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.     

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.     

On unilateral testicular and epididymal torsion: no effect on the contralateral testis

It is often stated that unilateral testicular torsion results in damage to the contralateral testis; however, there are a growing number of experimental and clinical papers which suggest this is not so. Conflicting results from experimental studies confuse the issue and may be due, among other things, to some specifics of the experimental model. In the present paper, we have examined bilateral rat testes 30 and 60 days after 720 degrees torsion to determine 1) the effect of unilateral testicular torsion with and without the inclusion of epididymal torsion, 2) the effect of relatively chronic torsion (24 hr., 10 day) versus relatively acute torsion (two hr., four hr.), and 3) the effect of establishing the model using scrotal surgery versus using an abdominal approach. Bilateral testicular histology, testis wt. (gm.), cauda epididymal sperm concentrations (sp./ml.), and cauda sperm motility scores (0-4) were examined. Ipsilateral testicular torsion or testicular plus epididymal torsion of two hr. or four hr. duration significantly reduced (p less than .05) ipsilateral testis weights, sperm concentrations, and motility scores, and disrupted normal tissue histology. Contralateral testicles were not altered. Epididymal ischemia alone produced no significant ipsilateral or contralateral effects. Chronic torsion (one day, 10 days) also destroyed ipsilateral testis function without altering the contralateral testicles. The occult cryptorchidism associated with the scrotal approach to establishing the torsion model had no effect on contralateral testicles. In no group, using either Lewis rats or Sprague-Dawley rats, were contralateral testicles altered by unilateral testicular torsion. These results plus recent clinical reports indicate that contralateral testicular damage due to ipsilateral torsion is hardly a proven phenomenon, let alone a significant factor contributing to male infertility.     

Perinatal testicular torsion: a unique strategy

Background/Purpose

Perinatal testicular torsion (PTT) is defined as testicular torsion occurring prenatally or within the first 30 days of life. The aim of this study was to evaluate the data obtained from patients with PTT and propose principles of management based on clinical, surgical, and histologic findings.

Methods

A retrospective analysis of 27 boys seen between 1990 and 2005 with surgically documented PTT was conducted. Patients were divided into 2 groups: A, prenatal testicular torsion; B, postnatal testicular torsion. The presence of acute scrotal inflammatory signs defined the urgency to operate.

Results

There were 4 clinical pictures in group A: A1, patients with a nubbin testis (n = 3); A2, patients with a small and hard testis (n = 12); A3, patients with a normal-sized and hard testis (n = 8); and A4, patients with an acute scrotum (n = 2). Group B (n = 2) presented no sign after birth and later developed an acute scrotum. Surgical exploration and histologic examination showed clear signs of a long-standing testicular torsion in groups A1, A2, and A3 or a recent-onset testicular torsion in groups A4 and B. Only one testis could be salvaged (group B).

Conclusions

Clinical signs correlated very well with surgical and histologic findings and can define the need and the urgency to operate. Although testicular salvage rate is very low, the affected side always should be explored to confirm the diagnosis and to fix or remove the affected testicle. The contralateral scrotum also should be explored because of the risk of asynchronous contralateral testicular torsion.     

Prepubertal testicular torsion: subsequent fertility

Eighteen patients were reviewed 7 to 23 years after prolonged unilateral testicular torsion. They had all undergone surgical untwisting with replacement of the nonviable testis in the scrotum during prepubertal period. Five patients were now married and had fathered one or more children. Thirteen patients were unmarried. There was absence of testis on the affected side in 14 of 18 patients. Four patients had severe testicular atrophy on the affected side (testicular volume less than 1 mL). The contralateral side showed either a normal testicular volume or a compensatory hypertrophy (testicular volume greater than 25 mL). Seminal analysis was done in 13 unmarried men and it was completely normal in 10 patients. Two patients had low sperm density but normal semen volume and motility. One patient had pathologic semen analysis. IgG and IgA specific mixed agglutination reaction (MAR) test did not show evidence of sperm autoantibodies in any patient. Our clinical experience shows that, after prepubertal torsion, the contralateral testis undergoes normal development. Furthermore, torsion in the prepubertal male does not cause autosensitization and diminished fertility in adult life.     

