Intermittent torsion: association with horizontal lie of the testicle

The bell-clapper deformity of the testis: The definitive pathological anatomy

INTRODUCTION

The bell-clapper deformity (BCD) predisposes to intravaginal torsion (IVT) and is classically bilateral. The precise pathological definition of what constitutes a BCD is not clear. The current study aims to clarify the specific anatomic details of this anomaly.

METHODS

A systematic review was performed utilizing the PRISMA principles. Studies are presented chronologically based on their level of evidence. They are further divided into study types: autopsy and operative studies of acute torsion, intermittent torsion and studies of the contralateral testis in vanishing testis.

RESULTS

The bell-clapper deformity is best defined by complete investment of the testis, epididymis and a length of the spermatic cord by the tunica vaginalis. Based on autopsy studies the rate of BCD in scrotal testis varied from 4.9% to 16%; with bilaterality in 66%-100%. In cases of acute IVT bilaterality was noted in 54%-100%. The most disparate results were in cases of testicular regression syndrome where contralateral BCD was noted in 0%-87% of cases.

CONCLUSION

We suggest future studies employ the strict anatomical definition above. As there is evidence of age-dependent investment of the testes, it will be important to develop age-standardized measurements of intravaginal length of spermatic cord. This critical morphometric measurement will allow a better understanding of the risk of IVT.

LEVEL OF EVIDENCE

Systematic review of diagnostic studies: lowest level of evidence of included manuscripts Level IV (case-control studies with a poor reference standard).

Ultrasonography of pediatric urogenital emergencies: review of classic and new techniques

Urogenital emergencies are fairly common in the pediatric population, and a timely and correct diagnosis is necessary to avoid possible future infertility. In this field, ultrasonography is essential, as it has the advantages of being radiation-free and readily accessible. In particular, a high-frequency transducer allows precise evaluation of the morphology and vascularity of the scrotum, which is on the surface of the body. Beyond conventional techniques, new advanced imaging techniques have been developed, including elastography and contrast-enhanced ultrasonography. However, several pitfalls remain in the diagnosis of urogenital diseases using ultrasonography. Thus, accurate knowledge and sufficient experience with the technique are essential for making a correct diagnosis. This review provides an overview of pediatric urogenital emergency pathologies and recent ultrasonography techniques.

Intermittent Testicular Torsion in Adults: An Overlooked Clinical Condition

OBJECTIVES

The aim of this study was to describe the management protocol for intermittent testicular torsion (ITT) in adults and report the outcome of this clinical condition, which is commonly overlooked in adults.

SUBJECTS AND METHODS

Sixty-three patients were included in the study. The inclusion criterion was the presence of sudden intermittent testicular pain over a duration of 3 months. All the patients underwent clinical examination, urine analysis, culture, and scrotal ultrasound with Doppler. The testicle was in an abnormal or in transverse lie and/or could easily be twisted. Scrotal support and analgesia were given for 1 month, then patients were offered orchidopexy or conservative treatment. Nineteen patients chose orchidopexy while 44 chose conservative treatment. Follow-up ranged from 3 months to 2 years. The improvement was assessed using a visual analog pain score. The outcome of the treatment was compared between the surgical and conservative groups using a χ2 test.

RESULTS

The median age of the patients was 28 years (range: 17-50). Of the 19 patients who underwent orchidopexy, the pain resolved or visual analog pain scores improved (median 1/10) in 18 (94.7%) cases. On the other hand, 21 of the 44 (47.7%) cases that chose the conservative approach claimed their pain resolved or improved (visual analog pain scores: median 3/10) with a median of 13 months of follow-up.

CONCLUSION

In this study, scrotal orchidopexy proved to be superior to conservative measures in cases of ITT in adults.

Testicular torsion: a 15-year single-centre clinical and histological analysis

AIM

This study reviewed the demographic, epidemiological and clinical factors of boys seen at a single centre who underwent surgical exploration for testicular torsion.

METHODS

Retrospective single-centre review of boys with testicular torsion between 1996 and 2011 was made.

