Extravaginal Torsion Research Articles

The diagnosis and treatment of testicular torsion in children with non-scrotal initial symptoms.

To explore the clinical characteristics of testicular torsion in children with non-scrotal initial symptoms who were misdiagnosed. A retrospective analysis of 73 cases children with testicular torsion and non-scrotal symptoms who were admitted to our department from October 2013 to December 2021 was performed. Patients were divided into misdiagnosis (27 cases) and clear diagnosis at first visit (46 cases) groups. Clinical data, including age at surgery, clinical presentation, physical examination, number of visits (≥2 times), affected side, time from initial symptoms to surgery, and surgical outcomes, were collected. The TWIST (Testicular Workup for Ischemia and Suspected Torsion) score was calculated and analyzed. Statistically significant differences between the misdiagnosis and clear diagnosis groups were seen in the time from initial symptoms to surgery, the number of visits, the degree of testicular torsion, and the rate of orchiectomy (P < 0.05). There were no statistically significant differences (P > 0.05) in age, affected side, TWIST score, guardian, direction of testicular torsion, intra-vaginal or extra-vaginal torsion, and Arda classification. Postoperative follow-up was 6-40 months. Of the 36 patients who required an orchiopexy, 1 had testicular atrophy at six months and 2 were lost to follow-up. The contralateral testis of the 37 children who underwent orchiectomies developed normally without torsion. The clinical manifestations of testicular torsion in children are diverse and can easily lead to misdiagnosis. Guardians should be aware of this pathology and seek timely medical attention. When the initial diagnosis and treatment of testicular torsion is difficult, the TWIST score during the physical examination may be useful, especially for patients with intermediate-to-high risk scores. Color Doppler ultrasound can assist in making the diagnosis, but when testicular torsion is highly suspected, routine ultrasound is not necessary as it may lead to delayed surgical treatment.

Delaying Urgent Exploration in Neonatal Testicular Torsion May Have Significant Consequences for the Contralateral Testis: A Critical Literature Review

To assess the optimal management strategy for boys with neonatal testicular torsion (NTT) in the first 30 days of life, and to stratify outcomes for prenatal, postnatal, unilateral, synchronous, and asynchronous events METHODS: All articles including case reports published between 1946 and 2020 in Embase/Scopus/Medline/Pubmed and Web of Science that had a defined diagnosis of NTT within the first 30 days of life were reviewed. Data and outcomes were analyzed individually, and together as pooled data, using a random effect model. There was a total of 152 studies representing 1336 patients. Outcome data was available on 974 patients (1121 testes). NTT was unilateral in 829 cases, synchronous bilateral in 80 cases, and asynchronous in 66 cases. There were a total of 1107 orchiectomies, and 229 salvage orchiopexies. A total of 2.5% synchronous NTT underwent successful salvage. A total of 95.7% of prenatal unilateral torsions underwent orchiectomy, compared with 92% postnatal torsions. 11.8% of all NTT events were asynchronous with a median time to second torsion of 1 day (Range 1-8). The contralateral orchiectomy rate in this group was 31.8%, with a 40% atrophy rate following orchiopexy. The number needed to treat to avoid bilateral orchiectomy was 1.6, and the number needed to treat to avoid solitary atrophy was 2.6. NTT is an important condition carrying a significant risk for testicular loss and endocrine insufficiency. Given the potential catastrophic risk of asynchronous extravaginal torsion, we recommend urgent, safe, surgical intervention with both unilateral and bilateral NTT.

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.

