(1)
Pediatric Surgery, AlSadik Hospital, Qatif, Saudi Arabia
29.1 Introduction
The term acute scrotum refers to acute scrotal pain with or without swelling and erythema.
Acute scrotum is considered a surgical emergency and although there are several causes for acute scrotum, prompt differentiation between testicular torsion and other causes of acute scrotum is critical.
The possibility of testicular torsion and permanent ischemic damage to the testis must always be kept in mind if the diagnosis is delayed.
There are several causes of acute scrotum and the etiology is age dependent.
Testicular torsion is commonly seen in neonates and adolescents.
Torsion of the appendix testis and acute epididymo-orchitis on the other hand are seen most commonly in prepubertal boys.
The differential diagnosis of acute scrotum include:
Testicular torsion (16 %)
Torsion of a testicular appendage (46 %)
Acute epididymo-orcitis (35 %)
Idiopathic scrotal edema
Schönlein-Henoch purpura
Incarcerated inguinal hernia
Scrotal trauma
Splenogonadal fusion
Common Causes of Acute Scrotum
- 1.
Testicular torsion (16 %)
- 2.
Torsion of a testicular appendage (46 %)
- 3.
Acute epididymo-orchitis (35 %)
- 4.
Idiopathic scrotal edema
- 5.
Schonlein-henoch purpura
- 6.
Incarcerated inguinal hernia
- 7.
Scrotal and testicular trauma
The child with acute scrotum should be evaluated rapidly both clinically and if required radiologically and the possibility of torsion of testis must always be kept in mind.
This is important because salvaging a testis in a child with testicular torsion is time dependent.
In doubtful cases, it is important to do an emergency testicular exploration rather than wait and loss the testis.
29.2 Torsion of Testes
29.2.1 Introduction
Testicular torsion is the most surgical emergency of acute scrotum as delay in diagnosis is known to be associated with testicular ischemia and infarction.
It results from twisting of the spermatic cord leading to venous and arterial obstruction and loss of the blood supply to the affected testis.
Early diagnosis and treatment are vital to saving the testis and preserving future fertility.
Testicular torsion is primarily a disease of adolescents and neonates.
Neonates develop a special type of testicular torsion which is called intrauterine testicular torsion.
This is different from the more common torsion seen in adolescent.
This type of torsion occurs extravaginally while the adolescent torsion occurs intravaginally.
This type of torsion commonly occurs in utero but there are reported cases occurring shortly after birth.
Intrauterine torsion is known to be associated with a high incidence of testicular infarction as in the majority of reported cases, the testis is already necrotic at the time of exploration
There are however rare reports of testicular salvage in some of these patients.
Diagnosis of testicular torsion is clinical, and diagnostic testing should not delay treatment.
Approximately 32 % of pediatric torsion cases resulted in the orchiectomy.
29.2.2 Classification
Testicular torsion is divided into two types (Fig. 29.1):
Fig. 29.1
Diagrammatic representation of the two types of testicular torsion
- 1.
Intravaginal torsion:
Intravaginal torsion most commonly occurs in adolescents.
Intravaginal torsion constitutes approximately 16 % of cases in patients presenting to an emergency department with acute scrotum.
This form of testicular torsion is most commonly seen in males younger than 30 years.
The peak incidence occurs at age 12–18 years.
The left testis is more frequently involved.
Bilateral torsion account for 2 % of all torsions.
- 2.
Extravaginal torsion (Figs. 29.2 and 29.3):
Figs. 29.2 and 29.3
Intraoperative photographs of two newborns with extravaginal testicular torsion
Extravaginal torsion occurs most commonly in neonates.
It accounts for approximately 5 % of all torsions.
The timing of occurrence of extravaginal torsion is not known exactly and it is estimated that about 70 % of the cases occur prenatally and 30 % occur postnatally.
Extravaginal torsion is also known to occur in patients with high birth weight.
Extravaginal torsion occurs most commonly on one side and bilateral perinatal torsion is extremely rare, but an increase in the number of case reports with bilateral intrauterine torsion has been observed.
The occurrence of bilateral torsion can be:
Synchronous (occurring simultaneously)
Metachronous (occurring at different times).
This is one reasons why contralateral orchidopexy is important in those with unilateral intrauterine torsion.
29.2.3 Etiology
- 1.
Intravaginal torsion:
The exact etiology of intravaginal torsion is not known.
Normally, once the testes reaches the scrotum it is fixed in place by mature attachments. This ensures firm fixation of the epididymal-testicular complex posteriorly and effectively prevents twisting of the spermatic cord.
The tunica vaginalis is normally attached to the postero-lateral aspect of the testes.
The most accepted embryological etiology of intravaginal testicular torsion is the bell clapper deformity.
This defect occurs in about 17 % of males and is bilateral in 40 %.
High abnormal attachment of the tunica vaginalis to the testicle makes the spermatic cord liable to rotate within it, which can lead to intravaginal torsion.
