Intrauterine testicular torsion: a surgical emergency

Background

Intrauterine torsion of testes (IUTT) is a very rare condition that is being recognized with increasing frequency. The exact cause of IUTT is not known, and controversies still continue regarding the need for urgent exploration as well as the necessity of contralateral orchidopexy. This is a review of our experience with 11 cases of IUTT, highlighting aspects of diagnosis and management.

Patients and Methods

From 1990 to 2005, we treated 11 newborns with IUTT. Their mean birth weight was 3.50 kg (range, 2.6-4.12 kg). Their age at presentation ranged from 2 hours to 10 days (mean, 45 hours). All underwent emergency exploration. There were 6 left-sided, 4 right-sided, and 1 bilateral torsion.

Results

In all, the affected testis was enlarged, tender, firm in consistency, and higher in position, and the overlying skin was dark red in color. Exploration revealed extravaginal torsion in all. In 1, there was partial torsion and the testis was enlarged, congested, but not gangrenous. Another child had complete torsion, but the testis was found enlarged, congested with hemorrhage, but not gangrenous. Both were treated with detorsion and preservation of testes and bilateral orchidopexy. On follow-up, both testes were viable, of good size, and in normal position. The patient with bilateral torsion had frankly necrotic left testis that was removed, but the right testis was smaller in size and ischemic but not frankly necrotic, so it was preserved, but on follow-up, it was found atrophic. One of our patients was evaluated few hours after delivery and found to have normal testes. On the second day, he was found to have enlarged, tender left testis. Emergency exploration revealed extravaginal torsion with slightly enlarged left testis that was ischemic but not frankly necrotic. This was preserved and bilateral orchidopexy was done. On follow-up, both testes were viable, of good size, and normal position. In the remaining 7 patients, the testes were frankly necrotic. They were treated with orchidectomy and contralateral orchidopexy. Histology of the removed testes was variable. In 6, the testes were totally necrotic without any viable testicular tissue, whereas in the remaining 2, there was preservation of some semineferous tubules and hemorrhage with ischemic infarction.

Conclusion

Intrauterine torsion of testes should be treated as an emergency. To obviate the risk of anorchia, we advocate early recognition of IUTT, expeditious exploration and simultaneous contralateral orchidopexy.     

Prenatal testicular torsion: Ultrasonographic features, management and histopathological findings

AIM: To highlight the ultrasonographic features of prenatal torsion of the testis in utero (IUTT) at presentation, the neonatal management and the histological findings postorchiectomy or biopsy. METHODS: Seven newborns underwent emergency exploration for IUTT. All patients underwent a sonography and real-time color Doppler ultrasound study of the scrotum before any surgical procedure. A histological examination was performed in the removed specimens. RESULTS: Sonography of the scrotum revealed enlarged, heterogeneous testes. In all cases the color and power Doppler did not reveal any flow signal on the affected side. Four newborn with unilateral testicular torsion underwent orchiectomy and contralateral orchidopexy. In one neonate after detorsion and with the absence of gangrenous changes and a reassuring biopsy, a twisted testis could be treated conservatively with orchidopexy. In another case, the parents, acknowledging the inviability of the affected testis, gave consent only for a biopsy of the testis. In the neonate with bilateral IUTT, bilateral testicular biopsies were performed. Histology of the removed testes variably showed interstitial red cell extravasion and coagulation or hemorrhagic necrosis. Light microscopy of the preserved testis highlighted surviving seminiferous tubules, with gonocytes, spermatogonia and fetal Sertoli cells. CONCLUSIONS: An early diagnosis and treatment in IUTT is essential. Surgical exploration should be always performed through the inguinal route. In bilateral IUTT testes should be left to try to assure, as long as possible, a residual Leydig cell function.     

Torsion of the testis. A 5-year material

During a 5-year period 111 patients were operated for suspected torsion of the testis. In 64 patients with an age range from 2 months to 46 years acute torsion was found. Eleven testes were gangrenous. In four patients contralateral testis was undescended. Indications for explorative surgery on the acute scrotum should be wide even if operation has been previously performed.     

A case of bilateral neonatal testicular torsion

We report a case of bilateral synchronous testicular torsion in a newborn. A male neonate was referred one day after birth because his left testis was firm and enlarged. We found that the scrotum was firm bilaterally and suspected it to be bilateral testicular tumor. Surgical exploration which was performed at 2 days after birth revealed testicular torsion on both sides. Left orchiectomy, right detorsion biopsy and orchiopexy were performed. Histopathological examination confirmed hemorrhagic necrosis of bilateral testes.     

