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Pelvis » Scrotum And Testicles
Neonatal extravaginal testicular torsion
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Author(s) :
Taco Geertsma, MD
Presentation Neonate with a scrotal swelling on the right side
Caption: Transverse image of both testicles
Description: The left testis and peritesticular structures are normal. The right testis (anterior side) is small with peripheral hyperechogenicity and the peritesicular structures are very inhomogeneous
Caption:  Detail of the right testis
Description: The testis (right side of the image) is small and the testis and the peritesicular structures are inhomogeneous
Caption:  Image of the left testis
Description: The testis presents the normal homogeneous echo pattern and is surrounded by a physiological amount of fluid
Caption:  Color doppler image of the right testis
Description: There is no flow in the right testis, only in the scrotal wall. The testis shows peripheral hyperechogenicity
Caption:  Color doppler image of the left testis
Description: There is normal flow in the left testis
Differential Diagnosis Other causes of scrotal swelling include a hydrocele, scrotal hernia and a tumor
Final Diagnosis Neonatal or extravaginal testicular torsion
Discussion It is important to realize that there are two types of testicular torsion.

The type that is most common and usually seen in older children is the intravaginal torsion: This type occurs within the tunica vaginalis. 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.

The type that occurs in the neonatal age group is the so called extravaginal torsion. It most commonly develops prenatally in the spermatic cord, proximal to the attachments of the tunica vaginalis. It occurs when the testes may freely rotate prior to the development of testicular fixation via the tunica vaginalis within the scrotum.

The extravaginal torsion comprises approximately 5% of all torsions. and is often associated with  a high birth weight.

Up to 20% of cases are bilateral. Bilateral neonatal torsion can occur at the same time or at different times in utero. The latter can result in a different aspect of the testes at the time of examination.

Torsion of the spermatic cord may interrupt blood flow to the testis and epididymis. The degree of torsion may vary. The extent and duration of the torsion 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. After 24 hours testicular necrosis develops in most patients.

In the case of a neonatal testicular torsion because of the long time between the onset of the torsion and the moment of examination there are nearly always necrotic changes in the involved testis.

Prenatal torsion manifests as a firm, hard, scrotal mass, and is usually asymptomatic. The scrotal skin characteristically fixes to the necrotic gonad.

Traubici et al describe in their article Testicular Torsion in Neonates and Infants: Sonographic Features in 30 Patients in the American journal of radiology 3 types

Type 1.—In type 1 there was marked enlargement with heterogeneity in echogenicity of the affected testicle. No detectable Doppler flow could be detected in the testicle. In a few patients, linear hypoechoic striations were seen, oriented radially from the mediastinum testis A hydrocele occasionally with debris was present with thickening of the surrounding soft tissues (A simple hydrocele was seen in the contralateral scrotum in a few patients.

Type 2.— In these patients, the size of the testicle was normal and symmetric with the uninvolved testicle, the echogenicity was heterogeneous. In a number of patients, peripheral hyperechogenicity was seen. A small hydrocele was present in several patients.

Type 3.—In the third group of patients the testicle was markedly diminished with only a small amount of testicular tissue persisting. Areas of increased echogenicity were seen scattered throughout the testicle. A hydrocele was not observed in these patients.

The different patterns represent stages in the evolution of the process of ischemic necrosis.

In the presented case the testis is small with slight peripheral hyperechogenicity and no hydrocele consistent with a type 2 to 3

For more examples of a testicular torsion including a bilateral neonatal testicular torsion see
Case References

van der Sluijs JW, den Hollander JC, Lequin MH, Nijman RM, Robben SG Prenatal testicular torsion: diagnosis and natural course. An ultrasonographic study. Eur Radiol. 2004 Feb;14(2):250-5.

Traubici J, Daneman A, Navarro O, Mohanta A, Garcia C.Original report. Testicular torsion in neonates and infants: sonographic features in 30 patients AJR Am J Roentgenol. 2003 Apr;180(4):1143-5.

Arena F, Nicòtina PA, Romeo C, Zimbaro G, Arena S, Zuccarello B, Romeo G.Prenatal testicular torsion: ultrasonographic features, management and histopathological findings. Int J Urol. 2006 Feb;13(2):135-41.

Yerkes EB, Robertson FM, Gitlin J, Kaefer M, Cain MP, Rink RC.Management of perinatal torsion: today, tomorrow or never? J Urol. 2005 Oct;174(4 Pt 2):1579-82; discussion 1582-3.

Follow Up Treatment

Since there is already necrosis of the involved testis at the time of examination immediate surgery as in the case of an acute intravaginal torsion is usually not necessary. However in many cases of neonatal testicular torsion the necrotic testis is surgically removed. In many cases also an orchidopexy of the contralateral side is performed unless of course the patient has a bilateral testicular tosion.
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