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The Management of Testicular Torsion in the Acute Pediatric Scrotum
0022-5347 /83/1293-0558$02.00/0 Vol. 129, March Printed in U.S. A.
THE JOURNAL OF UROLOGY
Copyright © 1983 by The Williams & Wilkins Co.
THE MANAGEMENT OF TESTICULAR TORSION IN THE ACUTE PEDIATRIC SCROTUM JOHN H. SCOTT, III, JAMES I. HARTY
AND
LONNIE W. HOWERTON
From the Department of Surgery, Division of Urology, University of Louisville School of Medicine, Louisville, Kentucky
ABSTRACT
From July 1976 through June 1981, 51 children with acute scrotal pain and swelling underwent surgical exploration. Testicular torsion (27 cases) and torsion of an appendage (18 cases) were the most common diagnoses. In the group with testicular torsion 5 testes were considered unsalvageable and these were removed. The remaining 22 testes, including those of questionable viability, were left in place. The early salvage rate of 81 per cent decreased to 50 per cent due to testicular atrophy found in the late followup period. The attempt to salvage all testes except those with obvious necrosis resulted in minimal morbidity. This approach is discussed in view of recent reports of long-term damage to the contralateral testis when an ischemic testis is not removed initially. Successful preservation of a testis that has undergone torsion is directly related to the duration and degree of torsion. Therefore, it is important to distinguish testicular torsion from other causes of an acutely swollen and painful scrotum. Since there are no consistently reliable distinguishing factors in the patient history, physical examination or laboratory data to distinguish testicular torsion from other acute scrotal problems, the Doppler flowmeter and radionuclide testicular scans are being used more frequently in an attempt to establish an accurate diagnosis. 1 However, these methods of investigation are neither universally available nor reliable. 2 • 3 The aggressive approach of early surgical exploration has yielded the highest rates of early testicular salvage in terms of preservation of the testis. 4 The late salvage is usually lower and, recently, in several reports it has been suggested that although anatomical integrity of the testis is maintained the exocrine function of the involved testis and even of the contralateral testis is impaired. 5• 6 PATIENTS AND MATERIALS
Between July 1976 and June 1981, 51 patients up to 18 years old underwent exploratory surgery for acute scrotal pain and swelling. It was our policy to perform early scrotal exploration of all such patients, except when there was obvious acute epididymitis diagnosed on the basis of a swollen tender epididymis, pyuria and a history of sexual activity. The Doppler flowmeter was not used in this series and testicular scans were performed in only a few cases when the decision for scrotal exploration had been made and there was a delay in obtaining operating room time. The findings at operation in the 51 patients are shown in the table. An inguinal orchiectomy was performed in the 1 patient with pure teratoma of the testis. Ligation of the sac was performed through an inguinal incision in 1 patient with a communicating hydrocele. Unilateral hematoceles were evacuated and drained in 2 patients. The etiology of the pain and swelling in 1 normal testis of 1 patient was unknown. Torsion of an appendage was managed by excision without contralateral exploration. Torsion of the testis was managed either by orchiectomy or orchiopexy and the contralateral testis was fixed in all cases. Long-term evaluation consisted of measuring the size of the involved testis and comparing it with the opposite testis at least 6 months after the time of torsion. Accepted for publication July 23, 1982. Read at annual meeting of Southeastern Section, American Urological Association, New Orleans, Louisiana, March 28-April 1, 1982. 558
RESULTS
The ages of the patients when torsion of the testis or an appendage occurred are shown in figure 1. Testicular torsion was seen predominantly in older children, between 11 and 17 years old, while torsion of an appendage occurred in younger patients, between 8 and 12 years old. The length of time from the onset of symptoms to relief of torsion in the 27 patients is shown in figure 2. Of the 27 patients with testicular torsion 5 required orchiectomy because of obvious necrosis. The duration of torsion ranged from 42 hours to 22 days in those patients requiring orchiectomy. There were 22 testes considered to be salvageable based on physical appearance, degree of torsion, restoration of a pulse, bleeding from the testis upon incision and, occasionally, testis biopsy. Only of the 22 patients whose testis was salvaged returned for long-term followup. Of these patients atrophy of the affected testis had developed in 3 and the remainder had a normal-sized testis when compared with the opposite side. The relationship between the duration of torsion and the degree of atrophy in these 3 patients is shown in figure 3. Most of the testes that were torsed for 12 hours were salvaged and 1 was salvaged even after 24 hours. The only complication in the 51 patients was a wound infection in a boy whose testis was salvaged after 48 hours of torsion and, subsequently, atrophy occurred.