新生儿睾丸扭转8例诊治分析

目的 探讨新生儿睾丸扭转临床特点及诊治方法.方法 回顾性分析我院近5年收治的8例睾丸扭转新生儿的临床资料并复习相关文献.结果 新生儿睾丸扭转共8例;年龄7h~8d;左侧3例,右侧5例;入院查体均发现阴囊肿大呈暗红色或黑紫色,内可及质硬包块,触痛阳性;超声检查示患睾增大、密度不均、血流信号减少或消失;均行阴囊探查术,术中均发现精索睾丸扭转并已坏死,7例行患睾切除;病理结果示睾丸大片出血坏死,5例择期行对侧睾丸固定术.所有患儿随诊3~12月,1例家长拒绝切除患睾的患儿3月时B超复查已经萎缩,超声检查均未发现对侧睾丸异常.结论 新生儿睾丸扭转的睾丸坏死率极高;当发现新生儿阴囊色泽改变、肿大触痛等改变,在不能除外睾丸扭转时应尽早行阴囊探查术.     

Effect of unilateral testicular torsion on blood flow and histology of contralateral testes.

BACKGROUND/PURPOSE: Infertility occurs in 25% of patients after unilateral testicular torsion; hence, the authors examined hemodynamic and histological changes in both testes after acute testicular torsion in neonatal piglets. METHODS: The animals were anesthetized, intubated, ventilated, catheterized, and assigned randomly to a sham group or one of three experimental groups undergoing 720 degrees torsion of the left testis for 8 hours after which it was untwisted in group I and removed in group II. In group III, both testes were removed. Data were collected at baseline (T = 0), 4 hours (T = 4), and 8 hours of torsion (T = 8) and at the ninth hour of the experiment (T = 9). Testicular blood flow was determined by using radiolabeled microspheres. The testes also were examined blindly with routine and electron microscopy. RESULTS: In group I, testicular blood flow decreased in the affected testis during torsion and increased significantly after detorsion, whereas blood flow to the contralateral testis increased significantly after detorsion. Sham-operated animals showed no histological abnormality in either testis. In all torsion groups, the affected testis showed extensive changes caused by hemorrhagic necrosis. The contralateral testis only showed changes in group I. CONCLUSION: Unilateral testicular torsion resulted in ipsilateral damage caused by a decrease and subsequent increase in blood flow while in the contralateral testis; damage was the result of a significant increase in blood flow after detorsion.     

睾丸钟摆畸形与睾丸扭转22例报告

目的 提高对睾丸钟摆畸形（bell-clapper deformity，BCD）的认识，探讨鞘膜内睾丸扭转的解剖和发病特点。方法 回顾性分析22例间歇性睾丸疼痛病例，年龄7～23岁，平均17岁。左侧18例、右侧4例。其中睾丸扭转坏死16例、睾丸大小正常4例、左侧睾丸萎缩2例。结果 22例解剖上均有钟摆畸形即睾丸缺乏正常鞘膜的包裹，睾丸引带缺如，缺乏与壁层鞘膜的粘连，鞘膜腔大，鞘膜在精索上的止点较高，精索活动度较大。16例睾丸坏死或萎缩者行病侧睾丸切除，对侧睾丸固定；6例间歇性睾丸疼痛患者作双侧睾丸探查及固定。22例随访6个月～10年，平均4年9个月，均无睾丸疼痛症状。结论 应高度重视间歇性睾丸疼痛患者，提高间歇期或扭转早期的诊断率，在睾丸未发生扭转坏死之前及时行双侧睾丸探查及固定术，减少睾丸坏死率。     

Polyorchidism and torsion. A lesson from 2 cases

Two cases of polyorchidism with 2 left scrotal testes are referred. In both patients, the segmented gonads showed a “bell clapper” deformity. In the first patient, the contralateral gonad also presented a large mesorchium and absence of scrotal ligament, whereas in the second case, the right gonad was firmly adhered to the tunica vaginalis because of a previous appendix testis torsion. Orchidopexy of all testes, judged at risk for torsion, was performed. Contrary to what is recommended by recent literature, we consider scrotal exploration and testis fixation mandatory of the contralateral, apparently normal gonad as well, even in the absence of clinical and ultrasound signs of associated abnormalities or complications.     

