Testicular torsion and risk factors for orchiectomy

OBJECTIVE: To determine risk factors for testicular loss due to testicular torsion. DESIGN AND PARTICIPANTS: Medical records of patients aged 1 to 25 years with a principal diagnosis of testicular torsion were extracted from the 1998 Nationwide Inpatient Sample. Population-based rates of testicular torsion and orchiectomy were determined. Logistic regression was used to create a predictive model for orchiectomy. For comparison, medical records of patients aged 1 to 25 years with a principal diagnosis of testicular neoplasm were extracted. RESULTS: The sample comprised 436 participants. The estimated incidence of testicular torsion for males aged 1 to 25 years in the United States is 4.5 cases per 100,000 male subjects per year, and the estimated incidence of benign and malignant testicular tumors is 1.2 cases per 100,000. Of the estimated 2248 males diagnosed nationally in 1998 with testicular torsion, 762 (34%) had an orchiectomy. In the final multivariate model estimating the probability of orchiectomy, only age was significant. CONCLUSIONS: For males aged 1 to 25 years, testicular torsion is more common than testicular tumors, and increasing age is the sole identifiable risk factor for orchiectomy. We suggest that health care professionals educate prepubertal male patients about testicular torsion and the necessity of seeking timely care to reduce the risk of orchiectomy and of possible subsequent reduced fertility.     

小儿隐睾扭转的诊治体会

目的：探讨小儿隐睾合并扭转的临床诊治经验。方法回顾性分析2008年7月至2013年12月我们收治的14例小儿隐睾合并睾丸扭转病例的临床资料,其中左侧9例,右侧5例;左侧9例中,2例为双侧隐睾;右侧5例中,1例术中及术后病理检查证实为隐睾合并睾丸成熟畸胎瘤。14例均为单侧隐睾扭转。患儿年龄4岁至11岁5个月,平均3．1岁。结果14例患儿中,11例行扭转坏死睾丸切除术,3例行扭转睾丸复位＋下降固定术,患儿均同期行健侧睾丸固定术或健侧睾丸下降固定术。术后经2个月至5年随访,11例睾丸切除患儿健侧睾丸发育良好,血清睾酮水平正常;3例睾丸下降固定术患儿中,2例睾丸发育良好,1例合并睾丸畸胎瘤患儿经保睾手术后患侧睾丸发育较小,无肿瘤复发。结论早期诊断和及时手术治疗是提高隐睾并扭转患儿睾丸存活率的关键。     

小儿睾丸附件扭转的彩色多普勒超声诊断意义

目的探讨彩色多普勒超声检查在诊断小儿睾丸附件扭转中的意义。方法回顾性分析我院1999年2月～2005年11月收治的小儿睾丸附件扭转病例的临床资料及超声检查结果。结果在所有病人中,发现蓝斑征9例(8.6%),痛性结节23例(21.9%),74例超声检查资料完整的病例中,超声检查在睾丸上极发现无血流回声结节67例,均经手术证实。结论彩色多普勒超声检查若发现睾丸上极附近无血流回声团,则提示睾丸附件扭转。超声检查在小儿睾丸附件扭转的诊断中具有重要的意义。     

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.     

新生儿睾丸扭转临床特点探讨

目的 探讨新生儿睾丸扭转发生的特点及治疗时机选择.方法 回顾性分析近10年新生儿睾丸扭转患儿可能的致病危险因素、临床特点、超声检查结果、治疗策略、病理结果及术后随访情况.结果 新生儿睾丸扭转共17例,左侧7例,右侧10例;其中剖腹产11例(65%),第二产程延长5例(29%),羊水过少2例(12%);术前体检均发现睾丸增大,多伴有阴囊色泽改变(94%).超声检查均发现患睾体积增大、回声不均或增强、血流信号减小或消失.术中探查打开肉膜组织后均发现精索睾丸扭转并已坏死而行患睾切除,其中14例行对侧睾丸固定术.所有患睾病理活检均提示睾丸坏死,7例(41%)可见钙化灶.所有随诊病例超声检查未发现对侧睾丸异常.结论 新生儿睾丸扭转失睾率极高;当发现阴囊色泽改变、睾丸增大等改变,即应考虑睾丸扭转可能;超声检查敏感性高,可作为首选检查方法;患儿出生过程出现异常可能是新生儿睾丸扭转的诱因.