Intravaginal spermatic cord torsion without whirl pool sign before adolescence

Abstract Spermatic cord torsion in children is a urological emergency that requires operation and fixation within 6 h. Ultrasound sonography allows for the diagnosis of torsion in the early stages; however, some cases are sometimes overlooked and necrotize. While two peaks of onset have been reported (in the neonatal period and adolescence), attention must be paid to prepubertal children as well. Torsion manifests in two ways: as extravaginal torsion (EVT) and intravaginal torsion (IVT). EVT is common in newborns, and IVT is common in adolescents. Bell clapper deformity is thought to be a major cause of IVT. The bell clapper theory describes an anatomical anomaly wherein the testis is freely suspended, leading to its rotation. In EVT, spermatic cord twisting occurs outside of the tunica vaginalis because of a loose connection of the testis to the scrotum in newborns. However, we highlight the fact that IVT can also occur in prepubertal children. A one-year-old and three-year-old boy were admitted to our hospital with testicular pain as the chief complaint. Ultrasonography did not reveal any whirlpool sign. A physical examination showed apparent symptoms of testicular torsion; we therefore performed an emergency operation. We found both boys to be suffering from IVT-type torsion. We corrected the rotation and attempted an ultimately unsuccessful reperfusion. Both testes had bell clapper deformity and were torn in a narrow space. This small space can induce a steep and narrow pitch of torsion far beyond the detectability of ultrasonography. In prepubertal cases, we must pay attention to cases of torsion with no signs of whirlpools after ultrasonography.

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.

Acute Testicular Torsion: Presentation and Diagnosis

Testicular torsion is the most common pediatric urologic emergency and is a common cause of acute scrotal pain. Timely diagnosis is important for testicular salvage,as treatment delayed beyond 6 hours from the onset of symptoms is the most predictive factor of testicular death. There is a bimodal distribution of age with extravaginal torsion most commonly presenting in the neonatal period and intravaginal torsion most commonly presenting around the onset of puberty. Intermittent testicular torsion presents a unique challenge in making an accurate diagnosis, as patients most often present when asymptomatic. Several risk factors exist, although bell-clapper deformity is the most important. The diagnosis is made largely on history or physical examination. In equivocal cases, imaging with color Doppler ultrasonography may be helpful in making the diagnosis. Additional tools including near-infrared spectroscopy and Testicular Workup for Ischemia and Suspected Torsion score may be helpful in diagnosing testicular torsion. Possible long-term effects on fertility and hormonal function are also often a concern for the patient and clinician. This review contains 6 figures, 5 tables, and 34 references. Keywords: acute, infarction, ischemia, orchidopexy, scrotum, spermatic cord, testis, torsion

Successful outcome in perinatal intravaginal torsion of testis in neonate: Long-term outcome

Introduction Perinatal testicular torsion can be intravaginal or extravaginal. Extravaginal torsion can be managed in an elective manner. Intravaginal torsion needs an urgent operation to maximize the viability of the testis. The history is vital to distinguish between the two diagnoses. We report a case in which a perinatal intravaginal torted testicle was successfully salvaged due to a timely exploration. This was a retrospective review of a case and literature review of perinatal testicular torsion. Case description A term baby was transferred to a tertiary pediatric surgical unit in the for surgical management of exomphalos minor. The child was noted to have normal testes. On the seventh day of life, he was noted to have a firm swelling in his right scrotum with purple discoloration. He was promptly reviewed by the surgical team. A perinatal torsion of intravaginal type was suspected and he was booked for emergency exploration. The surgical findings were 1) significant edema of the right scrotal wall, 2) a thickened tunica vaginalis and small volume of hemolyzed fluid, and 3) a bluish and congested torted testicle in intravaginal plane. Testis was de-rotated and color returned within 5 minutes. A three-point testicular fixation was performed bilaterally. He was reviewed in clinic for the following 2 years and found to have equal growth of the testicles, both of which were appropriately positioned within the scrotum. Results and conclusions This case highlights the importance of being aware that perinatal torsion can be extravaginal or intravaginal. The patient history is important to distinguish between the two diagnoses as proven by the above case. A positive outcome can be achieved with judicious assessment and emergent management of perinatal intravaginal torsions. Take-home message Clinicians should maintain a high level of suspicion of intravaginal torsion in all cases of perinatal testicular torsion.

To 'Pex or Not to 'Pex: What to Do for the Contralateral Testis When a Nubbin Is Discovered.

Testicular remnants or nubbins are commonly found in the evaluation and treatment of cryptorchidism. While much debate focuses on the management of the nubbin itself, there is also great uncertainty and variation in the management of the contralateral descended testis. Herein, we review the relevant literature informing the decision to perform a contralateral orchiopexy. Although there is very little recent literature directly addressing the question, some studies have better characterized differences in practice, the risk of intravaginal torsion in the contralateral testis and potential consequences in the selection of technique. The etiology of a vanishing testis remains obscure, but appears more likely to be the result of a prenatal extravaginal torsion. While indeterminate, the risk of contralateral torsion of a descended testis appears to concentrate around the neonatal period with no substantially increased risk in later years. Contralateral orchiopexy, although a low-risk procedure, likely benefits very few and may carry an as yet poorly described risk to the contralateral testicle depending on the technique of fixation.

