Segmental ischemia in testicular torsion Binnur Tavaslı, MD, Hikmet Köseog˘lu, MD, and Halime Çevik, MD
Testicular torsion is a rare but important entity in the discipline of urology, as urgent action is required to save the testicle anatomically and functionally. Occurring mainly in the young prepubertal or pubertal male, testicular torsion is also seen in young adults. The annual incidence has been estimated to be 4.5 cases per 100,000 male subjects. The outcome of testicular torsion, in cases of unsuccessful emergent intervention, is total or partial infarction of the testicular tissue. We present a case of partial testicular ischemia due to testicular torsion.
T
esticular torsion, though rare, is mainly encountered in emergency departments and requires urgent treatment. The annual incidence of testicular torsion has been estimated to be 4.5 cases per 100,000 male subjects (1). Although it can be encountered in any age group, it is mostly seen in males younger than 21 years and comparatively rarely in young adults (2, 3). The outcome of testicular torsion, in cases of unsuccessful emergent intervention, is total or partial infarction of the testicular tissue (4–9). Some cases with partial ischemia, as in our case, can be challenging to manage. CASE PRESENTATION A 25-year-old man was admitted to the emergency department with acute progressive left scrotal pain lasting approximately 12 hours. His past medical history was unremarkable. Examination revealed normal scrotal skin, left minimal hydrocele, and bilateral testicles in the scrotum with minimal pain on the left side with palpation, without varicocele, testicular mass, or hernia. Complete blood count, urinalysis, serum alpha-fetoprotein, and human chorionic gonadotropin β subunit tests were normal. Color Doppler ultrasonography of the scrotum revealed a normalsized testicle with thickened tunica albuginea and minimal hydrocele on the left side. No arterial or venous blood flow was detected in the left testicle, sparing only the superior part (Figures 1a and 1b). Emergent surgical exploration with a scrotal approach was performed. When the hydrocele was incised, the cord was found to be twisted one total turn, with bluish discoloration at the twist of the cord. After detorsion, 58
the discoloration on the cord was corrected. An ultrasound 24 hours postoperatively revealed normal echogenicity and vascularity in the left testicle (Figure 1c). DISCUSSION Testicular torsion is rare but requires urgent action to save the testicle (1). Before radiologic diagnostic tests were available, 90% of these patients lost their testes, mostly due to orchiectomy and rarely ischemic atrophy (4). The orchiectomy rate has declined to 2% to 34% in the era of advanced imaging (1, 3). Th e timing of surgery after the onset of testicular torsion is the most important parameter for saving testicular tissue (5). While color Doppler ultrasonography has high sensitivity and specificity for testicular torsion, normal ultrasonography can detect only about a quarter of the cases of testicular torsion among patients admitted to the clinic with acute scrotum (6, 7). Therefore, although ultrasonography is helpful, high clinical suspicion is still important for emergent surgical intervention in challenging cases. Some cases of testicular torsion result in segmental testicular infarction (8, 9). In the rare cases when segmental ischemia progresses to segmental testicular infarction, it is usually diagnosed following orchiectomy (9). In these cases, the most common differential diagnosis is testicular tumor, due to the ultrasonographic resemblance of the two entities. The time period of ischemia is an important factor in the outcome of the patient with partial testicular ischemia resulting from torsion. The testis can be saved, but a longer period of infarction results in either partial loss of testicular mass or orchiectomy. In our case, the period of ischemia was approximately 12 hours, and the high suspicion of testicular torsion, with testicular pain and uncommon partial ischemia of the testis on Doppler ultrasonography, drove emergent surgical intervention, which saved the testis.