n
DISCUSSION
Most discussions of acute testicular torsion revolve around making the correct diagnosis. Less attention is paid to factors that influence surgical management, that is to perform orchiectomy or to preserve the testis. The duration of torsion appears to be one of the most reliable indicators of whether a testis will be salvageable, although atrophy can occur in testes that have been torsed for as few as 4 hours. 5 On the other hand, we had 2 patients whose testes did not atrophy, although torsion had been present for 12 and 24 hours, respectively. Other indicators at the time of operation may be the gross appearance of the testis, the degree of torsion and the presence of fresh bleeding from the testis when it is incised. Intravenous sodium fluorescein has been used intraoperatively as an objective measure of testicular viability. 7 Testicular biopsy has not proved to be useful. 6 It was our policy .to remove only frankly necrotic testes because of reports of salvage after even prolonged periods of torsion. 4 We also believed that even if exocrine function was lost some hormonal function might be maintained, and that
559 }--:indings in 51 patients undergoing scrotal exploration No. Cases
(%)
27 18 2 1 1 1 1 51
(53) (35) (4)
Torsion of testis Torsion of an appendage Hematocele Acute hydrocele Teratoma of testis Epididymitis Normal testis
6
(<2) (<2) (<2) (<2)
0 TORSIOI~ OF APPENDAGE ii!! TORSION OF TESTIS
5 (f)
~
4
~
3
~
2
w
ci
z
I
4
5
6
7
8
9
10
11
12
13
14
15
16
17
AGE
FIG. 1. Age distribution in torsion of testis and appendages
DURATION OF TORSION 12
•
11
SALVAGE
~ ORCHIECTOMY
10 9 8 (fJ
f--
z 7 w
~ a.:
6
LL
5
0
0
z 4
:IUD
3
I
·"""=====,:,!:
2
0
>24
24
8 TIME IN HOURS
FIG. 2. Duration of torsion in relation to early salvage
even an testis might be of some cosmetic or value to the patient. The of resulted in a diagnosis of torsion in 53 per cent of the patients, an early salvage rate of 81 per cent (22 of 27 cases) and an overall salvage rate of 50 per cent in late followup (8 of 16 cases). We had a delayed atrophy rate of 27 per cent (3 of 11), which is less than that reported by others 5 • 6 but our numbers are small. However, there are other criteria by which salvage may be measured, namely spermatogenesis, hormone production and fertility. These may be more important than preservation of testicular size. Krarup found that 95 per cent of the patients who had testicular torsion had defective spermatogenesis based on an abnormal semen analysis. 5 This finding occurred regardless of whether the testis was salvaged or removed. He hypothesized that patients who suffer from unilateral testicular torsion have bilateral testicular abnormalities that account for the impaired spermatogenesis. Bartsch and associates found abnormal semen analyses as well as increased serum follicle-stimulating hormone and luteinizing hormone in 50 per cent of patients with testicular torsion. 6 They also noted that semen analysis was normal in 3 patients in whom orchiectomy was done for torsion that had lasted >24 hours. In contrast, sperm analysis was abnormal in 4 patients who had torsion for a similar duration but whose testes were salvaged, Bartsch and associates found that late biopsy of the contralateral testis showed hypospermatogenesis in 3 patients whose testes were salvaged, while in l patient who had had an orchiectorny the biopsy of the contralateral testis was normal. These findings suggested that preservation of an ischemic testis in some way damaged the contralateral testis. Harrison and associates, in an experimental study in rats, showed that interruption of the testicular artery destroyed all spermatogenic function and also resulted in considerable damage to the opposite testis. 8 They showed that this damage was caused by an immunological response demonstrated as an increase in cytotoxicity in rat serum, Based on this finding they proposed early removal of an ischemic testis rather than attempts at preservation. Despite these arguments, however, it is not clear whether the abnormalities in spermatogenesis are merely laboratory findings or if they have clinical significance in terms of fertility in humans. Merimsky and associates found that preservation of an ischemic testis reduced fertility in rats. 9 However, in a large series of infertile patients none had a history of testicular torsion, 10 which suggests that abnormalities of spermatogenesis found on semen analysis are not great enough to render a patient infertile. Until long-term foHowup studies of fertility in patients with testicular torsion are undertaken, we believe that the present approach of early surgical exploration and rn·"'Q''"'."' of the testis in all cases is justified, except when there is obvious necrosis.
