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Torsion of the Testis in the Newborn
Vol. 101, Feb. Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1969 by The Williams & Wilkins Co.
TORSION OF THE TESTIS IN THE NEWBORN BRAHM B. HYAMS*
From the Department of Urology, Jewish General Hosvital, Montreal, Quebec, Canada
Torsion of the spermatic cord is a condition encountered by the practicing urologist one or more times a year. However, its occurrence in the newborn is uncommon. In 1961, 56 cases were reviewed by Peterson1 and 14 articles have been collected since, 2- 15 each with one or more clinical cases. The pathological basis almost always differs from that in the older age group. The diagnosis is often missed until belated exploration is carried out. The case herein is reported because of the unusual presenting feature.
CASE REPORT
A full-term white male infant was born at the Jewish General Hospital in Montreal on August 7, 1964. The delivery was spontaneous and uncomplicated. Birth weight was 3,690 gm. The mother was multiparous. On examination a tense, transilluminating mass was noted in the left scrotum. The scrotal skin was dark. The infant was afebrile and comfortable. When the pediatrician saw him 24 hours after birth, he requested urological opinion since he thought such a, large hyclrocele was unusual in a newborn.
Accepted for publication January 20, 1968. Read at annual meeting of Northeastern Section, American Urological Association, Bolton's Landing, New York, September 17-20, 1967. * Current address: 5972 Dolbeau St., Montreal 26, Quebec, Canada. 1 Peterson, C. G., Jr.: Testicular torsion and infarction in the newborn. J. Urol., 85: 65-68, 1961. 2 Donaldson, A. N. and Pearlman, C. K.: Torsion of the spermatic cord. Amer. Surg., 33:
68-72, 1967. 3 Fields, D. L. and Michael, R. L.: Torsion of the spermatic cord in the newborn. J. Indiana Med. Ass., 57: 329-330, 1964. 4 Frederick, P. L., Dushku, N. and Eraklis, A. J.: Simultaneous bilateral torsion of testes in a newborn infant. Arch. Surg., 94: 299-300,
1967. 5 Gillenwater, J. Y. and Burros, H . M.: Torsion of the spermatic cord in utero. J.A.M.A., 198:
1123-1124, 1966.
Fra. 1. Operative findings with extravaginal torsion at hemostat labeled fine. Opened tunica vaginalis and infarcted epididymis, hydatid of Morgagni and testis below.
6 Lawless, E. C. and Lindner, H. H.: Torsion of the spermatic cord. Surgery, 54: 471-476, 1963. 7 Lester, D. B. and Gummess, G. H.: Torsion of the spermatic cord in the newborn infant. J. Urol., 86: 631-633, 1961. 8 Lyon, R. P. · Torsion of the testicle in childhood. A painless emergency requiring contra.lateral orchiopexy. J. A. M.A., 178: 702-705, 1961. 9 Myers, N. A.: Torsion of the spermatic cord in neonatal period. Med. J. Aust., 48: 793-795, 1961. 10 Reeves, H. H., Sigler, R. M., Hahn, H.B., Jr. and Lynn, H.B.: Torsion of the spermatic cord in the newborn. Amer. J. Dis. Child., 110: 676-677,
Physical examination revealed a normal penis and right scrotum. A 3 by 4 cm. dark ovoid mass filled the left scrotum, was not tender and transilluminated except at the upper margin where the testis was presumed to be. The mass was fluct.uant and the skin covering the mass was tense but not fixed. There was minimal blue discoloration, and the spermatic cord was questionably thickened. No communication with the left inguinal canal was found. The diagnosis of hydrocele of the left tunica vaginalis with overlying edema clue to the delivery was felt to be correct, and the attendants thought the latter was subsiding. After 5 days, with the infant afebrile, gaining
1965.
11 Stut, .J. C.: Newborn infant with torsion of testis. Nederl. T. Geneesk., 108: 1077-1078, 1964. 12 Swaffield, W. R.: Congenital torsion of the spermatic cord. Canad. Med. Ass. J., 86: 375, 1962. 13 Whittlesey, R.H.: Intrauterine torsion of the spermatic cord. Amer . .J. Surg., 102: 699-701, 1961. 14 Yunen, J. R.: Testicular torsion in the newborn: report of a case. J. Urol., 97: 318-319, 1967. 15 Zaffa.roni, G. and Baldi, U.: Torsion of the testicle and of the hydatid of Morgagni in childhood. Arch. Ital. Chir., 90: 139-155, 1964.
