Case of the Week #563

O.V. Chursina, V.G. Volkov, O.V. Cherepenko
Tula Regional Perinatal Center

Posting Dates: July 15 - July 30, 2022

Reviewer:  Irina Tihonenko

A 33-year-old woman with no past medical history was followed at the Antenatal Clinic starting at 8 weeks gestation. She previously delivered two healthy children. Combined first-trimester screening was negative. The 2nd trimester screening done at 20-21 weeks showed fetal growth was consistent with gestational age. The patient had mild infection with COVID-19 at 24 weeks' gestation, thus underwent ultrasound examinations once every 3-4 weeks according to current guidelines. The following images were obtained at 33-34 weeks.

Image 1 © 2022 Chursina Olga
Image 2 © 2022 Chursina Olga
Image 3 © 2022 Chursina Olga
Video 1 © 2022 Chursina Olga
Video 2 © 2022 Chursina Olga

Type your content here.

View the Answer Hide the Answer

Answer

We present a case of antenatal left testicular torsion with irreversible sclerotic changes.

Our ultrasound examination revealed appropriate fetal growth, as well as normal amniotic fluid and placenta. Examination of the fetal scrotum showed a discrepancy in size between the right and left with the left side being smaller (Image 1). A rounded bean-shaped mass measuring 8.8 x 4.6 mm with a thick, hyperechogenic fibrous contour was detected in the left half of the scrotum. The normal structure of the left testis is not detected. The right fetal testis was normal (Image 2). On doppler imaging, there is absence of flow in the left hemiscrotum, and normal flow on the right side (Image 3). The left testicular appendages are not visualized. On dynamic observation, there is no peristaltic movement in the left half of the scrotum. The right scrotum shows a normal testicular structure with appendages. There is no hydrocele in the scrotum (Image 3).

  • Image 1: Asymmetry of the left and right halves of the fetal scrotum
  • Image 2: Bean-shaped formation of the left half of the fetal scrotum, the right testicle is normal
  • Image 3: Absence of blood flow in the left half of the fetal scrotum
  • Video 1: Hyperechoic contour of the formation of the left half of the fetal scrotum, the right testicle is normal
  • Video 2: Lack of blood flow in the left half of the fetal scrotum. No peristalsis identified.

The diagnosis of left testicular torsion with atrophy was made. Repeat ultrasound at 37-38 weeks' gestation showed the same findings in the scrotum

Postnatal ultrasound examination of the scrotum confirmed the prenatal diagnosis. The left half of the scrotum had no normal testicular structure. The testis was structureless with a hyperechogenic sclerotic contour, avascular, and there was no differentiation of the parenchyma and testicular appendage. The right testis was normal in size and structure (Image 1,2).

Normal structure of the contralateral right testicle of a newborn
Image 1 Normal structure of the contralateral right testicle of a newborn © 2022 Chursina Olga
Postnatal structure of the left testicle of a 3-day-old newborn
Image 2 Postnatal structure of the left testicle of a 3-day-old newborn © 2022 Chursina Olga

Given the presumed chronicity of the torsion, surgical treatment was not indicated. The prognosis for left testicular function is unfavorable, but, given the normal parameters of the right testicle, the reproductive potential should be intact.

Discussion

Perinatal testicular torsion is defined as occurring before 30 days of life. This includes both prenatal cases of testicular torsion as well as those diagnosed after birth. The prevalence of perinatal testicular torsion has been estimated at 1 in 80,000 male deliveries [1]. Approximately 80-85% of perinatal testicular torsion is identified at birth, suggesting the process began prenatally [2,3]. While most cases are unilateral, approximately 7-18% of cases are bilateral [2,3].

There are rare case reports of prenatal diagnosis of testicular torsion [1,4,5]. Testicular torsion is more commonly detected in the third trimester [1,4,5], though there have been reports of earlier events [6]. The presence of hydrocele can be an early sign of testicular torsion [7]. Prenatal ultrasound can show a “double ring hemorrhage,” which is an enlarged testes surrounded by two hypoechogenic fluid concentric layers [5]. This double layer is explained by accumulation of hemorrhagic fluid between the visceral and parietal layers of the tunicae vaginalis and outside the tunica vaginalis [5].

The differential diagnosis of testicular torsion includes inguinal hernia, scrotal tumor, orchiepididymitis, and torsion of the testicular-epididymal appendage [4].

The management of perinatal testicular torsion is debated. In a review of the literature including 59 cases of perinatal testicular torsion, there was a 0% salvage rate of the affected testicle [1]. Other series report a 6-7% salvage rate [2,3], though these cases were postnatal in onset [2] or salvage of a contralateral torsed gonad that was not suspected pre-operatively [3]. The most compelling reason for urgent exploration in neonates with unilateral torsion is suspected torsion of the contralateral viable gonad without obvious clinical or radiographic findings [2,3,8,9]. A prenatal diagnosis of unilateral torsion is not an indication for delivery unless there is imaging evidence that the torsion occurred within 24 hours. In cases of bilateral torsion diagnosed after 34 weeks, induced delivery and neonatal surgical intervention is advocated to attempt preservation of at least one testis [1].

