Neonatal testicular torsion
- Adam B Hittelman, MD, PhD
Adam B Hittelman, MD, PhD
- Assistant Professor of Surgery
- Yale University School of Medicine
Neonatal testicular torsion, defined as torsion occurring within the first 30 days of life, is a rare occurrence . It is most commonly an extravaginal process that involves twisting of the spermatic cord, resulting in compromise to the testes, as the spermatic cord contains the vasculature to the testicle and vas deferens. In neonatal torsion, the tunica vaginalis is not well-fixed to the scrotal wall, and the torsion involves the entire testicle, including the tunica vaginalis investment [2,3]. Neonatal torsion is a distinct entity from testicular torsion in older patients, which typically is caused by intravaginal torsion when the testis twists within its tunica vaginalis (figure 1).
Both extravaginal and intravaginal testicular torsion result in vascular compromise to the testes. If blood flow is not restored in a timely fashion (about four to six hours ), testicular ischemia, infarction, and subsequent atrophy will occur.
The management of neonatal testicular torsion remains controversial, as opinions differ on whether surgery can successfully salvage the torsed testis, which may have occurred in utero, and whether the contralateral side is at increased risk for concomitant (synchronous) or subsequent (asynchronous) torsion.
The clinical presentation and the controversies regarding management of neonatal testicular torsion will be reviewed here. Testicular torsion in children and adolescents is presented separately. (See "Causes of scrotal pain in children and adolescents", section on 'Testicular torsion'.)
Neonatal testicular torsion is defined as torsion that occurs prenatally and up to 30 days after delivery .
- Das S, Singer A. Controversies of perinatal torsion of the spermatic cord: a review, survey and recommendations. J Urol 1990; 143:231.
- Gillenwater JY, Burros HM. Torsion of the spermatic cord in utero. JAMA 1966; 198:1123.
- McFarland JB. Testicular strangulation in children. Br J Surg 1966; 53:110.
- Visser AJ, Heyns CF. Testicular function after torsion of the spermatic cord. BJU Int 2003; 92:200.
- Kaye JD, Levitt SB, Friedman SC, et al. Neonatal torsion: a 14-year experience and proposed algorithm for management. J Urol 2008; 179:2377.
- Driver CP, Losty PD. Neonatal testicular torsion. Br J Urol 1998; 82:855.
- John CM, Kooner G, Mathew DE, et al. Neonatal testicular torsion--a lost cause? Acta Paediatr 2008; 97:502.
- Yerkes EB, Robertson FM, Gitlin J, et al. Management of perinatal torsion: today, tomorrow or never? J Urol 2005; 174:1579.
- Djahangirian O, Ouimet A, Saint-Vil D. Timing and surgical management of neonatal testicular torsions. J Pediatr Surg 2010; 45:1012.
- Kyriazis ID, Dimopoulos J, Sakellaris G, et al. Extravaginal testicular torsion: a clinical entity with unspecified surgical anatomy. Int Braz J Urol 2008; 34:617.
- Kaplan GW, Silber I. Neonatal torsion- to pex or not?. In: Urologic Surgery in Neonates and Young Infants, WB Saunders, Philadelphia 1988. p.386.
- Burge DM. Neonatal testicular torsion and infarction: aetiology and management. Br J Urol 1987; 59:70.
- Baglaj M, Carachi R. Neonatal bilateral testicular torsion: a plea for emergency exploration. J Urol 2007; 177:2296.
- Mano R, Livne PM, Nevo A, et al. Testicular torsion in the first year of life--characteristics and treatment outcome. Urology 2013; 82:1132.
- Callewaert PR, Van Kerrebroeck P. New insights into perinatal testicular torsion. Eur J Pediatr 2010; 169:705.
- Brandt MT, Sheldon CA, Wacksman J, Matthews P. Prenatal testicular torsion: principles of management. J Urol 1992; 147:670.
- Al-Salem AH. Intrauterine testicular torsion: a surgical emergency. J Pediatr Surg 2007; 42:1887.
- Kaplan GW, Retik A, Snyder HM III, et al. Neonatal Torsion: Immediate Surgical Exploration versus Conservative Mangagement. Dialogues in Pediatric Urology 2004; 26:2.
- Sorensen MD, Galansky SH, Striegl AM, et al. Perinatal extravaginal torsion of the testis in the first month of life is a salvageable event. Urology 2003; 62:132.
- Stone KT, Kass EJ, Cacciarelli AA, Gibson DP. Management of suspected antenatal torsion: what is the best strategy? J Urol 1995; 153:782.
- Pinto KJ, Noe HN, Jerkins GR. Management of neonatal testicular torsion. J Urol 1997; 158:1196.
- Roth CC, Mingin GC, Ortenberg J. Salvage of bilateral asynchronous perinatal testicular torsion. J Urol 2011; 185:2464.
- 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.
- SMITH GI. Cellular changes from graded testicular ischemia. J Urol 1955; 73:355.
- Sessions AE, Rabinowitz R, Hulbert WC, et al. Testicular torsion: direction, degree, duration and disinformation. J Urol 2003; 169:663.
- Cimador M, DiPace MR, Castagnetti M, DeGrazia E. Predictors of testicular viability in testicular torsion. J Pediatr Urol 2007; 3:387.
