Intravaginal Torsion Research Articles

Clinical characteristics and identification of risk factors of testicular torsion in children: Aretrospective study in a singleinstitution.

Testicular torsion (TT) is a common urological emergency posing serious health problem in children. Prompt diagnosis and treatment of TT are very important for children to protect the affected testis. The aim of this study was to evaluate the historical features, physical examination findings, laboratory tests, and ultrasound examinations in children with TT, as well as to identify the predictors of testicular salvage in children. We conducted a retrospective record of clinical findings, laboratory data, ultrasound findings, operating results, and the results of follow-up in hospitalized children with TT from November 2004 to December 2021. A multivariable logistic regression model was used to identify predictors of testicular salvage. A total 102 hospitalized children who presented with TT were included. Patients were aged from 1 month to 16 years, with a median age of 7.71 years. TT is significantly more common in the winter. Of these patients, 77 torsions were left-sided, 24 were on the right side, and only 1 was on bilateral sides. Meanwhile, we detected that 88 children suffering from TT had intravaginal torsion of the spermatic cord, and the rest were outside. Anticlockwise torsion was found in 65 cases (63.73%) and clockwise torsion in 37 (36.27%). As a result, 60 underwent orchidectomy, while 42 had a scrotal exploration with fixation of the testis. Multivariate analysis showed that cause of TT, time to intervention, white blood cell (WBC), and mean platelet volume (MPV) were correlated with the risk of a surgical outcome. Only a small proportion of TT children received timely surgical management. Testicular salvage can be predicted by cause of TT, time to intervention, WBC, and MPV. Early scrotal exploration based on careful physical examination decreases the risk of misdiagnosis of spermatic cord torsion. A certain percentage of children with TT presenting with scrotal trauma or epididymo-orchitis should have their testicles checked to make sure that they do not have torsion, especially those who visit in the cold season.

A case of intra-vaginal intrauterine testicular torsion

Abstract Objectives Intrauterine testicular torsion is extremely rare and the exact cause remains largely unknown. It is the result of an ischemic insult intrauterine, which presents as either extra-vaginal or intravaginal testicular torsion. Urgent surgical exploration and fixating the contralateral testis is key in the management of this condition. Case presentation We present here the case of a two-day old neonate with in-born right scrotal swelling admitted at Children’s hospital. The patient was born at term via cesarean section at a private hospital. Upon arrival in the emergency department, he was well hydrated, pink at room temperature with good perfusion. Upon examination, the right testis was found to be enlarged, tense, non-tender visibly reddish with overlying skin excoriation. Trans-illumination was negative in right but positive in the contralateral testis. Both hernial orifices were normal. Doppler ultrasound of the inguinoscrotal area found the right testis to be enlarged (15.6*9.4 mm) and showed heterogeneous hypoechoic texture with prominent rete testis and no flow on color doppler analysis. An urgent scrotal exploration was undertaken. Intra-operatively there was frank necrotic right testis with intravaginal torsion of the testis and minimal hydrocele. A right orchidectomy and contralateral orchidopexy were performed. Conclusions Intrauterine testicular torsion should be treated as a surgical emergency. We advocate early recognition of intrauterine testicular torsion, alongside surgical exploration and simultaneous contralateral orchidopexy.

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.

Management of perinatal testicular torsion: experience of two tertiary centers.

Perinatal testicular torsion is a rare condition in which testicular salvage rates are significantly low and management is controversial. We retrospectively evaluated our patients and aimed to go through our management approach. The newborn patients who underwent surgery for testicular torsion in two tertiary referral centers between 2000 and 2019 are enrolled. Radiological and clinical findings are retrospectively evaluated. Thirty-two newborns are enrolled in the study. All of the cases were unilateral and 30 ended up with immediate orchidectomy while 2 received orchidopexy but both underwent atrophy on follow-up. No bilateral torsion is demonstrated neither in 16 patients with bilateral exploration nor in the follow up of the rest 16 with unilateral exploration. Intravaginal torsion was encountered in five patients (16%). No morbidity or mortality related to anesthesia is documented. No malignancy is encountered in any of the patients. Although ipsilateral testicular salvage rates are low, urgent bilateral exploration in a multidisciplinary center seems reasonable to give a chance to the ipsilateral testis and to avoid the rare but catastrophic bilateral torsion, after discussing with the family.

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.

