Extravaginal testicular torsion in neonates - review of

clinical symptoms with ultrasound and intraoperative photo

documentation.
Poster No.:

C-1013

Congress:

ECR 2014

Type:

Educational Exhibit

Authors:

P. Bombinski, M. Brzewski, M. #era#ska; Warsaw/PL

Keywords:

Intraoperative, Ultrasound, Elastography, Pediatric, Genital /

Reproductive system male, Acute, Congenital

DOI:

10.1594/ecr2014/C-1013

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Learning objectives
- to illustrate spectrum of clinical and radiological findings in extravaginal testicular
torsion
(ETT) in neonates.
- to revise embryological development of the ETT.
- to present usefulness of ultrasound (US) examination, including elastography, in
correlation with clinical and intraoperative findings with photo documentation.

Background
Testicular torsion is taken into consideration in differential diagnosis of acute scrotum. It
should be confirmed or ruled out at first diagnostic step. It may concern children,
including prenatal age, and adults as well.
Ultrasonography with colour Doppler is a first choice diagnostic method [1].
Extravaginal testicular torsion (ETT), also called prenatal or perinatal testicular torsion,
occurs prenatally and is present at birth OR appears within the first month of life [2]. It is
connected to the high mobility of the tunica vaginalis inside the scrotum due to the poor
fixation to the scrotal wall [6]. Fixation occurs in the first weeks after birth.
Intravaginal torsion appears in older children and adults. It has a different etiology than
ETT - tunica vaginalis is already fixed to the scrotal wall and the spermatic cord
undergoes torsion within the tunica vaginalis (Fig. 1).
Irreversible damage of spermatogenesis occurs after 4-6 hours of ischemia, and
damage of Leydig cells responsible for testosterone production - after 12 hours of
ischemia [3].
Most cases of ETT appear prenatally, and testicles are unsalvageable [4]. Clinical
examination of scrotum, performed by pediatrician at birth, can reveal hardened testicle
[5] or scrotal mass. Differential diagnosis of a palpable scrotal mass in the newborn
should include ETT, as well as tumors of the testicle, inguinal hernia with or without
incarceration, hydrocele and hematocele [1,6].
Postnatal testicular torsion is an acute state and needs immediate surgery. However,
acute torsion in older children and adults has a different clinical presentation than in
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newborn. First of all, older patient will highlight the pain in scrotum, while the newborn
will manifest not characteristic general signs and symptoms, like pain or irritability. Local
signs, as swelling, redness and tenderness of scrotum will also appear.
Immediate surgery is a standard procedure in acute perinatal testicular torsion. There
are however still wide discussions concerning management of the "old" prenatal
testicular torsions - varying from immediate orchiectomy to conservative treatment
resulting in testicle atrophy [3,7-12]. The argument for immediate orchiectomy is a
possibility of contralateral healthy testicle damage through antisperm antibody
production [13]. On the other hand, data from literature suggest that some tissue after
torsion can survive, even if perfusion does not resume - this concerns especially the
Leydig cells.
Orchiectomy of the necrotic testicle is a standard procedure in our Hospital.
The knowledge about this disease is essential to manage the patient appropriately.
Images for this section:

Fig. 1: Anatomical background of testicular torsion: comparison of normal structures of

scrotum, intravaginal spermatic cord torsion and extravaginal testicular torsion with
tunica
Page 3 of 18

vaginalis involvement. From: Callewaert PRH., Van Kerrebroeck P. New insights into
perinatal testicular torsion. Eur J Pediatr (2010) 169:705-712.

