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Color doppler ultrasound in newborn testis torsion
COLOR DOPPLER ULTRASOUND NEWBORN TESTIS TORSION
IN
PATRICK C. CARTWRIGHT, M.D. BRENT W. SNOW, M.D. BARBARA S. REID, M.D. PAULA K. SHULTZ, M.D. From the Divisions of Pediatric Urology and Radiology, University of Utah and Primary Children’s Medical Center, Salt Lake City, Utah
ABSTRACT-Objectives. To assess the usefulness of color Doppler ultrasound in evaluating the newborn with suspected antenatal testis torsion. Methods. Nine newborns with 10 antenatally torsed testes were examined using color Doppler and gray-scale ultrasound. Results. Each examination revealed lack of intratesticular blood flow on the affected side and normal flow within the contralateral testis. In addition, gray-scale sonographic architecture of the affected testes appeared to reflect the duration of in utero torsion. Conclusions. Color Doppler sonography accurately assesses intratesticular blood flow in newborns with antenatal testis torsion and offers interesting details.
Newborn testis torsion was recognized as early as 1897.l The entity is probably most accurately termed “perinatal torsion,” because the event may occur either antenatally or postnatally, the former being much more common.2 There is a modest amount of literature concerning ultrasound evaluation of testicular ischemia or torsion in older children or adults.3-9 Certainly, color Doppler sonography has proven to be helpful in these circumstances. Middleton and associates’ have shown impressive results in men, with sensitivity and specificity equaling or exceeding radionuclide scintigraphy. There is much less reported experience utilizing this technology in the evaluation of newborns.1o-14 This report describes our experience with color Doppler ultrasound in assessing newborns with suspected antenatal testis torsion. MATERIAL AND METHODS During a 4-year period, 9 newborns were evaluated for suspected torsion of the testis. All were evaluated at birth by a pediatrician or the delivering obstetrician and a scrotal mass or swelling was noted. They were assessedby a pediatric urologist at less than 24 hours following delivery. In 8 paSubmitted: December January 9,1995
19, 1994, accepted (with
UROLOGY@ /APRIL 1995 J VOLUME 45,
NUMBER
4
revisions):
tients, unilateral testis torsion was the clinical diagnosis, whereas in the remaining patient bilateral torsion was suspected. Each patient underwent immediate ultrasound assessmentof scrotal contents. Real-time testicular ultrasonography was performed using a 7.5 MHz linear transducer on an Acuson 128 (Acuson, Mountain View, Calif) or an Ultramark 9 with a 7.5 MHz sector scanner. Doppler imaging was performed utilizing a 5 MHz phased-array transducer (ATL, Bother, Wash). Longitudinal and transverse images of each testis were obtained along with a transverse image to include both testes. Color Doppler imaging was performed usually along the medial longitudinal plane, although coronal and transverse planes were also scanned when necessary. Color Doppler settings were optimized for detection of low flow. In the infant or child testis, a demonstrable arterial branching pattern is not usually identified. The capsular artery is also difficult to identify as it wraps around the testicle. The Doppler waveform in the normal testis shows a low resistance pattern with high levels of diastolic flow. In the infant and child, there is no identifiable flow in the normal epididymis. RESULTS In all patients, there was a dusky or deep red discoloration of the affected hemiscrotum. In each 667
FIGURE 1. (A) Enlarged, antenatally torsed testis showing mixed echogenicity and little or no peripheral hyperechoic ring. [B) Antenatally torsed testis with marked hyperechoic ring and diffusely hypoechoic parenchyma. (C) Ultrasound at age 12 hours: testis fixed, enlarged, and hard. Mixed parenchymal echogenicity (contralateral hydrocele]. (0) Same patient as in Figure 1 C at age 5 weeks: testis smaller, less fixed to skin, more hypoechoic internally with a modest echogenic encompassing ring.