Abstract：

Objective To investigate the clinical characteristics and management of neonatal testicular torsion. Methods Neonatal testicular torsion were reviewed focusing on the possible risk factors, clinical features, ultrasonic characteristics, management, pathological outcome and follow-up results. Results A total of 17 neonatal testicular torsion (left side 7, right side 10) was diagnosed. 11cases of them were cesarean delivery (65 %). 5 cases were found a prolonged second stage of labor (29%), and 2 cases with oligohydramnios (12%) before birth. All patients presented an enlarged testes. Most of them presented with scrotal discoloration (94%). Ultrasound examination showed enlargment of testicular volum, heterogeneity and lacked of blood flow. The twisted testes and spermatic cord showed necrosis intra-operatively. Orchiectomy was carried out. Orchidopexy on contralateral testis was performed in 14 cases. Pathology of ipsilateral testes showed necrosis, and calcification occurred in 7 cases(41 %). All contralateral testes presented normal Ultrasound image during the followup. Conclusions The rate of testicular necreosis was high in neonatal testicular torsion. Testicular torsion should be suspected when neonatal testis presents scrotal discoloration and enlarged testicular mass. Ultrasound inspection is a sensitive method in diagnosing neonatal testis torsion, and should be recommended. Abnormal labor may lead to the neonatal testis torsion.     

Testicular torsion in children: scintigraphic assessment

Seventy-five patients with suspected testicular torsion who had scintiscans and adequate clinical follow-up were analyzed retrospectively. The scintiscans diagnosed 12/13 cases of surgically proven missed torsion and 3/3 cases of surgically proven acute complete torsion. The scintiscans successfully distinguished all 35 cases of epididymo-orchitis, 14 cases of torsion of the appendix testes and 8 other miscellaneous conditions from testicular torsion. The incidence of testicular torsion in our patients undergoing scrotal scintigraphy was approximately 24%.     

Age for testicular torsion?]

Classically, testicular torsion occurs in neonates or during puberty. Between these two ages, is it really an exception? METHOD AND PATIENTS: In order to answer the question, we reviewed the charts of the patients referred to the department of pediatric surgery of Bicêtre hospital between 1992 and 2001. We studied the preoperative examinations, the operative data and the long term evolution. Cases of torsion occurring during neonatal or pubertal periods were excluded. RESULTS: During nine years, 86 patients with "acute scrotum symptoms" underwent surgery. The ages of patients ranged from one month to 11 years (average age: five years) in 26 patients, among which 12 had true testicular torsion. Consultation at the emergency room occurred after one to 72 hours (average of 17). The localization of the pain was on the left in eight cases and on ectopic testicle in two. The testicular volume was increased in 11 cases. Cremasteric reflex was absent in four cases. The doppler flow was normal in four cases and absent in four. During surgery, the testis appearance was considered as normal in six testicles, as necrotized in three (and an orchidectomy was performed) and as ischemic in three. In seven cases, a peroperative contralateral testicle fixation was performed and later one in two. The postoperative course was simple, without infection and with a normal testicular volume in eight cases, increased in one ischemic testis. Testicular atrophy was noted in an ischemic testis, after several months. CONCLUSION: Whatever the age, testicular torsion remains a surgical emergency even with a normal doppler flow.     

睾丸扭转的诊断及治疗

目的 提高睾丸扭转的诊治水平。方法 回顾性分析总结16例睾丸扭转的临床资料。结果 16例均经彩色多谱勒血流成像(Color Doppler ultrasonics flow image，CDFI)确诊为睾丸扭转，2例经手法复位，5例经手术复位固定，9例行睾丸切除加对侧睾丸固定。11例获0．5～4．5年随访，手法复位者1例再次发生扭转，经手术复位治愈。结论 CDFI是诊断急性睾丸扭转的可靠方法，早期诊断、及时手术探查是提高睾丸存活率的关键，术中应同时固定对侧睾丸。     

Testicular torsion following orchiopexy

A case of testicular torsion one year after orchiopexy is presented. The occurrence of testicular torsion following surgery is a rare event which has the potential for diagnostic misadventures. To better delineate this condition, we performed a literature review of all reported cases of recurrent testicular torsion. Thirteen reported patients with testicular torsion following orchiopexy are presented and discussed.     