192
193
TORSION OF TESTIS IN NEWBORN
FIG. 2. Section of specimen under low magnification with infarcted testis and central liquefaction on left and congested spermatic veins on right.
weight and with no change in size of the scrotal swelling, the hydrocele was tapped to be sure the underlying testis was normal. This procedure was delayed to allow enough time for coagulation processes to mature. Aspiration of 8 cc of slightly sanguineous fluid was accomplished. The testis was 3 times the size of its normal mate, nontender and rubbery, with a nodular epididymal region. The spermatic cord was thickened. With a preoperative impression of testicular neoplasm or possible torsion, the scrotum was explored. An infarcted testis, epididymis and hydatid of Morgagni were found, with a 360 degree extravaginal torsion of the spermatic cord (fig. 1). Orchiectomy was performed, and the right testis was fixed in the scrotum. Convalescence was uneventful, the aspirated cavity being drained for 24 hours. The pathological diagnosis was acute hemorrhagic infarction of the left testis. The center of the necrosed testis was liquified and the spermatic
veins were congested (fig. 2). The hemorrhagic nature of the lesion and recognizable infarcted tissue were noted (fig. 3). DISCUSSION
Normally the tunica vaginalis lies anterior and lateral to the testis, with the gubernaculum fixing it in place inferiorly and the spermatic cord invested by connective tissue (fig. 4, A). With the clapperbell deformity, the tunica vaginalis completely surrounds the testis which lies free and covers the lower portion of the spermatic cord for some distance (fig. 4, B). A strong cremasteric reflex will allow rotation about a vertical axis. Less commonly the mesorchium is elongated, and without inferior fixation rotation about an anteroposterior horizontal axis can occur with vascular embarrassment-that is venous congestion allowing for the hemorrhagic component, followed by arterial compression, ischemia and
194
HYAMS
Fm. 3. Recognizable infarcted tissue with predominant hemorrhagic element at lower right
Fm. 4. A, normal anatomy of testis in scrotum. B, clapperbell deformity of tunica vaginalis allowing rotation of spermatic cord about vertical axis. C, alternate mechanism with elongated mesorchium about which torsion may occur.
19:'i
TORSION OF TESTIS l;\i ::-SKWBORN
Fm 5 . "1, normal hemiRcroturn of newborn as seen from frollt. B, extravaginal Lorsion. Dotted line shows plane of shearing about which rotation occnrs"
infarctiou of the te;;tis (fig. 4, C). Smith has shown in the dog that 6 hours after complete vascular occlusion, spermatogeneRis is lost, and after 8 to 10 hours the Leydig cells die. 16 In this group, the anatomical defect tends to be bilateral. In the newborn, the process is almost ahvays extravaginal. It has been demonstrated previously that the scrotal contents can be freely lifted out of the scrotum without any substantial tearing of tissue.17 Thus under appropriate cir-· cumstances the spermatic cord may rotate sufficiently to infarct everything distal to the rotated 3egrnent, including the tunica vaginalis (fig. 5). One might speculate what those circumstances may be. It has been shown by Reeves and associates that these infants are all appreciably above average in birth weight.10 Presumably, then, the :stress of strong uterine contraction and/or passage through the birth canal with coincident local trauma, incite a cremasteric reflex and sufficient shearing to twist the spermatic cord. In one recent report by Frederick and associates bilateral torsion and infarction were encountered. 4 It seems likely that the process is complete birth. Not a single testicle has been saved in the newborn, though early exploration has been the exception rather than the rule. Whether orchiectomy rather than detorsion should be performed, or the other testis fixed in the scrotum, is debated in the literature. Proponents for not removing the te,otis state that sepsis does not, in fact, occur 12 • 17 Some go so far as 16 Smith, G. I.: Celhilar changes from graded testicular ischemia. J. Urol., 73: 355-362, 1955. 17 Campbell,M. F.: Urology. Philadelphia: W. B. Saunders Co., pp. 2002-2006, 196:3.