Page 4 of 18

Findings and procedure details

We present clinical findings and pictorial review of testicular torsion in neonates
in US, including elastography, in correlation with intraoperative findings with photo
documentation.
In the period 2008-2013 there were 11 cases of perinatal testicular torsion in our
Hospital. The clinical signs were present at birth in 8 cases, while in 3 cases they
appear within the first month of life. In the first group, the most common signs in clinical
examination were: hardened testicle and discoloration of the scrotum (Fig. 2), while in
the second group - signs of acute scrotum, i.e. scrotal swelling, redness and
tenderness. Testicular torsion occured on the right side in 6 patients and on the left
side in 3 patients. One patient had torsion of both testicles (Fig. 7-8). Primary
diagnosis was assessed according to clinical examination performed by a surgeon. In
all cases US was performed (Fig. 3-4, Fig. 9-11), which revealed: thickening of the
tunica vaginalis (6), heterogenous testicle with hypoechoic areas of necrosis (6),
testicular enlargement (6), reduction or absence of blood flow in Doppler
ultrasonography (5), hydrocele (3), contralateral hydrocele (4). Normal testicular
echogenicity was present in 4 cases, including 2 cases of postnatal and
2 prenatal torsions. In 1 case the testicle was small with increased echogenicity, what
suggests testicular atrophy.
Surgical management included: ipsilateral orchiectomy and contralateral orchiopexy (4),
ipsilateral orchiectomy without orchiopexy of the contralateral testicle (5) and bilateral
orchiectomy of both necrotic testicles (2). Surgery was performed immediately after
diagnosis. During surgery there was only 1 case of a certain diagnosis of extravaginal
testicular torsion. In all other cases this macroscopic diagnosis was very difficult due to
thickening and necrotic changes within testicle, spermatic cord and their layers.
Preoperative ultrasonographic findings of suspected testicular torsion were correlated
with findings at surgery at 7 cases.
Images for this section:

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Fig. 2: 1-day old newborn with suspected prenatal testicular torsion. Clinical
examination revealed swelling and redness of the right hemi-scrotum (Fig. 2). US
revealed enlarged and heterogenous right testicle (Fig. 3) without blood flow in Doppler
US (Fig. 4). Intraoperative findings included hemorrhagic and necrotic right testicle (Fig.
5, Fig. 6).

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Fig. 3: 1-day old newborn with suspected prenatal testicular torsion. Clinical
examination revealed swelling and redness of the right hemi-scrotum (Fig. 2). US
revealed enlarged and heterogenous right testicle (Fig. 3) without blood flow in Doppler
US (Fig. 4). Intraoperative findings included hemorrhagic and necrotic right testicle (Fig.
5, Fig. 6).

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Fig. 4: 1-day old newborn with suspected prenatal testicular torsion. Clinical
examination revealed swelling and redness of the right hemi-scrotum (Fig. 2). US
revealed enlarged and heterogenous right testicle (Fig. 3) without blood flow in Doppler
US (Fig. 4). Intraoperative findings included hemorrhagic and necrotic right testicle (Fig.
5, Fig. 6).

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Fig. 5: 1-day old newborn with suspected prenatal testicular torsion. Clinical
examination revealed swelling and redness of the right hemi-scrotum (Fig. 2). US
revealed enlarged and heterogenous right testicle (Fig. 3) without blood flow in Doppler
US (Fig. 4). Intraoperative findings included hemorrhagic and necrotic right testicle (Fig.
5, Fig. 6).

Page 9 of 18

Fig. 6: 1-day old newborn with suspected prenatal testicular torsion. Clinical
examination revealed swelling and redness of the right hemi-scrotum (Fig. 2). US
revealed enlarged and heterogenous right testicle (Fig. 3) without blood flow in Doppler
US (Fig. 4). Intraoperative findings included hemorrhagic and necrotic right testicle (Fig.
5, Fig. 6).

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Fig. 7: Newborn in the second day of life with signs of acute scrotum and suspected
right testicle torsion. US revealed enlarged right testicle with normal echogenicity of
both testicles. Intraoperative findings included torsion of both testicles, with
hemorrhagic and necrotic right testicle (Fig. 7) and necrotic left testicle (Fig. 8).

Page 11 of 18

Fig. 8: Newborn in the second day of life with signs of acute scrotum and suspected
right testicle torsion. US revealed enlarged right testicle with normal echogenicity of
both testicles. Intraoperative findings included torsion of both testicles, with
hemorrhagic and necrotic right testicle (Fig. 7) and necrotic left testicle (Fig. 8).

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Fig. 9: 1-day old newborn with suspected prenatal testicular torsion. US revealed
enlarged and heterogenous right testicle (Fig. 9) without blood flow in Doppler US (Fig.
10), and contralateral hydrocele. Elastography revealed abnormal structure of the right
testicle, related to necrotic changes - stiffer peripheral part with soft tissue central part
(hard tissues are displayed in blue, soft tissues - in red) (Fig. 11). Intraoperative findings
included necrosis of the right testicle (Fig. 12). Elastography images correlated with
clinical examination and intraoperative findings.

