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Testicular Torsion and Infarction in the Newborn
THE JOURNAL OF UROLOGY
Vol. 85, No. 1, January 1961 Printed in U.S.A.
TESTICULAR TORSION AND INFARCTION IN THE NEWBORN CARL G. PETERSON, JR.* Frain the Los Angeles County Harbor General Hospital, Torrance, Cal. and the University o.f California Medical Center, Los Angeles, Cal.
Available reports concerning torsion and infarction of testes in the newborn reveal but 55 cases since M. R. Taylor recorded the first in 1897. 1 - 29 It would appear that the majority of Accepted for publication May 5, 1960. The contents of this paper reflect the author's personal views and are not to be construed as a statement of official Air Force policy. * Capt. USAF(MC). USAF sponsored Resident in Urology, Harbor General Hospital and University of California Medical Center, Los Angeles, Cal. 1 Abeshouse, B. S.: Torsion of the spermatic cord, report of three cases and review of the literature. Urol. & Cutan. Rev., 40: 688, 1936. 2 Begg, R. C.: Torsion of testis occurring during or immediately after birth. Brit. J. Med., 2: 843, 1921. 3 Biorn, C. L. and Davis, J. R.: Torsion of the spermatic cord in the newborn. J.A.M.A., 145: 1236, 1951. 4 Campbell, M. F.: Torsion of the spermatic cord in the newborn infant. J. Pediat., 33: 323, 1948. 5 Campbell, M. F.: Urology. Philadelphia: W. B. Saunders Co., 1954. 6 Carson, R. B.: Torsion of the spermatic cord. South. Med. J., 46: 909, 1953. 7 Ewert, E. E. and Hoffman, H. A.: Torsion of the spermatic cord. J. Urol., 51: 551, 1944. 8 Fernicola, A. K.: Idiopathic hemorrhagic infarction of the testicle in the newborn. J. Urol., 72: 230, 1954. 9 Franzblau, A. H.: Torsion of the spermatic cord in the newborn. J. Dis. Child., 92: 179, 1956. 10 Glaser, S. and Wallis, H. R. E.: Torsion or spontaneous hemorrhagic infarction of testicle in the newborn infant. Brit. Med. J., 2: 88, 1952. 11 Hogan, J. F., Jr,: Idiopathic hemorrhagic infarction of the testis in the newborn. Maryland State Med. J., 8: 58, 1959. 12 Golden, J. L. and Hamilton, H. H.: Strangulated inguinal hernia with unusual complications in infants of five weeks, report of cases. New Eng. J. Med., 210: 857, 1934. 13 James, T.: Torsion of the spermatic cord in the first year of life. Brit. J. Urol., 25: 56, 1953. 14 Longino, L. A. and Martin, L. W.: Torsion of the spermatic cord in the newborn infant. New Eng. J. Med., 253: 695, 1955. 15 lVIaclean, J. T.: Hemorrhagic infarct of the testicle in the newborn. 8mg. Gynec. & Obst., 76: 319, 1943. 16 Nash, W. G.: Torsion of the testis in an infant. Brit. Med. J., 1: 267, 1921. 17 Nowland, R. E.: Med. J. Australia, 2: 51, 1926. "Pinto, P. S. and Kiefer, J. N.: Infarction of the testicle in the newborn infant. J. Pediat., 51: 80-84, 1957.
