Testicular Torsion in Neonates - Essay Example

Testicular Torsion in Neonates Introduction Testicular torsion is actually torsion of the spermatic cord and occurs commonly in neonate males and adolescent boys. It is a surgical emergency because of its potential to cause obstruction of arterial blood supply to the testis and consequent hemorrhagic infarction and necrosis of the testis (1, 2). In the neonate, although rare, it is a significant source of morbidity (2). Unlike in adolescents where in the torsion is intravaginal; in the neonates, the torsion is extravaginal with the spermatic cord and the adjacent tunica twisting as a unit (2). The entire testis, epididymis and tunica vaginalis twist together in a vertical axis on the spermatic cord (3). However, intravaginal torsion testis has also been reported in neonates (Burge). Most of the cases of torsion testis detected in the new born period are believed to occur inutero (2). Torsion testis occurs due to loose attachments of the tunica to the scrotal wall (4). It is associated with high birth weight (5). Most of the times, it is unilateral and may be associated with undescended testis. Case history Baby of Gracy Thomas was noticed to have swelling and redness at the right half of the scrotum, 12 hours after birth. The baby was born full term by normal delivery. The birth weight was 3.5 kg. Antenatal scans were normal. On examination, there was redness and swelling over the right testis. No ecchymoses were noted on the skin of the scrotum. The testis was tender, firm and hard to feel. The opposite testis appeared normal. The vital signs were stable and other systems examination was normal. A diagnosis of torsion of the right testes was made and an emergency Doppler ultrasound arranged. Doppler study revealed gross swelling of the testis along with heterogeneous echogenicity. Subtunica fluid was noted and Doppler was absent. This confirmed the diagnosis of torsion testis. The baby was taken in for surgery immediately. On exploration during surgery, there was no evidence of necrosis of the affected testis. Incision of the right testis caused bleeding suggesting the viability of the testis. Detorsion of the right testes was done following which it was fixed to the scrotal wall. Also, orchidopexy of the opposite testis was also undertaken. Intra-operative Doppler study revealed return of blood supply to the testes, thus proving the success of detorsion. Post-sugery, the baby was stable. He was discharged after 2 days and asked to return after a week for follow up. On follow up, examination of the testes were normal. The baby is one year of age now. He is thriving well. Discussion Neonatal testicular torsion can be divided into two groups: prenatal testicular torsion presenting at birth (torsion inutero) and postnatal testicular torsion (torsion within the first 30 days of life) (3). It has been estimated that 72.4% of neonatal torsions are prenatal and only 27.5% occurred during the postnatal period (3). Perinatal testicular torsion occurs mostly in full term babies with above average birth weight, usually more than 3.0 kg (6). The predisposing factor is probably higher pressures in the uterus and birth canal (6) caused by high birth weight, trauma from difficult labour or breech presentation, or by over active cremasteric reflex (6). However, the most commonly implicated reason is increased mobility of the neonatal tunica vaginalis within the scrotum that allows torsion to occur in the presence of an active cremasteric reflex (6). In the newborn period, the testis has just descended in to the scrotum and the gubernaculum is still not attached to the scrotum wall and hence the testis and gubernaculum are free to rotate within the neonatal scrotum (3) The exact timing of the event has not been proved. In fact, it has been detected as early as 34 weeks of gestation and as late as 2 weeks after delivery (6). Most of the times, the event occurs intrauterine and hence at the time of birth, the damage is already done and post-natal surgery can not salvage the testis. Intrauterine torsion is usually unilateral and affects both the testis equally, although occasionally, it may present bilaterally (6). Testicular torsion needs to be differentiated from other conditions such as torsion of a testicular appendage and inguinal hernia (4). Other conditions which mimic torsion testis are hydrocele, hematocele, epididymo- orchitis, idiopathic infarction of the testis, ectopic splenic or adrenal rests, and benign and malignant tumors of the testis and epididymis (3). These are actually rare. It is important to diagnose testicular torsion as soon as possible because early surgical repair can prevent irreversible damage to the testis. It has been proved that delay of more than 6-8 hours between onset of symptoms and the time of surgical detorsion reduces the salvage rate to 55-85% and also increases the enhances for delayed testicular atrophy (5). On examination in a neonate, there will be