to avoid exploration, reasoning that the testis 1,. already beyond saving. I cannot agree with thi., The differential diagnosis bet,Yeen and torsion can only be resolved at exploration should interYention be early enough, there is ahrnys a possibility of saving the lestis ..·\s to fixing the other side, this point is debatable. 7 , "· Personally, it seems best to do tbi~ minimal additional procedure and obviate future exploration to rule out a ton-;ed cord in ca,e of intra .. scrotal pathology, or run any risk o[ mforction ii, the single remaining testicle. Search of the literature revealed uo other case of extravaginal torsion in the newborn as a hydrocele. The classical and rqwatecl tion is that of a hard, non-transillmmnating masP with reddish-blue discoloration of, and fixation to the oYerlying scrotal skin. The asymptomatic nature of the condition in tlw ne\Yborn was again illustrated in this infant. SUMMARY j_ case of cxtravaginal torsion of the cord with infarction of the testis in the presenting uniquely as a transilluminating clrocele, is report.eel. The etiology and management are discussed. Unfortunately, in rccord(c,cl. cases, not a single testis has been leading one to speculate that the process occur& in utero or in the birth canal. \Yherc exploration is inclicatecl, if only for Exploration should be clone as in the hope of saving at least wme testicular function. REFERENCES Bm,T, A, J. AND CouPE, C.: Apropos de la torsion du cordon spermatique chez le nouvean-116. Arch. fr. pediat., 14: 261-272, 1957. CAMPBELL, JVL F.: Hemorrhagic infarction of the testicle in newborn. In: Pediatric Urology. New York: The MacMillan Co., 19:37 CAMPBELL, M. F.: Torsion of the spermll tie cord: report of 15 cases. Surg., Gynec. & Obst,, 44:
311-316, 1927.
UALPF;RT, B.: Intratesticula.r hemordrnge; birth trauma., with report of 8 cases, Amer ,L Obst. & Gynec., 43: 1028-1032, 1942 . MAcLJ.,AN, J. T.: Hemorrhagic infarct of the testicl.e in the newborn. Surg., Gynec. & Obst., 76: 319, 1943.
MuscHAT, M.: Pathological anatomy c,f testicHla.r torsion; explanation of its mechanism. Surg., Gynec. & Obst., 54: 758, 1932. RA vrcH, R., A.: Hemorrhagic infa"ction of the testicle in the newborn. J. Urol., 57: 875-879, 1947.
TAYLOR, lvI. R.: A case of the testis strm,gnlatcd a:c birth. Brit. :.VIed. J., 2: 458, 1897.
THE JOURNAL OF UROLOGY
Copyright © 1969 by The Williams & Wilkins Co.
TORSION OF THE TESTIS IN THE NEWBORN BRAHM B. HYAMS*
From the Department of Urology, Jewish General Hosvital, Montreal, Quebec, Canada
Torsion of the spermatic cord is a condition encountered by the practicing urologist one or more times a year. However, its occurrence in the newborn is uncommon. In 1961, 56 cases were reviewed by Peterson1 and 14 articles have been collected since, 2- 15 each with one or more clinical cases. The pathological basis almost always differs from that in the older age group. The diagnosis is often missed until belated exploration is carried out. The case herein is reported because of the unusual presenting feature.
CASE REPORT
A full-term white male infant was born at the Jewish General Hospital in Montreal on August 7, 1964. The delivery was spontaneous and uncomplicated. Birth weight was 3,690 gm. The mother was multiparous. On examination a tense, transilluminating mass was noted in the left scrotum. The scrotal skin was dark. The infant was afebrile and comfortable. When the pediatrician saw him 24 hours after birth, he requested urological opinion since he thought such a, large hyclrocele was unusual in a newborn.
Accepted for publication January 20, 1968. Read at annual meeting of Northeastern Section, American Urological Association, Bolton's Landing, New York, September 17-20, 1967. * Current address: 5972 Dolbeau St., Montreal 26, Quebec, Canada. 1 Peterson, C. G., Jr.: Testicular torsion and infarction in the newborn. J. Urol., 85: 65-68, 1961. 2 Donaldson, A. N. and Pearlman, C. K.: Torsion of the spermatic cord. Amer. Surg., 33:
68-72, 1967. 3 Fields, D. L. and Michael, R. L.: Torsion of the spermatic cord in the newborn. J. Indiana Med. Ass., 57: 329-330, 1964. 4 Frederick, P. L., Dushku, N. and Eraklis, A. J.: Simultaneous bilateral torsion of testes in a newborn infant. Arch. Surg., 94: 299-300,
1967. 5 Gillenwater, J. Y. and Burros, H . M.: Torsion of the spermatic cord in utero. J.A.M.A., 198:
1123-1124, 1966.