cases have been published in the past two decades. These include idiopathic infarction as well as true torsion of tbe spermatic cord. Authors were generally careful, however, not to include cases in which the etiology might have been trauma.. This fact, along with the acceptance of trauma as an initiating factor in torsion, raises the question of accuracy in the incidence noted above. One might suspect it to be much less of a rarity than suggested by the literature. The age of onset varied from prenatal status to 2~~ months. Average age of detection was one or two weeks, yet 22 of the cases were noted at birth and 10 during the first day of life, thus accounting for 60 per cent of those so far reported. No significant lateralization was noted and only one infant had bilateral infarction (Campbell). Pathologically the involved testis is often grossly dark blue, smooth, firm to stony hard and enlarged several times normal size. Microscopic examination reveals hemorrhagic infarc19 Ravich, R.: Hemorrhagic infarction of the testicle in the newborn infant. J. Urol., 57: 875, 1947. 20 Rhyne, J. L. and associates: Hemorrhagic infarction of testis in newborn. J. Dis. Child., 89: 240, 1955. 21 Rosenblatt, M. S. and Bueermann, VY. H.: Strangulated hernia with acute hemorrhagic infarction of the testicle in infants. Northwest Med., 38: 18, 1939. 22 Scott, W.W.: In Year Book of Urology, footnote p. 308, 1958-,59 series. Chicago: Year Book Publishers. 23 Sloman, J. G. and Mylius, R. E.: Testicular infarction in infancy: association with irreducible inguinal hernia. :Med. J. Australia, 1: 242, 1958. 24 Smith, A. M. and Riese, K.: Infarction of the testis in the newborn. Conn. State Med. J., 22: 180, 1958. 25 Tankin, L. H. and Robbins, JVI. A.: Henrnrrhagic infarct of the testis in the newborn. J. Urol., 79: 119, 1958. 2 6 Taylor, ::VI. R.: A case of testis strangulated at birth. Brit. Med. J., 1: 458, 1897. 28 Thiel, S. W.: Prenatal testicular infarction. Ill. Med. J., 109: 255, 1956. 28 Wheeler, J. S. and Clark, F. B.: Torsion of the spermatic cord. New Eng. J- Med., 247: 973, 1952. 29 Winstead, A. G.: Infarction of the testicle . .J. Urol., 69: 830, 19,53.
65
66
CARL G. PETERSON, JR.
tion. There may be partial to complete replacement of the tubules with blood. Usually there is no infection, so dry gangrene and atrophy occur eventually. It is of note that torsion is usually extravaginal (tunica vaginalis) and involves the whole testis and surrounding fascia! layers. This is in contradistinction to the intravaginal torsion ordinarily found in the youth or adult. Another difference from the older child is an apparent lack of symptoms in the newborn, who presents ·with only the signs of a very hard, markedly enlarged, non-transilluminating scrotal mass. The overlying skin may be discolored and adherent. Differential diagnosis must include neoplasm of the testis, strangulated inguinal hernia, scrotal hematoma, torsion of the appendix testis, hydrocele of the tunica vaginalis, and perhaps gumma of the testis. Treatment is usually surgical exploration. Most of the reported cases underwent orchiectomy. Some authors report leaving noninfected testes in the scrotum without complications. Longino states that two of seven infarcted testes thus treated have not developed significant atrophy, and he hopes to have preserved some hormonal function. Such extensive destruction was present in cases in the literature where changes were recorded and also in our case that we doubt whether any function, either spermatogenic or endocrine, could remam.
child didn't void during his first 24 hours of life. Pregnancy had been uneventful, the mother took no hormone therapy, and the delivery was a normal spontaneous atraumatic vertex. Examination revealed a 2 by 3 cm. hard, nodular, midline scrotal mass which was nontender and did not transilluminate. The penis though present was retracted beneath subcutaneous tissues pulled over it by distortion due to the presence of the scrotal mass. The mass was believed adherent to the bulbous urethra. A normal right testis was found at its external inguinal ring. The left testis was not found as such. No hernia was present and the mass was obviously not reducible. The patient finally voided and continued to void normally. He remained afebrile, but had a postnatal leukocytosis of 35,000. Urinalysis, blood urea nitrogen, and intravenous pyelographic studies were normal except for apparent calcifications in the scrotal mass. On the fifth day of life, scrotal exploration was performed; the preoperative diagnosis was probable teratoma of the testis. The cord was approached via a high left scrotal incision. The ves-
CASE REPORT
A full term l\!Ie;,.ican boy was noted at birth to have an enlarged scrotum and "retracted" penis (fig. 1). The urologist was called when the
FIG. 1. Scrotal mass with hyperpigmentation
of overlying skin
FIG. 2. A, testicular mass with clamp on cord above partial torsion. B, gross appearance of hemorrhagic infarct of testis.
