Clinical diagnosis
Case 115
【Progress】Because we could not give the surgical service related to testicular torsion, he was transported to the other emergency hospital with urology department in order to get the surgical distorsion.
【Discussion】
Testis and spermatic cord exist in the vaginal tunica. Testicular torsion is categorized into two types: extra-vaginal tunica and intra-vaginal tunica. Extra-vaginal tunica testicular torsion occurs in preborn or newborn (1-4). Meanwhile, intra-vaginal testicular torsion does in youth, less than 30. The peak age is around 12 to 18 (1-3). Left-sided is more often than right-sided. Our patient also had a type of intra-vaginal tunica testicular torsion in the left testis and his age was 14.
Normal testis is surrounded with vaginal tunica and anchored by caudal genital ligament. The etiology of testicular torsion with intra-vaginal tunica is lack of caudal genital ligament (gubernaculum) which play a role attachment of testis to the scrotum (4). When testis is surrounded by vaginal tunica without caudal genital ligament, testis can move freely in the scrotum. In this situation, testis is only attached to the spermatic cord and can swing in the scrotum like swinging a bell clapper in a bell, which is called a “bell clapper scrotum”.
As testicular torsion often happens in older children, it is related to rapid growth of testis during puberty. It can occur at any time, while sleeping, standing and exercising but often occur when the weather is cold. Cremasteric muscle fibers exist surrounding the spermatic cord and testis. They spasm or contract in case of cooling, inducing contraction of the scrotum and elevation of testis. In bell clapper scrotum, testis can lie in transverse position or longitudinal position or torsion position in warm bed. When he rises up leaving bed, the sudden contraction by cremasteric muscle fibers because of cool temperature can induce testicular torsion, which is called “winter syndrome” (1-4). In our case, abdominal pain which was never encountered occurred early in the morning.
Spermatic cord includes arteries (testicular artery, cremasteric artery, deference artery), veins (pampiniform vein plexus), nerves, lymphatics and ductus deference. If spermatic cord rotated 180 degrees, blood supply would be supplied. But if spermatic cord rotated 720 degree, blood supply would be compromised (5, 6). Enhanced CT in our case showed two rotates (720 degree) of spermatic cord (Figs 1, 2), indicating compromise of the blood supply to the testis. Our case got surgical untwisted of spermatic cord 5 hours after the onset. It is reported that if treated within 6 hours, the testis can usually be saved, waiting longer can cause disability of sperm function and/or permanent damage of testis.
【Summary】
We present a fourteen year-old boy with left abdominal pain from around 7 AM that he has never experienced. Medical findings revealed left swollen hard testis. Enhanced abdominal CT showed twisted sperm cord with two rotated (720 degree) which makes blood supply compromised, leading to diagnosis of testicular torsion. We should keep in mind that testicular torsion happens at puberty, peak age of 12 to 18 in the bell clapper scrotum which indicate the lack of caudal genital ligament (gubernaculum) which play a role attachment of testis to the scrotum. Testis freely can swing in the scrotum and testis can lie in transverse position or longitudinal position or torsion position in warm bed. When leaving bed, the sudden contraction by cremasteric muscle fibers because of cool temperature can induce testicular torsion with 720 degree rotation, which is called “winter syndrome”. If treated within 6 hours, the testis can usually be saved, waiting longer can cause the disability of sperm function and/or permanent damage of testis. Our case got untwisted operation 5 hours after the onset.
【References】
1.Ludvigson, AE, et al. Urologic Emergencies. The Surgical clinics of North America. 2016; 96 (3): 407–424. doi:10.1016/j.suc.2016.02.001. PMID 27261785.
2.Sharp, VJ, et al. "Testicular torsion: diagnosis, evaluation, and management". American Family Physician. 2013; 88 (12): 835–840. PMID 24364548. Archived from the original on 2016-11-04.
3.Ringdahl E, et al. "Testicular torsion". Am Fam Physician. 2006; 74 : 1739–1743. PMID 17137004.
4.Callewaert PR, et al. New insights into perinatal testicular torsion. Eur J Pediatr. 2010; 169 : 705–12. doi:10.1007/s00431-009-1096-8. PMC 2859224. PMID 19856186.
5.Lavallee ME, et al. Testicular torsion: evaluation and management. Curr Sports Med Rep. 2005; 4 (2): 102–4. doi:10.1097/01.CSMR.0000306081.13064.a2. PMID 15763047.
6.Arce J, et al. "Sonographic diagnosis of acute spermatic cord torsion. Rotation of the cord: a key to the diagnosis". Pediatr Radiol. 2003; 32 (7): 485–91. doi:10.1007/s00247-002-0701-z. PMID 12107581.
2018.8.1