In intravaginal torsion, the testis can rotate freely on the spermatic cord within the tunica vaginalis.
In males with the bell-clapper deformity, torsion can occur because of a lack of fixation, resulting in the testes being freely suspended within the tunica vaginalis (Fig. 29.4).
Fig. 29.4
Diagrammatic representation of the bell-clapper deformity. This predisposes to intravaginal torsion of testis
The bell clapper deformity can result in the long axis of the testicle being oriented transversely rather than cephalocaudal.
Another abnormality that can predispose to intravaginal torsion is abnormal mesentery between the testis and its blood supply.
- 1.
Extravaginal torsion:
This occurs because the tunica vaginalis is not yet secured to the gubernaculum and, therefore, the spermatic cord, as well as the tunica vaginalis, undergo torsion as a unit.
In neonates, the testes frequently has not yet fully descended into the scrotum, where it becomes attached within the tunica vaginalis. This mobility of the testicle predisposes it to extravaginal torsion.
29.2.4 Clinical Features
Intravaginal Torsion
The usual presentation of intravaginal testicular torsion is a sudden onset of severe unilateral scrotal pain followed by inguinal and/or scrotal swelling. Gradual onset of pain is an uncommon presentation.
The pain may decrease in severity as the necrosis of testis becomes more complete.
Torsion of testis commonly occurs spontaneously but may occur during sports or physical activity.
Torsion of testis can also occur in association of trauma. This is seen in 4–8 % of the cases.
Approximately one third of patients also have gastrointestinal upset with nausea and vomiting.
The patients rarely report voiding difficulties or painful micturition.
In some patients, scrotal trauma or other scrotal disease (including torsion of appendix testis or epididymitis) may precede the occurrence of subsequent testicular torsion.
The patients may describe previous episodes of recurrent acute scrotal pain that has resolved spontaneously. This history is highly suggestive of intermittent torsion and detorsion of the testis. A detailed history is important in this regard.
Acute testicular torsion develops in 10 % of patients with intermittent torsion while they waite for surgery.
Physical examination may reveal:
A swollen, tender, high-riding testis
Abnormal transverse lie of testis
Loss of the cremasteric reflex
Edema involving the entire scrotum
Enlargement and edema of the testis
Fever is uncommon
Scrotal erythema
The cremasteric reflex is almost always absent or diminished on the affected side in patients with testicular torsion.
Prehn’s sign: Relief of pain with elevation of the affected testis.
Although a negative Prehn’s sign is classically thought to be a predictor of torsion, this is unreliable for diagnosis.
Factors predictive of testicular torsion include:
Acute onset of testicular pain
Duration of pain of less than 6 h
Fever, nausea and vomiting
History of trauma or physical activities
Absence of cremasteric reflex
Abnormal transverse lie of affected testis
Extravaginal Torsion
In neonates, prenatal extravaginal torsion presents as a hard, nontender testis that is fixed to the overlying scrotal skin which is discolored (Figs. 29.5 and 29.6).
Figs. 29.5 and 29.6
Clinical photographs showing two newborns with torsion of testis. Note the enlarged scrotum in both. Sometimes the skin is discolored and the affected testis is elevated
The affected testis is swollen.
Unilateral absence of the testis with blind-ending vas and vessels is thought to be a manifestation of early in utero torsion. This is also supported by finding hemosiderin in the distal section of the spermatic cord (Fig. 29.7).
Fig. 29.7
A clinical intraoperative photograph showing a small atrophic testis with an intact vas suggestive of intrauterine torsion of testis
Acute scrotal swelling and tenderness without fixation to the scrotal wall, may represent a postnatal torsion with some hope of subsequent testicular salvage with early surgical management.
Prenatal torsion manifests as:
A firm, hard, scrotal mass
It does not transilluminate
It occurs in an otherwise asymptomatic, healthy and of good weight male newborn
The scrotal skin characteristically fixes to the necrotic gonad and the scrotum is enlarged
29.2.5 Effects of Torsion of Testes
Torsion of the testes causes venous occlusion and engorgement as well as arterial ischemia and subsequent infarction of the testis. The extent of this depends on two factors:
The degree of torsion (Fig. 29.8):
Fig. 29.8
A clinical photograph showing a newborn with extravaginal torsion. Not the already necrotic testis
Torsion occurs as the testis rotates between 90° and 180°, compromising blood flow to and from the testis.
Incomplete or partial torsion occurs with lesser degrees of rotation.
Complete torsion usually occurs when the testis twists 360° or more. The degree of torsion may extend to 720°.
The duration of torsion:
The duration of torsion is the most important factor that influences the rates of both immediate salvage and late testicular atrophy.
Testicular salvage is most likely if the duration of torsion is less than 6 h.
If 24 h or more elapse, testicular necrosis develops in most patients.
The cause of decreased fertility observed in patients with unilateral testicular torsion is not known and two factors were suggested as possible theories.
An inherent bilateral testicular abnormalitiesRelated posts:
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