Unnecessary ultrasound imaging in the management of undescended testis

To the Editor: Undescended testis affects 2–4% of term male newborns.1 Clinical examination by an experienced clinician remains the most accurate method of assessing the position of the testis. It allows for the clear distinction between a retractile testis and palpable and impalpable undescended testes. In 2013, an evidence‐based statement on undescended testes was released jointly by Choosing Wisely and the American Urological Association which advocated against performing ultrasounds to investigate undescended testes due to their poor ability to localise non‐palpable testes.2 Unfortunately, this recommendation is not listed in the Australian Choosing Wisely website.

Our study intended to improve awareness of the American Urological Association Choosing Wisely guidelines among Australian general practitioners and draw attention to the resources misspent due to lack of awareness. A retrospective audit was undertaken of 50 children referred in 2017 for an undescended testis to a single paediatric urologist in a private clinic. De‐identified data were extracted from the practitioner’s medical record system. The research ethics committee at the Sydney Adventist Hospital approved the publication of the audit.

Of the patients referred with a diagnosis of an undescended testis, 35 testes (70%) were palpable in the scrotum on the day of consultation. However, 32 of 50 children (64%) already had an ultrasound by the time they were seen, with 51 testes (79%) labelled as undescended testis. Thus, more than two‐thirds of children had an ultrasound that was not needed, and the specificity was low at 27% (95% CI, 15–42%) (Box).

About 159 379 boys were born in Australia in the study period.3 The cost of an ultrasound of the scrotum as per the Medicare Benefits Schedule was $109.50 (item 55048). Assuming an incidence of undescended testis of 2% and assuming ultrasounds were ordered in three times as many children, as happened in our study (15 undescended testes and 35 descended testes), the cost of unnecessary studies is calculated to be $1 047 120 (3 × 0.02 × birth cohort of 159 379 × $109.50). The numbers of Medicare claims for item 55048 have increased by 5% each year since 2010.4

Health budgets are finite, and expenditure should be linked to quality metrics. GPs and paediatricians are undoubtedly trying to be helpful by organising an ultrasound before the referral, but it is unnecessary. This letter is an attempt to continue the discussion with referring doctors to let them know that ultrasound is not required before referral for an undescended testis.

This is a single clinic audit. We hope it will inspire larger population‐based audits to facilitate systemic change.