Protective role of erythropoietin during testicular torsion of the rats

Testicular torsion is an important clinical urgency. Similar mechanisms occurred after detorsion of the affected testis as in the ischemia reperfusion (I/R) damage. This study was designed to investigate the effects of erythropoietin (EPO) treatment after unilateral testicular torsion. Fifty male Sprague-Dawley rats were divided into five groups. Group 1 underwent a sham operation of the right testis under general anesthesia. Group 2 was same as sham, and EPO (3,000 IU/kg) infused i.p., group 3 underwent a similar operation but the right testis was rotated 720° clockwise for 1 h, maintained by fixing the testis to the scrotum, and saline infused during the procedure. Group 4 underwent similar torsion but EPO was infused half an hour before the detorsion procedure, and in group 5, EPO was infused after detorsion procedure. Four hours after detorsion, ipsilateral and contralateral testes were taken out for evaluation. Treatment with EPO improved testicular structures in the ipsilateral testis but improvement was less in the contralateral testis histologically, but EPO treatment decreased germ cell apoptosis in both testes following testicular IR. TNF-α, IL-1β, IL-6 and nitrite levels decreased after EPO treatment especially in the ipsilateral testis. We conclude that testicular I/R causes an increase in germ cell apoptosis both in the ipsilateral and contralateral testes. Eryhropoietin has antiapoptotic and anti-inflammatory effects following testicular torsion.     

Noradrenaline and nitrite-nitrate concentrations in the contralateral testes during ipsilateral spermatic cord torsion in the presence or absence of a testis and epididymis.

OBJECTIVE: To determine the changes occurring during ipsilateral spermatic cord torsion either in the presence or absence of the ipsilateral testis and epididymis, by evaluating noradrenaline and nitrite-nitrate concentrations in the contralateral testes. MATERIALS AND METHODS: Forty male albino rats were allocated randomly to one of four equal groups undergoing: group 1, a sham operation; group 2, ipsilateral spermatic cord torsion; group 3, epididymo-orchidectomy only; and group 4, spermatic cord torsion after epididymo-orchidectomy. The contralateral testes were harvested after 24 h and the noradrenaline and nitrite-nitrate contents determined. The levels in each group were compared using the Kruskal-Wallis and Mann-Whitney U-tests. RESULTS: The noradrenaline content of testes from group 2 was significantly lower than in those of groups 1 and 3, but there were no significant differences in content between groups 1 and 3, 1 and 4, and 2 and 4. The content in group 4 was significantly less than that in group 3. There were no significant differences in nitrite-nitrate contents among any of the groups. CONCLUSION: Spermatic cord torsion for 24 h, either in the presence or absence of a testis and epididymis, significantly decreased the noradrenaline content in the contralateral testis. This finding supports the suggestion that the sympathetic system is activated by exposure to noradrenaline in the contralateral testis during ipsilateral spermatic cord torsion, with no dependency on the presence of a testis and epididymis. As the nitrite-nitrate concentrations were unaffected, nitric oxide seems to have no role in contralateral testicular deterioration.     

Re-exploration of the acute scrotum

OBJECTIVE: To investigate children and adolescents who had scrotal exploration more than once. PATIENTS AND METHODS: Between 1994 and 2004, 64 of 840 (7.6%) boys had more than one scrotal exploration at our institution. The age, laterality of the explorations, the interval between and findings at operation, whether the testes were managed by orchidopexy and how, and the complications, were reviewed from the medical records and the operating reports of the patients. All the boys were followed at the outpatient clinic 2-4 weeks after surgery. RESULTS: The median (range) age of the patients was 11.5 (2-15) years; 61 had two scrotal explorations and three were explored three times. Of the patients, 32 presented with right testicular pain, 31 had left pain, and one had bilateral testicular pain. In the second exploration, 56 of 64 had the contralateral testis explored, five had an ipsilateral exploration and three had bilateral exploration. Forty-eight of the 64 boys (70%) had torsion of the contralateral appendix testis at the second exploration, and 5.3% (45/840) of the total number of children operated for acute scrotum had metachronous torsion of the appendix testis. The median interval between the first and second exploration was 8 months (1 day to 10.5 years). Two boys had three scrotal explorations, and three of 64 (4.7%) boys developed complications that required re-exploration. CONCLUSIONS: Most indications for recurrent scrotal exploration in this study are because of a twisted contralateral appendix testis, but the risk of developing this pathology is similar to the complication rate of repeat scrotal exploration. These data support our policy that the contralateral testis should not be routinely explored nor its appendix removed unless there is ipsilateral testicular torsion.     

