Effect of unilateral testicular torsion on blood flow and histology of contralateral testes.

BACKGROUND/PURPOSE: Infertility occurs in 25% of patients after unilateral testicular torsion; hence, the authors examined hemodynamic and histological changes in both testes after acute testicular torsion in neonatal piglets. METHODS: The animals were anesthetized, intubated, ventilated, catheterized, and assigned randomly to a sham group or one of three experimental groups undergoing 720 degrees torsion of the left testis for 8 hours after which it was untwisted in group I and removed in group II. In group III, both testes were removed. Data were collected at baseline (T = 0), 4 hours (T = 4), and 8 hours of torsion (T = 8) and at the ninth hour of the experiment (T = 9). Testicular blood flow was determined by using radiolabeled microspheres. The testes also were examined blindly with routine and electron microscopy. RESULTS: In group I, testicular blood flow decreased in the affected testis during torsion and increased significantly after detorsion, whereas blood flow to the contralateral testis increased significantly after detorsion. Sham-operated animals showed no histological abnormality in either testis. In all torsion groups, the affected testis showed extensive changes caused by hemorrhagic necrosis. The contralateral testis only showed changes in group I. CONCLUSION: Unilateral testicular torsion resulted in ipsilateral damage caused by a decrease and subsequent increase in blood flow while in the contralateral testis; damage was the result of a significant increase in blood flow after detorsion.     

Etiology of acute scrotum at surgical exploration in children, adolescents and adults.

Between January 1970 and December 1989, 171 patients underwent scrotal exploration for acute scrotum (an acute painful swelling of the scrotum or its content), at our hospital. Of 70 children scrotal explorations, torsion of appendages was found in 33 cases (47%). Torsion of testis was found in 24 patients (34%). Of the 84 adolescent scrotal explorations performed, 72 (86%) had torsion of testis, and 8 (9%) had torsion of appendages. Of 17 adults, torsion of testis was found in 15 cases (88%). These results clarify that unnecessary explorations are much more common in children (66%) than in adolescents and adults (14%). We therefore suggest using radionuclear scans and/or Doppler ultrasound to facilitate clinical diagnosis in the children group.     

睾丸扭转的诊治(附59例报告)

目的 探讨睾丸扭转的诊治。方法 回顾性分析59例睾丸扭转患者的临床资料。结果 1例为腹腔内恶变隐睾扭转，余58例（59次）发病时中位年龄18．5岁，均无发热，50例次在夜间或剧烈运动后发病。4例手法复位成功。1例手法复位后再次扭转，拒行手术致睾丸萎缩。2例明确睾丸已坏死未手术治疗，患睾逐渐萎缩。接受手术探查的52例中有15例睾 丸存活，其中发病超过24d的1例，不到10h11例。结论 青少年夜间或运动后突发急性睾丸痛应该警惕扭转的可能，必要时紧急手术探查，手法复位可尝试应用。     

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.     

Acute scrotal pain in children--ten years' experience

INTRODUCTION: Acute scrotal pain sometimes requires prompt surgical intervention and therefore accurate diagnosis of different etiologies of acute scrotal pain has great therapeutical and prognostic significance. The aim of this study was to analyze the incidence, symptomatology and results of treatment of acute scrotal pain in children. MATERIAL AND METHOD: The study included patients hospitalized at the Pediatric Surgery Clinic with a diagnosis of acute scrotal pain. We retrospectively analyzed anamnestic data (age of patient and duration of anamnesis prior to admission), clinical parameters obtained during physical examination, mode of treatment (operative or medical), intraoperative findings and (postoperative) treatment. RESULTS: The study included 256 patients with acute scrotal pain, aged from several hours up to 17 years of age (average 9.73 years). The average duration of symptoms prior to admission was 56.74 h. Acute epididymitis was diagnosed in 110 patients (43.0%), torsion of the testicular appendage in 104 patients (40.6%), torsion of the testis in 30 patients (11.7%) and other pathologies in another 12 patients. 166 patients (64.8%) underwent surgery, 42 patients with orchiepididymitis (38.2%), 92 patients with torsion of the testicular appendage (88.5%), and 16.6% of the patients with other pathologies. 22 patients with torsion of the testis underwent surgery (73.3%), while the rest of the 8 patients underwent manual detorquation of the testis. CONCLUSION: Regardless of the etiology of the acute scrotal pain, it is of great importance that the patient seeks medical assistance promptly. It is therefore important to educate the parents and patients about the problems related to acute scrotal pain.     