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.     

儿童睾丸附件扭转的保守治疗指征

目的探讨儿童睾丸附件扭转保守治疗的指征。方法回顾性总结分析1993～1997年底的25例急性阴囊疼痛患儿的诊疗情况,结合文献提出鉴别诊断及选择疗法的依据,将其应用于1998年以后收治的26例患儿中,进一步探讨诊断和治疗指征。结果回顾性总结表明睾丸扭转症状重,就诊早,就诊时间多在发病24h之内。附件扭转疼痛轻,就诊晚,多有48h以上的病史,两者比较,差异有显著性意义(P＜0.05)。1998年后治疗的26例中,5例就诊时疼痛时间短于48h,1例在睾丸上极摸到疼痛性结节,诊断睾丸附件扭转,行保守治疗;4例行急症手术,证实1例睾丸扭转、3例附件扭转。21例就诊时疼痛已48h以上,19例症状轻,彩色多普勒检查,睾丸血流正常,行保守治疗,治疗过程中均可摸到大小不等的触痛性结节,诊断睾丸附件扭转。2例睾丸扭转坏死而行睾丸切除。结论睾丸附件扭转是一种自限性疾病。扪到其特有体征,即阴囊内触疼性结节者;阴囊痛持续48h以上,彩色多普勒检查,睾丸血流正常者,可行保守治疗。睾丸扭转是外科急症,应急症手术。彩色多普勒超声检查对鉴别诊断有重要意义。     

Critical validation of colour Doppler ultrasound in diagnostics of acute scrotum in children.

Acute scrotum in children is generally a symptom. Several pathologies of the testis, scrotum or groin may cause it, including inflammatory as well as ischaemic processes. Testicular torsion with ischaemia of the testis is an emergency requiring prompt surgical intervention. Even experienced paediatric surgeons and urologists may have difficulties differentiating an ischaemic from an inflammatory aetiology solely on the basis of clinical signs and symptoms. In cases of aetiologic uncertainty, operative exploration has to be performed to rule out ischaemia, which led in the past to a high rate of surgery. More recently, colour Doppler ultrasonography (CDUS) has become an imaging modality for the examination of the acute scrotum with the purpose of detecting ischaemia, thus reducing the need for explorative surgery. In this study we examined the reliability of CDUS, comparing the sonographical diagnoses with both the intraoperative findings and the clinical course. We present here 132 consecutive cases of acute scrotum in children, who were admitted from 01/98 through 10/02 to our hospital. All patients underwent CDUS. Patients with ultrasonographic signs of ischaemia of the testis (group A) and patients with demonstrated perfusion and suspicious or severe clinical symptoms (group B) were operated immediately. Patients with demonstrated perfusion without suspicious or severe symptoms (group C) were treated conservatively. Thirty-eight patients (28.8%) were treated operatively. Eleven cases of testicular torsion in group A (12 pat.) could be confirmed intraoperatively, in one case there was no testicular torsion but a severe inflammation of the testis with torsion of the appendix testis. In group B (26 pat.) operative exploration revealed one case of testicular torsion. In group B two cases of sonographically suspected torsions of the appendix testis also emerged as epididymitis intraoperatively. In the other cases postoperative diagnosis was in agreement with the preoperative CDUS. The clinical course of 94 conservatively treated patients (71.2%) (group C) confirmed in all cases a non-ischaemic aetiology. There was a total of 12 cases (9.1%) where acute scrotum was caused by testicular torsions. This relatively low rate underlines the necessity to differentiate between ischaemic and other aetiologies, thus avoiding operation in many patients. 71.2% of our patients could be treated conservatively. However, it is essential to exclude an ischaemic cause before opting for conservative therapy. Even though CDUS is a very valuable diagnostic tool in this sense, this exclusion cannot be ensured in every case and is highly dependent on the expertise and technique of the investigator. Therefore in cases with any doubts an operative exploration has to be performed to avoid the most dreaded complication in the treatment of acute scrotum.     