Neonatal testicular torsion and infarction: aetiology and management

Thirty neonates presented with signs of testicular ischaemia over a 20-year period. Eighteen children had primary exploration revealing extravaginal torsion (10), intravaginal torsion (3), infarction without torsion (2) and torsion of the appendix testis (1). The other two children had simple biopsy of necrotic testes. In two instances the testis was untwisted and retained but both subsequently atrophied. The remainder underwent orchiectomy. Twelve children did not have initial exploration and 11 of these had subsequent testicular atrophy. At contralateral testis fixation, performed in 17 cases, signs of contralateral involvement in the ischaemic process were found in seven, suggesting that the primary event in the condition is infarction, with torsion occurring secondarily.     

Polyorchidism discovered as testicular torsion associated with an undescended atrophic contralateral testis: a surgical solution

We report a case of polyorchidism presenting as torsion of the supernumerary testis associated with an undescended atrophic contralateral testis. Biopsies of both descended testes revealed a normal histological pattern with active spermatogenesis. After the testicular torsion was corrected, one of the supernumerary testes was placed in the contralateral empty hemiscrotum and the undescended atrophic testis was removed. The aesthetic and functional results were excellent.     

Stagnation of blood in the microvasculature of the affected and contralateral testes of men with short-term torsion of the spermatic cord

Bilateral testicular biopsies from four men with a short duration (3 hours 10 minutes to 4 hours 30 minutes) of unilateral spermatic cord torsion and testicular biopsies from six men with irreversible brain death were used for the present investigation. Extensive light and electron microscopic studies and quantitative analyses of all biopsy materials were performed. The torsioned testes revealed variable degrees of damage to the seminiferous tubules, including germ cell disorganization and sloughing of immature germ cells. Ninety-five percent of the blood vessels from the biopsied tissue specimens were clogged with blood cells. The seminiferous tubules of the contralateral testis had normal germ cell arrangements and counts. However, 88% of the microvessels from the tissue biopsied from the contralateral testes were packed with blood cells, whereas only 10% of the blood vessels in the control biopsy specimen were clogged with blood cells. At the electron microscopic level, fewer tight junctions and enlarged pores were found between the endothelial cells of the affected vessels, and microvilli were completely absent from these endothelial cells. The clogging caused by blood cells in the affected vessels was so severe that no space was found between the membrane of the endothelial cell and the membrane of the blood cells. It has been suggested that local clogging by blood is responsible for the initiation of degenerative changes in the testes of men with unilateral torsion of the spermatic cord.     

Impalpable testes: a review of 100 boys

A consecutive series of 100 boys with 104 impalpable testes is reviewed. Extended inguinal exploration was the main form of investigation and treatment. Hormone injections and studies were performed in bilateral cases and in the latter part of the series, laparoscopy supplemented inguinal operation. Sonography was unhelpful. Seventy-five testes were found, 34 in the abdomen, 34 in the inguinal canal, and 7 below the external ring. Seventeen of the abdominal testes, 31 of the inguinal testes, and all of those below the external ring were successfully brought to the scrotum. In ten boys no trace of testis was found and in 19 there was testicular or cord "remnant." Laparoscopy was performed before inguinal exploration in eight and it is concluded that this procedure is helpful but of limited value. It is indicated where no testis or testicular vessels are found on inguinal exploration and this occurs in about 15% of impalpable testes. When an atrophic testis is found, it is not evident whether the testis is agenetic or whether its disappearance resulted from torsion so fixation of the contralateral testis is recommended in all such patients.     

Experimental torsion of the spermatic cord. Histological and histochemical studies (author's transl)

In 40 male adult rats on unilateral torsion of the spermatic cord was initiated by operation. In the first group (4 x 5 animals) the testes were removed after 3, 6, 12, 24 hours. The treatment of the animals in the second group (4 x 5 animals) was untwisting of the torsion after 3, 6 12, 24 hours. Three months later both testes were removed. Histological and enzymehistochemical results are as follows: 1. The extend of acute damage to the affected testis depends on the length the torsion lasted. 2. The delay of time of untwisting the testis probably does not influence the degree of later regeneration. 3. Even short duration of torsion of the affected testis results in damage to the contralateral testies.     

Torsion of undescended testis in a man with Down''s syndrome

Undescended testis is one of the most common disorders in Down's syndrome. We present an extremely rare case of torsion of an inguinal undescended testis in a 35-year-old patient with Down's syndrome. Surgical exploration revealed a rotated gangrenous testis, radical orchiectomy was performed, and pathological examination confirmed the diagnosis of testicular torsion.     