A Case of Prenatal Testicular Torsion

We report a prenatal case of neonatal testicular torsion. A 0-day-old boy with left scrotal swelling from the time of birth was referred to us. The physical examination revealed left intrascrotal hard mass. The ultrasonography with doppler color flow showed heterogeneous parenchymal echogenicity and the lack of blood flow to the affected testis. Testicular torsion was suspected and emergent surgical exploration was performed. The left testis was necrotic with extravaginal torsion of the spermatic cord. Left high orchiectomy was performed, considering the possibility of inguinal hernia. The histopathological examination confirmed the necrosis of the left testis.

Successful Outcome in Perinatal Intravaginal Torsion of Testis in Neonate: Long-Term Outcome

Perinatal testicular torsion can be intravaginal or extravaginal. Extravaginal torsion can be managed in an elective manner. Intravaginal torsion needs an urgent operation to maximize the viability of the testis. The history is vital to distinguish between the two diagnoses. We report a case in which a perinatal intravaginal torted testicle was successfully salvaged due to a timely exploration. This was a retrospective review of a case and literature review of perinatal testicular torsion. A term baby was transferred to a tertiary pediatric surgical unit in the United Kingdom for surgical management of exomphalos minor. The child was noted to have normal testes. On the seventh day of life, he was noted to have a firm swelling in his right scrotum with purple discoloration. He was promptly reviewed by the surgical team. A perinatal torsion of intravaginal type was suspected and he was booked for emergency exploration. The surgical findings were 1) significant edema of the right scrotal wall, 2) a thickened tunica vaginalis and small volume of hemolyzed fluid, and 3) a bluish and congested torted testicle in intravaginal plane. Testis was de-rotated and color returned within 5 minutes. A three-point testicular fixation was performed bilaterally. He was reviewed in clinic for the following 2 years and found to have equal growth of the testicles, both of which were appropriately positioned within the scrotum. This case highlights the importance of being aware that perinatal torsion can be extravaginal or intravaginal. The patient history is important to distinguish between the two diagnoses as proven by the above case. A positive outcome can be achieved with judicious assessment and emergent management of perinatal intravaginal torsions. Clinicians should maintain a high level of suspicion of intravaginal torsion in all cases of perinatal testicular torsion. Int J Clin Pediatr. 2016;5(2):38-40 doi: http://dx.doi.org/10.14740/ijcp250e

The "whirlpool sign", a US finding in partial torsion of the spermatic cord: 4 cases.

The "whirlpool sign", a US finding in partial torsion of the spermatic cord: 4 cases.

Intravaginal testicular torsion in newborns. To fix or not to fix the contralateral testis?

Scrotal swelling suggesting testicular torsion is a rare urological emergency which requires a clinical urgent evaluation and most of the times must be managed surgically. In newborns it can occur in the postnatal period, usually within the twenty-eighth day of life, or more frequently in utero, during the descent of the testis into the scrotum. Usually its poor fixedness allows the testis an abnormal mobility inside the scrotum, configuring the framework of extravaginal torsion. On the contrary during the perinatal period a twist that takes place inside the tunica vaginalis, known as intravaginal torsion, is extremely uncommon and only few cases are well documented in the literature. Authors present a rare case of intravaginal testicular torsion occurred in perinatal period. In this situation only the early surgical exploration of the scrotum may allow the rescue of the gonad, although in rare cases. Timing of surgical treatment and need for contralateral testicular fixation remain controversial. However since the anatomical defect of the tunica vaginalis can be bilateral the surgical fixation even of the contralateral testis is important, now or later, in order to prevent any future torsion of this gonad. The authors also present a brief review of recent literature on the subject.