Colour Doppler ultrasonography replacing surgical exploration for acute scrotum: myth or reality?

Background: Traditionally, every patient with an acute scrotum needed surgical exploration for definitive exclusion of testicular torsion. Objective: In this study, we aimed to evaluate the improved accuracy in clinical diagnosis with colour Doppler Ultrasonography (US) added to normal clinical assessment. Materials and methods: We retrospectively reviewed 626 patients, who presented with acute scrotal pain between January 1998 and June 2004. Following history and physical examination, the patients either proceeded directly to surgery or underwent US examination. If clinical suspicion of testicular torsion persisted after US, the patients would still undergo scrotal exploration. Results: Of the 294 patients who had routine scrotal exploration without preliminary US, only 23 (7.8%) were found to have testicular torsion. Amongst the 332 cases that had initial US, 9 (2.7%) patients revealed testicular torsion that was confirmed at subsequent surgery. The remaining 323 patients had initial negative US, but 29 were explored eventually on clinical indications. Of these, 4 (1.2% of 323) cases were diagnosed intra-operatively as testicular torsion. None of the remaining 294 patients who were managed conservatively proved to have testicular torsion after a minimum follow-up of 2 weeks. For testicular torsion, US yielded a sensitivity of 69.2% (95% confidence interval =38.9–89.5), specificity of 100% (95% CI=98.5–100), positive predictive value of 100% and negative predictive value of 97.5%. Conclusions: US has proven to decrease the number of emergency scrotal explorations, length of hospital stay and hence reduce the cost of management of acute scrotum.     

Color Doppler sonography in the diagnosis of acute scrotum in boys.

Evaluation of acute painful scrotum is difficult and imaging studies have been reported to be unreliable in detecting testicular torsion. In order to assess the value of color Doppler sonography in acute scrotal disease, the authors reviewed 65 consecutive boys, ranging in age from 1 to 16 years. The study demonstrated absent or diminished flow signals in 11 patients. All of them had a surgical intervention, and in 8 of them, a testicular torsion was confirmed. 54 boys had a symmetrical or increased flow signal on the affected side. Just 5 boys among this group underwent surgical exploration. On follow up, none of the 54 patients with good flow signals proved to have a testicular torsion. Sonography and color Doppler sonography helped to differentiate epididymitis and torsion of a testicular appendage as a basis for further investigations and correct conservative therapy. In detecting a testicular torsion, color Doppler sonography yielded a positive predictive value of 73%, a sensitivity of 100% and a negative predictive value of 100%. We therefore conclude, that Doppler sonography can reliably rule out testicular torsion so that routine scrotal exploration in cases of acute scrotum is no longer necessary. By reducing the number of emergency operations and hospitalization days, color Doppler sonography can cut down the total cost of managing acute painful scrotum in boys.     

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     

Testicular torsion versus epididymitis: a diagnostic challenge.

Unlike the patient who presents with a potentially acute abdomen, the child or adolescent with a potentially acute scrotum cannot simply be observed. If testicular torsion is present, the testicle must be detorted and orchiopexy performed as soon as possible for fertility to be maintained. Torsion of the appendix testis, however, can usually be managed without surgery. Since the presentations of epididymitis and testicular torsion overlap, it is sometimes difficult to rapidly make the correct diagnosis. Early genitourinary consultation is appropriate in this setting. Any patient in whom testicular torsion is strongly considered should undergo immediate exploratory surgery without diagnostic studies. If the findings overlap, immediate testicular radionuclide scanning should be arranged; alternatively, with experience, Doppler sonography can be carried out. If these radiographic studies cannot be arranged and interpreted within one to two hours, scrotal exploration should be performed. Any patient with an acute scrotal complaint and a negative scan should receive daily follow-up until the symptoms subside. Although our adolescent patient did well, his acute presentation and findings should have warranted immediate exploration. It is only through this aggressive approach that we can continue to increase testicular salvage rates.     