Perinatal testicular torsion: Ultrasound assessment and differential diagnosis

Perinatal testicular torsion, defined as torsion occurring in the prenatal period or in the first month after birth, accounts for 10% of all cases of testicular torsion in pediatric patients. Most are extravaginal, and intravaginal torsion is rare. Its management is controversial, due to the low viability of the testis and the possibility of bilateral torsion. Ultrasonography is the method of choice to study testicular torsion. Combining B-mode and power Doppler imaging facilitates a fast reliable diagnosis. We review the ultrasonographic appearance of neonatal testicular torsion for each presentation, the differential diagnosis with other causes of increased scrotal volume in neonates, and its treatment.

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.

Torsión testicular perinatal. Valoración ecográfica y diagnóstico diferencial

Perinatal testicular torsion, defined as torsion occurring in the prenatal period or in the first month after birth, accounts for 10% of all cases of testicular torsion in pediatric patients. Most are extravaginal, and intravaginal torsion is rare. Its management is controversial, due to the low viability of the testis and the possibility of bilateral torsion. Ultrasonography is the method of choice to study testicular torsion. Combining B-mode and power Doppler imaging facilitates a fast reliable diagnosis. We review the ultrasonographic appearance of neonatal testicular torsion for each presentation, the differential diagnosis with other causes of increased scrotal volume in neonates, and its treatment.

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.

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

Is contrast-enhanced MRI efficient in testicular infarction mimicking testicular tumor on scrotal ultrasound?

A 4-year-old boy was admitted to emergency department of our institution with left testicular swelling and pain started 48 h ago. Physical examination revealed left sided erythema and tenderness in scrotum which was refractory to testicular elevation. The parents did not describe undescended testis, trauma or recent mumps history that may explain acute swelling of left scrotum. Immediately after the physical examination, a scrotal Doppler ultrasonography was performed using a high frequency linear transducer. Ultrasonographic evaluation showed heterogeneously enlarged left testis and edema in the left scrotum. Blood supply was decreased in left testis in comparison to the right, however, arterial waveforms were still preserved in the left epididymis. In addition to Doppler and gray scale ultrasonography features, a smooth contoured demarcation line in the left testis was also observed which simulated mass lesion in the left testis. Based on the ultrasonography findings a concurrent testicular neoplasia could not be ruled out completely and the patient was referred to contrast-enhanced magnetic resonance imaging (MRI) promptly after ultrasound examination. MRI revealed left testicular enlargement, scrotal edema, and heterogeneous hypointense areas in T2-weighted images, but there was no solid or cystic mass lesion within the left testis. The affected testis was observed to be prominently hypointense on T1-weighted images compared to right. At post-contrast and subtraction MRI sequences avid contrast enhancement was detected in left paratesticular tissue however, left testis was completely avascular at post-contrast MRI sequences (Fig. 1). Based on the MRI findings, the diagnosis of testicular torsion was made confidently. Emergency surgical exploration confirmed intravaginal testicular torsion but, unfortunately detorsion operation could not have been performed and left sided orchiectomy was required because left testis was observed to be totally necrotic during surgical intervention (Fig. 2). Fig. 1 Post-contrast subtraction axial MRI image reveals left testicular enlargement and left paratesticular enhancement. Note that the affected left testis is hypointense and no contrast enhancement is observed diagnostic for testicular torsion (arrows). However, ... Fig. 2 Photographic view of the left testis during operation shows left testicular necrosis. Intravaginal torsion accounts for most cases of testicular torsion. Most cases are spontaneous but, rarely intravaginal testicular torsion may result from testicular trauma.1 Since irreversible damage may occur within 4–6 h of symptom onset, early diagnosis and urgent surgical intervention are critical.2 In the early stage of torsion, the echogenicity and size of the affected testis may be normal. Later findings include testicular enlargement and increased parenchymal echogenicity. If left untreated, the torsion will eventually progress into infarction which is seen as decreased or absent blood flow in color Doppler ultrasonography.1 The latter is sometimes diagnostic challenge in ultrasonography since, demarcation line of the infarcted testis tissue may simulate tumor particularly in late testicular torsion.3 In the current case, as reported in the literature,4 a testicular tumor was accurately ruled out via emergency contrast-enhanced MRI. In conclusion, late testicular torsion may mimic testicular mass lesion in ultrasonography which may cause a diagnostic challenge in Emergency Medicine. Contrast-enhanced MRI is helpful in the diagnosis as well as in the differential diagnosis in such complex cases.

Morphological and microcirculatory evaluation of the rat testis after detorsion with or without a capsular release with a tunica vaginalis flap.

