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.     

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.     

Color Doppler ultrasonography in the diagnosis of the acute scrotum

PURPOSE: To determine the value of color Doppler ultrasonography (CDUS) in the diagnosis of acute scrotum. MATERIALS AND METHODS: 10 patients referred to our hospital with acute scrotal pain were included in this study. All patients were evaluated with CDUS after the initial clinical examinations. Blood flow of the involved testis was compared semiquantitatively to that of the opposite testis. Patients with a diagnosis of testicular torsion by CDUS underwent surgical exploration. Patients with CDUS diagnosis of epididymitis were treated with intravenous antibiotics. RESULTS: Of the 10 patients evaluated, CDUS diagnosed 5 patients with testicular torsion and 5 patients with epididymitis. All cases of torsion were confirmed intraoperatively. 2 cases with no intratesticular blood flow on CDUS had necrotic testes and underwent orchiectomy with orchiopexy of the contralateral testes. A case with absent flow and 2 cases with decreased flow had bilateral orchiopexy. CDUS findings of normal or increased flow were present in all patients with epididymitis. No cases of testicular atrophy were encountered on long-term follow up in patients with epididymitis. CONCLUSION: CDUS is helpful in detecting the perfusion of the testis as well as in getting anatomical information. CDUS is a very useful device which causes a minimal burden to the patient with acute scrotum. In most cases it will rapidly provides us the correct information although it may not be regarded as the definitive adjunct.     

精索形态观察在睾丸扭转早期诊治中的意义

目的:提高睾丸扭转早期的诊断和治疗水平。方法:回顾性分析49例睾丸扭转的临床资料及睾丸内血流声像图和精索超声特征。结果:49例睾丸扭转患者,彩色多普勒血流显像出现睾丸血流改变42例,其中血流增加3例,睾丸血流无明显改变7例;二维超声检查发现精索形态异常47例。手术复位固定21例,睾丸存活12例。结论:彩色多普勒超声扫描精索形态与睾丸血流变化对睾丸扭转的早期诊断有重要价值,尽早手术探查有助于挽救存活睾丸。     

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。     

Metachronous bilateral torsion of the testicular appendices

BACKGROUND: Torsion of the appendix testis is a common cause of scrotal pain in children and a common cause for surgical exploration of the pediatric scrotum. The first case of metachronous bilateral torsion of the testicular appendices managed by a non-operative approach is reported. METHODS/RESULTS: A case report and a computer-assisted review of the literature are presented. Physical findings of a tender, mobile mass over the anterior surface of the testis characterize the presentation. Doppler findings of normal blood flow to the testes with increased flow to the adjacent appendix testis can be utilized as an adjunct to diagnosis. Ultrasonographic findings of a pedunculated mass with a central hypoechoic area at the superior aspect of the testis support the diagnosis. Accurate non-operative diagnosis of torsion of the appendix testis permits successful conservative management with non-steroidal anti-inflammatory agents. CONCLUSIONS: Improvements in ultrasonographic and Doppler imaging of torsion of the appendix testis have facilitated the diagnosis of this entity and decreased the need for surgical exploration of the scrotum.     

Impalpable testis: testicular vessel division in treatment.

Between 1984 and 1989, 110 boys with 130 impalpable testes were investigated and treated. One hundred and six boys underwent laparoscopy. Twenty had bilateral impalpable testes and 13 had a palpable, but maldescended, testis on the other side. Forty-nine testes were absent and one atrophic testis was found in the scrotum. Twelve orchidectomies were performed. One child had a microvascular transfer procedure. The remaining 67 testes were treated by orchidopexy: 28 single-stage and 39 two-stage procedures. One of the single-stage and 29 of the two-stage orchidopexies included division of the testicular vessels. Twenty-three testes examined 12 or more months after staged testicular vessel division revealed a good result in 15.     

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.     

