Protection of the solitary testis

In 15 negative explorations for unilateral cryptorchidism, inspection of the contralateral scrotum revealed a "bell-clapper" deformity in 13 patients. Since the descent of the testis is influenced by the gubernaculum and gubernacular abnormalities are usually bilateral, the data suggest that an inadequate gubernaculum is associated with most instances of antenatal and postnatal torsion. Unilateral absence of the testis is a form of this syndrome; congenital monorchidism is probably due to antenatal torsion rather than hypoplasia or agenesis. When monorchidism is confirmed at operation, exploration and suture fixation of the contralateral testis at the same procedure is recommended to protect the solitary testis from future torsion.     

Scrotal swelling in the Sch?nlein-Henoch syndrome.

Testicular and scrotal hemorrhage is uncommon in the Sch?nlein-Henoch syndrome. The diagnosis of testicular torsion is difficult to make when it is complicated by vasculitis of the testis. Since both conditions can occur simultaneously, torsion of the testis must be considered and surgical exploration performed whenever acute testicular pain and swelling occur during the course of the Sch?nlein-Henoch syndrome. Two patients with this syndrome as well as scrotal and testicular involvement are described.     

“Acute scrotum” in Henoch-schönlein syndrome

Two patients with Henoch-Schönlein syndrome presented with clinical pictures mimicking testicular torsion. No evidence of testicular torsion was found. A review of the literature revealed that testis torsion is very rarely associated with testicular involvement in Henoch-Schönlein syndrome, and hence only rarely is surgical exploration required.     

Ultrastructure of Leydig cells in Down's syndrome

Hormonal and ultrastructural examinations of the testis were performed in a patient with Down's syndrome. Plasma testosterone was abnormally low, and circulating levels of LH and FSH were higher than the normal range. The administration of HCG resulted in a low response of plasma testosterone. Electron microscopy revealed proliferation of smooth endoplasmic reticulum, an increase in paracry stalline inclusions and the absence of Reinke's crystals in Leydig cells.     

Testicular dysplasia causing disturbance of spermiogenesis in patients with unilateral torsion of the testis.

Fifty-five patients were followed up for their state of fertility at a time varying in length after testicular torsion. In addition to the spermiogram they were screened for sperm antibodies. Biopsy samples were collected from the contralateral (not contorted) testis in 34 patients at the time of torsion or immediately afterwards. Two to 8 years after torsion only 7 out of 55 patients had a normal spermiogram. Nineteen had an OAT syndrome, 10 had asthenospermia and 19 had teratospermia. Sperm antibodies occurred very rarely at the time of torsion (2/36) or at the time of a further checkup (2/36). Immunological damage to the noncontorted testis by the contorted one seems therefore rather unlikely. Histology of the contralateral testis, the samples of which were taken at the time of torsion (30) or up to 4 months later (4), showed pathological conditions in 30/34 cases (desquamation of the germinative epithelium, atrophy of the Leydig cells, malformation of spermatoblasts) and normal spermiogenesis in 4 cases only. Hence, a preexistent congenital testicular dysplasia must be assumed to be the cause of the observed disturbance of spermiogenesis and reduced fertility.     

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.     

A case of Down's syndrome associated with testicular seminoma

Down's syndrome is an inherited disorder caused by trisomy of chromosome 21. In patients with Down's syndrome, an increased risk of leukemia has been observed. Recently, the coincidence of testicular cancer with this syndrome has been also emphasized. We present a case of Down's syndrome associated with testicular seminoma. This is the 19th case of Down's syndrome associated with testicular tumor in Japan.     

Unpredictability of capsulotomy in testicular torsion

Testicular torsion results in irreversible histologic changes in the ipsilateral testis, which may induce alterations in contralateral testicular histology and in fertility. It was hypothesized that these ipsilateral changes could be minimized by splitting the tunica albuginea at the time of detorsion, thus decompressing the testicular "closed compartment syndrome." Unilateral spermatic cord torsion was induced in prepubertal, male Sprague Dawley rats for a period of 0, 4, 8, or 12 hours. At the time of detorsion, capsulotomy was performed on half the animals. The mature rats were killed 35 days after detorsion and the testes examined histologically. Testicular capsulotomy did not alter the significant histologic changes observed in the affected testis following spermatic cord torsion.     