67
TESTICULAR TORSION
I
Fw. 3. Microscopic section of testis (X 125) shows replacement of normal architecture with blood
sels of the cord first were identified, occluded with a rubbershod clamp, and then the dissection extended down over the mass (fig. 2, A_) A partial torsion of the spermatic cord was found extravaginally. It was necessary to rcmm-e an ellipse of adherent overlying skin, but the mass separated from the urethra without fistulous communication being found. The testicular mass measuring 3 by 2 by 2 cm. was removed with its cord and prepared for frozen section (fig. 2, B). The calcifications seen on x-ray examination were visible on the gross specimen. An orchiopexy of the testis was performed in the right scrotum, the incision closrd with drainage and a pressure dressing applied. The diagnosis of hemorrhagic infarct of the testis was confirmed by permanent sections (fig. 3). The postoperative course was uncomplicated except for slightly delayed healing of the rather large scrotal wound. DISCUSSION
This case is of interest because of the infrequency of the disease entity involved and the following differences from previously reported
cases: nodularity, fixation to urethra, midline position, and the presence of calcifications. Another case in this area has been brought to our attention 30 and is of interest in that after removal of the involved testis, an orchiopexy was performed on the remaining testicle without removing the tunica vaginalis. Subsequent swelling, tenderness, and inflammation dictated re-exploration revealing communicating hydrocele or patent processus vaginalis. This may well be kept in mrnd when performing such an orchiopexy. SUMMARY
A case of testicular infarct in the newborn has been presented with a rcvie\v of the literature. The incidence is probably greater than these 55 cases would suggest. Etiology is either torsion of the spermatic cord or undetermined. The clinicopathological picture is that of an afebrilc, asymptomatic infant with a dark, firm scrotal mass which is usually three or more times the size of so Kaufman, J.: Personal cornmunication.
68
CARL G. PETERSON, JR.
the normal testis. The mass does not transilluminate and the overlying hyperpigmented skin is often adherent to it. This last may accrue because the torsion is commonly external to the tunica vaginalis with involvement of the testis and surrounding tissues as well. This is in contradistinction to the usual intravaginal torsion found in juveniles and adults. An hemorrhagic type of infarction is found with more or less complete replacement of the tubules with blood. This is probably due to the torsion occluding the
venous return but not the arterial supply of the testis initially. Treatment is surgical with extirpation of the involved testis, and orchiopexy of the remaining testis either promptly or within a sensible period of time. The author wishes to thank Milo Ellik, M.D. for interest and guidance in the care of this case. Department of Urology 823rd Medical Group (SAC) Homestead A.F.B., Florida
Vol. 85, No. 1, January 1961 Printed in U.S.A.
TESTICULAR TORSION AND INFARCTION IN THE NEWBORN CARL G. PETERSON, JR.* Frain the Los Angeles County Harbor General Hospital, Torrance, Cal. and the University o.f California Medical Center, Los Angeles, Cal.
Available reports concerning torsion and infarction of testes in the newborn reveal but 55 cases since M. R. Taylor recorded the first in 1897. 1 - 29 It would appear that the majority of Accepted for publication May 5, 1960. The contents of this paper reflect the author's personal views and are not to be construed as a statement of official Air Force policy. * Capt. USAF(MC). USAF sponsored Resident in Urology, Harbor General Hospital and University of California Medical Center, Los Angeles, Cal. 1 Abeshouse, B. S.: Torsion of the spermatic cord, report of three cases and review of the literature. Urol. & Cutan. Rev., 40: 688, 1936. 2 Begg, R. C.: Torsion of testis occurring during or immediately after birth. Brit. J. Med., 2: 843, 1921. 3 Biorn, C. L. and Davis, J. R.: Torsion of the spermatic cord in the newborn. J.A.M.A., 145: 1236, 1951. 4 Campbell, M. F.: Torsion of the spermatic cord in the newborn infant. J. Pediat., 33: 323, 1948. 5 Campbell, M. F.: Urology. Philadelphia: W. B. Saunders Co., 1954. 6 Carson, R. B.: Torsion of the spermatic cord. South. Med. J., 46: 909, 1953. 7 Ewert, E. E. and Hoffman, H. A.: Torsion of the spermatic cord. J. Urol., 51: 551, 1944. 8 Fernicola, A. K.: Idiopathic hemorrhagic infarction of the testicle in the newborn. J. Urol., 72: 230, 1954. 9 Franzblau, A. H.: Torsion of the spermatic cord in the newborn. J. Dis. Child., 92: 179, 1956. 10 Glaser, S. and Wallis, H. R. E.: Torsion or spontaneous hemorrhagic infarction of testicle in the newborn infant. Brit. Med. J., 2: 88, 1952. 11 Hogan, J. F., Jr,: Idiopathic hemorrhagic infarction of the testis in the newborn. Maryland State Med. J., 8: 58, 1959. 12 Golden, J. L. and Hamilton, H. H.: Strangulated inguinal hernia with unusual complications in infants of five weeks, report of cases. New Eng. J. Med., 210: 857, 1934. 13 James, T.: Torsion of the spermatic cord in the first year of life. Brit. J. Urol., 25: 56, 1953. 14 Longino, L. A. and Martin, L. W.: Torsion of the spermatic cord in the newborn infant. New Eng. J. Med., 253: 695, 1955. 15 lVIaclean, J. T.: Hemorrhagic infarct of the testicle in the newborn. 8mg. Gynec. & Obst., 76: 319, 1943. 16 Nash, W. G.: Torsion of the testis in an infant. Brit. Med. J., 1: 267, 1921. 17 Nowland, R. E.: Med. J. Australia, 2: 51, 1926. "Pinto, P. S. and Kiefer, J. N.: Infarction of the testicle in the newborn infant. J. Pediat., 51: 80-84, 1957.