From the Departments of Radiology (Tavaslı, Çevik) and Urology (Köseog˘lu), Bas¸kent University, Istanbul, Turkey. Corresponding author: Hikmet Köseog˘lu, MD, Department of Urology, Bas¸kent University, Valide-i Atik Mah, Çinili Mescit Sok, Yıldız Apt. No:33 D:16, Istanbul, Turkey (e-mail: [email protected]). Proc (Bayl Univ Med Cent) 2016;29(1):58–59
a
b
c
Figure 1. Color Doppler ultrasonography. (a) Preoperative image of both testes demonstrating absent flow in the left testis. (b) Preoperative image demonstrating minimal blood flow in the superior part of the left testis. (c) Image 24 hours postoperatively demonstrating uniform echogenicity and flow throughout the left testicle. 1. 2. 3.
4. 5.
Mansbach JM, Forbes P, Peters C. Testicular torsion and risk factors for orchiectomy. Arch Pediatr Adolesc Med 2005;159(12):1167–1171. Cummings JM, Boullier JA, Sekhon D, Bose K. Adult testicular torsion. J Urol 2002;167(5):2109–2110. Tajchner L, Larkin JO, Bourke MG, Waldron R, Barry K, Eustace PW. Management of the acute scrotum in a district general hospital: 10-year experience. ScientificWorldJournal 2009;28(9):281–286. Barker K, Raper FP. Torsion of the testis. Br J Urol 1964;36:35–41. King LM, Sekaran SK, Sauer D, Schwentker FN. Untwisting in delayed treatment of torsion of the spermatic cord. J Urol 1974;112(2):217–221.
January 2016
6.
7.
8. 9.
Baker LA, Sigman D, Mathews RI, Benson J, Docimo SG. An analysis of clinical outcomes using color Doppler testicular ultrasound for testicular torsion. Pediatrics 2000;105(3 Pt 1):604–607. Bentley DF, Ricchiuti DJ, Nasrallah PF, McMahon DR. Spermatic cord torsion with preserved testis perfusion: initial anatomical observations. J Urol 2004;172(6 Pt 1):2373–2376. Costa M, Calleja R, Ball RY, Burgess N. Segmental testicular infarction. BJU Int 1999;83(4):525. Shen YH, Lin YW, Zhu XW, Cai BS, Li J, Zheng XY. Segmental testicular infarction: a case report. Exp Ther Med 2015;9(3):758–760.
Segmental ischemia in testicular torsion
59
Testicular torsion is a rare but important entity in the discipline of urology, as urgent action is required to save the testicle anatomically and functionally. Occurring mainly in the young prepubertal or pubertal male, testicular torsion is also seen in young adults. The annual incidence has been estimated to be 4.5 cases per 100,000 male subjects. The outcome of testicular torsion, in cases of unsuccessful emergent intervention, is total or partial infarction of the testicular tissue. We present a case of partial testicular ischemia due to testicular torsion.
T
esticular torsion, though rare, is mainly encountered in emergency departments and requires urgent treatment. The annual incidence of testicular torsion has been estimated to be 4.5 cases per 100,000 male subjects (1). Although it can be encountered in any age group, it is mostly seen in males younger than 21 years and comparatively rarely in young adults (2, 3). The outcome of testicular torsion, in cases of unsuccessful emergent intervention, is total or partial infarction of the testicular tissue (4–9). Some cases with partial ischemia, as in our case, can be challenging to manage. CASE PRESENTATION A 25-year-old man was admitted to the emergency department with acute progressive left scrotal pain lasting approximately 12 hours. His past medical history was unremarkable. Examination revealed normal scrotal skin, left minimal hydrocele, and bilateral testicles in the scrotum with minimal pain on the left side with palpation, without varicocele, testicular mass, or hernia. Complete blood count, urinalysis, serum alpha-fetoprotein, and human chorionic gonadotropin β subunit tests were normal. Color Doppler ultrasonography of the scrotum revealed a normalsized testicle with thickened tunica albuginea and minimal hydrocele on the left side. No arterial or venous blood flow was detected in the left testicle, sparing only the superior part (Figures 1a and 1b). Emergent surgical exploration with a scrotal approach was performed. When the hydrocele was incised, the cord was found to be twisted one total turn, with bluish discoloration at the twist of the cord. After detorsion, 58