Fixation of a single testis: always, sometimes or never.

If it is necessary to perform an orchiectomy for an intravaginal testicular torsion it is the usual practice of surgeons to fix the contralateral testis. When faced with a child with only one testis for another reason it is our practice to fix this single testis to eliminate the small but disastrous risk of a torsion. We were interested to see whether this practice was usual and therefore sent out a questionnaire to the 67 consultant paediatric surgeons and urologists in Great Britain. Sixty-six surgeons replied. Seven surgeons (11%) always fix the single testis, 28 (42%) sometimes and 31 (47%) never fix a single testis. Five surgeons had looked after 6 patients who had a torsion of a second unfixed testis after losing the first for a reason other than intravaginal torsion. Four of these patients had initially had a neonatal supravaginal torsion, 1 had a torsion of an undescended testis and the sixth had severe testicular atrophy following an inguinal herniotomy. In our opinion the devastating loss of these solitary testes makes contralateral testicular fixation after an orchiectomy for whatever reason mandatory.     

Do experimentally induced ipsilateral testicular torsion, vas deferens obstruction, intra-abdominal testis or venous obstruction damage the contralateral testis through a common mechanism?

OBJECTIVE: To evaluate if various conditions affecting the ipsilateral testis which also damage the contralateral testis share a common pathway for their effects. MATERIALS AND METHODS: The study comprised five groups of 10 adult rats which underwent surgery to produce (on their left sides); group 1, a sham operation (control); group 2, testicular torsion; group 3, vas deferens obstruction; group 4, an intra-abdominal testis; and group 5, venous obstruction. The ipsilateral and contralateral testes were harvested 4 weeks after surgery. The relative proportions of haploid cells, the mean seminiferous tubular diameter (MSTD), mean testicular biopsy scores (MTBS), and lactate and hypoxanthine levels were determined and compared. RESULTS: The proportions of haploid cells in the ipsilateral and the contralateral testes of groups 2-5 were significantly lower than those of the corresponding testes of the control group. The MSTD and MTBS of the ipsilateral testes in groups 2-5 were also significantly lower than the ipsilateral testes of controls and the contralateral testes within the same groups. While the MSTD and MTBS of the contralateral testes of groups 1 and 5 were not significantly different, those of the contralateral testes of groups 2-4 were significantly less than that of group 1. The lactic acid and hypoxanthine levels of the ipsilateral and contralateral testes were significantly increased in groups 2 and 3. While only the hypoxanthine level of group 5 increased significantly, both variables were not significantly different between the ipsilateral testes of groups 1 and 4. CONCLUSIONS: These four treatments damaged both the ipsilateral and contralateral testes. As the lactic acid and hypoxanthine levels within the contralateral testis were greater than in the controls, testicular torsion and vas deferens obstruction seem to share a common pathway (which may be a reflex decrease in contralateral testicular blood flow) for their effects on the contralateral testis.     

New animal model to evaluate testicular blood flow during testicular torsion.

BACKGROUND/PURPOSE: Unilateral testicular torsion is known to cause infertility because of damage to the contralateral testis. Testicular damage has been attributed to many different mechanisms, one of which is altered contralateral blood flow. In our experiment, in an effort to identify the reason for contralateral testicular injury, the authors developed an accurate method of measuring blood flow in both testes before, during, and after unilateral torsion. METHODS: Four- to 6-week-old piglets weighing 4 to 6 kg were studied. The animals were anesthetized, intubated, ventilated, and catheterized for vascular access. Piglets were assigned randomly to a sham group or a group undergoing 360 degrees or 720 degrees torsion of the left testis (n = 5 per group) for 8 hours, after which it was untwisted. Data were collected at baseline (T = 0), 8 hours of torsion (T = 8), and 1 hour after detorsion (T = 9). Mean arterial blood pressure and heart rate were monitored continuously. Testicular blood flow was determined using radiolabeled microspheres. Blood flow data were evaluated by analysis of variance. RESULTS: In the 360 degrees torsion group, blood flow changes were insignificant during torsion and after detorsion. In the 720 degrees torsion group, blood flow to the twisted testis was reduced significantly, whereas the contralateral testis was unaffected. One hour after detorsion, blood flow to both testes was increased significantly. CONCLUSIONS: The authors describe a new animal model to evaluate testicular blood flow during and after testicular torsion. Increased blood flow after detorsion may be the cause of testicular damage in patients with unilateral testicular torsion.