cases have been published in the past two decades. These include idiopathic infarction as well as true torsion of tbe spermatic cord. Authors were generally careful, however, not to include cases in which the etiology might have been trauma.. This fact, along with the acceptance of trauma as an initiating factor in torsion, raises the question of accuracy in the incidence noted above. One might suspect it to be much less of a rarity than suggested by the literature. The age of onset varied from prenatal status to 2~~ months. Average age of detection was one or two weeks, yet 22 of the cases were noted at birth and 10 during the first day of life, thus accounting for 60 per cent of those so far reported. No significant lateralization was noted and only one infant had bilateral infarction (Campbell). Pathologically the involved testis is often grossly dark blue, smooth, firm to stony hard and enlarged several times normal size. Microscopic examination reveals hemorrhagic infarc19 Ravich, R.: Hemorrhagic infarction of the testicle in the newborn infant. J. Urol., 57: 875, 1947. 20 Rhyne, J. L. and associates: Hemorrhagic infarction of testis in newborn. J. Dis. Child., 89: 240, 1955. 21 Rosenblatt, M. S. and Bueermann, VY. H.: Strangulated hernia with acute hemorrhagic infarction of the testicle in infants. Northwest Med., 38: 18, 1939. 22 Scott, W.W.: In Year Book of Urology, footnote p. 308, 1958-,59 series. Chicago: Year Book Publishers. 23 Sloman, J. G. and Mylius, R. E.: Testicular infarction in infancy: association with irreducible inguinal hernia. :Med. J. Australia, 1: 242, 1958. 24 Smith, A. M. and Riese, K.: Infarction of the testis in the newborn. Conn. State Med. J., 22: 180, 1958. 25 Tankin, L. H. and Robbins, JVI. A.: Henrnrrhagic infarct of the testis in the newborn. J. Urol., 79: 119, 1958. 2 6 Taylor, ::VI. R.: A case of testis strangulated at birth. Brit. Med. J., 1: 458, 1897. 28 Thiel, S. W.: Prenatal testicular infarction. Ill. Med. J., 109: 255, 1956. 28 Wheeler, J. S. and Clark, F. B.: Torsion of the spermatic cord. New Eng. J- Med., 247: 973, 1952. 29 Winstead, A. G.: Infarction of the testicle . .J. Urol., 69: 830, 19,53.
65
66
CARL G. PETERSON, JR.
tion. There may be partial to complete replacement of the tubules with blood. Usually there is no infection, so dry gangrene and atrophy occur eventually. It is of note that torsion is usually extravaginal (tunica vaginalis) and involves the whole testis and surrounding fascia! layers. This is in contradistinction to the intravaginal torsion ordinarily found in the youth or adult. Another difference from the older child is an apparent lack of symptoms in the newborn, who presents ·with only the signs of a very hard, markedly enlarged, non-transilluminating scrotal mass. The overlying skin may be discolored and adherent. Differential diagnosis must include neoplasm of the testis, strangulated inguinal hernia, scrotal hematoma, torsion of the appendix testis, hydrocele of the tunica vaginalis, and perhaps gumma of the testis. Treatment is usually surgical exploration. Most of the reported cases underwent orchiectomy. Some authors report leaving noninfected testes in the scrotum without complications. Longino states that two of seven infarcted testes thus treated have not developed significant atrophy, and he hopes to have preserved some hormonal function. Such extensive destruction was present in cases in the literature where changes were recorded and also in our case that we doubt whether any function, either spermatogenic or endocrine, could remam.