FOLLOWUP ;,5 MONTHS) OF SALVAGED TESTIS
"
11 CASES
. 50
>-
it
40
~
30
'o'2-
20
0 0::
.
10
0 0
2
4
6
8
12
24
DURATION OF TORSION IN HOURS
FIG. 3. Degree of atrophy in relation to duration of torsion
REFERENCES
1. Flanigan, R. C., DeKernion, J.B. and Persky, L.: Acute scrotal pain and swelling in children: a surgical emergency. Urology, 17: 51, 1981. 2. Brereton, R. J.: Limitations of the Doppler flow meter in the diagnosis of the "acute scrotum" in boys. Brit. J. Urol., 53: 380, 1981. 3. Wasnick, R. J., Pohutsky, K. R. and Macchia, R. J.: Testicular torsion and usefulness ofradionuclide scanning, Urology, 15: 318, 1980. 4. Cass, A. S., Cass, B. P. and Veeraraghavan, K.: Immediate exploration of the unilateral acute scrotum in young male subjects. J. Urol., 124: 829, 1980. 5. Krarup, T.: The testes after torsion. Brit. J. Urol., 50: 43, 1978. 6. Bartsch, G., Frank, St., Marberger, H. and Mikuz, G.: Testicular torsion: late results with special regard to fertility and endocrine function. J. Urol., 124: 375, 1980.
560
SCOTT, HARTY AND HOWERTON
7. Schneider, H. C., Jr., Kendall, A. R. and Karafin, L.: Fluorescence of testicle: an indication of viability of spermatic cord after torsion. Urology, 5: 133, 1975. 8. Harrison, R. G., de Marval, M. J. M., Lewis-Jones, D. I. and Connolly, R. C.: Mechanism of damage to the contralateral testis
in rats with an ischaemic testis. Lancet, 2: 723, 1981. 9. Merimsky, E., Rock, M. and Katz, S.: Assessment of fertility after testicular torsion: an experimental study. Urol. Res., 10: 51, 1982. 10. Amelar, R. D. and Dubin, L.: Male infertility: current diagnosis and treatment. Urology, 1: 1, 1973.
THE JOURNAL OF UROLOGY
Copyright © 1983 by The Williams & Wilkins Co.
THE MANAGEMENT OF TESTICULAR TORSION IN THE ACUTE PEDIATRIC SCROTUM JOHN H. SCOTT, III, JAMES I. HARTY
AND
LONNIE W. HOWERTON
From the Department of Surgery, Division of Urology, University of Louisville School of Medicine, Louisville, Kentucky
ABSTRACT
From July 1976 through June 1981, 51 children with acute scrotal pain and swelling underwent surgical exploration. Testicular torsion (27 cases) and torsion of an appendage (18 cases) were the most common diagnoses. In the group with testicular torsion 5 testes were considered unsalvageable and these were removed. The remaining 22 testes, including those of questionable viability, were left in place. The early salvage rate of 81 per cent decreased to 50 per cent due to testicular atrophy found in the late followup period. The attempt to salvage all testes except those with obvious necrosis resulted in minimal morbidity. This approach is discussed in view of recent reports of long-term damage to the contralateral testis when an ischemic testis is not removed initially. Successful preservation of a testis that has undergone torsion is directly related to the duration and degree of torsion. Therefore, it is important to distinguish testicular torsion from other causes of an acutely swollen and painful scrotum. Since there are no consistently reliable distinguishing factors in the patient history, physical examination or laboratory data to distinguish testicular torsion from other acute scrotal problems, the Doppler flowmeter and radionuclide testicular scans are being used more frequently in an attempt to establish an accurate diagnosis. 1 However, these methods of investigation are neither universally available nor reliable. 2 • 3 The aggressive approach of early surgical exploration has yielded the highest rates of early testicular salvage in terms of preservation of the testis. 4 The late salvage is usually lower and, recently, in several reports it has been suggested that although anatomical integrity of the testis is maintained the exocrine function of the involved testis and even of the contralateral testis is impaired. 5• 6 PATIENTS AND MATERIALS
