Int. Med J Vol. 6 No 2 December 2007

Viable testis after prolong torsion. A Case report

Afshar Zomorrodi , F. Soleymanzadeh , M. Zeinali, and  N. ghorbani

Urology service, Tabriz-Iran,

ABSTRACT

A 17 year-old boy was admitted into hospital for acute left testicular pain fourty eight hours earlier. A diagnosis of epididymorchitis was made from Ultrasound examination. Urinalysis was normal and cremasteric reflex was intact. The worsening of pain and normal urinalysis necessitated an exploration. There was torsion of the cord (two cycles). The testis was slightly ischaemic, and with detorsion. There was complete return the colour of testis. Bilateral orchidopexy was performed .There was not epididymorchitis.

KEY WORD: Torsion, testis, prolonged torsion, scrotal pain

INTRODUCTION:

Torsion of the testis, or more correctly, torsion of the spermatic cord, is a surgical emergency because it causes strangulation of gonadal blood supply with subsequent testicular necrosis and atrophy. Acute scrotal swelling in children indicates torsion of the testis until proven otherwise. In approximately two thirds of patients, history and physical examination are sufficient to make an accurate diagnosis.

In testicular torsion necrosis of the gonad can develop within 2 hours in experimental animals and within 6 hours in humans (1).

The risk of a male developing torsion of the testis by the age of 25 years is in the region of 1 in 135 (2).

Peak incidence occurs in adolescents aged 13 years, and the left testis is more frequently involved. Bilateral cases account for 2% of all torsions. Some studies (3, 4, 5) conducted in recent years have shown that only 16 to 42 percent of boys with an acute scrotum pain have testicular torsion.

Torsion occurs in two forms:

Extravaginal torsion: This type manifests in the neonatal period and most commonly develops prenatally in the spermatic cord, proximal to the attachments of the tunica virginals.

Intravaginal torsion: This type occurs within the tunica vaginalis, usually in older children. Intravaginal torsion is related to an anomalous testicular suspension that has been referred to as the bell-clapper anomaly. In many instances, this anomaly may be bilateral.

Extravaginal torsion comprises approximately 5% of all torsions. The condition is most often a prenatal (in utero) event and is associated with high birth weight. Up to 20% of cases are synchronous, and 3% are asynchronous bilateral.

Intravaginal torsion comprises approximately 16% of patients with torsion presenting in emergency departments with acute scrotum.

The extent and duration of torsion prominently influence both the immediate salvage rate and late testicular atrophy. Testicular salvage most likely occurs if the duration of torsion is less than 6-8 hours. If 24 hours or more elapse, testicular necrosis develops in most patients.

A physical examination may reveals a swollen, tender, high-riding testis . The absence of the cremasteric reflex in a patient with acute scrotal pain supports the diagnosis of torsion. In time, a reactive hydrocele, scrotal wall erythema, and ecchymosis become more striking. Whilst human testes occasionally survive up to 10 hours of torsion  (6,7) viability is considerably reduced after 4-6 hours of ischaemia   (8).But here A testis torsion case presents  that it was viable after 54 hours torsion.

CASE:

The presenting case is a 17 year-old adolescent with scrotal pain that started since morning two days before admission. There was no urinary symptom. He had a history of scrotal pain several times few months previously which resolved spontaneously. There was no change in pain intensity with elevation of scrotum (prehieghn sign).A very outstanding point in this history was single anal sex contact (five months before admission).

At physical examination, temperature was normal, there was no swelling or erythema of the scrotum. The epididymis of left testis was swollen and there was tenderness but it was in the normal position. Cremasteric reflex was present. At Ultrasound examination there was increased volume of the epididymis and heterogenicity of the parenchyma. This ultrasound finding is suggestive of epididymo-orchitis. Color Doppler ultrasound was not available. Due to persistence of pain, an equivocal ultrasound and age of patient a surgical exploration was carried out. At exploration the left testis was in torsion (two cycles- Fig. 1). The testis was detorsioned and the color of testis returned to normal. A bilateral orchideopexy was performed.

Fig 1

DISCUSSION:

 Torsion of testis is an acute emergency in urology .This must be diagnosed and treated as soon as possible .History and clinical examination are the keys for diagnosis. Scrotal pain without urinary symptoms and transverse position of testis and absence of cremasteric reflex are key points for diagnosis. In this case the cremasteric reflex was intact whereas absence of this reflex supports diagnosis (9). 

Doppler stethoscopes and conventional gray-scale ultrasonography have not been useful (10). In this case the gray scale ultrasound was not conclusive.

A colour doppler scanning of the acute scrotum if signs of torsion are equivocal (11) and an experienced radiologist are most desirable to help diagnosis readily available.  

In this case after a prolonged duration of torsion the testis was viable .An important message of this case is that in all clinical suspicion of testicular torsion, the patient should have an urgent scrotal exploration, regardless of the number of hours since the onset of presenting symptoms.

REFERENCE:

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2.   Williamson RC. Torsion of the testis and allied conditions. Br J Surg1976; 63:465 -76 al Mufti RA, Ogedegbe AK, Lafferty K. The use of Doppler ultrasound in the clinical management of acute testicular pain. Br J Urol 1995; 76:625-7.

3.   Lewis AG, Bukowski TP, Jarvis PD, Wacksman J, Sheldon CA. Evaluation of acute scrotum in the emergency department. J Pediatr Surg 1995; 30:277-82.

4.    Watkin NA, Reiger NA, Moisey CU. Is the conservative management of the acute scrotum justified on clinical grounds? Br J Urol 1996; 78:623-7.

5.   Ransler CW, Allen TD. Torsion of the spermatic cord. Urol Clin North Am1982; 9:245 -50

6.    Jones DJ, Macreadie D, Morgans BT. Testicular torsion in the armed services: twelve year review of 179 cases. Br J Surg1986; 73:624 -6

7.    Kallerhoff M, Gross AJ, Botefur IC, et al. The influence of temperature on changes in pH, lactate and morphology during ischaemia. Br J Urol1996; 78:440 -5

8.   Rabinowitz R. The importance of the cremasteric reflex in acute scrotal swelling in children. J Urol 1984;132:89-90.

9.   Deeg KH, Wild F. Colour Doppler imaging--a new method to differentiate torsion of the spermatic cord and epididymo-orchitis. Eur J Pediatr 1990; 149:253-5.

10. Kass EJ, Lundak B. The acute scrotum. Pediatr Clin North Am 1997;44:1251 -61

Correspondence

Dr.  Afshar Zomorrodi

Associate professor of urology,

Urology service, Tabriz-Iran,