Testicular Torsion in the First Year of Life – Characteristics and Treatment Outcome

To review the characteristics and treatment outcome of testicular torsion in infants, aged 1 month to 1 year, and compare them with those seen in neonates. The study group included 30 patients aged younger than 1 year who were treated for testicular torsion at a tertiary pediatric medical center between 1993 and 2012. Medical records were retrospectively reviewed for clinical characteristics and treatment outcome. Findings were compared between patients who presented before age 1 month (neonate group, n = 17) or later (infant group, n = 13). The common clinical presentation in the neonate group was a solid, nontender scrotal mass apparent in 13 of 17 patients (76%). In the infant group, 11 of 13 patients (85%) presented with restlessness and 12 of 13 (92%) with a tender scrotal or inguinal mass. Torsion of an undescended testis was significantly more prevalent in infants, 7 of 13 (54%), than neonates, 1 of 17 (6%; P = .009). Although extravaginal torsion was documented in 5 of 6 neonates (83%), 8 of 9 infants (89%) had an intravaginal torsion (P = .011). Orchiectomy was performed in 14 of 17 neonates (82%) and 6 of 13 infants (46%; P = .056). Of the 29 patients with follow-up data, testicular salvage was documented in 1 of 17 neonates (6%) and 2 of 12 infants (17%), at a minimum follow-up of 5 months (P = .55). Testicular torsion in the first year of life is a diverse condition. Although neonatal torsions were predominantly extravaginal, infantile torsions were mostly intravaginal, involving undescendent testes in more than half of the cases. Despite fewer orchiectomies performed on the infant group, testicular salvage rates in both groups were similarly low.

Ultrasound imaging of the “on call” acute scrotum

Causes of the acute scrotum1. Vascular– Spermatic cord torsion– Torsion of the appendix testis2. Trauma– Testicular rupture/fracture– Haematoma/haematocele– Penetrating injury3. Infective/Inflammatory– Epididymitis/epididymo-orchitis– Testicular abscess– Fournier’s gangrene4. Miscellaneous– Acute idiopathic scrotal oedema– Inguinoscrotal hernia– Testicular tumours– Henoch–Schonlein purpuraTorsion of the spermatic cord– Is a surgical emergency—irreversible ischaemia occurs after 6 h– Represents 17% of all acute scrotal presentations, the incidence is 1 in 4000 males– Intravaginal torsion is associated with the bell-clapper deformity. Presentation is most commonly between the ages of 12–18 years– Extravaginal torsion is rare and occurs in utero or the perinatal period, the testis is usually unsalvageable– Greyscale ultrasound may be normal in immediate post-torsion period. Following this, sonographic changes frequently mimic acute epididymo-orchitis.– Lack of flow or diminished flow on colour/power Doppler ...

Incomplete Prenatal Torsion of the Testicle—A Successful Salvage

The role of emergent intervention in prenatal testicular torsion is controversial. We report a case of successful testicular salvage of incomplete prenatal torsion. A 1-day-old male infant presented with a bluish-hued scrotum at birth. Testicular ultrasonography demonstrated right testicular torsion with minimal peripheral blood flow. Scrotal exploration was performed, confirming extravaginal torsion; both testes underwent orchiopexy. Subsequent imaging demonstrated normal bilateral testes with good vascular flow. Although intervention of prenatal torsion has been debated, the present case represents prenatal torsion saved by intervention. We propose the presence of any blood flow suggests incomplete torsion and the potential for salvage.

Salvage of Bilateral Asynchronous Perinatal Testicular Torsion

Current management strategies for prenatal torsion include observation alone, delayed contralateral orchiopexy and emergent contralateral orchiopexy. Bilateral torsion is now being reported with more frequency and approximately a third of these patients have asynchronous torsion. We highlight the role of scrotal exploration in neonates diagnosed with bilateral asynchronous testicular torsion. We reviewed the clinical experience from 2000 to present of 2 senior pediatric urologists to identify cases of bilateral perinatal testicular torsion. Asynchronous torsion was identified by the varying physical findings of each testicle at exploration. A literature review was done to evaluate the evolving management of perinatal testicular torsion. Six cases of bilateral perinatal torsion were identified since 2000. In 3 of the 6 cases extravaginal torsion of the contralateral testis was incidentally identified at surgical exploration. All 3 testes had normal Doppler flow before exploration. Testicular salvage was not successful in the 2 patients with bilaterally absent blood flow on newborn ultrasound. The 3 cases of incidentally diagnosed contralateral torsion and 1 of preoperatively diagnosed contralateral torsion were successfully salvaged. Thus, 4 of 6 patients with bilateral torsion were left with 1 viable testis. Physical examination findings and radiography can be inaccurate to assess the contralateral testis in males born with prenatal torsion. We have adopted the strategy of emergent surgical exploration in cases of prenatal torsion. Using this approach anorchia was minimized in patients with bilateral asynchronous torsion.

