Testicular Torsion in a Neonate
A boy was born to a 27-year-old gravida 1, para 1 mother at 39 weeks’ gestation by spontaneous vaginal delivery. The mother had a normal pregnancy, with normal prenatal laboratory test findings. Results of all prenatal ultrasonograms were normal. The delivery was not particularly difficult; the baby had Apgar scores of 8 at 1 minute and 9 at 5 minutes. Birth weight was 3,714 g, length was 51.5 cm, and head circumference was 35.5 cm.
At the initial newborn examination at 2 hours of age, swelling and ecchymosis of the right side of the scrotum was noted. The right testicle was enlarged, about 2 × 2 cm in size, firm, and mildly tender. The left testicle was normal in size and nontender. No hernia was noted. Phimosis was noted. The rest of the physical examination findings were normal.
Scrotal ultrasonography revealed absent blood flow on the right side, suggestive of the presence of testicular torsion. A urology consult was sought immediately. The infant was taken to the operating room and on exploration was noted to have right spermatic cord torsion with testicular necrosis.
Detorsion was attempted, followed by orchiectomy. Left scrotal orchiopexy also was done to fix the other testicle. Circumcision was performed. The infant tolerated the surgery well and was discharged on the second postoperative day.
Neonatal testicular torsion accounts for approximately 12% of all cases of torsion among children. Neonatal torsion is almost always extravaginal in origin, whereby the testicle and its investing tunica vaginalis twist together around the axis of the spermatic cord.1,2 A few intravaginal cases also have been reported in the literature.3
Testicular torsion results in acute ischemia with its resultant sequelae, such as abnormality of testicular function and infertility. Urgent surgical exploration and fixation of the other testis are the key management points.
The exact etiology of neonatal torsion has not been described; however, predisposing factors include difficult labor, breech presentation, high birth weight, a hyperactive cremasteric reflex, and multiparity.2-4
Cases of neonatal torsion have been divided into a prenatal group, in which the torsion is detected at delivery, and a postnatal group, in which the torsion is detected later. About 70% of cases have been reported to occur prenatally, with the rest occurring during the first month of life.2,4,5
In contrast with older patients with torsion, who present with sudden excruciating pain and gastrointestinal symptoms such as nausea and vomiting, prenatal torsion is associated with minimal to no discomfort at birth.6,7 Postnatal torsion has an association with a swollen and tender scrotum. The newborn may appear otherwise healthy without any symptoms. Vital signs and also blood work may be unrevealing. A pathognomonic finding is a hard, nontender testicle fixed to the discolored scrotum. Other findings include a scrotal mass that does not transmit light.2,3,6
In a newborn with acute scrotum, the differential diagnosis is broad and includes testicular torsion, torsion of testicular appendages, reducible hernia, strangulated inguinal hernia, trauma following breech delivery, hematocele, scrotal hematoma, meconium peritonitis, epididymitis or orchitis, scrotal abscess, malignancy, ectopic spleen, and ectopic adrenal gland.3
The diagnosis of testicular torsion can be made on clinical presentation alone.6 Color Doppler ultrasonography and scintigraphic imaging studies typically reveal diminished testicular flow on the side with torsion. Doppler ultrasonography is highly sensitive, frequently revealing testicular heterogeneity, swelling, hydrocele, skin thickening, and absent flow, but these findings can be nonspecific, particularly because identifying Doppler flow in normal neonates can be difficult.4,7 Some authors have suggested that the role of ultrasonography is mainly visualization of scrotal contents to exclude alternative diagnoses.
In the largest published case series of neonatal testicular torsion, the salvage rate was 8.96%.8 If operated on earlier as an emergency, the rate increased to 21.7%.8
Early asynchronous torsion, while rare, has been described; bilateral torsion can present with unilateral signs. We therefore urge a more expedient surgical approach. While salvage of a prenatal torsion is difficult, it is possible. Deciding whether a testicle has undergone torsion prenatally or perinatally can be difficult. We advocate for semi-emergent exploration of prenatal torsion, both to confirm the diagnosis and to examine and fix the contralateral testicle.
If a normal testicle has been observed previously, we advocate for urgent emergency exploration in postnatal cases, provided the child is otherwise well and specialist pediatric anesthesia is available, with the aim being to salvage the testis and fix the contralateral side.8
If torsion occurs in the prenatal period, the newborn will present with a firm and painless scrotal mass at birth. The affected testicle is bigger or similar in size to the contralateral normal testicle, without acute inflammatory signs, and does not transmit light.9
We believe the newborn in our case had prenatal testicular torsion that most likely had occurred close to the time of delivery, since the enlarged testicle was enlarged, firm, and necrotic but not atrophic.
References
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2. Brandt MT, Sheldon CA, Wacksman J, Matthews P. Prenatal testicular torsion: principles of management. J Urol. 1992;147(3):670-672.
3. Driver CP, Losty PD. Neonatal testicular torsion. Br J Urol. 1998;82(6):855-858.
4. Kaye JD, Levitt SB, Friedman SC, Franco I, Gitlin J, Palmer LS. Neonatal torsion: a 14-year experience and proposed algorithm for management. J Urol. 2008;179(6):2377-2383.
5. Das S, Singer A. Controversies of perinatal torsion of the spermatic cord: a review, survey and recommendations. J Urol. 1990;143(2):231-233.
6. Gillenwater JY, Burros HM. Torsion of the spermatic cord in utero. JAMA. 1966;198(10):1123-1124.
7. Arena F, Nicòtina PA, Romeo C, et al. Prenatal testicular torsion: ultrasonographic features, management and histopathological findings. Int J Urol. 2006;13(2):135-141.
8. Nandi B, Murphy FL. Neonatal testicular torsion: a systematic literature review. Pediatr Surg Int. 2011;27(10):1037-1040.
9. Riaz-Ul-Haq M, Mahdi DE, Elhassan EU. Neonatal testicular torsion; a review article. Iran J Pediatr. 2012;22(3):281-289.