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。     

Incomplete prenatal torsion of the testicle--a successful salvage

The role of emergent intervention in prenatal testicular torsion is controversial. We report a case of successful testicular salvage of incomplete prenatal torsion. A 1-day-old male infant presented with a bluish-hued scrotum at birth. Testicular ultrasonography demonstrated right testicular torsion with minimal peripheral blood flow. Scrotal exploration was performed, confirming extravaginal torsion; both testes underwent orchiopexy. Subsequent imaging demonstrated normal bilateral testes with good vascular flow. Although intervention of prenatal torsion has been debated, the present case represents prenatal torsion saved by intervention. We propose the presence of any blood flow suggests incomplete torsion and the potential for salvage.     

Bell-Clapper综合征

目的：加强对Ｂｅｌｌ－Ｃｌａｐｐｅｒ综合征的认识，以及早诊断与手术，减少睾丸扭转坏死的发生率。方法：对４例间歇性睾丸疼痛及３例睾丸扭转坏死或萎缩病例的临床资料进行回顾性分析。结果：７例解剖上均有Ｂｅｌｌ－Ｃｌａｐｐｅｒ。对４例间歇性睾丸疼痛患者作了双侧睾丸探查及固定，３例睾丸坏死或萎缩者作了病睾切除及对侧睾丸固定术。     

Is the vanished testis always a scrotal event?

OBJECTIVE: To determine if perinatal testicular torsion resulting in a vanished testis is an event that primarily occurs in the scrotum. PATIENTS AND METHODS: The records of 54 boys identified as having a solitary testis were reviewed. The side of absence, size of the solitary testis, method of surgical evaluation (scrotal, inguinal or abdominal), surgical findings and histology of the tissue removed were noted. RESULTS: The testis was absent twice as often on the left side, the solitary testis was hypertrophic in 25 of 42 boys in whom it was evaluated, and tissue grossly or histologically consistent with a testicular 'nubbin' was removed in 52 boys. Scrotal (47) or inguinal (seven) exploration was carried out in all. Laparoscopy (28) or abdominal exploration (two) was undertaken to confirm that no testicular tissue was present in the abdomen in 30 boys, including the two in whom no tissue was found on scrotal or inguinal exploration. CONCLUSIONS: Perinatal testicular torsion occurs after descent but before fixation of the tunica vaginalis to the scrotal wall. These testes atrophy, leaving a remnant of tissue in the scrotum that can be identified on scrotal exploration in almost all cases. Therefore, it is recommended that the evaluation of the child with a solitary palpable testis start with scrotal exploration. Laparoscopy should be reserved for those in whom no tissue consistent with a testicular nubbin is found in the scrotum.     

未成熟大鼠睾丸单侧扭转后对健侧血流和组织学的影响

目的:观察未成熟大鼠睾丸单侧扭转后对健侧睾丸血流供应和组织学的影响,并比较不同处理方法的疗效。方法:建立Wistar3周龄大鼠左侧睾丸扭转模型,分别建立对照组、扭转组、扭转复位组和扭转切除组,每组10只。彩色多普勒测量各组术前、术后8h(即扭转复位或切除术后2h)、12h、24h、72h右侧睾丸动脉收缩期最大血流速度,并于对照组和扭转组术后2h,扭转复位组和扭转切除组第1次术后12h各取2只大鼠右侧睾丸进行组织病理学观察。各组喂养至9周龄时分别取右侧睾丸进行组织学观察及检测各组大鼠右侧睾丸的生精小管直径(STD)、生精上皮细胞计数(CMSE)和睾丸活检评分(TBS)。结果:①未成熟睾丸左侧扭转后,右侧睾丸的血供呈持续性增加。②扭转组、扭转复位组和扭转切除组右侧睾丸均有不同程度的间质水肿和超微结构改变。③9周龄时扭转组、扭转切除组右侧睾丸重量均较对照组显著增加(P<0.01);各组大鼠STD、CMSE、TBS均无显著性差异(P>0.05)。结论:未成熟大鼠睾丸单侧扭转后可引起对侧睾丸的血供增加和组织学改变,轻微损伤后扭转复位和睾丸切除预后效果相似。     

Intra-uterine testicular torsion: early diagnosis and treatment.