Between July 1976 and June 1981, 51 patients up to 18 years old underwent exploratory surgery for acute scrotal pain and swelling. It was our policy to perform early scrotal exploration of all such patients, except when there was obvious acute epididymitis diagnosed on the basis of a swollen tender epididymis, pyuria and a history of sexual activity. The Doppler flowmeter was not used in this series and testicular scans were performed in only a few cases when the decision for scrotal exploration had been made and there was a delay in obtaining operating room time. The findings at operation in the 51 patients are shown in the table. An inguinal orchiectomy was performed in the 1 patient with pure teratoma of the testis. Ligation of the sac was performed through an inguinal incision in 1 patient with a communicating hydrocele. Unilateral hematoceles were evacuated and drained in 2 patients. The etiology of the pain and swelling in 1 normal testis of 1 patient was unknown. Torsion of an appendage was managed by excision without contralateral exploration. Torsion of the testis was managed either by orchiectomy or orchiopexy and the contralateral testis was fixed in all cases. Long-term evaluation consisted of measuring the size of the involved testis and comparing it with the opposite testis at least 6 months after the time of torsion. Accepted for publication July 23, 1982. Read at annual meeting of Southeastern Section, American Urological Association, New Orleans, Louisiana, March 28-April 1, 1982. 558
RESULTS
The ages of the patients when torsion of the testis or an appendage occurred are shown in figure 1. Testicular torsion was seen predominantly in older children, between 11 and 17 years old, while torsion of an appendage occurred in younger patients, between 8 and 12 years old. The length of time from the onset of symptoms to relief of torsion in the 27 patients is shown in figure 2. Of the 27 patients with testicular torsion 5 required orchiectomy because of obvious necrosis. The duration of torsion ranged from 42 hours to 22 days in those patients requiring orchiectomy. There were 22 testes considered to be salvageable based on physical appearance, degree of torsion, restoration of a pulse, bleeding from the testis upon incision and, occasionally, testis biopsy. Only of the 22 patients whose testis was salvaged returned for long-term followup. Of these patients atrophy of the affected testis had developed in 3 and the remainder had a normal-sized testis when compared with the opposite side. The relationship between the duration of torsion and the degree of atrophy in these 3 patients is shown in figure 3. Most of the testes that were torsed for 12 hours were salvaged and 1 was salvaged even after 24 hours. The only complication in the 51 patients was a wound infection in a boy whose testis was salvaged after 48 hours of torsion and, subsequently, atrophy occurred.
n
DISCUSSION
Most discussions of acute testicular torsion revolve around making the correct diagnosis. Less attention is paid to factors that influence surgical management, that is to perform orchiectomy or to preserve the testis. The duration of torsion appears to be one of the most reliable indicators of whether a testis will be salvageable, although atrophy can occur in testes that have been torsed for as few as 4 hours. 5 On the other hand, we had 2 patients whose testes did not atrophy, although torsion had been present for 12 and 24 hours, respectively. Other indicators at the time of operation may be the gross appearance of the testis, the degree of torsion and the presence of fresh bleeding from the testis when it is incised. Intravenous sodium fluorescein has been used intraoperatively as an objective measure of testicular viability. 7 Testicular biopsy has not proved to be useful. 6 It was our policy .to remove only frankly necrotic testes because of reports of salvage after even prolonged periods of torsion. 4 We also believed that even if exocrine function was lost some hormonal function might be maintained, and that
559 }--:indings in 51 patients undergoing scrotal exploration No. Cases
(%)
27 18 2 1 1 1 1 51
(53) (35) (4)
Torsion of testis Torsion of an appendage Hematocele Acute hydrocele Teratoma of testis Epididymitis Normal testis
6
(<2) (<2) (<2) (<2)
0 TORSIOI~ OF APPENDAGE ii!! TORSION OF TESTIS
5 (f)
~
4
~
3
~
2
w
ci
z
I
4
5
6
7
8
9
10
11
12
13
14
15
16
17
AGE
FIG. 1. Age distribution in torsion of testis and appendages
DURATION OF TORSION 12
•
11
SALVAGE
~ ORCHIECTOMY
10 9 8 (fJ
f--
z 7 w
~ a.:
6
LL
5
0
0
z 4
:IUD
3
I
·"""=====,:,!:
2
0
>24
24
8 TIME IN HOURS
FIG. 2. Duration of torsion in relation to early salvage