References

[1] Melcer Y, Mendlovic S, Klin B et al. Fetal diagnosis of testicular torsion: what shall we tell the parents? Prenat Diagn. 2015 Feb;35(2):167-73.
[2] Kaye JD, Levitt SB, Friedman SC, et al. Neonatal torsion: a 14-year experience and proposed algorithm for management. J Urol. 2008 Jun;179(6):2377-83.
[3] Abraham MB, Charles A, Gera P, et al. Surgically managed perinatal testicular torsion: a single centre experience. J Matern Fetal Neonatal Med. 2016;29(8):1265-8.
[4] Devesa R, Muñoz A, Torrents M, et al. Prenatal diagnosis of testicular torsion. Ultrasound Obstet Gynecol. 1998 Apr;11(4):286-8.
[5] Herman A, Schvimer M, Tovbin J, et al. Antenatal sonographic diagnosis of testicular torsion. Ultrasound Obstet Gynecol. 2002 Nov;20(5):522-4.
[6] Sauvestre F, André G, Harran MH, et al. Prenatal Testicular Torsion: Not Always in the Late Third Trimester. Urology. 2016 Mar;89:132-3.
[7] Arena F, Nicòtina PA, Romeo C, et al. Prenatal testicular torsion: ultrasonographic features, management and histopathological findings. Int J Urol. 2006 Feb;13(2):135-41.
[8] Roth CC, Mingin GC, Ortenberg J. Salvage of bilateral asynchronous perinatal testicular torsion. J Urol. 2011 Jun;185(6 Suppl):2464-8.
[9] Yerkes EB, Robertson FM, Gitlin J, et al. Management of perinatal torsion: today, tomorrow or never? J Urol. 2005 Oct;174(4 Pt 2):1579-82.

With thanks to the great Philippe Jeanty in whose article I found the correct diagnosis

Discussion Board

Start a discussion about this case

Winners

Dianna Heidinger Profile Pic

Dianna Heidinger United States Sonographer

Javier Cortejoso Profile Pic

Javier Cortejoso Spain Physician

Danilo Feitosa Profile Pic

Danilo Feitosa Brazil Physician

Fatih ULUC Profile Pic

Fatih ULUC Turkey Physician

Umber Agarwal Profile Pic

Umber Agarwal United States Physician

Igor Yarchuk Profile Pic

Igor Yarchuk Ukraine Physician

Cem Sanhal Profile Pic

Cem Sanhal Turkey Physician

Ana Ferrero Profile Pic

Ana Ferrero Spain Physician

Mayank Chowdhury Profile Pic

Mayank Chowdhury India Physician

filiz halici öztürk Profile Pic

filiz halici öztürk Turkey Physician

Oskar Sylwestrzak Profile Pic

Oskar Sylwestrzak Poland Physician

DAVID BEAUMONT Profile Pic

DAVID BEAUMONT United Kingdom Physician

Lames Ghith Profile Pic

Lames Ghith United States Physician

Tatyana Koipish Profile Pic

Tatyana Koipish Belarus Physician

Sara Abdallah Salem Profile Pic

Sara Abdallah Salem Egypt Physician

Halil Mesut Profile Pic

Halil Mesut Turkey Physician

Rushina Patel Profile Pic

Rushina Patel United States Sonographer

Rebecca Evans Profile Pic

Rebecca Evans Australia Sonographer

Suat İnce Profile Pic

Suat İnce Turkey Physician

Rime NSEIR Profile Pic

Rime NSEIR France Physician

Liem Dang Le Profile Pic

Liem Dang Le Viet Nam Physician

Elena Andreeva Profile Pic

Elena Andreeva Russian Federation Physician

muradiye yıldırım Profile Pic

muradiye yıldırım Turkey Physician

Ta Son Vo Profile Pic

Ta Son Vo Viet Nam Physician

ALBANA CEREKJA Profile Pic

ALBANA CEREKJA Italy Physician

SAMUEL GELVEZ TELLEZ Profile Pic

SAMUEL GELVEZ TELLEZ Colombia Physician

Murat Cagan Profile Pic

Murat Cagan Turkey Physician

Rasha Abo Almagd Profile Pic

Rasha Abo Almagd Egypt Physician

Ionut Valcea Profile Pic

Ionut Valcea Romania Physician

José Lambertino Profile Pic

José Lambertino Colombia Physician

Elham Eghbali Profile Pic

Elham Eghbali Iran, Islamic Republic of Radiologist

KHALED RAMADAN Profile Pic

KHALED RAMADAN Egypt Physician

mahmoud elbohy Profile Pic

mahmoud elbohy Egypt Physician

Katie Montagne Profile Pic

Katie Montagne United States

Ramesh Giti Profile Pic

Ramesh Giti United States Physician

TATIANA VOLKOVA Profile Pic

TATIANA VOLKOVA Kyrgyzstan Physician

SUSAN FORDEN Profile Pic

SUSAN FORDEN Australia Sonographer

Add bookmark Bookmarked

Menu