Intermittent testicular pain: fix the testes

OBJECTIVE: To analyse the presenting features, signs and operative findings of children presenting with intermittent testicular pain, as testicular torsion is a relatively common and serious emergency in children that can lead to testicular loss in up to 80%, although half of these children have previous episodes of pain suggestive of intermittent torsion. PATIENTS AND METHODS: Data were collected prospectively for all patients presenting with recurrent pain between December 2000 and June 2001. Variables assessed included presenting symptoms, age, size, lie and position of the testis when supine and erect, the operative findings and follow-up. RESULTS: Eight children had at least two previous episodes of testicular pain; four of these were admitted on six occasions. Two had undergone previous scrotal exploration. On clinical examination, six boys had a transverse testicle and two a discrepancy in testicular size. All children had their testes fixed. At operation in all patients there was abnormal attachment of the tunica vaginalis with a typical 'bell clapper' deformity. On follow-up only one patient still complains of pain. CONCLUSION: In view of high incidence of abnormalities we consider that to improve the testicular salvage rate and prevent testicular atrophy, bilateral testicular fixation is recommended for boys with intermittent testicular pain and positive clinical findings.     

Exocrine and endocrine testicular function following unilateral torsion--a retrospective clinical study of 36 patients

Of 86 patients who had undergone unilateral testicular torsion the fertility in 36 patients could be examined 1-9 years later. The testis in 27 patients (= 75%) was surgically untwisted. Of 9 patients (= 25%) the testis was removed because of marked hemorrhagic infarction. Fixation of the contralateral testis was prophylactically performed in all cases. The testis of all patients who had undergone the detorsion within the first 22 h were saved and there was no significant difference of the testicular volume compared with the contralateral side. An atrophy of the contralateral testis following prophylactical fixation was never observed. In most of the 36 patients the fertility was diminished: Seminal analysis revealed an oligozoospermia in 44%, a teratozoospermia in 20%, an asthenozoospermia in 20% and a normozoospermia in 16% only. This result was independent of the duration of the torsion. There was no difference in the group of patients with detorsion and the group with orchidectomy. The endocrinological examination revealed a statistically significant correlation between FSH and sperm density and between FSH and the duration of the torsion. But both correlation coefficients were less than 0.5 and are therefore without any clinical relevance. Testosterone, LH and prolactin were normal in all cases.     

Blood perfusion of the contralateral testis evaluated with contrast-enhanced ultrasound in rabbits with unilateral testicular torsion

The changes of blood perfusion of contralateral testis after unilateral testicular torsion remain controversial. In this study, 28 New Zealand white male rabbits were randomly divided into five groups. Group A (n = 8), the control group, underwent a sham operation on the unilateral testis without inducing testicular torsion. In groups B, C, and D (n = 5 each), unilateral testicular torsion was induced, and, after 3, 6 or 24 h, respectively, detorsion was performed. In group E (n = 5), permanent unilateral testicular torsion was applied. Contrast-enhanced ultrasound was used to observe the blood perfusion of the contralateral testis at the following stages: pre-torsion (preopration), immediately post-torsion (postopration), pre-detorsion, immediately post-detorsion, and late-stage post-detorsion (6–12 h post-detorsion in groups B–D) or at a similar time point (15–21 h post-torsion in group E). Time-intensity curves were generated, and the following parameters were derived and analyzed: arrival time, time to peak intensity, peak intensity, and half-time of the descending peak intensity. The analysis revealed that blood perfusion of the contralateral testis increased immediately after testicular torsion on the opposite side (P < 0.05), which increased with prolonged testicular torsion of the other testis. This research demonstrated that contrast-enhanced ultrasound was valuable in evaluating blood perfusion of the contralateral testis after unilateral testicular torsion.     

Neonatal testicular torsion: a survey of current practice amongst paediatric surgeons and urologists in the United Kingdom and Ireland

Purpose

Management of neonatal testicular torsion (NTT) is controversial, with varied opinion regarding the merit(s) and role of “emergent” testicular exploration and/or contralateral orchidopexy of the healthy testis.