child didn't void during his first 24 hours of life. Pregnancy had been uneventful, the mother took no hormone therapy, and the delivery was a normal spontaneous atraumatic vertex. Examination revealed a 2 by 3 cm. hard, nodular, midline scrotal mass which was nontender and did not transilluminate. The penis though present was retracted beneath subcutaneous tissues pulled over it by distortion due to the presence of the scrotal mass. The mass was believed adherent to the bulbous urethra. A normal right testis was found at its external inguinal ring. The left testis was not found as such. No hernia was present and the mass was obviously not reducible. The patient finally voided and continued to void normally. He remained afebrile, but had a postnatal leukocytosis of 35,000. Urinalysis, blood urea nitrogen, and intravenous pyelographic studies were normal except for apparent calcifications in the scrotal mass. On the fifth day of life, scrotal exploration was performed; the preoperative diagnosis was probable teratoma of the testis. The cord was approached via a high left scrotal incision. The ves-
CASE REPORT
A full term l\!Ie;,.ican boy was noted at birth to have an enlarged scrotum and "retracted" penis (fig. 1). The urologist was called when the
FIG. 1. Scrotal mass with hyperpigmentation
of overlying skin
FIG. 2. A, testicular mass with clamp on cord above partial torsion. B, gross appearance of hemorrhagic infarct of testis.
67
TESTICULAR TORSION
I
Fw. 3. Microscopic section of testis (X 125) shows replacement of normal architecture with blood
sels of the cord first were identified, occluded with a rubbershod clamp, and then the dissection extended down over the mass (fig. 2, A_) A partial torsion of the spermatic cord was found extravaginally. It was necessary to rcmm-e an ellipse of adherent overlying skin, but the mass separated from the urethra without fistulous communication being found. The testicular mass measuring 3 by 2 by 2 cm. was removed with its cord and prepared for frozen section (fig. 2, B). The calcifications seen on x-ray examination were visible on the gross specimen. An orchiopexy of the testis was performed in the right scrotum, the incision closrd with drainage and a pressure dressing applied. The diagnosis of hemorrhagic infarct of the testis was confirmed by permanent sections (fig. 3). The postoperative course was uncomplicated except for slightly delayed healing of the rather large scrotal wound. DISCUSSION
This case is of interest because of the infrequency of the disease entity involved and the following differences from previously reported
cases: nodularity, fixation to urethra, midline position, and the presence of calcifications. Another case in this area has been brought to our attention 30 and is of interest in that after removal of the involved testis, an orchiopexy was performed on the remaining testicle without removing the tunica vaginalis. Subsequent swelling, tenderness, and inflammation dictated re-exploration revealing communicating hydrocele or patent processus vaginalis. This may well be kept in mrnd when performing such an orchiopexy. SUMMARY
A case of testicular infarct in the newborn has been presented with a rcvie\v of the literature. The incidence is probably greater than these 55 cases would suggest. Etiology is either torsion of the spermatic cord or undetermined. The clinicopathological picture is that of an afebrilc, asymptomatic infant with a dark, firm scrotal mass which is usually three or more times the size of so Kaufman, J.: Personal cornmunication.
68
CARL G. PETERSON, JR.
the normal testis. The mass does not transilluminate and the overlying hyperpigmented skin is often adherent to it. This last may accrue because the torsion is commonly external to the tunica vaginalis with involvement of the testis and surrounding tissues as well. This is in contradistinction to the usual intravaginal torsion found in juveniles and adults. An hemorrhagic type of infarction is found with more or less complete replacement of the tubules with blood. This is probably due to the torsion occluding the
venous return but not the arterial supply of the testis initially. Treatment is surgical with extirpation of the involved testis, and orchiopexy of the remaining testis either promptly or within a sensible period of time. The author wishes to thank Milo Ellik, M.D. for interest and guidance in the care of this case. Department of Urology 823rd Medical Group (SAC) Homestead A.F.B., Florida