Islet autoimmunity in children with Down's syndrome

There is an unexplained excess of type 1 diabetes and other organ-specific autoimmune diseases in children with Down's syndrome, but the immunogenetic characteristics of diabetes in Down's syndrome have not been investigated. We studied the frequency of islet autoantibodies in 106 children with Down's syndrome and no history of autoimmunity and analyzed HLA class II genotypes in 222 children with Down's syndrome, 40 children with Down's syndrome and type 1 diabetes, 120 age- and sex-matched children with type 1 diabetes, and 621 healthy control subjects. Co-occurrence of at least two islet autoantibody markers was observed in 6 of 106 nondiabetic children with Down's syndrome compared with 13 of 2,860 healthy age-matched children (P < 0.001). There was an excess of diabetes-associated HLA class II genotypes in children with Down's syndrome and type 1 diabetes compared with age- and sex-matched healthy control subjects (P < 0.001). Down's syndrome children with type 1 diabetes were, however, less likely to carry the highest risk genotype DR4-DQ8/DR3-DQ2 than children with type 1 diabetes from the general population (P = 0.01) but more likely to carry low-risk genotypes (P < 0.0001). The frequency of subclinical islet autoimmunity is increased in Down's syndrome, and susceptibility to type 1 diabetes in Down's syndrome is partially HLA mediated. Other factors, possibly including genes on chromosome 21, may increase the penetrance of type 1 diabetes in Down's syndrome.     

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.     

To pex or not to pex

There is little agreement as to the performance of an exploration and orchiopexy on the asymptomatic side when the neonate is found to have unilateral extravaginal torsion of the testis. If extravaginal torsion does not present bilaterally, many surgeons feel that the uninvolved testis is not at risk. Extravaginal torsion of the testis, fortunately, is a rare problem. Armed with the knowledge of this case report and one previous case report, however, it is clear that extravaginal torsion can present as separate and asynchronous events. Knowledge of this fact should stimulate surgeons to explore and pex the contralateral side upon finding extravaginal torsion of the testis.     

Torsion of bilobed testis and biopsy-proven ipsilateral supernumerary testis in an adolescent

Testicular torsion in patients with polyorchidism is rare, with less than 20 cases being reported. Bilobed testis has only been reported once in the literature to date. We report an interesting case of polyorchidism with torsion of an ipsilateral bilobed testis. The abnormal looking bilobed infarcted testis was removed, but the smaller viable supernumerary testis was biopsied and preserved.     

Isolated epididymal torsion in dissociation of testis-epididymis

Complete dissociation of testis and epididymis is rare. An isolated torsion of the epididymis has not been reported so far. We report two cases: a 6-month-old boy who was admitted with fever and swollen hemiscrotum and an 18-year-old youth with acute onset of pain in the left hemiscrotum. Immediate inguinal surgical exploration of the baby showed a complete infarction of the epididymis due to an isolated epididymal torsion with dissociation of testis and epididymis. Epididymectomy was carried out and the testis was sutured down. In the case of the youth, the surgical exploration also showed an isolated epididymal torsion due to dissociation of testis and epididymis. The epididymis could be rescued by raising the torsion. The isolated torsion of the epididymis should be included in the differential diagnosis of acute scrotum in childhood.     

An autopsy case of Down's syndrome with moyamoya syndrome

We reported an autopsy case of Down's syndrome with moyamoya syndrome. A 30-year-old male with Down's syndrome suffered from a cerebral infarction and died of brain herniation. Cerebral angiography showed vascular abnormalities that were the same as moyamoya disease. Pathological findings revealed multiple stenosis of main trunk of the cerebral arteries. Pathologically, the stenosed vessels showed eccentric intimal thickness with cholesterin deposit, unlike moyamoya disease. There are only two previous reports of autopsied cases of Down's syndrome with moyamoya syndrome. We postulate that a protein encoded on chromosome 21 may be related to the pathogenesis of Down's syndrome with moyamoya syndrome.     

Seminoma associated with bilateral cryptorchidism in Down's syndrome: A case report

BACKGROUND: A case of testicular typical seminoma associated with bilateral undescended testes in Down's syndrome is reported. A 42-year-old institutionalized male patient developed left testicular seminoma with retroperitoneal metastasis. METHODS/RESULTS: Neither adjuvant chemotherapy nor radiotherapy were performed due to his severe mental retardation. He died as a result of the cancer 2 years after a left radical orchiectomy and an autopsy was carried out. DISCUSSION: Recently an increase in the incidence of the association of testicular tumors and Down's syndrome has been repeatedly documented. Thirty-six cases of testicular tumors associated with Down's syndrome have been reported and of these 17.1% had cryptorchidism. This is a much lower percentage considering the high risk of cryptorchidism in males with Down's syndrome. The relationship between testicular germ cell tumors associated with cryptorchidism and Down's syndrome is discussed.     

Testicular torsion: a review

Torsion of the testis, also referred to as torsion of the spermatic cord, is a subject of debate among physicians and surgeons. Testicular torsion is an acute vascular event causing the rotation of the vascular pedicle of the testis, thereby impeding the blood flow to the testis and the scrotal contents. It could be either within or outside the tunica vaginalis. Testicular torsion causes immediate circulatory changes and long-term sequelae such as testicular function and fertility. It is considered a surgical emergency, as a delay causes irreversible testicular damage. The diagnosis and treatment of testicular torsion are discussed in this review, which also illustrates an algorithm and a scoring system for the diagnosis and management of this condition based on current literature.     

