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Bilateral Testicular Torsion In A Newborn – A Case Report

Radu N. Balanescu¹², Laura Topor¹², Ruxandra Caragata¹, Andreea Moga¹, Gabriel Dragan¹

¹ “Grigore Alexandrescu” Clinical Emergency Hospital for Children

² “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

 

Abstract

Bilateral perinatal testicular torsions are rarely encountered and they represent a real emergency due to the high risk of anorchism. We report the case of a 2 days old newborn who presented with tumefaction and hyperemia of the left hemiscrotum. Intraoperative findings revealed a left testis of increased proportions, which had a blackish color and was torsioned and necrotic. Left orchiectomy was performed and the decision was made to explore the right hemiscrotum. The right testicle was found to be smaller in size and hypotrophic and right orchidopexy was performed. The management of neonatal bilateral testicular torsion is controversial. Emergency surgical exploration is indicated, with some authors suggesting that orchiectomy should be performed, while others plead for preserving the affected testis. Contralateral exploration with subsequent orchidopexy should also be performed.

Key words: asynchronous torsion, perinatal, orchiectomy, orchidopexy

 

Correspondence

Laura Topor

“Grigore Alexandrescu” Clinical Emergency Hospital for Children
Vaporul lui Assan Street No. 4
Bucharest, Romania
Tel: +40722.984.237.
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Introduction

While testicular torsion is a frequently encountered pathology in boys in the pre-puberty stage, it is a rare affliction in the neonatal period, most probably with a prenatal debut [1,2]. Perinatal testicular torsion (PTT) represents 5-12% of all the testicular torsions which develop in childhood and it can be divided into two categories: prenatal TT (72%), which appears in the intrauterine life and postnatal TT (28%), which is usually diagnosed in the first month of life [3].

PTT is, in 95% of the cases, unilateral, while bilateral torsions are rarely encountered and they represent a real emergency due to the high anorchism risk. Bilateral torsions can be synchron or asynchron, with only 5 cases of asynchronous PTT having been reported. PTT is extravaginal and it occurs because the testicle is barely lowered into the scrotum and the gubernaculum is not completely attached to the scrotal wall, so that the testicle, epididymis and the vaginalis testis are free to rotate in a vertical axis around the spermatic cord [1]. We present the case of a 2 days old newborn, who was diagnosed with bilateral asynchron testicular torsion during surgery.

Case report

We present the case of a 2 days old newborn, born by cesarean section, weighing 3.400 g, who was transferred to the surgical ward of our hospital from a local maternity for tumefaction and hyperemia of the left hemiscrotum.

Clinical examination of the genital organs showed swelling of increased consistency, pain and hyperemia of the left hemiscrotum, while the inspection of the right hemiscrotum found a right testicle smaller in size. Decision was made to perform a bilateral testicular ultrasound and the Doppler examination showed the absence of vascular signal in both testicles.

The suspicion of left testicle torsion was raised and the bilateral scrotal surgical exploration was performed. When exploring the left hemiscrotum, the testis presented with increased proportions, had a blackish color, was torsioned and necrotic; left orchiectomy was performed. The right testis was smaller in size, hypotrophic and a testicular biopsy was (Figure. 1). Due to the high risk of anorchism, the decision was made to leave the right testis in its place and a right orchidopexy was performed.

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Figure 1: On the left - testis with increased proportions and a blackish color. On the right - biopsy fragment from the right testicle

Postoperatively, the newborn presented tachycardia (AV >200 bpm), with subsequent investigations determining the diagnosis of atrial flutter; for that reason Amiodarone and Propranolol treatment was established. The postoperative evolution of the newborn was favorable and he was discharged 13 days after surgery with a good general condition, the right, smaller testicle palpable in the hemiscrotum. The patient required periodic reassessment for the cardiac disorder and continued his antiarrhythmic therapy.

Discussions

Perinatal testicular torsion is defined as the torsion of the spermatic cord which can occur immediately before birth or up to 30 days after birth; it can be unilateral or bilateral [1,4]. BTT (bilateral testicular torsion) is a rarely encountered pathology and it represents a true emergency in pediatric surgical pathology, due to the fact that the lack of a timely diagnosis can lead to anarchism [1].

The etiology of PTT is still unclear and the involvement of predisposing factors has not been proven yet [4,5]. Unlike torsion occurring in older children or adults, the perinatal torsion is an extravaginal torsion and it can be frequently asymptomatic (Figure 2). Diagnosis is based on clinical considerations such as an enlarged testis and a Doppler ultrasound examination [1,5].

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Figure 2: A. Extravaginal testicular torsion. B. Intravaginal torsion

The differential diagnosis of TTP is made with: testicular tumors, hydrocele, torsion of the appendix testis, strangulated inguinal hernia, scrotal hematoma, scrotal abscess or orchipididymitis [1].

The management of neonatal testicular torsion has raised many controversies regarding the approach, the moment of surgery, contralateral exploration, the treatment of the necrotic testicle and the treatment of the healthy testis. In cases of bilateral torsion, emergency bilateral surgical exploration is indicated, as a mean of both diagnosis and surgical treatment (orchiectomy), thereby decreasing the risk of infection of the necrotic tissue [6,7]. However, some authors suggest that the affected testicle should be preserved, thus trying to preserve the Leydig cells for the secretion of androgens hormones by detwisting and fixing of the testis [2].

Another controversy is related to the contralateral exploration of the unaffected hemiscrotum and the subsequent orchidopexy. Although the number of cases of perinatal asynchronous torsion is small, in order to reduce the risk of anorchism, the indication is to perform contralateral orchidopexy [6,8].

Conclusion

Neonatal bilateral perinatal testicular torsion is a rare pathology and it represents a true emergency due to the high risk of anorchism. Establishing a correct and fast diagnosis and the emergency bilateral surgical exploration are essential in trying to save the testicular function. Our recommendation is that in any suspicion of bilateral perinatal torsion of the testicles a bilateral exploration be carried out.

 

 

 

References

1. Nariman S, Khaleghnejad-Tabari A. Perinatal testicular torsion: a case report. Archives of Iranian Medicine 2005;8(4): 321-322

2. Rhodes HL, Corbett HJ, Horwood JF, Losty P. Neonatal testicular torsion. A survey of current practice amongst paediatric surgeons and urologist in the United Kingdom and Ireland. Journal of Pediatric Surgery 2011;46:2157-2160

3. Olguner M, Akgür FM, Aktug T, Derebek E. Bilateral asynchronous perinatal testicular torsion: a case report. Journal of Pediatric Surgery 2000;35(9):1348-1349

4. Don Lee S, Sek Cha C. Asynchronous bilateral torsion of the spermatic cord in the newborn: a case report. J Korean Med Sci 2002;17:712-714

5. Shrivasta NS, Gopalaswamy C, Venugopal RMC. Prenatal torsion of the testis: a rare emergency. J Neonat Surg 2012;1:30

6. Djahangirian O, Ouimet A, Saint-Vil D. Timing an surgical management of neonatal testicular torsions. Journal of Pediatric Surgery 2010;45:1012-1015

7. Riaz-Ul-haq M, Mahdi DEA, Elhassan EU. Neonatal testicular torsion; a review article. Iran J Pediatr 2012;22(3):281-289

8. Al-Salem AH. Intrauterine testicular torsion: a surgical emerngecy. Journal of Pediatric Surgery 2007;42:1887-1891