evidence of acute scrotal swelling. The testis will be firm and hard to feel and the scrotal skin characteristically fixes to the necrotic gonad (5). Usually the mass is not tender, probably because the testis is already gangrenous in many cases at the time of diagnosis (3). Transillumination test will be negative. The diagnosis is confirmed by color doppler sonogram. Treatment constitutes of early elective exploration and contralateral orchidopexy  (5). Sonologic findings in neonatal torsion testis can be divided in to 3 types (4). These include: Type-1: Marked enlargement of the affected testicle with heterogeneity in echogenicity along with presence of subtunica fluid (hydrocele) and absent doppler flow. Type-2:  Normal size of the testicle with peripheral hyperechogenicity and small hydrocele. Type-3: Diminished size of testicle with increased echogenicity scattered throughout the testicle and absent hydrocele. These types are infact stages of torsion of testis (4).   In those with intra-uterine testicular torsion, surgery is undertaken only after stabilizing the neonate. This is because, the potential to salvage such a testis is almost 0% and hence it is an unwarranted risk to perform surgery in an unstabilized new born (5). However, in those neonates in whom, testicular torsion has occurred after birth, immediate surgical exploration can salvage the testis (5). It is important to do contralateral orchidopexy because of the possibility bilateral testicular torsion (5). Even in case of necrotized testis detected on ultrasound, surgical exploration and removal of the necrotic testis is important to prevent autoimmune damage to the other normal testis and also to avoid debilitating pain and tenderness (5). Following detorsion, signs of viability of the testis intraoperatively include return of color of the testis, return of blood flow as evidenced by doppler ultra sound, and arterial bleeding after incision of tunica albuginea (5). In case of intrauterine torsion testis, the much debated issue is whether surgery must be undertaken immediately despite the fact that the testis is already necrosed (4, 6). It is important to remove this testis as soon as the baby is stabilized to prevent gangrene and sepsis in the baby and also to protect the normal testis from autoimmune complications and complete infertility. Also, during the procedure, the opposite testis should be fixed to prevent torsion. Torsion can also occur in undescended testis which is intraabdominal. A high degree of suspicion is necessary to diagnose this condition. One must consider the possibility of intrauterine torsion in a neonate who presents with an undescended testis and an abdominal mass (7). References 1. Galejs LE, Kass EJ. Diagnosis and Treatment of the acute scrotum. American Family Physician 1999; 59(4) [Cited 2007 Sep 29]; Available from URL: http://www.aafp.org/afp/990215ap/817.html 2. Zinn ZL, Cohen HL, Horowitz M. Testicular Torsion in Neonates: Importance of Power Doppler Imaging. Journal of Ultrasound Medicine 1998; 17: 385-388. 3. Nariman S, Tabari AK. Perinatal testicular torsion: A case report. Archives of Iranian Medicine 2005; 8(4): 321-322. 4. Traubici J, Daneman A, Navarro O, mohanta A and Garcia C. Testicular torsion in neonates and infants: Sonographic features in 30 patients. American Journal of Radiology 2003; 180: 1143-1145 5. Minevich E, Tackett L. Testicular torsion. eMedicine from WebMD 2007. [Cited 2007 Sep 29]; Available from URL: http://www.emedicine.com/med/topic2780.htm 6. Salem AH. Intrauterine testicular torsion: early diagnosis and treatment. British Journal of Urology 1999; 83. 1023-1025. 7. Campbell JR, Schneidner CP. Intrauterine torsion of an intra-abdominal testis. Pediatrics 1976; 57(2): 262-264.4. Traubici J, Daneman A, Navarro O, mohanta A and Garcia C. Testicular torsion in neonates and infants: Sonographic features in 30 patients. American Journal of Radiology 2003; 180: 1143-1145. Bibliography Campbell JR, Schneidner CP. Intrauterine torsion of an intra-abdominal testis. Pediatrics 1976; 57(2): 262-264. Galejs LE, Kass EJ. Diagnosis and Treatment of the acute scrotum. American Family Physician 1999; 59(4) [Cited 2007 Sep 29]; Available from URL: http://www.aafp.org/afp/990215ap/817.html Minevich E, Tackett L. Testicular torsion. eMedicine from WebMD 2007. [Cited 2007 Sep 29]; Available from URL: http://www.emedicine.com/med/topic2780.htm Nariman S, Tabari AK. Perinatal testicular torsion: A case report. Archives of Iranian Medicine 2005; 8(4): 321-322. Salem AH. Intrauterine testicular torsion: early diagnosis and treatment. British Journal of Urology 1999; 83. 1023-1025. Traubici J, Daneman A, Navarro O, mohanta A and Garcia C. Testicular torsion in neonates and infants: Sonographic features in 30 patients. American Journal of Radiology 2003; 180: 1143-1145. Zinn ZL, Cohen HL, Horowitz M. Testicular Torsion in Neonates: Importance of Power Doppler Imaging. Journal of Ultrasound Medicine 1998; 17: 385-388. Read More