睾丸扭转手术方式的选择

目的 :探讨手术治疗睾丸扭转时的发病时间对手术方式选择的意义。方法 :对本院 1993～ 2 0 0 0年间收治的 19例睾丸扭转患者的发病至手术时间和手术效果进行观察。结果 :发病至手术时间 10 h内的 8例扭转复位患者 ,术后睾丸均存活 ;发病至手术时间 10～ 2 4h的 4例睾丸扭转复位患者 ,3例睾丸存活 ;发病至手术时间 >2 4h的 2例睾丸扭转复位患者 ,1例睾丸存活。结论 :10 h以内的扭转均应行睾丸扭转复位固定术 ;10～ 2 4h的扭转睾丸复位存活的可能性尚存在 ;>2 4h者应行手术切除 ,不宜保留     

Torsion of an intra-abdominal testis

To present a case of torsion of a nonneoplastic intra-abdominal testis with an unusual clinical presentation.A 26-year-old active duty Navy Petty Officer presented to the emergency department on 3 occasions over a 5-day period with lower abdominal pain. Physical examination demonstrated acute tenderness in the left lower quadrant with sugestion of a normal spermatic cord and atrophic testis in the left scrotum. Computed tomography scan demonstrated an intra-abdominal lesion near the internal inguinal ring. The patient underwent surgical exploration through an inguinal incision. Torsion of a nonviable intra-abdominal testis was present. The scrotum contained only the vas deferens and cremasteric muscle. An orchiectomy was performed with removal of the vas deferens and other cord structures.The unusual clinical finding of acute torsion of an intra-abdominal testis, associated with an apparent atrophic scrotal testis, presented a confusing clinical picture. Computed tomography scan did not clarify the issue sufficiently to establish a definite preoperative diagnosis. Clinical suspicion prompted early surgical intervention. Review of the current literature produced 60 reported cases of torsion of an intra-abdominal testis. Two thirds of these involved testicular neoplasm, usually seminoma. Although the clinical presentation varied, most patients had recent onset of lower abdominal pain associated with tenderness and, in half the cases, a mass. Patients almost always presented with an absent scrotal testis on the involved side, and not infrequently reported previous surgery thought to be an orchiectomy.Diagnosis of an intra-abdominal testicular torsion is rare, particularly when no neoplasm is present. A high index of suspicion must be maintained whenever there is abdominal pain and undescended testis. The surgical history and imaging studies may not clarify a confusing clinical picture.     

维拉帕米及低温对大鼠睾丸扭转复位后生精功能的保护作用

目的:探讨药物维拉帕米及低温对大鼠睾丸扭转复位后生精功能的影响。方法:60只健康青春期SD大鼠随机均分成5组,A组为睾丸扭转组,25℃室温,扭转时间2h;B组为睾丸扭转加维拉帕米组;C组为睾丸扭转加低温(9～13℃)组;D组为睾丸扭转加维拉帕米、低温组;E组为对照组。按Turner法制作睾丸扭转模型,取手术侧睾丸,光镜下观察组织学变化,行生精小管Makler评分,流式细胞术检测凋亡细胞百分率。结果:HE染色:除E组光镜下观察正常外,其余各组生精细胞排列不整齐,层次减少,生精细胞数量减少,可见凋亡小体及坏死区,部分区域可见炎症细胞浸润,其中扭转组最明显。生殖细胞凋亡率:A、B、C、D、E组分别为(32.11±2.20)%,(20.18±1.50)%,(20.02±1.90)%,(13.75±1.40)%,(8.56±0.90)%,与A组比较,B、C、D组凋亡率降低,差异有显著性(P<0.01)。Makler评分结果:A、B、C、D、E组分别为(14.47±1.35)、(15.45±0.75)、(15.48±0.75)、(16.22±0.72)、(19.60±0.56)分,与A组比较,B、C、D组Makler评分升高,差异有显著性(P<0.01)。结论:睾丸扭转复位后生精细胞凋亡增加可导致睾丸生殖能力下降;应用钙通道阻滞剂维拉帕米及局部低温均能增强睾丸组织的抗损伤能力;两者联合应用能更好地保护扭转复位睾丸的生殖功能。     

Torsion of the epididymis

Anomalies of the epididymis are most commonly associated with an undescended testis but also found occasionally in a normally descended testis. Our 11-year-old patient presented with an acute scrotum and Doppler ultrasound that suggested epididymitis. Painful symptoms required scrotal exploration with the finding of a torsion and infarction of the epididymis. The etiology of the torsion was an abnormal attachment of the epididymis to the testis. Torsion of the epididymis has not previously been reported.