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Bell-Clapper Deformity

Case Western Reserve University Cleveland, OH 44106

I read with great interest the article by Ledwidge et al. [1] entitled "Sonographic Diagnosis of Superior Hemispheric Testicular Infarction" in the September issue of the American Journal of Roentgenology.

The bell-clapper deformity or anomaly is not the shortened connection of the testicle to the dorsal scrotal wall, as described in their article [1], but an entity in which the tunica vaginalis completely encircles the epididymis, distal spermatic cord, and the testis rather than attaching to the posterolateral aspect of the testis (Fig.1). The deformity leaves the testis free to swing and rotate within the tunica vaginalis, much like a clapper inside a bell. Bell-clapper deformity is bilateral in most cases. A 12% incidence of bell-clapper deformity was found in one autopsy series [2], suggesting that it is a common deformity, more prevalent than intravaginal torsion. Intratesticular infarction has been described previously [3].

View larger version (12K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1. —Diagram represents abnormal (bell-clapper deformity) and normal insertion of tunica vaginalis.

References

1. Ledwidge ME, Lee DK III, Winter TC III, Uehling DT, Mitchell CC, Lee FT Jr. Sonographic diagnosis of superior hemispheric testicular infarction. AJR 2002;179:775 –776[Free Full Text]
2. Caesar RE, Kaplan GW. Incidence of the bell-clapper deformity in an autopsy series. Urology1994;44:114 –116[Medline]
3. Dogra VS, Gottlieb RH, Rubens DJ, Liao L. Benign intratesticular cystic lesions: US features. RadioGraphics 2001;21:S273 –S281[Abstract/Free Full Text]

Reply

University of Wisconsin Hospital and Clinics Madison, WI 53792

We thank Dr. Dogra for expressing interest in our work [1] and for the clarification of the anatomy that comprises the bell-clapper deformity. The bell-clapper deformity is the extreme case of a narrow attachment of the epididymis to the tunica vaginalis that causes the testicle to hang free within the vaginal sac. This anatomic abnormality predisposes to spermatic cord torsion. An intermediate form of testicular investment by the tunica vaginalis also exists, with a short posterior attachment of the tunica vaginalis to the epididymis. This condition also predisposes to spermatic cord torsion, and thus the clinical implications are the same as for the bell-clapper deformity [2]. In the case we presented, true bilateral bell-clapper deformities were present.

We also thank Dogra for bringing to our attention a case of focal testicular infarction. The case referred to by Dogra was simply one in a series of intratesticular cystic masses (not a hemispheric infarction) and did not include color or pulsed Doppler images, clinical information, or an association with the bell-clapper deformity. In fact, no explanation for the abnormal finding was offered [3]. After publication of our case, we became aware of several earlier reports of hemispheric testicular infarction diagnosed with color Doppler sonography [4, 5]—a regrettable oversight by both our group and that of Dogra et al. [3] that can only be explained by the vagaries of computerized literature searches.

References

1. Ledwidge ME, Lee DK, Winter TC III, Uehling DT, Mitchell CC, Lee FT Jr. Sonographic diagnosis of superior hemispheric testicular infarction. AJR 2002;179:775 –776
2. Caesar RE, Kaplan GW. Incidence of the bell-clapper deformity in an autopsy series. Urology 1994;44:114 –116

3. Dogra VS, Gottlieb RH, Rubens DJ, Liao L. Benign intratesticular cystic lesions: US features. RadioGraphics 2001;21:S273 –S281
4. Kramolowsky EV, Beauchamp RA, Milby WP. Color Doppler ultrasound for the diagnosis of segmental testicular infarction. J Urol 1993;150:972 –973[Medline]
5. Sriprasad S, Kooiman GG, Muir GH, Sidhu PS. Acute segmental testicular infarction: differentiation from tumour using high frequency colour Doppler ultrasound. Br J Radiol 2001;74:965 –967[Abstract/Free Full Text]

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