Acute experimental testicular torsion. No effect on the contralateral testis

Other investigators have shown that chronic unilateral testicular torsion produces negative effects on the contralateral testis in experimental animals. In the present study, bilateral testicular weight and histology, and concentrations and motility of spermatozoa from the cauda epididymidis were studied after 0 to 4 hours of acute unilateral testicular torsion in the rat. The obstruction of blood flow by torsion was documented, as well as the presence or absence of return blood flow after the relief of torsion. The above mentioned parameters of testicular function were studied at 7, 30, and 60 days after relief of torsion. Ipsilateral testis weights and epididymal sperm concentrations and motility were significantly reduced by 1, 2, and 4 hours of torsion. The histology of torsioned testes was also severely altered, and no seminiferous epithelial repair was evident 60 days after torsion. Contralateral testicles were not affected by ipsilateral torsion of 1, 2, or 4 hours duration, despite the fact that the ipsilateral testis function was completely compromised by 2 and 4 hours of torsion. These results indicate that there would be no clinical benefit in removing the acutely torsioned testis of Sprague-Dawley rats since it poses no threat to the contralateral testis.     

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.     

阴囊急症93例诊断分析

目的 总结阴囊急症患者的临床特点及超声图像特征,提高早期诊断及鉴别诊断的准确率.方法 首先观察93例阴囊急症患者的临床表现及体征;其中78例患者先用二维超声检测睾丸、附睾的位置、大小、形态及回声强弱,再用彩色多普勒观察睾丸、附睾的血供情况,并与临床、手术及病理结果进行对照.结果 93例阴囊急症患者具有相似的临床表现和体征.78例患者经二维超声与彩色多普勒超声检查,28例病侧睾丸血流消失或减少,睾丸内血流阻力指数增高,超声诊断睾丸扭转,与手术病理结果相符.结论 阴囊急症患者的临床表现多样性,易误诊.二维超声结合彩色多普勒超声在阴囊急症患者的诊断中具有较强的敏感性和特异性,是目前鉴别睾丸扭转与急性睾丸附睾炎的首选方法.     

Clinical study on acute scrotum]

Between April 1986 and July 1990, we experienced 13 cases of acute scrotum with surgical exploration. Six of the patients had torsion of the spermatic cord; three had torsion of an appendix of the epididymis, one had torsion of a testicular appendix, one had testicular rupture, one had acute epididymitis and one was normal. Their ages ranged from 3 months to 55 years (mean: 17.7 years), and the patients with torsion of the spermatic cord ranged from 5 to 25 years in age (mean: 16.3 years). No specific symptoms, signs, or laboratory findings were noted in patients with torsion of the spermatic cord. In the majority of cases, scrotal swelling and redness of the scrotal skin were present, and we could not distinguish parts of the scrotal contents. From 2 to 92 hours had passed before the patients presented, and patients who first attended other clinics tended to be treated in an inappropriate manner. Orchidopexy was performed in all patients with torsion of the spermatic cord. At present, only one testis which was treated after a delay of 92 hours has proven to be atrophic. Early consultation of a urological clinic and early surgical exploration are important in the treatment of the acute scrotum.     

Experimental torsion of the spermatic cord. Histological and histochemical studies (author's transl)

In 40 male adult rats on unilateral torsion of the spermatic cord was initiated by operation. In the first group (4 x 5 animals) the testes were removed after 3, 6, 12, 24 hours. The treatment of the animals in the second group (4 x 5 animals) was untwisting of the torsion after 3, 6 12, 24 hours. Three months later both testes were removed. Histological and enzymehistochemical results are as follows: 1. The extend of acute damage to the affected testis depends on the length the torsion lasted. 2. The delay of time of untwisting the testis probably does not influence the degree of later regeneration. 3. Even short duration of torsion of the affected testis results in damage to the contralateral testies.     