case, the torsed testis was diffusely hard and smooth to palpation. In 4 cases, the testis was enlarged, being two to three times larger than its normal mate. In these 4 patients, edema and erythema were pronounced, with distinct fixation to the overlying skin. In the remaining 6 (including the bilateral case), the testis was only slightly larger than the contralateral testis. These cases demonstrated less scrotal edema and minimal fixation of the testis to overlying skin. Intratesticular flow was absent by color Doppler on the affected side in all 8 unilateral cases. The contralateral testis in each of these cases displayed normal flow. The case of bilateral torsion demonstrated no flow within either testis. On gray-scale sonography, two distinct echo texture patterns were observed. The larger testes 668
demonstrated mixed echogenicity of the testicular parenchyma; certain areas were distinctly hypoechoic, whereas others were hyperechoic, showing areas of probable calcification (Fig. 1A) The six minimally enlarged testes demonstrated a more confluent hypoechoic echo pattern and an impressive encompassing hyperechoic ring corresponding to the tunica albuginea of the testis (Fig. 1B). The patient with bilateral torsion had modestly enlarged (2.1 X 2.1 X 1.5 cm and 2.0 X 1.5 X 1.3 cm), firm testes with ultrasound demonstrating hypoechoic parenchyma and partial hyperechoic rings. He underwent immediate exploration, and the testes were found to be torsed extravaginally. There appeared to be long-standing necrosis and no change was seen on detorsion. Pathologically, both testes displayed extensive hemorrhagic UROLOGY@ /APRIL 1995 I VOLUME 45, NUMBER 4
necrosis. Calcification of the tunica albuginea was noted in many areas, with further calcium deposits noted within the ducts of the epididymis. Little calcification was found within the necrotic parenchyma of either testis. The remaining patients did not undergo exploration. Clinical follow-up ranges from 4 months to 4 years. Consistent with the diagnosis of torsion, all testes have atrophied, with all but two becoming impalpable. These two are 3-mm fibrotic calcified remnants. Contralateral testes have continued to be normal on examination, although several are large for age. Two of the patients presenting with an enlarged testis (two to three times normal size) have undergone follow-up color Doppler ultrasound. In both cases, the original heterogeneous internal echo pattern has become more homogeneously hypoechoic and a hyperechoic ring around the testis has developed (Fig. 1C and 1D). COMMENT The role of color Doppler ultrasound in assessing testicular torsion and ischemia continues to be defined. In adults and older children, initial reports indicate that color Doppler assessment can define both anatomy and blood flow within testes accurately.3-9 This report documents that color Doppler ultrasound was accurate assessing testicular flow in 9 of 9 newborns with testis torsion as well. This is compatible with the few scattered cases in the literature involving newboms.lO-l3 The technical key is to optimize color Doppler settings to detect low flow and to be certain that intratesticular flow is detected and not flow within extracapsular vessels, epididymis, or surrounding structures. It seems probable that the gray-scale sonographic appearance of these testes relates to the in utero duration of the torsion. This may be the defining element of the two groups observed in this study. Torsion occurring late in gestation (shortly before birth) would likely result in an acutely inflamed scrotum, an enlarged testis, and edema, erythema, and fixation of the overlying skin. Such a testis, undergoing early necrotic changes, would be expected to show mixed internal echoes and minimal dystrophy calcification. This describes four of the testes in this series. In distinction, testes torsed earlier in gestation, having undergone more extensive necrotic change and parenchymal liquefaction, would likely demonstrate a more homogeneous echo pattern. Dystrophic calcium deposits should be more common. In our 6 cases, calcification seemed to occur preferentially in the tunica albuginea, accounting for the characteristic encir-
UROLOGY@ IAPRIL~~~~IVOLLJME~~,
NUMBER
4
