perinatal testicular · pdf fileperinatal testicular torsiontorsion audrey c. durrant, ......

Perinatal Testicular Perinatal Testicular Perinatal Testicular Perinatal Testicular TorsionTorsion

Audrey C. Durrant, M.D.Audrey C. Durrant, M.D.

Long Island College HospitalLong Island College HospitalLong Island College HospitalLong Island College Hospital

2/06/20092/06/2009

www.downstatesurgery.org

Case PresentationCase PresentationCase PresentationCase Presentation

HPIHPI: A 41wk 5000+ gm baby : A 41wk 5000+ gm baby HPIHPI: A 41wk 5000+ gm baby : A 41wk 5000+ gm baby boy was born NSVD to a boy was born NSVD to a healthy woman after an healthy woman after an uneventful first pregnancy, uneventful first pregnancy, APGAR 9 and 9; and was APGAR 9 and 9; and was i di t l t d t h i di t l t d t h immediately noted to have a immediately noted to have a large mass in the right large mass in the right hemiscrotumhemiscrotumhemiscrotum.hemiscrotum.Surgical consult called for Surgical consult called for r/o testicular torsionr/o testicular torsionr/o testicular torsionr/o testicular torsion



Physical ExamPhysical Exam::Physical ExamPhysical Exam::WD, NADWD, NADAbdomen: soft nt ndAbdomen: soft nt ndAbdomen: soft, nt, ndAbdomen: soft, nt, ndScrotum: left testicle was normal in size and configurationScrotum: left testicle was normal in size and configuration

Bilaterally no hernias or hydroceles with no evidence of scrotal or Bilaterally no hernias or hydroceles with no evidence of scrotal or Bilaterally no hernias or hydroceles with no evidence of scrotal or Bilaterally no hernias or hydroceles with no evidence of scrotal or inguinal inflammationinguinal inflammationright hemiscrotum did not transilluminateright hemiscrotum did not transilluminate



Doppler UltrasoundDoppler Ultrasound:: no no Doppler UltrasoundDoppler Ultrasound:: no no flow to right testicleflow to right testicle



IntraIntra--operative Course:operative Course:IntraIntra operative Course:operative Course:BB was taken urgently to OR BB was taken urgently to OR for bilateral scrotal for bilateral scrotal exploration; the right testicle exploration; the right testicle was blackened and grossly was blackened and grossly

ti d d t ti d d t necrotic and appeared to necrotic and appeared to represent long standing represent long standing torsion therefore orchiectomy torsion therefore orchiectomy torsion, therefore orchiectomy torsion, therefore orchiectomy was performed.was performed.



The contra lateral The contra lateral Postoperative CoursePostoperative Course::The contra lateral The contra lateral hemiscrotum was explored hemiscrotum was explored and the left testicle was and the left testicle was

Postoperative CoursePostoperative Course::He did well and was He did well and was discharged to home on discharged to home on

viable and in normal position, viable and in normal position, an orchiopexy was performed an orchiopexy was performed t fi th t ti l i iti t fi th t ti l i iti

POD#5POD#5

to fix the testicle in position to fix the testicle in position and prophylac against furture and prophylac against furture torsiontorsiontorsiontorsion


Perinatal Testicular Perinatal Testicular T iT iTorsionTorsion


HistoryHistoryHistoryHistory

Perinatal Testicular Torsion (PTT) initially described in Perinatal Testicular Torsion (PTT) initially described in Perinatal Testicular Torsion (PTT) initially described in Perinatal Testicular Torsion (PTT) initially described in 1897 by Taylor1897 by Taylor11 in Britain and then again about 50 in Britain and then again about 50 years later in North America by Campbellyears later in North America by Campbell22

Extremely rare entity Extremely rare entity –– estimated incidence 1 in 7500 estimated incidence 1 in 7500 live birthslive births33

Testicular torsion refers to twisting of the spermatic cord Testicular torsion refers to twisting of the spermatic cord structures structures –– either in inguinal canal or just beloweither in inguinal canal or just below


ProblemProblemProblemProblem

Two most common types Two most common types ypyptesticular torsiontesticular torsion44

1.1. Extravaginal torsionExtravaginal torsion:: this type this type manifests in neonatal period and manifests in neonatal period and manifests in neonatal period and manifests in neonatal period and is associated with the lack of is associated with the lack of tunica vaginalis attachment to the tunica vaginalis attachment to the scrotumscrotum