Methods

A survey of consultant paediatric surgeons and urologists working in the United Kingdom and Ireland was conducted to ascertain views to guide best practice.

Results

A total of 148 questionnaires were mailed, of which 110 were returned (74% response rate). Of these, 60 (54.5%) surgeons considered NTT secondary to torsion of the spermatic cord and 8 (7.2%) thought primary vascular infarction of the testis responsible. Twelve (10.9%) use Doppler ultrasound to guide management and exclude tumour. Eighty-two surgeons (74.5%) explore the scrotum, and 59 (71.9%) perform ipsilateral orchidectomy and contralateral orchidopexy of the “healthy” testis. Few surgeons undertake emergent exploration. Only 11 (10%) surgeons have ever found a viable testis. Seven (6.4%) cases of synchronous NTT were reported. Twenty-four (21.8%) surgeons do not perform contralateral orchidopexy with concerns of damaging a healthy testis. Orchidopexy is favoured by 89 surgeons, with 46 (52%) using nonabsorbable suture fixation and 28 (31.4%) creating a sutureless extradartos pouch. In boys later found to have a “solitary scrotal testis” and a contralateral testicular remnant, 38 (36.5%) of 104 would always “pex” the testis to avert anorchia.

Conclusions

Surgeons' opinions with NTT in the United Kingdom and Ireland remain diverse. Strong argument can be made for scrotal exploration with/without contralateral orchidopexy. Parents should be counselled on the merits of varied strategies to gain better understanding of the long-term outcomes for their male child.     

Torsion of only spermatic cord in the absence of testis and/or epididymis results in contralateral testicular hypoxia

Unilateral spermatic cord torsion in the presence or absence of ipsilateral testis causes hypoxia in the contralateral testis. An experimental study was conducted to find the most important structure that causes contralateral testicular hypoxia following ipsilateral twisting. In five groups each consisting of 10 rats sham operations, epididymoorchiectomy, spermatic cord torsion, spermatic cord torsion following subepididymal orchiectomy or spermatic cord torsion following epididymoorchiectomy were performed. Lactic acid, hypoxanthine and thiobarbituric acid reactive products of lipid peroxidation (TBAR) were determined in the contralateral testis. While lactic acid, hypoxanthine and TBAR values did not differ significantly following sham and epididymoorchiectomy procedures, evaluation of other groups revealed significantly increased values compared with sham and epididymoorchiectomy groups. Since torsion of only spermatic cord and testicular vasculature causes contralateral testicular hypoxia, testis and epididymis do not seem to be mandatory for occurrence of contralateral testicular hypoxia. Testicular artery under distress seems to be the most important structure that results in contralateral testicular hypoxia following torsion.     

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。     

Two cases of testicular infarction: the usefulness of enhanced MRI for preoperative diagnosis]

The differential diagnosis in acute scrotum, particularly torsion of spermatic cord and epididymitis, is sometimes difficult. An erroneous diagnosis may result in unnecessary and improper treatment. We report two cases of testicular infarction including torsion of spermatic cord, preoperatively diagnosed by enhanced magnetic resonance imaging (MRI). Case 1: A 16-year-old boy presented with a 3-day history of left scrotal swelling and left lower abdominal pain. He had fever and leukocytosis. Antibiotics for 2 days failed to relieve the symptoms. Enhanced MRI showed absence of blood flow in the left testis. Scrotal exploration revealed hemorrhage and necrosis in the left testis. Left orchiectomy and right orchiopexy were performed. Case 2: A 12-year-old boy visited with scrotal swelling and fever 30 hours after an acute onset of left scrotal pain. Enhanced MRI showed absence of blood flow in the left testis. Exploration revealed left necrotic testis with torsion of spermatic cord. Left orchiectomy and right orchiopexy were performed. Our two cases suggested that enhanced MRI, by which the intratesticular blood flow can be evaluated, may be useful for the diagnosis of testicular infarction.     