cling hyperechoic ring. This observation was reported by Brown and associates” as well. Support for this idea is seen in images of Figure 1C and 1D. The initial image was made at birth with the follow-up at 5 weeks of age, demonstrating decreased size, more homogeneous parenchymal echo texture, and an encompassing echogenic ring. Thus, it is our supposition that duration of torsion determines sonographic architecture. Color Doppler sonography of the newborn testis may assist in the differential diagnosis of newborn scrotal masses. Such a differential includes hydrocele, hernia, hematocele, hematoma, teratoma (and other testis tumors), torsion, meconium deposit, ectopic spleen, and various other rare anomalies.15 The management of newborns with testis torsion remains controversial.i6 Based on the lack of reported testicular salvage in the setting of antenatal torsion, we have generally chosen no early exploration but close observation of the contralateral testis for signs of torsion during the first 2 weeks of life. Many cases of antenatal torsion may be diagnosed on clinical examination alone, whereas others will present a diagnostic dilemma. In such cases, sonography may prove valuable in assessing blood flow, parenchymal character, and surrounding structures. In addition, a newborn may be seen who has already undergone sonographic assessment of a scrotal swelling and the results of the study accompany him for interpretation. In such circumstances, the findings of this study should prove helpful for comparison. Patrick C. Cartwright, Primary Children’s Medical IO0 N. Medical Drive, Salt Lake City, UT
M.D. Center #22&I 84113
REFERENCES 1. Taylor MR: A case of testicle strangulated at birth; castration; recovery. Br Med J 1: 458, 1897. 2. Das S, and Singer A: Controversies of perinatal torsion of the spermatic cord: a review, survey and recommendations. J Urol 143: 231-233, 1990. 3. Burks DD, Markey BJ, Burkhard TK, Balsara ZN, Haluszka MM, and Canning DA: Suspected testicular torsion and ischemia: evaluation with color Doppler sonography. Radiology 175: 815-821, 1990. 4. Dewire DM, Begun FP, Lawson RK, Fitzgerald S, and Foley WD: Color Doppler ultrasonography in the evaluation of the acute scrotum. J Urol 147: 89-91, 1992. 5. Hricak H, Lue T, Filly RA, Alpers CE, Zeineh SJ, and Tanagho EA: Experimental study of the sonographic diagnosis of testicular torsion. J Ultrasound Med 2: 349-356, 1983. 6. Middleton WD, Thorne DA, and Melson GL: Color Doppler ultrasound of the normal testis. AJR Am J Roentgen01 152: 293-297, 1989.
669
7. Horstman WG, Middleton WD, and Melson GL: Scrotal inflammatory disease: color Doppler US findings. Radiology 179: 55-59, 1991. 8. Lemer RM, Mevorach RA, Hulbert WC, and Rabinowitz R: Color Doppler US in the evaluation of acute scrotal disease. Radiology 176: 355-358, 1990. 9. Middleton WD, Siegel BA, Melson GL, Yates CK, and Andriole GL: Acute scrotal disorders: prospective comparison of color Doppler US and testicular scintigraphy. Radiology 177: 177-181, 1990. 10. Mueller DL, Amundson GM, Rugin SZ, and Wesenberg RL: Acute scrotal abnormalities in children: diagnosis by combined sonography and scintigraphy. AJR Am J Roentgen01 150: 643-646, 1988. 11. Brown SM, Casillas VJ, Montalvo BM, and AlboresSaavedra J: Intrauterine spermatic cord torsion in the newborn: sonographic and pathologic correlation. Radiology 177: 755-757, 1990.
670
12. Atkinson GO Jr, Patrick LE, Ball TI Jr, Stephenson CA, Broecker BH, and Woodard JR: The normal and abnormal scrotum in children: evaluation with color Doppler sonography. AJR Am J Roentgen01 158: 613-617, 1992. 13. Patriquin HB, Yazbeck S, Trinh B, Jequier S, Burns PN, Grignon A, Filiatrault D, Garel L, and Dubois J: Testicular torsion in infants and children: diagnosis with Doppler sonography. Radiology 188: 781, 1993. 14. Luker GD, and Siegel MJ: Color Doppler sonography of the scrotum in children. AJR Am J Roentgen01 163: 649-655, 1994. 15. Kogan SJ: Acute and chronic scrotal swellings, in Gillenwater JY, Grayhack JT, Howards SS, and Duckett JW (Eds): Adult and Pediatric Urology, 2nd ed. St. Louis, MosbyYear Book, 1991. 16. Brandt MT, Sheldon CA, Wacksman J, and Matthews P: Prenatal testicular torsion: principles of management. J Urol 147: 670-672, 1992.