精索扭转的循证诊断与治疗

目的:系统评价精索扭转的诊断及处理方法。方法:计算机检索Cochrane图书馆、PubMed、维普资讯、CNKI,查找有关精索扭转的随机对照研究,检索时限均为1990~2012年,研究者对文献质量进行严格评价和资料提取,采用盲法分析。结果:共纳入27篇文献,3 541例患者纳入研究。结果表明:多普勒彩超在诊断阴囊急症明显优于常规超声,成为阴囊急症的首选影像学诊断方法;对任何年龄段的急性阴囊疼痛的患者均应行手术探查,没有足够的证据支持单侧精索扭转行对侧睾丸固定;精索扭转对于患侧睾丸生育功能的影响会随着患者年龄的增长而增加,对于健侧睾丸的影响尚存在争议。结论:对于有阴囊症状的患者应及时行阴囊多普勒彩超筛查,对于已确认精索扭转患者及阴囊急症患者应立即行阴囊手术探查,根据具体情况以决定是否行双侧睾丸固定术,对患者生育功能应加强随访。     

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.     

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.     

小儿服囊急症

目的：总结小儿阴囊急症手术或非手术治疗的可行性。方法：回顾性研究５２６例小儿阴囊急症患者的临床资料和诊疗经验。睾丸附件扭转３６８例（７０．０％）,急性鞘膜炎４９例（９．４％）,睾丸扭转４２例（８．０％）,急性附睾炎１９例（３．５％）,急性阴囊感染１８例（３．４％）,阴囊血肿１８例（３．４％）,睾丸炎６例（１．１％）,特发性阴囊水肿６例（１．１％）。前４种常见疾病共４７８例,占９０．９％。住院前误诊     

Perinatal testicular torsion: a unique strategy

Background/Purpose

Perinatal testicular torsion (PTT) is defined as testicular torsion occurring prenatally or within the first 30 days of life. The aim of this study was to evaluate the data obtained from patients with PTT and propose principles of management based on clinical, surgical, and histologic findings.

Methods

A retrospective analysis of 27 boys seen between 1990 and 2005 with surgically documented PTT was conducted. Patients were divided into 2 groups: A, prenatal testicular torsion; B, postnatal testicular torsion. The presence of acute scrotal inflammatory signs defined the urgency to operate.

Results

There were 4 clinical pictures in group A: A1, patients with a nubbin testis (n = 3); A2, patients with a small and hard testis (n = 12); A3, patients with a normal-sized and hard testis (n = 8); and A4, patients with an acute scrotum (n = 2). Group B (n = 2) presented no sign after birth and later developed an acute scrotum. Surgical exploration and histologic examination showed clear signs of a long-standing testicular torsion in groups A1, A2, and A3 or a recent-onset testicular torsion in groups A4 and B. Only one testis could be salvaged (group B).

Conclusions

Clinical signs correlated very well with surgical and histologic findings and can define the need and the urgency to operate. Although testicular salvage rate is very low, the affected side always should be explored to confirm the diagnosis and to fix or remove the affected testicle. The contralateral scrotum also should be explored because of the risk of asynchronous contralateral testicular torsion.     

Wiederauftretende Hodentorsionen: Kann ein pexierter Hoden torquieren?

Painful testicular torsion is an emergency which can occur at any age, even after previous fixation of the testis. In the described cases, it was not expected and a misdiagnosis led to loss of the testis. For a patient who has already lost one testicle, this is a catastrophe. A literature search was performed. Previous fixation of the testis does not always prevent torsion. The diagnostic work-up and management of acute testicular pain should not be different after previous fixation of the testis, regardless of age.     

Magnetic resonance imaging of experimental testicular torsion

We investigated the feasibility of contrast enhanced (CE)-dynamic magnetic resonance imaging (MRI) for the detection of testicular torsion induced hypoperfusion in an experimental rat model. Adult Sprague-Dawley rats were subjected to unilateral testicular torsion of 360 or 720 degrees. After 1 h, the tail veins of the anaesthetized rats were cannulated and T2 -, diffusion-weighted and T1-weighted CE-dynamic MRI were subsequently performed by a 1.5 T MRI scanner. On apparent diffusion coefficient (ADC) images, the region of interest values of the ischaemic and control testes was compared. From CE-dynamic MR images, the maximal slopes of contrast enhancement were calculated and compared. In testicular torsion of 360 degrees, the maximal slope of contrast enhancement was 0.072%/s vs. 0.47%/s in the contralateral control testis (p < 0.001). A torsion of 720 degrees diminished the slope of contrast enhancement to 0.046%/s vs. 0.37%/s in the contralateral testis (p < 0.001). Diminished blood flow during torsion also followed in decreased ADC values in both 360 degrees (12.4% decrease; p < 0.05) and 720 degrees (10.8% decrease; p < 0.001) of torsion. Torsion of the testis causes ipsilateral hypoperfusion and decreased gadolinium uptake in a rat model that can be easily detected and quantified by CE-dynamic MRI. In diffusion-weighted MRI images, acute hypoperfusion results in a slight decrease of ADC values. Our results suggest that CE-dynamic MRI in combination with diffusion-weighted MRI can be used to detect compromised blood flow due to acute testicular torsion.     