- Abeyaratne MR, Aherne WA, Scott JE. The vanishing testis. Lancet 1969; 2:822.
- Lamesch AJ. Monorchidism or unilateral anorchidism. Langenbecks Arch Chir 1994; 379:105.
- Belman AB, Rushton HG. Is an empty left hemiscrotum and hypertrophied right descended testis predictive of perinatal torsion? J Urol 2003; 170:1674.
- Harris BH, Webb HW, Wilkinson AH Jr, Stevens PS. Protection of the solitary testis. J Pediatr Surg 1982; 17:950.
- Bellinger MF. The blind-ending vas: the fate of the contralateral testis. J Urol 1985; 133:644.
- Cosentino MJ, Nishida M, Rabinowitz R, Cockett AT. Histological changes occurring in the contralateral testes of prepubertal rats subjected to various durations of unilateral spermatic cord torsion. J Urol 1985; 133:906.
- Tanyel FC, Büyükpamukçu N, Hiçsönmez A. Contralateral testicular blood flow during unilateral testicular torsion. Br J Urol 1989; 63:522.
- Madarikan BA. Testicular salvage following spermatic cord torsion. J Pediatr Surg 1987; 22:231.
- Nagler HM, White RD. The effect of testicular torsion on the contralateral testis. J Urol 1982; 128:1343.
- Barkley C, York JP, Badalament RA, et al. Testicular torsion and its effects on contralateral testicle. Urology 1993; 41:192.
- Arena F, Nicòtina PA, Romeo C, et al. Prenatal testicular torsion: ultrasonographic features, management and histopathological findings. Int J Urol 2006; 13:135.
- van der Sluijs JW, den Hollander JC, Lequin MH, et al. Prenatal testicular torsion: diagnosis and natural course. An ultrasonographic study. Eur Radiol 2004; 14:250.
- Kaye JD, Shapiro EY, Levitt SB, et al. Parenchymal echo texture predicts testicular salvage after torsion: potential impact on the need for emergent exploration. J Urol 2008; 180:1733.
- Brown SM, Casillas VJ, Montalvo BM, Albores-Saavedra J. Intrauterine spermatic cord torsion in the newborn: sonographic and pathologic correlation. Radiology 1990; 177:755.
- Traubici J, Daneman A, Navarro O, et al. Original report. Testicular torsion in neonates and infants: sonographic features in 30 patients. AJR Am J Roentgenol 2003; 180:1143.
- Ricci P, Cantisani V, Drudi FM, et al. Prenatal testicular torsion: sonographic appearance in the newborn infant. Eur Radiol 2001; 11:2589.
- Vieras F, Kuhn CR. Nonspecificity of the "rim sign" in the scintigraphic diagnosis of missed testicular torsion. Radiology 1983; 146:519.
- Trambert MA, Mattrey RF, Levine D, Berthoty DP. Subacute scrotal pain: evaluation of torsion versus epididymitis with MR imaging. Radiology 1990; 175:53.
- Arena F, Nicòtina PA, Scalfari G, et al. A case of bilateral prenatal testicular torsion: Ultrasonographic features, histopathological findings and management. J Pediatr Urol 2005; 1:369.
- Tripp BM, Homsy YL. Prenatal diagnosis of bilateral neonatal torsion: a case report. J Urol 1995; 153:1990.
- Hubbard AE, Ayers AB, MacDonald LM, James CE. In utero torsion of the testis: antenatal and postnatal ultrasonic appearances. Br J Radiol 1984; 57:644.
- Snyder HM, Diamond DA. In utero/neonatal torsion: observation versus prompt exploration. J Urol 2010; 183:1675.
- Broderick KM, Martin BG, Herndon CD, et al. The current state of surgical practice for neonatal torsion: a survey of pediatric urologists. J Pediatr Urol 2013; 9:542.
- Friedman AA, Elder JS. Words of wisdom: Re: The current state of surgical practice for neonatal torsion: a survey of pediatric urologists. Eur Urol 2013; 64:513.
- Cuervo JL, Grillo A, Vecchiarelli C, et al. Perinatal testicular torsion: a unique strategy. J Pediatr Surg 2007; 42:699.
- Cohen MM, Cameron CB, Duncan PG. Pediatric anesthesia morbidity and mortality in the perioperative period. Anesth Analg 1990; 70:160.
- Duckett JW. Routine Contralateral Explorationand Fixation Is Unjustified. Dialogues in Pediatric Urology 1991; 14:5.
- Huff DS, Wu HY, Snyder HM 3rd, et al. Evidence in favor of the mechanical (intrauterine torsion) theory over the endocrinopathy (cryptorchidism) theory in the pathogenesis of testicular agenesis. J Urol 1991; 146:630.
- CLINICAL PRESENTATION
- Bilateral involvement
- Testicular ischemia
- - Monorchidism
- - Endocrine abnormalities
- Contralateral testicle
- Prenatal diagnosis
- DIFFERENTIAL DIAGNOSIS
- When and if to perform surgery
- - Timing of surgery
- Orchiectomy or leave testicle in situ?
- Contralateral orchiopexy
- Our approach
- SUMMARY AND RECOMMENDATIONS