2.2. Intravaginal torsion:Intravaginal torsion: usually in usually in older children within the tunica older children within the tunica vaginalis and is related to vaginalis and is related to gganomalus testicular suspension anomalus testicular suspension known as bell clapper anomaly known as bell clapper anomaly ––often bilateraloften bilateral


PTT: PresentationPTT: PresentationPTT: PresentationPTT: Presentation

Extravaginal torsionExtravaginal torsion recently subcategorized as occurring recently subcategorized as occurring Extravaginal torsionExtravaginal torsion recently subcategorized as occurring recently subcategorized as occurring perintally in utero or immediately postnatallyperintally in utero or immediately postnatally55

Prenatal TorsionPrenatal Torsion: minimal to no discomfort and very localized : minimal to no discomfort and very localized Prenatal TorsionPrenatal Torsion: minimal to no discomfort and very localized : minimal to no discomfort and very localized findingsfindingsPostnatal TorsionPostnatal Torsion: acute manifestation with considerable : acute manifestation with considerable Postnatal TorsionPostnatal Torsion: acute manifestation with considerable : acute manifestation with considerable tenderness and swelling of a previously normal testicle tenderness and swelling of a previously normal testicle


FrequencyFrequencyFrequencyFrequency

Extravaginal TorsionExtravaginal Torsion::Extravaginal TorsionExtravaginal Torsion::approximately 5% of all torsions.approximately 5% of all torsions.most often a prenatal (in utero) event most often a prenatal (in utero) event 3% are bilateral. 3% are bilateral.

Intravaginal TorsionIntravaginal Torsion::Approx. 16% of patients with torsion presenting in emergency Approx. 16% of patients with torsion presenting in emergency departments with acute scrotum. departments with acute scrotum. P k i id i d l t d 13 P k i id i d l t d 13 Peak incidence occurs in adolescents aged 13 yearsPeak incidence occurs in adolescents aged 13 yearsleft testis is more frequently involved. left testis is more frequently involved. Bilateral cases account for 2% of all torsions Bilateral cases account for 2% of all torsions Bilateral cases account for 2% of all torsions. Bilateral cases account for 2% of all torsions.


PTT: Risk FactorsPTT: Risk FactorsPTT: Risk FactorsPTT: Risk Factors

No consistent pattern regarding possible etiologiesNo consistent pattern regarding possible etiologies66No consistent pattern regarding possible etiologiesNo consistent pattern regarding possible etiologiesSuggested risk factors includeSuggested risk factors include

Diffi lt l bDiffi lt l bDifficult labourDifficult labourBreech presentationBreech presentationHi h bi h i hHi h bi h i hHigh birth weightHigh birth weightAn overactive cremasteric reflexAn overactive cremasteric reflexmultiparitymultiparity


EtiologyEtiologyEtiologyEtiology

Extravaginal TorsionExtravaginal Torsion::ggAssociated with lack of tunica vaginalis attachment to scrotumAssociated with lack of tunica vaginalis attachment to scrotum

Intravaginal TorsionIntravaginal Torsion::Normal posterior anchoring of the gubernaculum epididymis and testesNormal posterior anchoring of the gubernaculum epididymis and testesprevents twisting of the spermatic cord. prevents twisting of the spermatic cord. bellbell clapper deformity allows torsion to occur because of a lack of clapper deformity allows torsion to occur because of a lack of bellbell--clapper deformity allows torsion to occur because of a lack of clapper deformity allows torsion to occur because of a lack of fixation, fixation, resulting in the testis being freely suspended within the tunica resulting in the testis being freely suspended within the tunica

i li i li vaginalis. vaginalis. Contraction of the spermatic muscles shortens the spermatic cord and Contraction of the spermatic muscles shortens the spermatic cord and may initiate testicular torsion. may initiate testicular torsion. yy


PathophysiologyPathophysiologyPathophysiologyPathophysiology

Torsion of the spermatic cord may interrupt blood flow to the Torsion of the spermatic cord may interrupt blood flow to the p y pp y ptestis and epididymis. testis and epididymis. The degree of torsion may vary from 180The degree of torsion may vary from 180--720720°°Increasing testicular and epididymal congestion promotes Increasing testicular and epididymal congestion promotes Increasing testicular and epididymal congestion promotes Increasing testicular and epididymal congestion promotes progression of torsion.progression of torsion.The extent and duration of torsion influences the immediate The extent and duration of torsion influences the immediate salvage rate and late testicular atrophysalvage rate and late testicular atrophyTesticular salvage most likely occurs if the duration of torsion is Testicular salvage most likely occurs if the duration of torsion is less than 6less than 6--8 hours 8 hours less than 6less than 6--8 hours. 8 hours. If 24 hours or more elapse, testicular necrosis develops in most If 24 hours or more elapse, testicular necrosis develops in most patients.patients.