OBJECTIVE: To review the incidence and treatment of intra-uterine torsion of the testis which although rare is being recognized with increasing frequency. PATIENTS AND METHODS: From 1988 to 1997, five newborns (mean birth weight 3.62 kg, range 3.15-4.12) with unilateral torsion of the testis were treated; all underwent emergency exploration. The right testis was affected in three and the left in two boys. RESULTS: In all except one child, the affected testis was enlarged, firm to hard, tender, the overlying skin dark red and the affected testis higher than the contralateral testis. In one child the right testis was enlarged and higher, but soft to firm, and the overlying skin was oedematous and red. The exploration revealed extravaginal torsion of the testis which was gangrenous in four; in one after detorsion there was haemorrhage and haematoma of the cord and the tunica, and the testis was slightly congested but not gangrenous. This testis was preserved and bilateral orchidopexies performed; at 18 months both testes are palpable and of normal size. In the remaining four children the testes were frankly necrotic; they underwent orchidectomy and contralateral orchidopexy. Histology in all four revealed a totally infarcted testis with extensive haemorrhage and vascular congestion. CONCLUSION: The early diagnosis and treatment of intra-uterine torsion of the testis is essential.     

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.     

Torsion of the testis and allied conditions.

In 15 years at Bristol there have been 293 cases of torsion of the testis, 55 cases of torsion of a testicular appendage and 5 cases of testicular ischaemia due to other causes. The risk of a male developing torsion of the testis or its appendix by the age of 25 is about 1 in 160. Both conditions occurred primarily in adolescents, but among prepubertal boys torsion of an appendage was as common as torsion of a normally descended testis. There was a slight left-sided preponderance in testicular torsion, more marked in torsion of the appendages; the incidence of bilateral torsion was 2-0 and 1-8 per cent respectively. The clinical features and differential diagnosis of the two conditions are compared. Torsion of a testicular appendage is the most commonly misdiagnosed scrotal lesion, the preoperative diagnosis being correct in only 11 per cent of cases compared with 90 per cent for torsion of the testis. Twenty-one cases of recurrent torsion underwent prophylactic bilateral orchidopexy. There were 20 cases of torsion of undescended testes, with a salvage rate of only 20 per cent. The overall testicular survival rate was 55-3 per cent. Viability depends upon the possibility of spontaneous reduction, the preoperative delay after the onset of symptoms, the degree of torsion of the cord and the length of follow-up in doubtful cases. Urgent scrotal exploration is advised in every case of acute testicular pain unless there is overwhelming evidence of epididymoorchitis. Exploration of the opposite side is mandatory in torsion of the testis and advisable in torsion of an appendage.     

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.     

The protective effects of nitric oxide on the contralateral testis in prepubertal rats with unilateral testicular torsion

OBJECTIVE: To investigate histological changes in the contralateral testis of rats with unilateral testicular torsion and the protective effects of nitric oxide (NO) on possible damage. MATERIAL AND METHODS: Twenty-eight prepubertal male Sprague-Dawley rats were divided into four equal groups. Group 1 underwent a sham operation of the right testis under general anaesthesia. Group 2 underwent a similar operation but the right testis was rotated 720 degrees clockwise for 6 h, maintained by fixing the testis to the scrotum, and saline infused during the procedure. Group 3 underwent similar torsion but L-arginine methyl ester (a precursor of NO) was infused during the procedure. In Group 4, NG-nitro-L-arginine-methyl ester, a NO synthase inhibitor, was infused separately during the administration of L-arginine methyl ester and torsion. All the left (untwisted) testes were removed from rats 21 days after surgery and evaluated histologically, assessing seminiferous tubule diameter, loss of sperm and spermatids, loss of germ cell layers, disarray of germ cell layers, rupture of tubules, Leydig cell proliferation and reaction in the ruptured tubules, and oedema. RESULTS: There was a significant difference in the indicators of histological damage between groups 2 and 4 and groups 1 and 3, except for the Leydig cell reaction in the ruptured tubules and oedema. The damage was significantly less in group 3 than in groups 2 and 4. CONCLUSION: These results suggest that long-term histopathological changes in the contralateral testes are important after unilateral testicular torsion and that NO has a protective effect on the contralateral testis.     

