Extravaginal Testicular Torsion Research Articles

Ultrasound characteristics of extravaginal testicular torsion at different stages of disease progression.

Extravaginal testicular torsion has profound clinical implications in neonates, but its ultrasound characteristics may vary at different disease stages. The purpose of this study was to identify the ultrasound characteristics of neonatal extravaginal testicular torsion and their diagnostic value at different disease stages. A retrospective analysis of the clinical and ultrasound examination data of 20 infants aged 1-75 days with surgically and pathologically confirmed unilateral extravaginal testicular torsion (10 right, 10 left) was conducted. The infants were divided into three stages based on the ultrasound characteristics: double-ring effusion, calcification of the tunica vaginalis, and testicular atrophy. In the double-ring effusion stage, the affected testicles were enlarged with axial abnormalities, with the parenchymal testicular blood flow signal significantly reduced or absent. Twisted paratesticular masses and a "double-ring effusion sign" were visible. In the tunica vaginalis calcification stage, the affected testicles were slightly smaller, with axial abnormalities, absent blood flow signals in the testicular parenchyma, and strong echogenicity of the tunica vaginalis. In the testicular atrophy stage, the affected testicles were markedly smaller, with enhanced echogenicity in the tunica vaginalis and parenchyma, and absent blood flow signal in the testicular parenchyma. The volumes of the affected testicles gradually decreased from the stage of double-ring effusion to that of tunica vaginalis calcification, and then to testicular atrophy (P<0.05). Neonatal extravaginal testicular torsion at different disease stages has distinct ultrasound features, and color doppler ultrasound plays an important role in the diagnosis and treatment of extravaginal testicular torsion.

Non-neonatal Men with Rare Testicular Torsion: A Case Series

Abstract Testicular torsion involves the testicle twisting which results in an infarcted testis. Emergency surgery is required to salvage the affected testis. There are 2 anatomic pathologies associated with testicular torsion: intravaginal testicular torsion and extravaginal testicular torsion (ETT). Extravaginal testicular torsion is seen perinatally and in neonates; beyond this period, ETT is regarded as exceptionally rare. This case series presents 7 cases of ETT seen in men aged 14 to 20 years. This is the largest and oldest group of patients seen with this pathology. These cases were defined by a pediatric surgeon in an inner city hospital in New York. Two patients' testes were not viable at the time of presentation, and the time of onset to presentation ranged from 30 minutes to 11 hours. Each of these cases had an orchiopexy concomitantly of the contralateral testis. This case series poses key questions regarding the etiology of ETT and the surgical management of such cases.

Doppler signs of extravaginal testicular torsion mimicked by small vessel intra-testicular vasculitis in henoch-schoenlein purpura: A case report

Henoch-Schoenlein Purpura (HSP) is one of the most common types of multi-systemic vasculitis seen in childhood with “classic triad” of purpura, arthritis, and abdominal pain. Scrotal disease including scrotal swelling, epididymitis, and orchitis are very rare complications of HSP that can mimic the symptoms and signs of testicular torsion, which is one of the major surgical emergencies in children. Radiological modalities are commonly used to diagnose possible causes of acute scrotum such as testicular torsion. Here we report an 8-year-old boy, complaining of acute pain and swelling in his left testicle. Although colour Doppler ultrasonography of his testes showed increased-size parenchymal echo in the left testicle and its epididymis, with no detectable blood flow on the same side, immediate surgical exploration indicated normal pulse in both testicles’ arteries, with no signs of torsion. Finally, the pathological specimen results were consistent with the diagnosis of HSP-related testicular involvement. In conclusion, the occurrence of small vessel intra-testicular vasculitis in Henoch-Schoenlein Purpura can mimic clinical and Doppler ultrasonic signs of extravaginal testicular torsion.

