Undescended testis and torsion: is the risk understated?
- 1Department of Pediatric Urology, MITR Healthcare Hospital, Kharghar & MGM's New Bombay Hospital, Navi Mumbai, India
- 2Department of Pediatrics, MGM University of Health Sciences, Navi Mumbai, India
- 3Department of Urology, MITR Healthcare Hospital, Kharghar & MGM's New Bombay Hospital, Navi Mumbai, India
- 4Department of Pediatric Nephrology, MGM's New Bombay Hospital, Navi Mumbai, India
- Correspondence to Dr Arbinder Kumar Singal, Department of Pediatric Urology, MITR Healthcare Hospital, Kharghar & MGM's New Bombay Hospital, RH-5, O-26, Sector-7, Vashi, Navi Mumbai, Maharashtra-400703, India;
- Accepted 29 October 2012
- Published Online First 24 November 2012
Undescended testis (UDT) is seen in 3% to 5% of all newborn boys. Complications such as infertility and malignant transformation have been well documented in UDT. However, torsion of a UDT can also occur and the diagnosis is often missed or delayed, leading to loss of testis. This event may occur even before the currently recommended age for surgery, which is at 6–9 months. We present a case series of six children with torsion of undescended testes and their subsequent diagnosis and management. The risk of torsion of UDT is understated. Paediatricians should be educated about this complication and torsion should be included in the differential diagnosis when a boy with an empty scrotum presents with acute abdomen or red and tender swelling in the groin, as early detection and intervention can help salvage the testes.
Undescended testis (UDT) is one of the most common congenital anomalies occurring in 3% to 5% of newborn boys.1–3 Up to 75% of UDT spontaneously descend, even as late as 4–6 months of age, though this incidence has been recently questioned.1–4 The primary reasons for bringing the testis into a scrotal location are the risks of malignant degeneration and infertility. The recommended age for orchiopexy has gradually decreased in the last two decades from 5 years to a current recommendation of 6 months–1 year of age.1 ,3 ,5 ,6 This age has been arrived at based on two facts: (1) the UDT may naturally complete its descent in the first 4 months of life, and (2) the earliest documentation of testicular damage in a position of non-descent has been shown at 1 year of age.1–3 Although among the less commonly reported complications, UDT is also prone to torsion. Only a handful of cases have been described to date and there are no recommendations regarding management of undescended testes vis-a-vis this possible complication. We surmise that torsion in a UDT is in fact far more common than previously reported, and can result in loss of testis (figure 1) as compared to other possible complications such as infertility or testicular tumours, which may be noted only much later in adulthood.
Our experience and observations in six cases of torsion of UDT over last 2 years is summarised in table 1. Two representative cases given below highlight the circumstances and delays in diagnosis.
This patient was first seen at 2 months of age with a diagnosis of non-palpable left UDT. A re-examination was scheduled for 6 months of age. The child developed incessant crying at 4.5 months of age and the treating paediatrician advised medicines for colic. The next day, a tender groin swelling was noticed and the child was referred to Urology Services. A provisional diagnosis of torsion of UDT was made. An ultrasound Doppler examination showed an avascular left upper inguinal testis with coarse echotexture. On inguinal exploration the left testis had undergone torsion and was necrotic. A left orchiectomy was performed and contralateral testis was pexed.
This patient had Beal's syndrome (congenital contractural arachnodactyly, a rare variant of Marfan's syndrome) and was seen at 1 month of age for bilateral non-palpable UDT. While awaiting a follow-up at 6 months of age, he presented at 4 months of age with red and tender left inguinal swelling. An ultrasound Doppler scan showed the avascular left testis in the inguinal canal. Emergency inguinal exploration was performed and a left orchiectomy was performed. He later underwent laparoscopic orchiopexy for intra-abdominal right testis at 6.5 months of age.