Testicular tissue bleeding as an indicator of gonadal salvageability in testicular torsion surgery

OBJECTIVE: To investigate the reliability of using bleeding from the cut surface of testicular tissue during surgery for testicular torsion to assess testicular viability, compared with the duration of symptoms and preoperative findings on testicular Doppler ultrasonography (DUS). PATIENTS AND METHODS: The study comprised 19 children with testicular torsion who underwent surgery; all underwent DUS before surgery. During surgery the tunica vaginalis of the affected gonad was incised and a deep incision made through the medulla after obtaining a wedge biopsy for histological examination. After waiting up to 10 min to assess any fresh arterial bleeding from the cut surface, the patients were categorized using three grades; grade I (sufficient bleeding, i.e. bleeding or oozing when the biopsy was obtained); grade II (insufficient bleeding, no bleeding immediately after the incision but starting within 10 min); and grade III (no bleeding within 10 min). The final surgical decision on whether to save the testis was made according to the grade of testicular tissue bleeding; grade I and II testes were saved and grade III testes were removed. The biopsies were histopathologically examined and classified as haemorrhagic, necrotic or indeterminate. The patients were followed up at 15 days and at 1, 3, 6 and 12 months, with the affected testis examined using DUS. At the end of the study, the sensitivity and specificity of the duration of symptoms, characteristics of blood flow on DUS and grading of testicular tissue bleeding at surgery were calculated for predicting testis viability, using the histopathological diagnosis as the reference standard. RESULTS: The sensitivity, specificity, positive and negative predictive values were respectively 100%, 90%, 90% and 100% for a duration of symptoms of > 10 h, 78%, 80%, 78% and 80% for DUS findings, and 100%, 78%, 83% and 100% for testicular tissue bleeding in predicting gonad viability after torsion, respectively. CONCLUSION: Although the 10 h limit for the duration of symptoms seems a more accurate predictor of the fate of a twisted testis than were the other variables, testicular tissue bleeding may also be a good indicator of gonadal viability during surgery. The surgeon should wait up to 10 min after incising the testicular tissue deep to the medulla before deciding the type of surgery. In cases where bleeding from the cut surface is sufficient or insufficient (according to the proposed grading system), orchidopexy is the treatment of choice. The salvaged testes should be assessed during follow-up, especially in those who had had insufficient bleeding at surgery and/or a duration of symptoms > 10 h, to assess for any delayed damage to the untwisted testis. If no bleeding is seen during surgery the best option is to remove the affected testis.     

The difficult orchidopexy: the value of the abdominal pre-peritoneal approach

OBJECTIVE: To analyse the outcome of using the abdominal pre-peritoneal (APP) approach to orchidopexy. PATIENTS AND METHODS: During an 8-year period, the experience of one surgeon in the management of 553 boys (median age 4.5 years, range 1-13) with undescended testes (596 testes) was assessed. The analysis emphasized those patients who had an orchidopexy performed using the APP approach detailing; the original position of the testis at exploration, whether successful placement within the scrotum was possible, and whether atrophy or ascent of the gonad occurred subsequently. RESULTS: In 98 boys (110 testes) the testes were impalpable or high within the inguinal canal and they were explored using the APP approach. Of the 34 testes (31%) which were found abdominally, 12 were high intra-abdominal and the remaining 22 just deep to the internal inguinal ring. These included seven bilateral and 20 unilateral intra-abdominal testes. The remaining 76 undescended testes included five with bilateral high testes, 29 high unilateral testes, 13 repeat orchidopexies, 17 'vanishing testis syndrome' and seven atrophic testes. The remaining 486 undescended testes were treated using a standard orchidopexy and were therefore excluded from analysis. CONCLUSION: The value and advantages of this operative approach and its place in the management strategy of the difficult orchidopexy are discussed.