Fra. 1. Operative findings with extravaginal torsion at hemostat labeled fine. Opened tunica vaginalis and infarcted epididymis, hydatid of Morgagni and testis below.
6 Lawless, E. C. and Lindner, H. H.: Torsion of the spermatic cord. Surgery, 54: 471-476, 1963. 7 Lester, D. B. and Gummess, G. H.: Torsion of the spermatic cord in the newborn infant. J. Urol., 86: 631-633, 1961. 8 Lyon, R. P. · Torsion of the testicle in childhood. A painless emergency requiring contra.lateral orchiopexy. J. A. M.A., 178: 702-705, 1961. 9 Myers, N. A.: Torsion of the spermatic cord in neonatal period. Med. J. Aust., 48: 793-795, 1961. 10 Reeves, H. H., Sigler, R. M., Hahn, H.B., Jr. and Lynn, H.B.: Torsion of the spermatic cord in the newborn. Amer. J. Dis. Child., 110: 676-677,
Physical examination revealed a normal penis and right scrotum. A 3 by 4 cm. dark ovoid mass filled the left scrotum, was not tender and transilluminated except at the upper margin where the testis was presumed to be. The mass was fluct.uant and the skin covering the mass was tense but not fixed. There was minimal blue discoloration, and the spermatic cord was questionably thickened. No communication with the left inguinal canal was found. The diagnosis of hydrocele of the left tunica vaginalis with overlying edema clue to the delivery was felt to be correct, and the attendants thought the latter was subsiding. After 5 days, with the infant afebrile, gaining
1965.
11 Stut, .J. C.: Newborn infant with torsion of testis. Nederl. T. Geneesk., 108: 1077-1078, 1964. 12 Swaffield, W. R.: Congenital torsion of the spermatic cord. Canad. Med. Ass. J., 86: 375, 1962. 13 Whittlesey, R.H.: Intrauterine torsion of the spermatic cord. Amer . .J. Surg., 102: 699-701, 1961. 14 Yunen, J. R.: Testicular torsion in the newborn: report of a case. J. Urol., 97: 318-319, 1967. 15 Zaffa.roni, G. and Baldi, U.: Torsion of the testicle and of the hydatid of Morgagni in childhood. Arch. Ital. Chir., 90: 139-155, 1964.
192
193
TORSION OF TESTIS IN NEWBORN
FIG. 2. Section of specimen under low magnification with infarcted testis and central liquefaction on left and congested spermatic veins on right.
weight and with no change in size of the scrotal swelling, the hydrocele was tapped to be sure the underlying testis was normal. This procedure was delayed to allow enough time for coagulation processes to mature. Aspiration of 8 cc of slightly sanguineous fluid was accomplished. The testis was 3 times the size of its normal mate, nontender and rubbery, with a nodular epididymal region. The spermatic cord was thickened. With a preoperative impression of testicular neoplasm or possible torsion, the scrotum was explored. An infarcted testis, epididymis and hydatid of Morgagni were found, with a 360 degree extravaginal torsion of the spermatic cord (fig. 1). Orchiectomy was performed, and the right testis was fixed in the scrotum. Convalescence was uneventful, the aspirated cavity being drained for 24 hours. The pathological diagnosis was acute hemorrhagic infarction of the left testis. The center of the necrosed testis was liquified and the spermatic
veins were congested (fig. 2). The hemorrhagic nature of the lesion and recognizable infarcted tissue were noted (fig. 3). DISCUSSION
Normally the tunica vaginalis lies anterior and lateral to the testis, with the gubernaculum fixing it in place inferiorly and the spermatic cord invested by connective tissue (fig. 4, A). With the clapperbell deformity, the tunica vaginalis completely surrounds the testis which lies free and covers the lower portion of the spermatic cord for some distance (fig. 4, B). A strong cremasteric reflex will allow rotation about a vertical axis. Less commonly the mesorchium is elongated, and without inferior fixation rotation about an anteroposterior horizontal axis can occur with vascular embarrassment-that is venous congestion allowing for the hemorrhagic component, followed by arterial compression, ischemia and
194
HYAMS
Fm. 3. Recognizable infarcted tissue with predominant hemorrhagic element at lower right
Fm. 4. A, normal anatomy of testis in scrotum. B, clapperbell deformity of tunica vaginalis allowing rotation of spermatic cord about vertical axis. C, alternate mechanism with elongated mesorchium about which torsion may occur.
