Spiral twist of the spermatic cord: a reliable sign of testicular torsion

Background. Colour Doppler sonography (CDS) has become the procedure of choice in evaluating testicular perfusion but false negative findings have been reported. Objective. To determine if direct visualisation of the twisted spermatic cord using high resolution US is a reliable sign to assess testicular torsion. Material and methods. Thirty patients (aged 2–26 years) with equivocal diagnosis of testicular torsion prospectively underwent high resolution and CDS. The results were correlated with surgical findings. Serial transverse and longitudinal scans were performed to compare the scrotal contents on each side and study the complete spermatic cord course, from inguinal canal to testis, to detect a spiral twist. Results. In 14 of the 23 cases of torsion, the diagnosis was based on the colour Doppler findings in the scrotum because blood flow was absent in the symptomatic testis and detectable without difficulty on the normal side. In nine cases, CDS was unreliable; in six cases intratesticular perfusion was present in a twisted testis and in three small boys, no colour signal was obtained in either testis. In all cases of torsion, the spiral twist of spermatic cord was detected at the external inguinal ring. The twist induced an abrupt change in spermatic cord course, size and shape below the point of torsion. It appeared in the scrotum as a round or oval, homogeneous or heterogeneous extratesticular mass with or without blood flow, that could be connected cephalad with the normal inguinal cord. In the other seven cases (three late torsions of the appendix testis, one epididymo-orchitis and three torsions with spontaneous reduction), no spiral twist was detectable. Conclusion. The detection of spermatic cord spiral twist appears a reliable US sign of torsion whatever the testicular consequences. Received: 1 December 1997 Accepted: 17 June 1998     

Sonographic diagnosis of acute spermatic cord torsion. Rotation of the cord: a key to the diagnosis

BACKGROUND: Although the primary abnormality in testicular torsion is at the spermatic cord, imaging studies up to now have mostly been oriented to evaluation of the testicle itself, with emphasis on color Doppler ultrasonography (US). However, findings can be inaccurate when there is incomplete interruption of testicular flow. Indirect findings, such as morphological changes in the testis alone, are not reliable for the diagnosis since they become evident late in the disease. OBJECTIVE: To call to attention to the fact that sonographic visualization of the spermatic cord can be the key for diagnosis in those patients with acute scrotal pain as a result of testicular torsion, particularly when color Doppler US shows that intratesticular flow is present within the affected testis. PATIENTS AND METHODS: Six patients who presented clinically with acute scrotal pain and had spermatic cord torsion, proven at surgery. All patients were initially studied with color Doppler US, and intratesticular flow was detected in all of them. Patients who showed structural abnormalities on gray-scale US and/or absence of intratesticular vascular flow in the affected testis were not included. In addition to a conventional study, the spermatic cord was examined. RESULTS: The spermatic cord was shown to be rotated on the symptomatic side in all patients. Local morphological and vascular flow changes, distal and at the site of the torsion, were found and registered. CONCLUSIONS: The finding of a rotated spermatic cord could be a highly reliable and direct sign for the diagnosis of a testicular torsion, and this is especially important when vascular flow is present within the affected testis on color Doppler US examination. Examination of the spermatic cord should be added to evaluation of the testis in patients with suspected testicular torsion to enhance sensitivity of the examination.     

Colour Doppler imaging — a new method to differentiate torsion of the spermatic cord and epididymo-orchitis

A newborn boy with torsion of the spermatic cord and an 8-year-old boy with epididymitis were investigated by colour Doppler imaging (CDI). Due to torsion of the spermatic cord, no blood flow could be observed within the testis and the epididymis. In epididymitis blood flow was markedly increased. CDI seems to be useful for differentiating between the two disorders.     

Epidermoid cyst of the spermatic cord

An epidermoid cyst in the spermatic cord of a child, which was found incidentally at operation for hydrocoele, is reported. Although well described in the testis, epidermoid cyst has not previously been reported as occuring in the spermatic cord. The possible pathological aetiology is discussed. Offprint requests to: A. C. Gordon     

Preoperative manual detorsion of the spermatic cord with Doppler ultrasound monitoring in patients with intravaginal acute testicular torsion

Objective. To assess the effectiveness of preoperative manual detorsion in acute testicular torsion.¶Materials and methods. Between June 1998 and March 1999, seven patients presenting with testicular torsion underwent manual manipulation under US monitoring in order to restore the flow to the testis prior to surgery (orchidopexy). All detorsions were lateral in direction. The success of the manoeuvre was assessed both clinically and sonographically and confirmed at surgery.¶Results. Six manoeuvres were successful in restoring flow to the testis. The failed attempt in the seventh patient was due to failure to manipulate beyond an initial 1 1/2 rotations (540 °).¶Conclusions. Preoperative detorsion is the fastest way to relieve testicular ischaemia. However, manual detorsion of the spermatic cord is not a substitute for surgical exploration and bilateral orchidopexy is still necessary.     

