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.     

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     

Intravaginal perinatal torsion of the spermatic cord

Spermatic cord torsion is an urologic emergency that requires urgent evaluation and possibly emergency surgical management. In a neonate it occurs during testicular descent and is usually due to an extravaginal torsion, where the testis and sperinatic cord twist. We present a case of intravaginal testicular torsion in a neonate. In this situation, as the anomalous implant of the tunica vaginalis can occur bilaterally, it is important to fix the contralateral testis in order to prevent late torsion of this gonad.     

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.     

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.     

Two cases of female hydrocele of the canal of nuck

The processus vaginalis within the inguinal canal forms the canal of Nuck, which is a homolog of the processus vaginalis in women. Incomplete obliteration of the processus vaginalis causes indirect inguinal hernia or hydrocele of the canal of Nuck, a very rare condition in women. Here, we report 2 cases of hydrocele of the canal of Nuck that were diagnosed with ultrasonography in both cases and magnetic resonance imaging in 1 case to confirm the sonographic diagnosis. High ligation and hydrocelectomy were conducted in both patients. In 1 patient, 14 months later, the occurrence of contralateral inguinal hernia was suspected, but did not require surgery. The other patient had a history of surgery for left inguinal hernia 11 months before the occurrence of right hydrocele of the canal of Nuck. In both cases, the occurrence of an inguinal hernia on the contralateral side was noted.     

Ascent of the testis in children

Among 460 children who had an orchiopexy (ORP), we identified 72 children who had attended our institution 1–12 years earlier and in whom the testicular position had been specified. Of the 72 boys 19 were had ascended testes (26%). The age at ORP of the children with ascent of the testes was 7.0 years (1.8–14.0 years). Light and electron microscopy of 13 testicular biopsies taken at ORP, showed alterations of germ cells and sertoli cells, similar but less pronounced than alterations seen in congenital undescended testes.Conclusion A normally positioned testis may ascend into the inguinal region or upper scrotum and remain there fixed. This secondary cryptorchidism does not usually respond to human chorionic gonadotropin treatment and must be corrected by orchiopexy.     

Abdominoscrotal hydrocele in infancy: a study of 15 cases

Only 25 cases of unilateral abdominoscrotal hydrocele (ASH) and 3 of bilateral ASH have been reported since 1834. Fifteen infants with ASH were treated on a single pediatric surgery service during a period of 4 years, accounting for 1.7 per 1,000 outpatient visits. In 4 cases the defect was bilateral. Although this unusual concentration of cases in unexplained, recognition and careful documentation of ASH in infancy is recommended. Accepted: 15 November 1996     

Epidermoid cyst of the testis in children

An epidermoid cyst of the testis was found in a 10 year-old child. The interest of this case report resides in the fact that it is rare in childhood and that its pathogenesis is not well known. Although the treatment of this condition remains controversial, a high orchidectomy through the inguinal tract was performed to a correct pathological diagnosis.     

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.     

Elective orchidopexy in the paediatric population: a trial of intra-operative spermatic cord block

It is well established that pre-emptive and multimodal analgesia improve pain control and decrease narcotic use as well as the length of stay. Whilst some form of local anaesthetic (LA) block is almost routine for most inguinal procedures in children, the best modality is uncertain for orchidopexy. We sought to explore as to whether the addition of spermatic cord block (SCB) to our standard ilio-inguinal block (IIB) in this situation had any impact on analgesic requirements post-operatively. A retrospective review of a single surgeon and single centre experience of LA block for elective orchidopexy is described for a 9-year period. In the first half of the study, the LA technique was an IIB. An SCB was added to the IIB in the second half using the same total dose of 0.8 ml/kg bupivacaine. In the entire group, 35% of the SCB + IIB boys required narcotics as compared to 56% with IIB alone (p > 0.05). On subgroup analysis of a “medium risk” procedure (i.e. inguinal approach for a superficial pouch testis) only 35% required narcotics in the SCB + IIB group as compared to 70% in the IIB (p < 0.05). Use of a SCB + IIB in elective orchidopexy in a paediatric population has additional benefit to IIB alone.     

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