19:'i
TORSION OF TESTIS l;\i ::-SKWBORN
Fm 5 . "1, normal hemiRcroturn of newborn as seen from frollt. B, extravaginal Lorsion. Dotted line shows plane of shearing about which rotation occnrs"
infarctiou of the te;;tis (fig. 4, C). Smith has shown in the dog that 6 hours after complete vascular occlusion, spermatogeneRis is lost, and after 8 to 10 hours the Leydig cells die. 16 In this group, the anatomical defect tends to be bilateral. In the newborn, the process is almost ahvays extravaginal. It has been demonstrated previously that the scrotal contents can be freely lifted out of the scrotum without any substantial tearing of tissue.17 Thus under appropriate cir-· cumstances the spermatic cord may rotate sufficiently to infarct everything distal to the rotated 3egrnent, including the tunica vaginalis (fig. 5). One might speculate what those circumstances may be. It has been shown by Reeves and associates that these infants are all appreciably above average in birth weight.10 Presumably, then, the :stress of strong uterine contraction and/or passage through the birth canal with coincident local trauma, incite a cremasteric reflex and sufficient shearing to twist the spermatic cord. In one recent report by Frederick and associates bilateral torsion and infarction were encountered. 4 It seems likely that the process is complete birth. Not a single testicle has been saved in the newborn, though early exploration has been the exception rather than the rule. Whether orchiectomy rather than detorsion should be performed, or the other testis fixed in the scrotum, is debated in the literature. Proponents for not removing the te,otis state that sepsis does not, in fact, occur 12 • 17 Some go so far as 16 Smith, G. I.: Celhilar changes from graded testicular ischemia. J. Urol., 73: 355-362, 1955. 17 Campbell,M. F.: Urology. Philadelphia: W. B. Saunders Co., pp. 2002-2006, 196:3.
to avoid exploration, reasoning that the testis 1,. already beyond saving. I cannot agree with thi., The differential diagnosis bet,Yeen and torsion can only be resolved at exploration should interYention be early enough, there is ahrnys a possibility of saving the lestis ..·\s to fixing the other side, this point is debatable. 7 , "· Personally, it seems best to do tbi~ minimal additional procedure and obviate future exploration to rule out a ton-;ed cord in ca,e of intra .. scrotal pathology, or run any risk o[ mforction ii, the single remaining testicle. Search of the literature revealed uo other case of extravaginal torsion in the newborn as a hydrocele. The classical and rqwatecl tion is that of a hard, non-transillmmnating masP with reddish-blue discoloration of, and fixation to the oYerlying scrotal skin. The asymptomatic nature of the condition in tlw ne\Yborn was again illustrated in this infant. SUMMARY j_ case of cxtravaginal torsion of the cord with infarction of the testis in the presenting uniquely as a transilluminating clrocele, is report.eel. The etiology and management are discussed. Unfortunately, in rccord(c,cl. cases, not a single testis has been leading one to speculate that the process occur& in utero or in the birth canal. \Yherc exploration is inclicatecl, if only for Exploration should be clone as in the hope of saving at least wme testicular function. REFERENCES Bm,T, A, J. AND CouPE, C.: Apropos de la torsion du cordon spermatique chez le nouvean-116. Arch. fr. pediat., 14: 261-272, 1957. CAMPBELL, JVL F.: Hemorrhagic infarction of the testicle in newborn. In: Pediatric Urology. New York: The MacMillan Co., 19:37 CAMPBELL, M. F.: Torsion of the spermll tie cord: report of 15 cases. Surg., Gynec. & Obst,, 44:
311-316, 1927.
UALPF;RT, B.: Intratesticula.r hemordrnge; birth trauma., with report of 8 cases, Amer ,L Obst. & Gynec., 43: 1028-1032, 1942 . MAcLJ.,AN, J. T.: Hemorrhagic infarct of the testicl.e in the newborn. Surg., Gynec. & Obst., 76: 319, 1943.
MuscHAT, M.: Pathological anatomy c,f testicHla.r torsion; explanation of its mechanism. Surg., Gynec. & Obst., 54: 758, 1932. RA vrcH, R., A.: Hemorrhagic infa"ction of the testicle in the newborn. J. Urol., 57: 875-879, 1947.
TAYLOR, lvI. R.: A case of the testis strm,gnlatcd a:c birth. Brit. :.VIed. J., 2: 458, 1897.