| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Original Report |
1 Department of Diagnostic Imaging, The Hospital for Sick Children, University
of Toronto, 555 University Ave., Toronto, Ontario M5G 1X8, Canada.
2 Departamento de Medicina, Pontificia Universidad Catolica de Chile, Marcoleta
347, Santiago, Chile.
Received January 8, 2002;
accepted after revision August 22, 2002.
Address correspondence to A. Daneman.
Abstract
 Top Abstract IntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
CONCLUSION. The sonographic appearance of testicular torsion in neonates and infants can be divided into three types. We believe that the findings represent different stages in the evolution of testicular torsion.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
At presentation, the age of patients ranged from birth to 2 months (mean, 6 days). Of the 30 patients, 29 were born at term and were otherwise healthy neonates. The remaining infant was diagnosed with testicular torsion at 4 months although he was born approximately 4 months prematurely; therefore, his corrected age placed him in the same age group as the others. All 30 patients presented with scrotal swelling and a variable degree of scrotal discoloration.
All patients were imaged with gray-scale, color Doppler sonography, and pulsed Doppler sonography. Because the imaging was performed over several years, the equipment varied. Most studies were performed on either HDI 3000/5000 scanners (Advanced Technologies Laboratories, Bothell, WA) or a Sequoia scanner (Acuson, Mountain View, CA). A linear transducer was used at varying frequencies (range, 5–15 MHz). Follow-up sonography was performed in seven patients.
Treatment of the patients was not uniform because they were diagnosed and treated at two different institutions by a variety of pediatricians, surgeons, and urologists over a 6-year period. Eleven patients were treated nonoperatively and 19 had surgery.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
Type 1.—In type 1 (n = 15) marked enlargement of the affected testicle with heterogeneity in echogenicity was observed. Subtunica fluid was noted, and no detectable Doppler flow could be elicited in the testicle. In two patients, linear hypoechoic striations were seen, oriented radially from the mediastinum testis (Figs. 1A and 1B). A hydrocele (n = 12), occasionally with debris (n = 8), was present with thickening of the surrounding soft tissues (n = 15). A simple hydrocele was seen in the contralateral scrotum in eight patients.
|
|
Type 2.—Twelve patients had a gray-scale pattern that we classified as type 2. In these patients, the size of the testicle was normal and symmetric with the uninvolved testicle; the echogenicity was heterogeneous. In 10 patients, peripheral hyperechogenicity (Fig. 1C) was seen. A small hydrocele was present in seven patients.
|
Type 3.—In the third group of patients (n = 3), the testicle was markedly diminished (range, 2–4 mm), at times with only a small amount of testicular tissue persisting (n = 2). Areas of increased echogenicity were seen scattered throughout the testicle (Fig. 2A, 2B). A hydrocele was not observed in these patients.
|
|
Treatment
Of the 30 patients in this series, 19 had surgery. In 16, ipsilateral
orchiectomy and contralateral orchidopexy were performed. The time between the
sonography and the orchiectomy varied from a few hours to 11 months (mean, 5.3
months). Only one patient had surgery within hours of sonography, and in the
other 15 patients, orchiectomy was performed electively days to months after
the sonography.
In the remaining three who had surgery, the ipsilateral testicle was left in situ, and contralateral orchidopexy was performed. In two of these patients, the affected testicle was only a small necrotic remnant at the time of surgery. In the third patient, an orchidopexy of the affected testicle was performed because the testicle was thought to be viable at the time of surgery, possibly because of detorsion.
The remaining 11 children were treated nonoperatively and are being followed up with plans for delayed contralateral orchidopexy and possible ipsilateral orchiectomy.
Follow-Up
Clinical follow-up was available in all 11 patients who were treated
nonoperatively and in the one child in whom the testicle, considered to be
viable, was left in situ at surgery. In all 12, there was progressive clinical
decrease of the affected testicle, whereas the contralateral testicle has
remained normal on physical examination. Seven patients (six treated
nonoperatively, one treated operatively) were also followed up with sonography
to reassess progression of the ipsilateral testicle and to reassess the
contralateral testicle. The length of time between the initial and follow-up
sonograms ranged from 3 to 18 months (mean, 7 months). In each patient, the
sonographic appearance of the affected testicle had changed. In five patients,
the appearance of the testicle changed from type 1 to type 2 (Fig.
1A,
1B,
1C), and in two patients, from
type 2 to type 3. In all seven patients, the contralateral testicle remained
normal sonographically.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
We believe that type 1 sonographic changes (Figs. 1A and 1B) correlate with the acute phase of testicular torsion. Hypoechoic radially oriented striations were observed in two patients (Fig. 1B) and may be related to the thickened interlobular fibrous septa separating the more echogenic necrotic parenchyma seen on pathologic examination. Although the striations cannot represent the individual septa themselves, we propose that the pattern is due to the composite effect of many thickened fibrous septa interspersed with columns of necrotic seminiferous tubules. The finding has been described in the literature and is not specific for testicular torsion [5]. Types 2 and 3 sonographic changes (Figs. 1C and 2A, 2B), we believe, reflect the later phases of progressive atrophy of the parenchyma.
We therefore believe that the heterogeneous areas with hyperechoic areas in the type 1 pattern represent ischemia and hemorrhage that subsequently evolve, resulting in the calcification and diminution seen in types 2 and 3. One can therefore postulate that the type 2 or type 3 appearance at birth indicates that the acute episode of torsion occurred antenatally.
Testicular torsion is divided into two broad categories. Intravaginal torsion is the type most commonly associated with older children and adults. Intravaginal torsion is associated with a tunica vaginalis that not only surrounds the testicle and most of the epididymis, as is the normal situation, but also surrounds the spermatic cord allowing free rotation of the structures within the tunica and is seen mainly in adolescents [6]. Extravaginal torsion is a different entity altogether, in which both the contents of the tunica and the tunica itself rotate, and is seen mainly in neonates. This condition is due to loose attachments of the tunica to the scrotal wall. As the child grows, the tunical attachments strengthen, lessening the likelihood of this type of torsion after the neonatal period [7].
The presence of a testicular mass or swelling in a neonate can be a dilemma. The sonographic spectrum we describe should allow one to easily differentiate neonatal testicular torsion from other conditions. The differential diagnosis in a neonate includes inguinal hernia, which occurs in 10–20 neonates per 1000 live births [8]. Neoplasm (germ cell tumor), infection, and trauma are exceedingly rare at this age.
Surgery is often performed in cases in which acute torsion is suspected, as in a patient in whom the initial clinical examination showed a normal scrotal appearance soon followed by scrotal swelling. A survey among urologists revealed that 80–100% of these testicles are nonviable at emergency exploration [9].
The approach to treatment is not without controversy. Whereas Stone et al. [10] recommend delay when the sonographic appearance is consistent with antenatal torsion until surgery and anesthesia carry less risk, LaQuaglia et al. [11] are of the opinion that the risk of synchronous torsion of the contralateral testicle necessitates early operative intervention.
In conclusion, neonatal testicular torsion represents a unique clinical entity. In addition to the absence of arterial flow to the testicle, characteristic sonographic features can be shown that aid in decisions regarding treatment and follow-up.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
 |
|
  I. Conkbayir, B. Yanik, B. Keyik, and B. Hekimoglu Eggshell Calcification of the Testis: Ultrasonographic Findings J. Ultrasound Med., November 1, 2009; 28(11): 1581 - 1583. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