A case of acute scrotum with an extremely rare etiology - extravaginal testicular torsion in adult male

Extravaginal torsion (EVT) of the testis occurs almost exclusively in neonates, being the most common mechanism of torsion in the fetus and newborn. In this condition, the spermatic cord is twisted outside the sack of tunica vaginalis in the scrotum. Unlike the intravaginal torsion reported in older children and adults, this entity is considered to have a different surgical anatomy. The incidence of intravaginal testicular torsion in patients under 25 years of age is estimated at around 1 per 4000, however, extravaginal testicular torsion in adults is an extremely rare entity. We present the case of a healthy 22-year-old patient who was admitted to the emergency room with right hemi-scrotal pain, tenderness, and swelling with acute onset of 8 hours. His initial evaluation included color doppler ultrasound that revealed a twisted right cord with no intratesticular vascular flow. The patient underwent emergency scrotal exploration revealing a 360° counterclockwise extravaginal torsion of the right testis. Testicle regained normal aspect after detorsion, and 3 point orchidopexy was performed. Recovery was uneventful and color doppler ultrasound revealed normal vascular flow 15 days after surgery.

An exceptional case of extra-vaginal testicular torsion in a 14-year-old boy

Abstract In children, peak incidence of testicular torsion occurs either in the neonatal period with extra vaginal torsion either during puberty with intra vaginal torsion. Preventive contralateral orchiopexy for intra vaginal torsion is routine but remain controversial in neonatal extra-vaginal torsion. This very unusual case of extra-vaginal torsion in a 14-year-old teenager suggests that controlateral orchiopexy should be systematically done, regardless of the age.

Ultrasonography of Extravaginal Testicular Torsion in Neonates.

SummaryBackgroundExtravaginal testicular torsion (ETT), also called prenatal or perinatal, occurs prenatally and is present at birth or appears within the first month of life. It has different etiology than intravaginal torsion, which appears later in life. Testicular torsion must be taken into consideration in differential diagnosis of acute scrotum and should be confirmed or ruled out at first diagnostic step. Ultrasonography is a basic imaging modality, however diagnostic pitfalls are still possible. There is still wide discussion concerning management of ETT, which varies from immediate orchiectomy to conservative treatment resulting in testicle atrophy.Material/MethodsIn this article we present ultrasonographic spectrum of ETT in neonates, which were diagnosed and treated in our hospital during the last 8 years (2008–2015), in correlation with clinical and intraoperative findings.ResultsThirteen neonates with ETT were enrolled in the study – 11 patients with a single testicle affected and 2 patients with bilateral testicular torsion. Most common signs on clinical examination were: hardened and enlarged testicle and discoloration of the scrotum. Most common ultrasonographic signs were: abnormal size or echostructure of the affected testicle and absence of the blood flow in Doppler ultrasonography. In 3 patients ultrasound elastography was performed, which appeared very useful in testicle structure assessment.ConclusionsTesticular torsion may concern boys even in the perinatal period. Ultrasonographic picture of acute scrotum in young boys may be confused. Coexistence of the abnormal size or echostructure of the torsed testicle with absence of the blood flow in Doppler ultrasonography appear as very specific but late ultrasonographic sings. Ultrasound elastography may be a very useful tool for visualisation of a very common clinical sign – hardening of the necrotic testicle.

Perinatal testicular torsion

Guerra and colleagues1 should be commended for their interest in addressing the controversial issue of perinatal testicular torsion (PTT) and for conducting an interesting survey of Canadian pediatric urologists. The survey was performed in a simple fashion, facilitating the responses and data analysis. However, as stated in their discussion, it has the limitation of potentially excluding some clinical scenarios that were not presented in the survey. The responses are surprising, reflecting an increasing tendency toward the operative approach among younger pediatric urologists as more cases of viable perinatally torted testicles have been published. In addition, PTT is a condition that is ripe for litigation. This may trigger a defensive surgical attitude among surgeons. In our institution most pediatric urologists prefer to explore cases of possible PTT in a semi-urgent fashion, respecting fasting time to ensure gastric emptying to avoid risk of aspiration. Furthermore, we have had cases of metachronous extravaginal testicular torsion (within a few weeks of life). This experience reinforced our indication for semi-urgent scrotal exploration, performing fixation of the contralateral normal testicle. However, we do not feel that fixation of the contralateral testis is indicated in patients with testicular atrophy identified after 3 months of life because the mechanism of torsion (intravaginal) is distinct from the perinatal event (extravaginal). Hence, the likelihood of contralateral torsion is no greater than that of the general population. We agree with Guerra and colleagues about the need for more robust research designs such as randomized clinical trials. However, such studies are unlikely to be performed due to the rarity of PTT.