Effect of testicular torsion on the contralateral testis

It has been previously shown that unilateral testicular torsion can cause disruptive anatomic changes in the contralateral testis in rats [1]. In this experimental study plasma and urine prostaglandin E2 levels were studied correlatively with testicular histopathology in acute testicular torsion cases. As a result of this study, necrobiotic morphologic alterations causing testis necrosis and significant increase in plasma prostaglandin E2 levels were observed. Contralateral testicular histology was analyzed in all dogs. None of them showed abnormal tubular architecture.     

Torsion of the cryptorchid testis--can it be salvaged?

PURPOSE: The literature concerning undescended testis mainly concentrates on the increased risks of infertility and development of germ cell tumors. Yet the UDT also appears to be at higher risk for torsion compared to the normally descended testis, and this issue is relatively poorly addressed. We reviewed all cases of torsion of UDTs operated on at our hospital during the last 20 years in an attempt to characterize better this condition and its salvageability. MATERIALS AND METHODS: In this retrospective clinical study we reviewed and analyzed all cases of testicular torsion involving UDT operated on at our hospital between 1984 and 2004. RESULTS: A total of 11 children were operated on at our hospital for torsion of undescended testis between 1984 and 2004. Patient age ranged from 1 month to 18 years (median 7.5 months). In all cases unilateral torsion of undescended testis was diagnosed, with 73% of cases involving the left side. Clinical symptoms included inguinal swelling and erythema associated with a tender, firm mass palpated in the groin area and an empty ipsilateral hemiscrotum. Doppler ultrasound examination was routinely performed in the last 7 patients to confirm the diagnosis. During inguinoscrotal exploration severe ischemia or overt necrosis of the testis was found in 5 of 11 cases. Three of these 5 cases were managed by orchiectomy, while in the other 2 cases the testis subsequently vanished. In the 6 patients who exhibited some improvement following detorsion and warming of the tissue the testes were preserved and orchiopexy was performed. Followup was available in only 5 patients, with vanishing of the torsed testis observed in 4 and a normal testicle detected 21 years postoperatively in 1 patient who was diagnosed early. CONCLUSIONS: This series clearly demonstrates poor rates of surgical salvage, which we mainly attribute to delays in parental response and in primary physician referral to the hospital. Parents, who have a pivotal role in early diagnosis, were usually unaware of this urological emergency, and some were surprisingly unaware of the presence of cryptorchidism. By increasing the awareness regarding this entity among members of the medical community and parents, we hope that torsion of the cryptorchid testis (literally, "hidden testis") will no longer necessarily be synonymous with "crypt-torsion" ("hidden torsion").     

Testicular torsion induced by epididymo-orchitis: A case report

Introduction and importanceAcute scrotum is considered a urological emergency requiring early intervention depending on the cause. There are multiple causes of acute scrotum with testicular torsion being the most feared as delayed treatment leads to testicular loss. However, differentiating between epididymo-orchitis and torsion can be very difficult.Case presentationWe present a case of an 18-year old male patient with 2 separate episodes of acute scrotum. He had epididymo-orchitis as the first presentation followed by testicular torsion 5 days later. To our knowledge this is the first case of testicular torsion secondary to epididymo-orchitis.Clinical discussionDifferentiating between epididymo-orchitis and torsion is challenging but important due to risk of loss of testis with a wrong diagnosis. Once you establish epididymo-orchitis the suspicion for subsequent torsion should be high with close follow up and adequate counselling.ConclusionHe ultimately had orchiectomy, although a rare presentation, enlarged testis due to epididymo-orchitis can predispose an individual to developing testicular torsion thus adequate counselling on warning signs to patients with epididymo-orchitis is of particular importance so as to intervene early and ultimately save the testis.