Experimental testicular torsion: Effect on endocrine and exocrine function and contralateral testicular histology

Summary In order to investigate whether unilateral testicular torsion exerts a negative influence on the previously undisturbed contralateral side, exocrine and endocrine testicular function were evaluated before and two months after torsion. A rat model with 6 hours', 12 hours' or permanent extravaginal 540° torsion of the right testis was used; a sham operated group of animals served as controls. Ejaculates were collected by electrostimulation; LH, FSH and testosterone serum levels were determined by radioimmunoassays. Eight weeks after torsion sperm output had decreased by half in the experimental groups, and LH levels increased significantly, whereas the other hormone levels, as well as the controls, remained unchanged. Morphometry of the contralateral testis revealed no alterations except a significant increase of the Leydig cells and interstitial cells in some subgroups. All observed changes correlate with the functional loss of one testis; definite evidence for contralateral damage was not observed.     

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.     

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.     

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.     

A rare simultaneous presentation of testicular mixed germ cell tumor with a contralateral testis torsion

We report a rare case of a 27-year-old man presenting with an acute scrotum with simultaneous occurrence of testicular tumor and contralateral torsion. Preoperative imaging demonstrated the testicular missed torsion, yet findings were equivocal with regard to the testicular tumor. On scrotal exploration the left testis was found to be ischemic due to threefold rotation. The right testis was not identifiable, being composed of numerous necrotic lesions. Frozen section suggested malignancy, hence high right orchiectomy was performed. Histologic examination of the right testis showed mixed germ cell tumor, containing all the subtypes. To our knowledge no similar case has been reported.     

儿童睾丸扭转103例诊治分析

目的提高儿童睾丸扭转的诊治水平。方法回顾分析1993年1月-2008年1月总计103例14岁以下睾丸扭转患儿的诊治临床资料。砖果年龄1．5d～14岁（平均4．8岁）。睾丸扭转部位：左侧64例,右侧34例,双侧5例。9例（8．74％）患儿（扭转〈6h）行手法复位成功;手术探查94例（91．26％）,保留睾丸行睾丸固定术25例（21例扭转〈6h,3例扭转12～24h,1例扭转〉24h）。睾丸坏死切除69例。右侧睾丸扭转而左侧精索明显长者19例行对侧睾丸固定术。52例（50．49％）患儿病理报告为睾丸附睾缺血性坏死。38例（36．89％）患儿随访1～6年,未发现再发睾丸扭转,5例患侧睾丸萎缩。结论儿童睾丸扭转的早诊断、及时手术治疗是睾丸成活的关键。     

Reperfusion injury after detorsion of unilateral testicular torsion

Summary Reperfusion injury has been well documented in organs other than testis. An experimental study was conducted to investigate reperfusion injury in testes via the biochemical changes after unilateral testicular torsion and detorsion. As unilateral testicular torsion and varicocele have been shown to affect contralateral testicular blood flow, reperfusion injury was studied in both testes. Given that testicular blood flow does not return after 720° testicular torsion lasting more than 3 h, the present study was conducted after 1 and 2 h of 720° torsion. Adult male albino rats were divided into seven groups each containing ten rats. One group served to determine the basal values of biochemical parameters, two groups were subjected to 1 and 2 h of unilateral testicular torsion respectively, two groups were subjected to detorsion following 1 and 2 h of torison respectively, and two groups underwent sham operations as a control. Levels of lactic acid, hypoxanthine and lipid peroxidation products were determined in testicular tissues. Values of these three parameters obtained from the sham operation control groups did not differ significantly from basal values (P>0.05). All three parameters were increased significantly in both ipsilateral and contralateral testes after unilateral testicular torsion when compared with basal values (P<0.01 and P<0.05, respectively). Detorsion caused significant changes in lipid peroxidation products levels in ipsilateral but not in contralateral testes when compared with values obtained after torsion (P<0.01 and P>0.05, respectively). It is concluded that ipsilateral testicular torsion causes a decrease in perfusion not only in the ipsilateral but also in the contralateral testis. Additionally, detorsion following up to 2 h of 720° torsion causes reperfusion injury in ipsilateral but not in contralateral testis.     

Testicular infarction in a 12-year-old boy with Wegener's granulomatosis

We present the case of a 12-year-old boy with testicular infarction secondary to Wegener's granulomatosis. Scrotal exploration revealed no evidence of testicular torsion. The testis was left in place, and, after systemic therapy, partial reperfusion was present.