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Bilateral Testicular Torsion in a Neonate: A case report

H Z Omari¹, M S Masarweh², M M Saleem³
¹Department of Radiology, Faculty of Medicine Jordan University of Science & Technology
²Department of Surgery, King Hussein Cancer Center Amman, Jordan
³Department of Surgery, University of Jordan

 

 

Correspondence

 M S Masarweh FRCSEd
Consultant Pediatric Surgery
King Hussein Cancer Center
P O Box 2441, 11953, Amman, Jordan
Tel: +962 6 5300460; Fax: +962 6 5342567
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

We report a case of a newborn male infant, who presented at five days of age, with bilateral scrotal swelling since birth. A diagnosis of testicular torsion was suspected. Color Doppler Ultrasound supported the diagnosis, with an absent blood flow signal on the right side and a weak signal on the left side. Bilateral testicular exploration through inguinal incisions confirmed the clinical diagnosis of bilateral testicular torsion. Both sides appeared grossly gangrenous, more severe on the right side. Histological examination confirmed the diagnosis of testicular infarction secondary to testicular torsion. We performed right orchiectomy because of gross infarction, and left orchidopexy because it appeared to be less infarcted. Follow up visit revealed atrophy of the remaining testicle. Bilateral synchronous testicular torsion is rare. Controversy surrounds the etiology, the approach to diagnosis and the management. Reporting such cases may increase awareness of this diagnosis to those involved in the management of neonates and young infants, as the effect of such a condition is profound.

Key words: testis torsion, newborn, synchronous, neonatal testicular torsion

 

 

Introduction

Neonatal testicular torsion (NTT) was first reported in 1897 by Taylor [1]. It may be unilateral or bilateral. Bilateral torsion may be synchronous or asynchronous. The time that the torsion occurred is very difficult to know; it has been reported to occur antenatally as well postnatally. The etiology is not known. Usually it affects healthy full term newborns, but it has been reported in preterm infants also. Definitive diagnosis is difficult to make without scrotal exploration. The optimum way of management (e.g. the best diagnostic tests, whether and when to explore the scrotum, whether to explore the contralateral side, the method of testicular fixation, and whether to remove the necrotic testes) is still controversial.

Case History:

A five day old, male newborn, which was the product of a normal vaginal delivery, presented at the age of five days with a history of bilateral scrotal swelling since birth, associated with bluish discoloration of the scrotal skin and no other associated symptoms ( fig. 1). General examination of the patient showed a healthy active new born with no signs of distress or pain, no clinical evidence of any congenital abnormality in the head, neck, heart, chest and skeletal system. An ultrasound of the abdomen showed normal kidneys, liver, spleen and pancreas. There was no evidence of inguinal hernias. Alpha feto-protein level was normal for a newborn. Color Doppler Ultrasound of the scrotum, showed heterogeneous tissue image in both testes, subtunical fluid and hydrocele with absent blood flow in the right testis ( fig. 2), and peripheral subcapsular arterial blood flow in the left testis ( fig. 3). Bilateral scrotal exploration was done through inguinal incisions and revealed bilateral testicular torsion ( fig. 4).

bilateral torsion 1

Fig. 1. Preoperative appearance of the scrotum

bilateral torsion 2

Fig. 2. Ultrasound shows heterogeneous testes with subtunical fluid and hydrocele

bilateral torsion 3

Fig. 3. Color Doppler Ultrasound shows peripheral subcapsular arterial blood flow in the left testis with reactive hydrocele 

 bilateral torsion 4

 Fig. 4. Intraoperative appearance of right and left testis

 

 

There was obvious gangrene of both testes, more advanced on the right side, but the left testis was thought to be still viable with bleeding from incised tunica albugenia and from the biopsy site. Right orchiectomy was done with fixation of the left testis. Histological examination confirmed bilateral testicular coagulative necrosis. Follow-up at one month and six months showed that the left testis was smaller in size but still viable with some peripheral testicular blood flow by Doppler signal. However, at one year follow up, there was atrophy of the left testes and hormonal assay showed very low testosterone and elevated follicular stimulating hormone, suggesting anorchia. FSH 149.6 (1-8) iu/l, LH 14(2-12) iu/L, Testosterone less than 0.2ng/ml (2.8-8).

Discussion

Neonatal testicular torsion (NTT) is a well recognized clinical entity. Although rare, it is being recognized with increasing frequency. Bilateral neonatal testicular torsion (BNTT) is very rare. The first case of BNTT was not reported until 1967 by Fredrick et al. [2] Only 23 cases have been reported through 1995. It is synchronous in 50-80% of the cases [3, 4, 5]. Speculations concerning etiology have included high birth weight, difficult labor or breach presentation. There is evidence to suggest that the initial event in neonatal torsion is vascular and that torsion may occur secondarily [6]. Usually it affects full term babies. Affected babies are usually asymptomatic on physical examination.

The scrotum of the affected testicle is large, firm, and edematous with bluish or dark discoloration. The clinical features are usually present since birth, but are often unnoticed until few days later. Diagnosis is usually made based on a high degree of suspicion and from the clinical features alone. Few other conditions simulate testicular torsion in the neonate. The clinical diagnosis of testicular torsion is sufficient to proceed with scrotal exploration. Color Doppler US, testicular isotope scan or MRI, may support the clinical diagnosis, but rarely preclude scrotal exploration especially in the neonate [11,12]. Controversy exists concerning the urgency of exploration.

Different views are held concerning the timing of operation, need for contralateral exploration and orchidopexy, and management of obviously necrotic testicles. Many surgeons recommend early surgical exploration primarily to avoid an error in diagnosis. A problem with this approach is that surgical intervention and general anesthesia in the new born are not without risk. However potential problems also exist with delayed surgery. Diagnosis based solely on clinical grounds increases the possibility of diagnostic error. Also there is a risk of torsion to the opposite testis and the potential loss of both testes. Some have suggested that surgical exploration is unnecessary [8]. Some reports suggest that the contralateral testicle is not at increased risk for torsion. They feel that there is no evidence that a contralateral orchidopexy is protective [7-10].

Reports of testicular salvage in newborn torsion are rare, due to the usual presence of established testicular infarction [4,7, 11-13]. Currently most surgeons recommend an operative approach for suspected neonatal torsion. In 1990 Das and Singer [5] reported the results of a survey of pediatric urologists and literature review and then concluded that early operative intervention with orchiectomy and contralateral orchidopexy was the preferred management strategy for cases of suspected neonatal torsion because surgical exploration was the only definitive way to establish the diagnosis and rule out other potential pathological conditions. While there is a theoretical possibility that retention of the infarcted testis may result in some hormonal production, in bilateral testicular torsion it is wise to preserve the least infracted testis. Another reason to remove the infarcted testicle is to minimize the chance of aptoposis of the germinal epithelium in the contralateral testicle [14].

Unfortunately, there is limited information as to the best way of managing such cases. Increased awareness and focused research into the nature of this disease entity is needed.

 

 

 

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