Torsion of the spermatic cord after orchiopexy

The cases of spermatic cord torsion reported here show that this condition may occur even some time after fixation. Three men, aged 22, 30 and 35 years, visited the urologist with complaints of an acute scrotum following earlier orchiopexy for spermatic cord torsion. Different techniques are employed to fixate the testicles after spermatic cord torsion. These cases confirm that Jaboulay's bottleneck procedure is the method of choice for bilateral fixation in patients presenting with this condition.     

Spin on perinatal testicular torsion

We describe a recent case of perinatal testicular torsion at our institution. The presentation, management and outcome of perinatal testicular torsion are quite different to testicular torsion in the general paediatric population. The literature describes a variety of management options for perinatal testicular torsion and these are briefly reviewed. In cases of unilateral perinatal testicular torsin, there is controversy over whether surgery to fix the contralateral testis is required, and if so, the appropriate timing for the surgery. A good understanding of the issues unique to perinatal torsion will facilitate appropriate counseling of parents of affected neonates.     

The morphological evaluation of ipsilateral and contralateral vasa deferentia in a rat model of unilateral spermatic cord torsion

Aim  

Spermatic cord torsion is a surgical emergency that requires early intervention to protect the effected testicle. The literature review about this ischemic reperfusion (I/R) injury reveals not only ipsilateral, but also contralateral testicular and epididymal injuries in a broad fashion. However, there is no data about vas deferens injury related with this surgical emergency. The aim of the study is to evaluate the morphological changes of the vas deferens due to testicular I/R injury.     

New insights into perinatal testicular torsion

Perinatal testicular torsion is a relatively rare event that remains unrecognized in many patients or is suspected and treated accordingly only after an avoidable loss of time. The authors report their own experience with several patients, some of them quite atypical but instructive. Missed bilateral torsion is an issue, as are partial torsion, possible antenatal signs, and late presentation. These data are discussed together with the existing literature and may help shed new light on the natural course of testicular torsion and its treatment. The most important conclusion is that a much higher index of suspicion based on clinical findings is needed for timely detection of perinatal torsion. It is the authors’ opinion that immediate surgery is mandatory not only in suspected bilateral torsions but also in cases of possible unilateral torsions. There is no place for a more fatalistic “wait-and-see” approach. Whenever possible, even necrotic testes should not be removed during surgery because some endocrine function may be retained.     

Cavernous haemangioma of the spermatic cord in a child

We present a unique case of an 11-year-old boy with a cavernous haemangioma of the spermatic cord. Sonography showed a well-defined, heterogeneous echoic mass with internal calcifications in the paratesticular region while radiography showed several phleboliths in the scrotum. Both were helpful in differentiating this paratesticular tumour.     

Hydrocele of the spermatic cord: Embryology and ultrasonographic appearance

Five cases of hydrocele of the spermatic cord are presented. All five patients had a firm inguinal mass, and ultrasonography, performed to exclude adenopathy, incarcerated hernia, and paratesticular tumor, showed an avascular cystic mass superior to and separate from the testicle. A testicular hydrocele did not coexist. This typical appearance should lead to a confident diagnosis of this benign but rare anomaly. Elective surgery may prevent the development of an acquired indirect hernia.     

Torsion of spermatic cord in children: A review

The current opinion on spermatic cord torsion is discussed in this review, with special attention to natural history, value of diagnostic tools, evidence for surgical management, outcome and management of atypical forms of torsion.     

Spermatic cord torsion: diagnostic limitations

To distinguish spermatic cord torsion from other intrascrotal pathology, scrotal ultrasound and radionuclide scanning have been highly recommended on the basis of both clinical and experimental studies. We review the data from six patients in whom ultrasound or nuclear medicine examination was misleading. We emphasize that history, physical examination, and urinalysis remain the cornerstones of the diagnosis of spermatic cord torsion. Scrotal ultrasound and nuclear medicine scans are useful adjuncts and are reassuring when in agreement with the clinical picture. However, they are not 100% sensitive or specific, and a negative study should not prevent emergency operative exploration of a clinically suspicious lesion.