PresentationPresentationPresentationPresentation

Extravaginal TorsionExtravaginal Torsion::ggmanifests as a firm, hard, scrotal mass, manifests as a firm, hard, scrotal mass, does not transilluminatedoes not transilluminate

i ii iotherwise asymptomatic newborn male. otherwise asymptomatic newborn male. scrotal skin characteristically fixes to the necrotic gonad. scrotal skin characteristically fixes to the necrotic gonad.

Intravaginal TorsionIntravaginal Torsion::Intravaginal TorsionIntravaginal Torsion::classic presentation is sudden onset of severe testicular painclassic presentation is sudden onset of severe testicular painfollowed by inguinal and/or scrotal swelling. followed by inguinal and/or scrotal swelling. Pain may lessen as the necrosis becomes more completePain may lessen as the necrosis becomes more completeone third of patients also have gastrointestinal upset with nausea and one third of patients also have gastrointestinal upset with nausea and vomitingvomitingvomitingvomiting


A physical examination may A physical examination may A physical examination may A physical examination may reveal a swollen, tender, reveal a swollen, tender, highhigh--riding testisriding testisThe absence of the The absence of the cremasteric reflex in a cremasteric reflex in a patient with acute scrotal patient with acute scrotal pain supports the diagnosis of pain supports the diagnosis of torsiontorsiontorsiontorsion


WorkWork--upupWorkWork upup

Laboratory StudiesLaboratory Studies::Laboratory StudiesLaboratory Studies::a urinalysis and culture may help exclude urinary tract infection and a urinalysis and culture may help exclude urinary tract infection and epididymitis as the etiology of the scrotal complaints. epididymitis as the etiology of the scrotal complaints.

Imaging StudiesImaging Studies::The following diagnostic tests may be useful when a low suspicion of The following diagnostic tests may be useful when a low suspicion of

i l i ii l i itesticular torsion exists:testicular torsion exists:Scrotal color Doppler sonogramScrotal color Doppler sonogram is usually diagnostic by verifying is usually diagnostic by verifying arterial flow. arterial flow. Nuclear testicular scanNuclear testicular scan can help differentiate torsion from acute can help differentiate torsion from acute epididymitis by demonstrating cold spot and ring signs.epididymitis by demonstrating cold spot and ring signs.


ManagementManagementManagementManagement

If testicular torsion is clinically suggested If testicular torsion is clinically suggested If testicular torsion is clinically suggested, If testicular torsion is clinically suggested, perform immediate surgical exploration, perform immediate surgical exploration, regardless of laboratory studies because a regardless of laboratory studies because a regardless of laboratory studies because a regardless of laboratory studies because a negative finding upon exploration of the negative finding upon exploration of the scrotum is more acceptable than the loss of a scrotum is more acceptable than the loss of a scrotum is more acceptable than the loss of a scrotum is more acceptable than the loss of a salvageable testis.salvageable testis.


Surgical TherapySurgical Therapyg pyg pyTreat patients who are born with testicular torsion Treat patients who are born with testicular torsion by performing by performing early elective explorationearly elective exploration and and by performing by performing early elective explorationearly elective exploration and and contralateral orchidopexy (anchoring) because contralateral orchidopexy (anchoring) because bilateral (synchronous or asynchronous) neonatal bilateral (synchronous or asynchronous) neonatal ( y y )( y y )testicular torsion is described. testicular torsion is described. The potential for salvage of such a testis is nil The potential for salvage of such a testis is nil making the risk of immediate surgery before making the risk of immediate surgery before complete stabilization of the newborn unwarranted. complete stabilization of the newborn unwarranted.