the discoloration on the cord was corrected. An ultrasound 24 hours postoperatively revealed normal echogenicity and vascularity in the left testicle (Figure 1c). DISCUSSION Testicular torsion is rare but requires urgent action to save the testicle (1). Before radiologic diagnostic tests were available, 90% of these patients lost their testes, mostly due to orchiectomy and rarely ischemic atrophy (4). The orchiectomy rate has declined to 2% to 34% in the era of advanced imaging (1, 3). Th e timing of surgery after the onset of testicular torsion is the most important parameter for saving testicular tissue (5). While color Doppler ultrasonography has high sensitivity and specificity for testicular torsion, normal ultrasonography can detect only about a quarter of the cases of testicular torsion among patients admitted to the clinic with acute scrotum (6, 7). Therefore, although ultrasonography is helpful, high clinical suspicion is still important for emergent surgical intervention in challenging cases. Some cases of testicular torsion result in segmental testicular infarction (8, 9). In the rare cases when segmental ischemia progresses to segmental testicular infarction, it is usually diagnosed following orchiectomy (9). In these cases, the most common differential diagnosis is testicular tumor, due to the ultrasonographic resemblance of the two entities. The time period of ischemia is an important factor in the outcome of the patient with partial testicular ischemia resulting from torsion. The testis can be saved, but a longer period of infarction results in either partial loss of testicular mass or orchiectomy. In our case, the period of ischemia was approximately 12 hours, and the high suspicion of testicular torsion, with testicular pain and uncommon partial ischemia of the testis on Doppler ultrasonography, drove emergent surgical intervention, which saved the testis.
From the Departments of Radiology (Tavaslı, Çevik) and Urology (Köseog˘lu), Bas¸kent University, Istanbul, Turkey. Corresponding author: Hikmet Köseog˘lu, MD, Department of Urology, Bas¸kent University, Valide-i Atik Mah, Çinili Mescit Sok, Yıldız Apt. No:33 D:16, Istanbul, Turkey (e-mail: [email protected]). Proc (Bayl Univ Med Cent) 2016;29(1):58–59
a
b
c
Figure 1. Color Doppler ultrasonography. (a) Preoperative image of both testes demonstrating absent flow in the left testis. (b) Preoperative image demonstrating minimal blood flow in the superior part of the left testis. (c) Image 24 hours postoperatively demonstrating uniform echogenicity and flow throughout the left testicle. 1. 2. 3.
4. 5.
Mansbach JM, Forbes P, Peters C. Testicular torsion and risk factors for orchiectomy. Arch Pediatr Adolesc Med 2005;159(12):1167–1171. Cummings JM, Boullier JA, Sekhon D, Bose K. Adult testicular torsion. J Urol 2002;167(5):2109–2110. Tajchner L, Larkin JO, Bourke MG, Waldron R, Barry K, Eustace PW. Management of the acute scrotum in a district general hospital: 10-year experience. ScientificWorldJournal 2009;28(9):281–286. Barker K, Raper FP. Torsion of the testis. Br J Urol 1964;36:35–41. King LM, Sekaran SK, Sauer D, Schwentker FN. Untwisting in delayed treatment of torsion of the spermatic cord. J Urol 1974;112(2):217–221.
January 2016
6.
7.
8. 9.
Baker LA, Sigman D, Mathews RI, Benson J, Docimo SG. An analysis of clinical outcomes using color Doppler testicular ultrasound for testicular torsion. Pediatrics 2000;105(3 Pt 1):604–607. Bentley DF, Ricchiuti DJ, Nasrallah PF, McMahon DR. Spermatic cord torsion with preserved testis perfusion: initial anatomical observations. J Urol 2004;172(6 Pt 1):2373–2376. Costa M, Calleja R, Ball RY, Burgess N. Segmental testicular infarction. BJU Int 1999;83(4):525. Shen YH, Lin YW, Zhu XW, Cai BS, Li J, Zheng XY. Segmental testicular infarction: a case report. Exp Ther Med 2015;9(3):758–760.
Segmental ischemia in testicular torsion
59