Testicular torsion may lead to serious ischemia, and the viability depends on the duration of torsion and the effect of ischemia-reperfusion. Testicular decompression and tunica vaginalis flap application technique were introduced in 2008 by Kutikov et al. We aimed to examine the impact of this method on the testicular microcirculation and hemorheological parameters in a rat model. Six adult rats underwent bilateral scrotal exploration. Intravaginal torsion of the testis was created by 720° rotation on both sides for 2 h. After detorsion, the right testes underwent tunica albuginea incision and tunica vaginalis flap application. Testicular microcirculation was monitored and hematological parameters, erythrocyte deformability, and aggregation were determined. Measurements were performed before and after torsion, directly after detorsion, on the 1st–2nd and 8th postoperative day. After the last sampling, testicles were removed to determine their volume for histological examinations. The microcirculatory parameters demonstrated slight differences between testicles. Apical zone of the left (nondecompressed) testicles had elevated compared to the middle zone (P < 0.05). On the 2nd and 8th day, the microcirculation of the testes normalized but not equally. The erythrocyte aggregation and deformability decreased by the 8th day. Both testicles underwent atrophy and epithelial necrosis, but the volume of the decompressed ones was lower (1.07 ± 0.08 vs 1.25 ± 0.31). Histologically, there was no significant difference in epithelial damage score between decompressed and nondecompressed testes. In conclusion, 2-h ischemia led to alteration in testicular microcirculation, reduction in volume, changes in hemorheological parameters and serious epithelial necrosis both in decompressed and nondecompressed testicles without remarkable differences.

Diagnosis of testicular torsion using near infrared spectroscopy: A novel diagnostic approach.

We report a case of testicular torsion in a 14-month old boy. Testicular ischemia was suspected based on history and clinical presentations. The patient was referred following 24 hours of left acute scrotum. Erythema, swelling and tenderness associated with nausea and emesis were present, but the patient was not febrile. We used a spatially resolved near-infrared spectroscopy (SR-NIRS) device to study and compare the tissue saturation index (TSI) on both right and left spermatic cords. The TSI was significantly reduced in the left side. Both testicles were surgically explored and the left testis was found non-viable with a 1080-degree intra-vaginal torsion. NIRS monitoring of spermatic cord oxygen saturation appears feasible as a non-invasive bedside optical method to identify testicular torsion.

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 ...

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.

Parenchymal Echo Texture Predicts Testicular Salvage After Torsion: Potential Impact on the Need for Emergent Exploration

In the setting of signs and symptoms of testicular torsion the absence of diastolic flow and/or color flow on Doppler ultrasound has traditionally prompted emergent scrotal exploration. This practice emanates largely from the difficulty on ultrasound of distinguishing salvageable torsed testes from those that are not salvageable. We identified ultrasound findings predictive of testicular viability or the lack thereof. We retrospectively reviewed the charts of all boys who underwent scrotal exploration for signs and symptoms of torsion during a 4-year period. In those who underwent preoperative Doppler ultrasound of the scrotum ultrasound findings were reviewed, as were the operative dictations. In patients who underwent orchiectomy the pathology reports were also reviewed. In patients in whom the torsed testis appeared viable and who underwent orchiopexy followup data were reviewed when available. Emergency room charts were also reviewed to ascertain, when documented, the duration of pain before presentation to the emergency room and the interval between ultrasound and operating room. During this period 55 boys underwent exploration after preoperative scrotal Doppler ultrasound revealed absent diastolic flow and/or color flow Doppler in the symptomatic testis. Assessment of parenchymal echogenicity revealed heterogeneity in 37 testes (67%), of which none were deemed viable at exploration. Orchiectomy was performed in 34 of 37 cases. Pathological examination revealed necrosis in all 34 cases, a finding consistent with late torsion. The remaining 3 testes underwent orchiopexy by parental directive despite nonviability, as confirmed by biopsy and subsequent atrophy. Thus, heterogeneity on preoperative ultrasound was universally predictive of organ loss (chi-square p <0.001). Of the 18 symptomatic testes (33%) demonstrating homogeneity and isoechogenicity on ultrasound 16 (89%) were deemed viable at exploration. Boys in whom the torsed testicle was nonviable on exploration experienced an average of 27.5 hours of pain preoperatively (range 5 to 72), whereas boys in whom the torsed testis was salvaged experienced an average of 20.5 hours of pain (range 2 to 96) (p = 0.073). The nonviable group underwent surgery an average of 49 minutes after ultrasound, whereas the viable group underwent surgery 52 minutes after ultrasound (p = 0.92). None of the 55 patients experienced any surgical or anesthetic complications and no pathological condition was noted intraoperatively in the contralateral asymptomatic testis. In the setting of Doppler proven testicular torsion heterogeneous parenchymal echo texture indicates late torsion and testicular nonviability. Therefore, the case may not require emergent scrotal exploration. On the other hand, homogeneous echo texture portends extremely well for testicular viability. Thus, such testes should be explored emergently.