RESULTS

Testicular torsion (right n = 43, left n = 60, bilateral n = 1) was identified in 104 boys between 0 and 18 years. Ten newborns presented with 11 intrauterine torsions. Nine torsions presented in undescended inguinal testes (one intrauterine). In 94 boys with descended testes, presentation included pain (76%), scrotal swelling (65%) and abdominal symptoms (22%). Ultrasonography was performed in 85 patients with false-negative results in 4 (4.7%). Orchiectomy was performed during initial exploration in 41, with significantly higher rates of orchiectomies in patients with late (>6 h) versus patients with early referrals (<6 h) (56% vs. 9.1%). Histological evaluation was carried out in 68 testes, with 43 resected testes demonstrating haemorrhagic necrosis. In 25 biopsied testes, histology revealed acute parenchymal bleeding (n = 14), onset of parenchymal infarction (n = 8), orchitis (n = 1) and normal tissue (n = 2). Eighty-two patients were followed up with pathological findings in four patients: testicular atrophies requiring orchiectomy (n = 2), testicular autolysis (n = 1) and small testicular vein thrombosis (n = 1).

CONCLUSION

Chances of testicular salvage after torsion are higher if patients present early. The majority of patients presenting late (>6 h) require orchiectomy owing to testicular necrosis.

Testicular torsion: a review

Torsion of the testis, also referred to as torsion of the spermatic cord, is a subject of debate among physicians and surgeons. Testicular torsion is an acute vascular event causing the rotation of the vascular pedicle of the testis, thereby impeding the blood flow to the testis and the scrotal contents. It could be either within or outside the tunica vaginalis. Testicular torsion causes immediate circulatory changes and long-term sequelae such as testicular function and fertility. It is considered a surgical emergency, as a delay causes irreversible testicular damage. The diagnosis and treatment of testicular torsion are discussed in this review, which also illustrates an algorithm and a scoring system for the diagnosis and management of this condition based on current literature.

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.

Sonographic differential diagnosis of acute scrotum: real-time whirlpool sign, a key sign of torsion

OBJECTIVE

The purpose of this study was to prospectively investigate the role of high-resolution and color Doppler sonography in the differential diagnosis of acute scrotum and testicular torsion in particular.

METHODS

Patients who underwent sonography for acute scrotum between April 2000 and September 2005 were included in the study. Gray scale and color Doppler sonography of the scrotum was performed. The spermatic cord was studied on longitudinal and transverse scans from the inguinal region up to the testis, and the whirlpool sign was looked for.

RESULTS

During this period, 221 patients underwent sonography for acute scrotum. Sixty-five had epididymo-orchitis with a straight spermatic cord, a swollen epididymis, testis, or both, an absent focal lesion in the testis, and increased flow on color Doppler studies along with the clinical features of infection. Three had testicular abscesses. Sonography revealed features of torsion of testicular appendages in 23 patients and acute idiopathic scrotal edema in 19. Complete torsion was seen in 61 patients who had the whirlpool sign on gray scale imaging and absent flow distal to the whirlpool. There was incomplete torsion in 4 patients in whom the whirlpool sign was seen on both gray scale and color Doppler imaging. Nine patients had segmental testicular infarction, and 1 had a torsion-detorsion sequence revealing testicular hyperemia. In 14 patients, the findings were equivocal. There was a complicated hydrocele, mumps orchitis, and vasculitis of Henoch-Schönlein purpura in 1 patient each. Five patients had normal findings. Fourteen were lost for follow-up.

CONCLUSIONS

Sonography of acute scrotum should include study of the spermatic cord. The sonographic real-time whirlpool sign is the most specific and sensitive sign of torsion, both complete and incomplete. Intermittent testicular torsion is a challenging clinical condition with a spectrum of clinical and sonographic features.

Assessment of acute scrotal symptoms and findings. A clinician's dilemma

Diagnosis of testis torsion relies on the clinical wisdom of the examining physician, supplemented with timely imaging techniques by color Doppler examination or scintigraphy. A knowledge of the pathophysiology of acute scrotal conditions can help to eliminate diagnostic errors but the literature demonstrates that errors can occur even with sophisticated testing. Data from the literature suggests that manual detorsion of the testis can successfully relieve ischemia until surgical correction can eliminate the possibility of testis torsion. Surgical therapy has progressively improved and can save the germinal function of the testis.

Cryptorchidism and testicular torsion

The cause of cryptorchidism remains obscure. Hormonal therapy is ineffective for most patients and initial response may be temporary. Surgery remains the most effective treatment for cryptorchidism. Testicular torsion is a surgical emergency in the postnatal infant and the pubertal male. Controversy surrounds the management of prenatal torsion.