UROLOGY@ /APRIL 1995 I VOLUME 45, NUMBER 4
IN
PATRICK C. CARTWRIGHT, M.D. BRENT W. SNOW, M.D. BARBARA S. REID, M.D. PAULA K. SHULTZ, M.D. From the Divisions of Pediatric Urology and Radiology, University of Utah and Primary Children’s Medical Center, Salt Lake City, Utah
ABSTRACT-Objectives. To assess the usefulness of color Doppler ultrasound in evaluating the newborn with suspected antenatal testis torsion. Methods. Nine newborns with 10 antenatally torsed testes were examined using color Doppler and gray-scale ultrasound. Results. Each examination revealed lack of intratesticular blood flow on the affected side and normal flow within the contralateral testis. In addition, gray-scale sonographic architecture of the affected testes appeared to reflect the duration of in utero torsion. Conclusions. Color Doppler sonography accurately assesses intratesticular blood flow in newborns with antenatal testis torsion and offers interesting details.
Newborn testis torsion was recognized as early as 1897.l The entity is probably most accurately termed “perinatal torsion,” because the event may occur either antenatally or postnatally, the former being much more common.2 There is a modest amount of literature concerning ultrasound evaluation of testicular ischemia or torsion in older children or adults.3-9 Certainly, color Doppler sonography has proven to be helpful in these circumstances. Middleton and associates’ have shown impressive results in men, with sensitivity and specificity equaling or exceeding radionuclide scintigraphy. There is much less reported experience utilizing this technology in the evaluation of newborns.1o-14 This report describes our experience with color Doppler ultrasound in assessing newborns with suspected antenatal testis torsion. MATERIAL AND METHODS During a 4-year period, 9 newborns were evaluated for suspected torsion of the testis. All were evaluated at birth by a pediatrician or the delivering obstetrician and a scrotal mass or swelling was noted. They were assessedby a pediatric urologist at less than 24 hours following delivery. In 8 paSubmitted: December January 9,1995
19, 1994, accepted (with
UROLOGY@ /APRIL 1995 J VOLUME 45,
NUMBER
4
revisions):
tients, unilateral testis torsion was the clinical diagnosis, whereas in the remaining patient bilateral torsion was suspected. Each patient underwent immediate ultrasound assessmentof scrotal contents. Real-time testicular ultrasonography was performed using a 7.5 MHz linear transducer on an Acuson 128 (Acuson, Mountain View, Calif) or an Ultramark 9 with a 7.5 MHz sector scanner. Doppler imaging was performed utilizing a 5 MHz phased-array transducer (ATL, Bother, Wash). Longitudinal and transverse images of each testis were obtained along with a transverse image to include both testes. Color Doppler imaging was performed usually along the medial longitudinal plane, although coronal and transverse planes were also scanned when necessary. Color Doppler settings were optimized for detection of low flow. In the infant or child testis, a demonstrable arterial branching pattern is not usually identified. The capsular artery is also difficult to identify as it wraps around the testicle. The Doppler waveform in the normal testis shows a low resistance pattern with high levels of diastolic flow. In the infant and child, there is no identifiable flow in the normal epididymis. RESULTS In all patients, there was a dusky or deep red discoloration of the affected hemiscrotum. In each 667
FIGURE 1. (A) Enlarged, antenatally torsed testis showing mixed echogenicity and little or no peripheral hyperechoic ring. [B) Antenatally torsed testis with marked hyperechoic ring and diffusely hypoechoic parenchyma. (C) Ultrasound at age 12 hours: testis fixed, enlarged, and hard. Mixed parenchymal echogenicity (contralateral hydrocele]. (0) Same patient as in Figure 1 C at age 5 weeks: testis smaller, less fixed to skin, more hypoechoic internally with a modest echogenic encompassing ring.