even an testis might be of some cosmetic or value to the patient. The of resulted in a diagnosis of torsion in 53 per cent of the patients, an early salvage rate of 81 per cent (22 of 27 cases) and an overall salvage rate of 50 per cent in late followup (8 of 16 cases). We had a delayed atrophy rate of 27 per cent (3 of 11), which is less than that reported by others 5 • 6 but our numbers are small. However, there are other criteria by which salvage may be measured, namely spermatogenesis, hormone production and fertility. These may be more important than preservation of testicular size. Krarup found that 95 per cent of the patients who had testicular torsion had defective spermatogenesis based on an abnormal semen analysis. 5 This finding occurred regardless of whether the testis was salvaged or removed. He hypothesized that patients who suffer from unilateral testicular torsion have bilateral testicular abnormalities that account for the impaired spermatogenesis. Bartsch and associates found abnormal semen analyses as well as increased serum follicle-stimulating hormone and luteinizing hormone in 50 per cent of patients with testicular torsion. 6 They also noted that semen analysis was normal in 3 patients in whom orchiectomy was done for torsion that had lasted >24 hours. In contrast, sperm analysis was abnormal in 4 patients who had torsion for a similar duration but whose testes were salvaged, Bartsch and associates found that late biopsy of the contralateral testis showed hypospermatogenesis in 3 patients whose testes were salvaged, while in l patient who had had an orchiectorny the biopsy of the contralateral testis was normal. These findings suggested that preservation of an ischemic testis in some way damaged the contralateral testis. Harrison and associates, in an experimental study in rats, showed that interruption of the testicular artery destroyed all spermatogenic function and also resulted in considerable damage to the opposite testis. 8 They showed that this damage was caused by an immunological response demonstrated as an increase in cytotoxicity in rat serum, Based on this finding they proposed early removal of an ischemic testis rather than attempts at preservation. Despite these arguments, however, it is not clear whether the abnormalities in spermatogenesis are merely laboratory findings or if they have clinical significance in terms of fertility in humans. Merimsky and associates found that preservation of an ischemic testis reduced fertility in rats. 9 However, in a large series of infertile patients none had a history of testicular torsion, 10 which suggests that abnormalities of spermatogenesis found on semen analysis are not great enough to render a patient infertile. Until long-term foHowup studies of fertility in patients with testicular torsion are undertaken, we believe that the present approach of early surgical exploration and rn·"'Q''"'."' of the testis in all cases is justified, except when there is obvious necrosis.
FOLLOWUP ;,5 MONTHS) OF SALVAGED TESTIS
"
11 CASES
. 50
>-
it
40
~
30
'o'2-
20
0 0::
.
10
0 0
2
4
6
8
12
24
DURATION OF TORSION IN HOURS
FIG. 3. Degree of atrophy in relation to duration of torsion
REFERENCES
1. Flanigan, R. C., DeKernion, J.B. and Persky, L.: Acute scrotal pain and swelling in children: a surgical emergency. Urology, 17: 51, 1981. 2. Brereton, R. J.: Limitations of the Doppler flow meter in the diagnosis of the "acute scrotum" in boys. Brit. J. Urol., 53: 380, 1981. 3. Wasnick, R. J., Pohutsky, K. R. and Macchia, R. J.: Testicular torsion and usefulness ofradionuclide scanning, Urology, 15: 318, 1980. 4. Cass, A. S., Cass, B. P. and Veeraraghavan, K.: Immediate exploration of the unilateral acute scrotum in young male subjects. J. Urol., 124: 829, 1980. 5. Krarup, T.: The testes after torsion. Brit. J. Urol., 50: 43, 1978. 6. Bartsch, G., Frank, St., Marberger, H. and Mikuz, G.: Testicular torsion: late results with special regard to fertility and endocrine function. J. Urol., 124: 375, 1980.
560
SCOTT, HARTY AND HOWERTON
7. Schneider, H. C., Jr., Kendall, A. R. and Karafin, L.: Fluorescence of testicle: an indication of viability of spermatic cord after torsion. Urology, 5: 133, 1975. 8. Harrison, R. G., de Marval, M. J. M., Lewis-Jones, D. I. and Connolly, R. C.: Mechanism of damage to the contralateral testis
in rats with an ischaemic testis. Lancet, 2: 723, 1981. 9. Merimsky, E., Rock, M. and Katz, S.: Assessment of fertility after testicular torsion: an experimental study. Urol. Res., 10: 51, 1982. 10. Amelar, R. D. and Dubin, L.: Male infertility: current diagnosis and treatment. Urology, 1: 1, 1973.