During the first few months of life, a temporal surge in androgen activity, as seen by increased levels of gonadotropin and testosterone, leads to spontaneous testicular descent by 2–3 months of age. Hamza et al reported that in patients with spontaneous descent there is a high postnatal peak of luteinising hormone and testosterone at age 2–3 months as compared to patients without spontaneous descent.7 Other factors predicting spontaneous descent are low birth weight, large scrotal size, bilateral cryptorchidism and lower testicular location at presentation.8 The first case of testicular torsion in a UDT was reported in 1840.9 ,10 UDT is prone to torsion due to various reasons such as the lack of anatomic fixation of the gonads in the scrotum and the possibility of spasmodic contractions of the cremaster muscle.10 ,11 Further, polar attachment of gubernaculum and association of patent processus also allow the testes a degree of freedom to rotate, predisposing to torsion.
In the present series, left-sided predisposition for torsion was observed and this has also been reported by Zilberman et al.11 In the present series, the majority of undescended testes were non-palpable, and when these children (cases 1–3) presented with torsion the tender swelling was uniformly in the upper inguinal area, in the region of the internal ring. This is precisely the kind of emerging or ‘peeping’ testis that may have undergone torsion just after emerging from the internal ring in the upper inguinal canal.
Torsion in an intra-abdominal location may lead to severe lower quadrant pain, and signs and symptoms may mimic those of appendicitis if on the right side.11–13 Unfortunately, in small children this presentation may be misdiagnosed as colic and the resulting delay in treatment can lead to testicular necrosis and vanishing testis syndrome. A laparoscopy may be worthwhile for a diagnostic and therapeutic benefit.12
However, a hot, red and tender mass may be present if the torsion has occurred in the inguinal canal or at the external inguinal ring.11 Ikeuchi compiled 51 cases of torsion of undescended testes, and in 22 of 51 cases a preoperative diagnosis was available.13 The preoperative diagnosis was correct in only 12 of the 22 cases. Thus, the preoperative diagnosis is often elusive.
Differential diagnosis of a red, tender inguinal swelling in a young infant should include incarcerated inguinal hernia or inguinal lymphadenitis. While in an incarcerated hernia there may be associated abdominal distension or vomiting, an empty scrotum and a history should always alert the doctor towards torsion of UDT. Inguinal lymphadenitis will have a source such as a boil or a furuncle in the perineum or the lower extremities, and multiple lymph nodes may be palpable. Also, the location of these nodes is generally around the inguinal ligament. In case of any doubt, an expeditious ultrasonography (USG) Doppler may help in diagnosis.
Roche in 1933 made a recommendation towards creating more awareness of this condition; however, in textbooks and paediatric literature torsion of the UDT is often not described or only mentioned as a rare event. Because of lack of awareness among referring paediatricians, torsion of UDT is often recognised late and the testis is often unsalvageable, as seen in the present report. Considering that 3% to 4% of neonate boys are born with a UDT, there is a sizeable population at risk for this event. Further, the present study dwells only on the torsed testes, which were recognised as a tender groin lump and were evident due to their extra-abdominal location. This incidence may be an underestimation as torsion of an intra-abdominal testis may be frequently missed. According to current knowledge we know that a UDT rarely descends after 4 months and, given the incidence of torsion,4 consideration should be given towards an earlier age for orchiopexy. A larger study or a collaborative dataset from multiple centres for incidence of torsion of UDT should be collected to arrive at guidelines. Awareness among paediatricians about the possibility of torsion in a UDT will lead to earlier detection and diagnosis, and this may result in better testicular salvage rates.
UDT is at a higher risk for torsion and this may occur much before the recommended 6 months of age for surgery. We suggest a concerted effort towards creating awareness among referring doctors and caregivers to achieve earlier diagnosis. Collection of more data, maybe in the form of a registry, may help to draw better conclusions.
Contributors All the authors contributed equally towards identification and management of the cases. Additionally, AKS was responsible for manuscript preparation and final revision. VJ and MD were responsible for the literature search and manuscript writing and submission. PD was responsible for manuscript writing.
Competing interests None.
Patient consent Obtained.
Ethics approval MGM University of Health Science Ethics Committee.
Provenance and peer review Not commissioned; externally peer reviewed.