case, the torsed testis was diffusely hard and smooth to palpation. In 4 cases, the testis was enlarged, being two to three times larger than its normal mate. In these 4 patients, edema and erythema were pronounced, with distinct fixation to the overlying skin. In the remaining 6 (including the bilateral case), the testis was only slightly larger than the contralateral testis. These cases demonstrated less scrotal edema and minimal fixation of the testis to overlying skin. Intratesticular flow was absent by color Doppler on the affected side in all 8 unilateral cases. The contralateral testis in each of these cases displayed normal flow. The case of bilateral torsion demonstrated no flow within either testis. On gray-scale sonography, two distinct echo texture patterns were observed. The larger testes 668
demonstrated mixed echogenicity of the testicular parenchyma; certain areas were distinctly hypoechoic, whereas others were hyperechoic, showing areas of probable calcification (Fig. 1A) The six minimally enlarged testes demonstrated a more confluent hypoechoic echo pattern and an impressive encompassing hyperechoic ring corresponding to the tunica albuginea of the testis (Fig. 1B). The patient with bilateral torsion had modestly enlarged (2.1 X 2.1 X 1.5 cm and 2.0 X 1.5 X 1.3 cm), firm testes with ultrasound demonstrating hypoechoic parenchyma and partial hyperechoic rings. He underwent immediate exploration, and the testes were found to be torsed extravaginally. There appeared to be long-standing necrosis and no change was seen on detorsion. Pathologically, both testes displayed extensive hemorrhagic UROLOGY@ /APRIL 1995 I VOLUME 45, NUMBER 4
necrosis. Calcification of the tunica albuginea was noted in many areas, with further calcium deposits noted within the ducts of the epididymis. Little calcification was found within the necrotic parenchyma of either testis. The remaining patients did not undergo exploration. Clinical follow-up ranges from 4 months to 4 years. Consistent with the diagnosis of torsion, all testes have atrophied, with all but two becoming impalpable. These two are 3-mm fibrotic calcified remnants. Contralateral testes have continued to be normal on examination, although several are large for age. Two of the patients presenting with an enlarged testis (two to three times normal size) have undergone follow-up color Doppler ultrasound. In both cases, the original heterogeneous internal echo pattern has become more homogeneously hypoechoic and a hyperechoic ring around the testis has developed (Fig. 1C and 1D). COMMENT The role of color Doppler ultrasound in assessing testicular torsion and ischemia continues to be defined. In adults and older children, initial reports indicate that color Doppler assessment can define both anatomy and blood flow within testes accurately.3-9 This report documents that color Doppler ultrasound was accurate assessing testicular flow in 9 of 9 newborns with testis torsion as well. This is compatible with the few scattered cases in the literature involving newboms.lO-l3 The technical key is to optimize color Doppler settings to detect low flow and to be certain that intratesticular flow is detected and not flow within extracapsular vessels, epididymis, or surrounding structures. It seems probable that the gray-scale sonographic appearance of these testes relates to the in utero duration of the torsion. This may be the defining element of the two groups observed in this study. Torsion occurring late in gestation (shortly before birth) would likely result in an acutely inflamed scrotum, an enlarged testis, and edema, erythema, and fixation of the overlying skin. Such a testis, undergoing early necrotic changes, would be expected to show mixed internal echoes and minimal dystrophy calcification. This describes four of the testes in this series. In distinction, testes torsed earlier in gestation, having undergone more extensive necrotic change and parenchymal liquefaction, would likely demonstrate a more homogeneous echo pattern. Dystrophic calcium deposits should be more common. In our 6 cases, calcification seemed to occur preferentially in the tunica albuginea, accounting for the characteristic encir-
UROLOGY@ IAPRIL~~~~IVOLLJME~~,
NUMBER
4