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Fig. 10: 1-day old newborn with suspected prenatal testicular torsion. US revealed
enlarged and heterogenous right testicle (Fig. 9) without blood flow in Doppler US (Fig.
10), and contralateral hydrocele. Elastography revealed abnormal structure of the right
testicle, related to necrotic changes - stiffer peripheral part with soft tissue central part
(hard tissues are displayed in blue, soft tissues - in red) (Fig. 11). Intraoperative findings
included necrosis of the right testicle (Fig. 12). Elastography images correlated with
clinical examination and intraoperative findings.

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Fig. 11: 1-day old newborn with suspected prenatal testicular torsion. US revealed
enlarged and heterogenous right testicle (Fig. 9) without blood flow in Doppler US (Fig.
10), and contralateral hydrocele. Elastography revealed abnormal structure of the right
testicle, related to necrotic changes - stiffer peripheral part with soft tissue central part
(hard tissues are displayed in blue, soft tissues - in red) (Fig. 11). Intraoperative findings
included necrosis of the right testicle (Fig. 12). Elastography images correlated with
clinical examination and intraoperative findings.

Page 15 of 18

Fig. 12: 1-day old newborn with suspected prenatal testicular torsion. US revealed
enlarged and heterogenous right testicle (Fig. 9) without blood flow in Doppler US (Fig.
10), and contralateral hydrocele. Elastography revealed abnormal structure of the right
testicle, related to necrotic changes - stiffer peripheral part with soft tissue central part
(hard tissues are displayed in blue, soft tissues - in red) (Fig. 11). Intraoperative findings
included necrosis of the right testicle (Fig. 12). Elastography images correlated with
clinical examination and intraoperative findings.

Page 16 of 18

Conclusion
Testicular torsion may concern children in perinatal period.
Diagnostic imaging procedures should confirm or rule out the testicular torsion,
however there are still many diagnostic pitfalls.
Ultrasoud elastography may be a very useful tool for visualisation of a very common sign
- hardening of the torsed testicle.
Patient management is still a subject of discussions.

Personal information
Przemyslaw Bombinski MD
przebom@op.pl
Pediatric Radiology Department
Medical University of Warsaw
Marszalkowska 24
00-576 Warsaw, Poland

References
1. Van der Sluijs JW, Den Hollander JC, et al. Prenatal testicular torsion: diagnosis and
natural course, an ultrasonographic study. Eur Radiol 2004;14:250-5.
2. Brandt MT, Sheldon CA, Wacksman J, Matthews P (1992) Prenatal testicular torsion:
principles of management. J Urol 147: 670-672.
3. Arena F, Nicotina PA, Romeo C, et al. Prenatal testicular torsion: ultrasonographic
features, management and histopathological findings. Int J Urol 2006;13:135-41.

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4. Kaye JD, Levitt SB, Friedman SC et al (2008) Neonatal torsion: a 14-year experience
and proposed algorithm for management. J Urol 179(6):2377-2383.
5. Baptist EC, Amin PV (1996) Perinatal testicular torsion and the hard testicle. J
Perinatol
16:67-68.
6. Callewaert PRH., Van Kerrebroeck P. New insights into perinatal testicular torsion.
Eur
J Pediatr (2010) 169:705-712.
7. Djahangirian O, Ouimet A, Saint-Vil D. Timing and surgical management of neonatal
testicular torsions. J Pediatr Surg 2010;45: 1012-5.
8. Ahmed SJ, Kaplan GW, DeCambre ME. Perinatal testicular torsion: preoperative
radiological findings and the argument for urgent surgical exploration. J Pediatr Surg
2008;43:1563-5.
9. Yerkes EB, Robertson FM, Gitlin J, et al. Management of perinatal torsion: today,
tomorrow or never? J Urol 2005;174:1579-83.
10. Stone KT, Kass EJ, Cacciarelli AA, et al. Pediatric urology: management of
suspected antenatal torsion, what is the best strategy? J Urol 1995;153:782-4.
11. The current state of surgical practice for neonatal torsion: a survey of pediatric
urologists. Broderick KM, Martin BG, Herndon CD, Joseph DB, Kitchens DM. J Pediatr
Urol. 2013 Oct; 9(5):542-5.
12. Guerra LA, Wiesenthal J, Pike J, Leonard MP (2008) Management of neonatal
testicular torsion: which way to turn? Can Urol Assoc J 2(4):376-379.
13. Rybkiewicz M. Long term and late results of treatment in patients with a history of
testicular torsion. Ann Acad Med Stetin 2001;47:61-75.

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