Neonatal testicular torsion with an unusual sonographic feature

Testicular Torsion in the Emergency Room: A Review of Detection and Management Strategies

Testicular torsion is a challenging and time-sensitive diagnosis that is encountered frequently in daily practice, especially in the emergency room. A thorough history, the presence of a painful and swollen testis and testicular ultrasonography plays a vital role in the prompt diagnosis of testicular torsion. Prompt diagnosis is essential to prevent complications of testicular torsion which include testicular infarction, necrosis, and sub/infertility. This can be challenging as there are various other conditions that may mimic the presentation of testicular torsion. Since testicular torsion is an extremely time-sensitive diagnosis, it may also be a subject of many medicolegal challenges. This review article serves as a guide for clinicians involved with the diagnosis and management of testicular torsion. We review and discuss detection and management strategies based on their validity, statistical significance, and effectiveness in enabling prompt diagnosis and management of testicular torsion. Medicolegal implications of testicular torsion are also highlighted.

Ultrasound assessment of perinatal testicular torsion

OBJECTIVE:

The goal of this study was to elucidate the different sonographic features of prenatal and postnatal testicular torsion (TT) using high-frequency colour Doppler ultrasound (HCDU) in an effort to increase diagnostic accuracy.

METHODS:

29 patients (average age, 7.5 days) with perinatal TT were divided into patients with postnatal (acute) TT vs patients with prenatal (chronic) TT and their clinical characteristics, imaging features on HCDU and surgical pathology results were retrospectively analyzed.

RESULTS:

Significant differences were observed between prenatal and postnatal TT cases with regard to testicular size (p = 0.01) and echogenicity (p = 0.007). All 17 prenatal cases had non-homogeneous testicular parenchymal echo patterns compared with only 9 (64.3%) postnatal TT cases. Five postnatal TT cases presented with homogeneous echo patterns compared with none of the prenatal TT cases. Testicular blood supply was absent in 25 (80.7%) of 31 testes on colour Doppler flow imaging, with the majority occurring in the prenatal TT cases [i.e. 16 (94.1%) cases]. 1 affected testis out of a total 17 testes from 16 patients with prenatal TT was salvaged, with a salvage rate of 1/17 or 0.06%. 7 affected testes out of a total 16 testes from 13 patients with postnatal neonatal TT were salvaged, with a salvage rate of 7/16 or 43.8%.

CONCLUSION:

In neonates with acute scrotal symptoms, the possibility of perinatal TT should be considered and HCDU examination should be performed in a timely manner. HCDU examination could aid in testicular salvage by prompting quick surgical intervention.

ADVANCES IN KNOWLEDGE:

This study underlined the clinical contribution of HCDU in evaluating postnatal (acute) vs prenatal (chronic) TT. The sonographic features of postnatal TT with salvageable testes were compared with prenatal torsion and the relative salvage rates in both cases were discussed.

Utility of Real-Time Shear Wave Elastography in the Assessment of Testicular Torsion

Real-time shear-wave elastography (SWE) is a newly developed method which can obtain the stiffness of tissues and organs based on tracking of shear wave propagation through a structure. Several studies have demonstrated its potential in the differentiation between diseased and normal tissue in clinical practices, however the applicability to testicular disease has not been well elucidated. We investigated the feasibility and reproducibility of SWE in the detection of testicular torsion. This prospective study comprised 15 patients with complete testicular torsion. Results obtained from SWE along with conventional gray-scale and color Doppler sonography and post-operative pathology were compared. The results revealed that (i) the size of injured testis was increased and the twisted testis parenchyma was heterogeneous. The blood flow signals in injured testis were barely visible or absent; (ii) The Young’s modulus, including Emean, Emax, Emin and SD values in the border area of torsional testis were higher than those of normal testis (Emean, 78.07±9.01kPa vs 22.0±5.10kPa; Emax,94.07±6.53kPa vs 27.87±5.78kPa; Emin, 60.73±7.84 kPa vs 18.90±4.39kPa; SD, 7.67±0.60 kPa vs 2.30±0.36 kPa, [P<0.05]); The Emax and SD values in the central area of the torsional testis were higher than the corresponding area of the normal testis (Emax, 8.23±0.30 kPa vs 3.97±0.95kPa; SD, 1.5±0.26kPa vs 0.67±0.35kPa,[P<0.05]) and Emin values was lower than those of normal testicles(0.93±0.51kPa vs 1.6±0.36kPa; [P<0.05]); (iii) The Young's modulus measurement between two physicians showed good agreement. The pathological findings were accordance with SWE measurement. SWE is a non-invasive, convenient and high reproducible method and may serve as an important alternative tool in the diagnosis and monitoring the progression of the acute scrotums, in additional to conventional Doppler sonography.