cling hyperechoic ring. This observation was reported by Brown and associates” as well. Support for this idea is seen in images of Figure 1C and 1D. The initial image was made at birth with the follow-up at 5 weeks of age, demonstrating decreased size, more homogeneous parenchymal echo texture, and an encompassing echogenic ring. Thus, it is our supposition that duration of torsion determines sonographic architecture. Color Doppler sonography of the newborn testis may assist in the differential diagnosis of newborn scrotal masses. Such a differential includes hydrocele, hernia, hematocele, hematoma, teratoma (and other testis tumors), torsion, meconium deposit, ectopic spleen, and various other rare anomalies.15 The management of newborns with testis torsion remains controversial.i6 Based on the lack of reported testicular salvage in the setting of antenatal torsion, we have generally chosen no early exploration but close observation of the contralateral testis for signs of torsion during the first 2 weeks of life. Many cases of antenatal torsion may be diagnosed on clinical examination alone, whereas others will present a diagnostic dilemma. In such cases, sonography may prove valuable in assessing blood flow, parenchymal character, and surrounding structures. In addition, a newborn may be seen who has already undergone sonographic assessment of a scrotal swelling and the results of the study accompany him for interpretation. In such circumstances, the findings of this study should prove helpful for comparison. Patrick C. Cartwright, Primary Children’s Medical IO0 N. Medical Drive, Salt Lake City, UT
M.D. Center #22&I 84113
REFERENCES 1. Taylor MR: A case of testicle strangulated at birth; castration; recovery. Br Med J 1: 458, 1897. 2. Das S, and Singer A: Controversies of perinatal torsion of the spermatic cord: a review, survey and recommendations. J Urol 143: 231-233, 1990. 3. Burks DD, Markey BJ, Burkhard TK, Balsara ZN, Haluszka MM, and Canning DA: Suspected testicular torsion and ischemia: evaluation with color Doppler sonography. Radiology 175: 815-821, 1990. 4. Dewire DM, Begun FP, Lawson RK, Fitzgerald S, and Foley WD: Color Doppler ultrasonography in the evaluation of the acute scrotum. J Urol 147: 89-91, 1992. 5. Hricak H, Lue T, Filly RA, Alpers CE, Zeineh SJ, and Tanagho EA: Experimental study of the sonographic diagnosis of testicular torsion. J Ultrasound Med 2: 349-356, 1983. 6. Middleton WD, Thorne DA, and Melson GL: Color Doppler ultrasound of the normal testis. AJR Am J Roentgen01 152: 293-297, 1989.
669
7. Horstman WG, Middleton WD, and Melson GL: Scrotal inflammatory disease: color Doppler US findings. Radiology 179: 55-59, 1991. 8. Lemer RM, Mevorach RA, Hulbert WC, and Rabinowitz R: Color Doppler US in the evaluation of acute scrotal disease. Radiology 176: 355-358, 1990. 9. Middleton WD, Siegel BA, Melson GL, Yates CK, and Andriole GL: Acute scrotal disorders: prospective comparison of color Doppler US and testicular scintigraphy. Radiology 177: 177-181, 1990. 10. Mueller DL, Amundson GM, Rugin SZ, and Wesenberg RL: Acute scrotal abnormalities in children: diagnosis by combined sonography and scintigraphy. AJR Am J Roentgen01 150: 643-646, 1988. 11. Brown SM, Casillas VJ, Montalvo BM, and AlboresSaavedra J: Intrauterine spermatic cord torsion in the newborn: sonographic and pathologic correlation. Radiology 177: 755-757, 1990.
670
12. Atkinson GO Jr, Patrick LE, Ball TI Jr, Stephenson CA, Broecker BH, and Woodard JR: The normal and abnormal scrotum in children: evaluation with color Doppler sonography. AJR Am J Roentgen01 158: 613-617, 1992. 13. Patriquin HB, Yazbeck S, Trinh B, Jequier S, Burns PN, Grignon A, Filiatrault D, Garel L, and Dubois J: Testicular torsion in infants and children: diagnosis with Doppler sonography. Radiology 188: 781, 1993. 14. Luker GD, and Siegel MJ: Color Doppler sonography of the scrotum in children. AJR Am J Roentgen01 163: 649-655, 1994. 15. Kogan SJ: Acute and chronic scrotal swellings, in Gillenwater JY, Grayhack JT, Howards SS, and Duckett JW (Eds): Adult and Pediatric Urology, 2nd ed. St. Louis, MosbyYear Book, 1991. 16. Brandt MT, Sheldon CA, Wacksman J, and Matthews P: Prenatal testicular torsion: principles of management. J Urol 147: 670-672, 1992.
UROLOGY@ /APRIL 1995 I VOLUME 45, NUMBER 4