Surgical TherapySurgical Therapyg pyg py

In contrast, a newborn with a normal testis at birth who In contrast, a newborn with a normal testis at birth who subsequently undergoes torsion requires immediate subsequently undergoes torsion requires immediate subsequently undergoes torsion requires immediate subsequently undergoes torsion requires immediate exploration. exploration. Perform the operation through the midline scrotal raphe. Perform the operation through the midline scrotal raphe. Enter the ipsilateral scrotal compartment; then deliver and Enter the ipsilateral scrotal compartment; then deliver and Enter the ipsilateral scrotal compartment; then, deliver and Enter the ipsilateral scrotal compartment; then, deliver and untwist the testis. untwist the testis. Evaluate the testis for viability. Evaluate the testis for viability. Remove the necrotic testis to avoid prolonged debilitating Remove the necrotic testis to avoid prolonged debilitating Remove the necrotic testis to avoid prolonged, debilitating Remove the necrotic testis to avoid prolonged, debilitating pain and tenderness. pain and tenderness. To prevent subsequent torsion, fix viable gonads to the To prevent subsequent torsion, fix viable gonads to the scrotal wall with 3scrotal wall with 3 4 nonabsorbable sutures 4 nonabsorbable sutures scrotal wall with 3scrotal wall with 3--4 nonabsorbable sutures. 4 nonabsorbable sutures. Perform both exploration and anchoring of the contralateral Perform both exploration and anchoring of the contralateral testis through the same incisiontestis through the same incision


Intraoperative DetailsIntraoperative DetailsIntraoperative DetailsIntraoperative Details

Signs of a viable testis after detorsion include Signs of a viable testis after detorsion include Signs of a viable testis after detorsion include Signs of a viable testis after detorsion include a return of colora return of colorreturn of Doppler flowreturn of Doppler flowreturn of Doppler flowreturn of Doppler flowarterial bleeding after incision of tunica albuginea.arterial bleeding after incision of tunica albuginea.


Future FertilityFuture FertilityFuture FertilityFuture Fertility

Only one functioning testicle is necessary for normal Only one functioning testicle is necessary for normal Only one functioning testicle is necessary for normal Only one functioning testicle is necessary for normal fertility potential and full masculinization. fertility potential and full masculinization. A single testicle should produce normal amounts of sperm A single testicle should produce normal amounts of sperm A single testicle should produce normal amounts of sperm A single testicle should produce normal amounts of sperm and testosterone. and testosterone.


Final WordFinal WordFinal WordFinal Word

Testicular torsion can present in both the neonatal and Testicular torsion can present in both the neonatal and Testicular torsion can present in both the neonatal and Testicular torsion can present in both the neonatal and adolescent populationadolescent populationIn the neonatal population it may present without painIn the neonatal population it may present without painIn the neonatal population it may present without painIn the neonatal population it may present without painTesticular torsion is a surgical emergencyTesticular torsion is a surgical emergencySurgical therapy involves a scrotal exploration, possible Surgical therapy involves a scrotal exploration, possible orchiectomy with a contralateral orchiopexyorchiectomy with a contralateral orchiopexy


ReferencesReferencesT l A f l l d b hT l A f l l d b h1.1. Taylor, MR. A case of testicle strangulated at birth; castration; recovery. Taylor, MR. A case of testicle strangulated at birth; castration; recovery. BMJ. BMJ. 1897;1:458.1897;1:458.

2.2. Campbell, MF. Torsion of the spermatic cord in the newborn infant. Campbell, MF. Torsion of the spermatic cord in the newborn infant. J Ped. J Ped. 1948;33:323.1948;33:323.;;

3.3. Kaplan, G. W., Silber, I.: Neonatal torsionKaplan, G. W., Silber, I.: Neonatal torsion——to pex or not? In: Urologic to pex or not? In: Urologic surgery in neonates and young infants. Edited by King, L.R. Philadelphia: surgery in neonates and young infants. Edited by King, L.R. Philadelphia: W.B. Saunders Co., 1988; Chapter 20, pp. 386W.B. Saunders Co., 1988; Chapter 20, pp. 386--395395

44 Minevich Eugene et al Testicular Torsion Emedicine comMinevich Eugene et al Testicular Torsion Emedicine com4.4. Minevich Eugene et al. Testicular Torsion. Emedicine.comMinevich Eugene et al. Testicular Torsion. Emedicine.com5.5. Brandt, MT; Sheldon, CA; Wacksman, J, et al. Prenatal testicular torsion: Brandt, MT; Sheldon, CA; Wacksman, J, et al. Prenatal testicular torsion:

principles of management. principles of management. J Urol. J Urol. 1992;147:6701992;147:670––2. 2. 6.6. Leach, GE; Masih, BK. Neonatal torsion of the testicle. Leach, GE; Masih, BK. Neonatal torsion of the testicle. Urology. Urology. , ; ,, ; , gygy

1980;16:6041980;16:604––5. [ 5. [ 7.7. Guerra LA et al. Management of Testicular Torsion: Which way to turn? Guerra LA et al. Management of Testicular Torsion: Which way to turn?

Canadian Urol. Ass. J. 2008 August, 2 (4): 376Canadian Urol. Ass. J. 2008 August, 2 (4): 376--379.379.


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