Gray-scale sonography in torsion of the testicular appendages

The reliability of gray-scale ultrasonography in diagnosing torsion of the testicular appendages was studied in a series of 54 boys with acute non-traumatic scrotal pain. All boys were operated upon, and the appendages extirpated irrespective of their appearance at exploration; the final diagnosis was based on histological examination. Forty-two boys had appendicular torsion, 2 had testicular torsion and 10 had other diagnoses. Using the sign of appendicular torsion — an echogenic extratesticular structure situated between the head of the epididymis and the upper pole of the testis — as the criterion, 37 displayed a true positive, 9 a true negative, 3 a false positive and 5 a false negative diagnosis. Thus, the sensitivity was 88%, the specificity 75% and the positive predictive value 93% respectively. The echogenic mass varied in size from 3 to 17 mm in diameter. In 34 of the 42 cases of appendicular torsion extratesticular fluid was present, and 19 patients showed enlargement of the head of the epididymis. It is concluded that gray-scale sonography is an accurate and valuable tool in diagnosing torsion of the testicular appendages.     

Early scrotal exploration in all cases is the investigation and intervention of choice in the acute paediatric scrotum

The acute scrotum in the paediatric population is a clinical dilemma where a definitive diagnosis can only truly be made at surgical exploration. We postulate that surgical exploration in all cases allows truly accurate diagnoses, treats the torted appendage testes and enables the validity of clinical signs associated with scrotal pathology to be assessed. We retrospectively reviewed all boys less than 15 years old who presented to our institution with scrotal pain over a 2 year period. A total of 121 patients attended of whom 113 had exploratory surgery, 31 (27%) had testicular torsion, 64 (57%) had a torted appendage testis, 12 (11%) had epididymitis, 1 (1%) had fat necrosis and 5 (4%) had no abnormality detected. On exploration 9 (29%) of the torted testis were unsalvageable and thus required excision. The initial clinical impression was frequently demonstrated to be flawed. Two patients with testicular torsion presented with a painless swelling and two further patients had necrotic testes despite a history of pain for less than 4 h. A normal cremasteric reflex and a visible blue dot were detected in boys with testicular torsion. Doppler ultrasound scans were not reliable with 50% sensitivity to clearly differentiate between torsion of the testis and that of the appendage testis. Absolute dependence on clinical features can lead to a misdiagnosis of testicular torsion. The surgical treatment of torted appendage testis is safe, allowing accurate diagnosis and pain relief with minimal morbidity. Early scrotal exploration of all cases with testicular pain ensures maximal testicular salvage.     

Testicular torsion: potential pitfalls in its diagnosis and management

Torsion of the testis is a surgical emergency. Within the paediatric population, peaks in incidence occur in the perinatal and adolescent age groups. There exist traps that can make torsion of the testis a difficult diagnosis to make and once made a tricky condition to manage, in some instances. It is becoming clear that perinatal torsion should serve as an umbrella term for what is increasingly being regarded as two separate entities: prenatal and post-natal torsion. Evidence suggests that the management for each of these may be different. While management of testicular torsion in the adolescent is universally agreed upon, the diagnosis can sometimes be difficult to make. This notwithstanding, early diagnosis is imperative for ensuring the best possible outcome.     

Familial testicular torsion: A meta analysis suggests inheritance

ObjectiveFamilial occurrence of testicular torsion has been infrequently reported. To date, no systematic analysis has been published. We systematically analyzed the literature to elucidate the epidemiology, presentation, management, and whether the observed prevalence of testicular torsion in families is consistent with absence of inheritance and is randomly distributed.Patients and methodsWe searched electronic databases using keywords “testicular torsion”, “spermatic cord torsion”, “familial torsion” and “sibling torsion”. Reports with genetically related first degree relatives were included in the analysis. Levene's nonparametric test was used to compare the variance of the age of presentation within families to that between different families to differentiate between familial predisposition and chance events.ResultsUp to 10% of patients with testicular torsion have an affected first degree relative. We were able to reject the null hypothesis that the observed prevalence of testicular torsion is due to chance (p < 0.001). Family history is missed in at least 27% of affected families. There is a high incidence of bilateral testicular torsion in families (37%) and probands (17%) and a high concordance rate for bilaterality among monozygous twins.ConclusionsCurrent evidence from clinical and animal studies suggests the presence of a genetically determined component in familiar testicular torsion. Increased awareness may lead to earlier clinical presentation and higher testicular salvage rates.