Extravaginal testicular torsion: a clinical entity with unspecified surgical anatomy

To review and evaluate the anatomical definitions of perinatal extravaginal torsion (EVT) of the testis. An extensive review of the literature was made to reveal the prevalent anatomical background predisposing to EVT. Gross appearance of twisted testes obtained during surgery for 14 cases of EVT was used to test the validity of the above theories. The most commonly accepted suggestions describe an EVT within dartos muscle that includes all layers of spermatic cord or an EVT outside parietal layer of tunica vaginalis within internal spermatic fascia. However, both of them were found inadequately documented, while a large volume of controversial data has been accumulated, that raises doubts regarding the validity of such definitions. The gross appearance of twisted testes failed to confirm both an EVT including all layers of the spermatic cord and also an EVT outside tunica vaginalis as possible mechanisms of torsion. The anatomical basis of EVT remains unclear and further investigation is required.

Testicular Torsion: Twists and Turns

Testicular torsion is one of the common causes of acute scrotal pain. This review discusses the clinical and sonographic findings of intravaginal and extravaginal testicular torsion, including the normal sonographic and vascular anatomy of the testis. The role of color flow Doppler and spectral Doppler is also emphasized in the patient's complete, incomplete, and intermittent testicular torsion. Sonographic features of testicular torsion mimics, such as vasculitis, venous thrombosis, scrotal edema, and technical parameters, are also presented. A brief description of new developments such as contrast-enhanced ultrasound, dynamic contrast magnetic resonance imaging, and near-infrared imaging is included.

Intrauterine Torsion of a Testicular Teratoma: A Case Report

Neonatal testicular tumors and intrauterine testicular torsions are very rare. The presented case is the first describing intrauterine torsion of a descended testis with a teratomatous tumor. Immediately after birth, right hemiscrotal swelling was seen in a preterm male newborn. Surgical intervention showed extravaginal testicular torsion and a highly differentiated testicular teratoma with haemorrhagic infarction. The testis was removed (orchiectomy). Over a period of twelve months no signs of tumor recurrence were found. While being extremely rare, testicular tumors should be included in the differential diagnosis of neonatal scrotal swelling.

Perinatal extravaginal torsion of the testis in the first month of life is a salvageable event

Objectives To determine the effectiveness of immediate surgical exploration in salvaging perinatal testicular torsion. Methods A retrospective analysis from 1995 to 2000 of boys younger than 30 days of age with surgically documented extravaginal testicular torsion was conducted. All cases were diagnosed after a normal testicular examination by a neonatologist, and all patients underwent urgent exploration to confirm the exact diagnosis and attempt testicular salvage by detorsion with bilateral orchiopexy. If a nonviable testis was determined intraoperatively, it was removed and contralateral orchiopexy was performed. Success was determined by physical examination at 6 months of follow-up. Results Ten patients with 10 affected testes were identified and a total of 4 (40%) were salvaged. All the studied testes were right-sided, and of the 4 salvaged testes, all were palpably normal and equal in size to their mate at the 6-month follow-up examination. Of the 6 removed testes, 1 was potentially viable by permanent pathologic section analysis despite preoperative ultrasonography demonstrating no flow and a negative intraoperative bleed test. Conclusions Boys younger than 30 days old presenting with clinical findings suggestive of extravaginal testicular torsion who are expeditiously explored surgically may have a salvageable event in at least 40% to 50%. These statistics are similar to the salvage rates found with the similar management approach of intravaginal torsion.

Hemodynamic effects of experimental testicular torsion.

Experimental testicular torsion must be used for certain studies of clinical relevance, but most experimental models either do not provide hemodynamic alteration comparable to the clinical situation or cannot guarantee reproducibility. Using a rat model arterial perfusion and hemorrhagic infarction were correlated to the degree of both intra- and extravaginal testicular torsion. Arterial inflow was measured sequentially with radiolabelled microspheres, hemorrhagic infarction was judged by the increase of testicular weight. Maximal hemorrhagic infarction and reproducible values were found when the spermatic cord was twisted together with the tunica vaginalis for 360 degrees-540 degrees.

Testicular survival after neonatal torsion.

Ten newborn patients with an extravaginal testicular torsion are presented. All were operated on with an emergency orchiopexy. At follow-up, two to 15 years after the operation, no significant difference was noted in the volumes of the operated and the contralateral testis in eight of the ten patients. The results show the importance of an emergency orchiopexy in order to ensure testicular survival after neonatal torsion.