasound. In most prospective studies, examinations were performed by experienced radiologists, potentially overestimating diagnostic accuracy compared with routine emergency practice.1–3 Conversely, one study included examinations performed by trainees and found a higher proportion of indeterminate ultrasound scans, particularly in prepubertal boys with small testicular volume.6 This finding highlights the recognised technical challenges of detecting normal intratesticular blood flow in younger children. It also suggests that diagnostic performance may be influenced by operator expertise and patient age. Testicular scintigraphy, although less operator-dependent, requires access to nuclear medicine facilities and may delay definitive management.
Although diagnostic accuracy was broadly comparable, practical considerations favour Doppler ultrasound as the first-line imaging modality. Ultrasound is widely available, rapid, non-invasive, and avoids ionising radiation. In contrast, nuclear scintigraphy is less readily available, often requires transfer to specialist departments and is associated with longer acquisition times. These factors may delay surgical exploration and reduce testicular salvage rates. None of the included studies formally evaluated diagnostic delay or patient-centred outcomes, but these logistical advantages strengthen the case for ultrasound in routine emergency practice.
Overall, current evidence suggests that Doppler ultrasound provides diagnostic accuracy comparable to, and in some studies superior to, testicular scintigraphy for diagnosing testicular torsion. Although the evidence base is limited by small, single-centre studies and potential operator dependence, the consistency of findings across comparative studies strengthens the overall conclusion. Doppler ultrasound's superior accessibility, rapid availability and absence of ionising radiation make it the preferred first-line imaging modality in patients with suspected testicular torsion. Larger multicentre prospective studies would help further define the relative performance of these imaging modalities.
The overall quality of the evidence is limited. All included studies were small, single-centre diagnostic cohort studies, with the largest including only 47 patients. These cohorts contained relatively few confirmed cases of testicular torsion, reducing the precision of reported diagnostic performance values.1–6 Several studies were conducted exclusively in paediatric populations, limiting generalisability to adult patients.1,2,6 Other studies included broad age ranges with insufficient subgroup analysis.3,4,5 Selection bias was also common, with one study excluding patients with clinically obvious torsion.3 Another study restricted inclusion to patients with positive scintigraphic findings, preventing meaningful comparison between the diagnostic modalities.5
Operator dependence is a key limitation of Doppler ultrasound. In most prospective studies, examinations were performed by experienced radiologists, potentially overestimating diagnostic accuracy compared with routine emergency practice.1–3 Conversely, one study included examinations performed by trainees and found a higher proportion of indeterminate ultrasound scans, particularly in prepubertal boys with small testicular volume.6 This finding highlights the recognised technical challenges of detecting normal intratesticular blood flow in younger children. It also suggests that diagnostic performance may be influenced by operator expertise and patient age. Testicular scintigraphy, although less operator-dependent, requires access to nuclear medicine facilities and may delay definitive management.
Although diagnostic accuracy was broadly comparable, practical considerations favour Doppler ultrasound as the first-line imaging modality. Ultrasound is widely available, rapid, non-invasive, and avoids ionising radiation. In contrast, nuclear scintigraphy is less readily available, often requires transfer to specialist departments and is associated with longer acquisition times. These factors may delay surgical exploration and reduce testicular salvage rates. None of the included studies formally evaluated diagnostic delay or patient-centred outcomes, but these logistical advantages strengthen the case for ultrasound in routine emergency practice.
Overall, current evidence suggests that Doppler ultrasound provides diagnostic accuracy comparable to, and in some studies superior to, testicular scintigraphy for diagnosing testicular torsion. Although the evidence base is limited by small, single-centre studies and potential operator dependence, the consistency of findings across comparative studies strengthens the overall conclusion. Doppler ultrasound's superior accessibility, rapid availability and absence of ionising radiation make it the preferred first-line imaging modality in patients with suspected testicular torsion. Larger multicentre prospective studies would help further define the relative performance of these imaging modalities.
Bottom Line:
In patients with suspected testicular torsion, Doppler ultrasound demonstrates comparable diagnostic accuracy to nuclear scintigraphy, with no consistent evidence that either modality is superior. Doppler ultrasound should therefore be considered the preferred first-line imaging modality given its widespread availability, rapid acquisition and lack of ionising radiation. Imaging should not delay urgent urological assessment or surgical exploration when clinical suspicion of torsion is high.
Level of Evidence:
Level 2: Studies considered were neither 1 or 3
References:
- Blask A.R.N.; Bulas D.; Shalaby-Rana E.; Rushton G.; Shao C.; Majd M.. Color Doppler sonography and scintigraphy of the testis: A prospective, comparative analysis in children with acute scrotal pain.
- Karadeniz T.; Topsakal M.; Ariman A.; Eksioglu A.; Erton H.; Ozpacaci T.; Basak D.. Prospective comparison of colour Doppler ultrasonography and testicular scintigraphy in acute scrotum.
- Middleton W.D.; Siegel B.A.; Leland Melson G.; Yates C.K.; Andriole G.L.. Acute scrotal disorders: Prospective comparison of color doppler US and testicular scintigraphy.
- Rodriguez DD; Rodriguez WC; Rivera JJ; Rodriguez S; Otero AA. Doppler ultrasound versus testicular scanning in the evaluation of the acute scrotum.
- Hod N.; Maizlin Z.; Strauss S.; Horne T.. The relative merits of Doppler sonography in the evaluation of patients with clinically and scintigraphically suspected testicular torsion.
- Paltiel H.J.; Connolly L.P.; Atala A.; Paltiel A.D.; Zurakowski D.; Treves S.T.. Acute scrotal symptoms in boys with an indeterminate clinical presentation: Comparison of color Doppler sonography and scintigraphy.