The return of the solitary testis

Purpose To assess what is done and what is recommended concerning fixation of the solitary testis. Material and method We conducted an e-mail survey of current practices in 28 pediatric surgery departments in 28 university or general hospitals in France. We then reviewed what evidence could be found in the literature. Results All surgeons fix the contralateral solitary testis following intravaginal torsion. Sixteen out of 28 fix the contralateral solitary testis following extravaginal torsion, 13/28 in cases of monorchia, and 8/28 following orchiectomy for trauma or tumour. Five surgeons have observed one case each of torsion of a solitary testis, and three have witnessed testicular necrosis following orchiopexy. Conclusion There is no consensus regarding fixation of the remaining testis in the literature. Scientific evidence does not show clearly whether fixation is necessary, regardless of the clinical situation. However, if fixation is performed it should be done using the dartos pouch sutureless technique.

Testicular torsion in a neonate; a case report

The testicular torsion which is typically seen in prepuberty is very rare in the early neonatal period; prenatal diagnosis is difficult. Herein, we report a five day-old male neonate with swelling and erythema of the right scrotum. Following Doppler ultrasound suggestive of testicular torsion, surgical exploration was undertaken. There was gangrene of the right testis with discoloration and necrosis due to complete extravaginal torsion. Right orchidectomy, along with a fixation of the left testis was performed. While perinatal testicular torsion is a rare condition, if a case is found it should be considered as an emergency situation. Treatment in the neonatal period is mandatory.

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.

Acute Testicular Disorders

1. John M. Gatti, MD* 2. J. Patrick Murphy, MD† 1. *Associate Professor, University of Missouri at Kansas City School of Medicine; Director, Minimally Invasive Urology, Children's Mercy Hospital, Kansas City, Kan 2. †Professor, University of Missouri at Kansas City School of Medicine; Chief, Section of Urology, Children's Mercy Hospital, Kansas City, Kan After completing this article, readers should be able to: 1. Describe the appropriate evaluation and management of the acute scrotum. 2. Discern testicular torsion from other, less urgent conditions that may mimic it. 3. Discuss the importance of prompt diagnosis and treatment of testicular torsion for gonadal salvage. Acute scrotal pain with or without swelling and erythema in the child or adolescent male should be treated as an emergent condition. The differential diagnosis includes: torsion of the spermatic cord, appendix testis or epididymis, epididymitis/orchitis, hernia, hydrocele, trauma, sexual abuse, tumor, idiopathic scrotal edema (dermatitis/insect bite), cellulitis, and vasculitis (Henoch–Schonlein purpura). Most of the conditions are nonemergent, but the prompt diagnosis and treatment of torsion of the spermatic cord is imperative to avoid permanent ischemic damage to the testicle. The most common causes of acute scrotal pain are testicular (spermatic cord) torsion and torsion of the rudimentary vestigial appendages of the testicle or epididymis. The child's age suggests the cause of the acutely painful scrotum because torsion of the appendix testes/epididymis is more common in prepubertal boys and spermatic cord torsion occurs more frequently in adolescents and newborns. Torsion of the testicle results from twisting of the spermatic cord, which compromises testicular blood supply. The number of twists determines the amount of vascular impairment, although generally a 4- to 8-hour window exists before significant ischemic damage occurs that can affect long-term testicular morphology and sperm formation. Testicular torsion is a true surgical emergency. Adolescent males tend to present beyond the “golden” 4- to 8-hour period, but urgent surgical treatment is indicated because viability of the testis is difficult to predict. Two types of testicular torsion may occur. Extravaginal torsion results from twisting of the cord proximal to the tunica vaginalis. This mechanism occurs perinatally during descent of the testicle before the scrotal investment of …