Acquired undescended testis and possibly associated testicular torsion in children with cerebral palsy or neuromuscular disease

Comparison of clinical features and outcomes between two age groups of cryptorchidism testicular torsion in children: a retrospective study in single center

Objective

The purpose of this study was to compare the clinical characteristics and outcomes of children with cryptorchidism testicular torsion between the younger age group and the older age group.

Methods

We collected the clinical data of children with cryptorchidism complicated with testicular torsion in our hospital from January 1, 2013 to January 1, 2023. The patients were divided into two groups: the younger age group (1month∼4 years old, n = 7) and the older age group (4∼18 years old, n = 7). The differences of clinical manifestations and surgical results between the two groups were compared.

Results

A total of 14 patients with unilateral cryptorchidism testicular torsion were included in this study, including 9 on the left side and 5 on the right side. The main clinical manifestations were pain /swelling of groin. The rate of crying in the younger age group was significantly higher than those in the older age group [(5,71.4%) vs. (0,0.0%), P < 0.05]. The median duration of symptoms of the younger group was less than the older group [42(7,96) h vs. 70(24, 96) h, P > 0.05]. The ipsilateral testicular salvage rate in the younger age group was 14.3% (1/7), which was lower than the older age group 57.1% [(4/7), P > 0.05]. The degree of testicular torsion in younger age group was more severe than the older age group [720(360, 1,080)° vs. 360(270, 360)°, P > 0.05].

Conclusions

The overall salvage rate of cryptorchidism testicular torsion is low. Although the duration of symptoms in the older age group was longer, the salvage rate of the older age group seemed to be higher than that in the younger age group. In addition, physical and imaging examination of the reproductive system should be carried out in time to identify the children with cryptorchidism testicular torsion in the early stage.

Point-of-care ultrasonography for the diagnosis and manual detorsion of testicular torsion

Testicular torsion is a urological emergency caused by the loss of testicular tissue due to ischemic damage. Rapid diagnosis and urgent treatment play a crucial role in the management of testicular torsion. Manual detorsion can be performed at the bedside, thereby reducing the duration of ischemia. Recent studies have reported the use of point-of-care ultrasonography for diagnosing testicular torsion; however, no review article has focused on the ultrasonographic findings pertaining to manual detorsion. This review describes the diagnosis of testicular torsion and the ultrasonographic indications for manual detorsion. Spermatic cord twisting or the whirlpool sign, absence of or decreased blood flow within the affected testis, abnormal testicular axis, abnormal echogenicity, and enlargement of the affected testis and epididymis due to ischemia are the sonographic findings associated with testicular torsion. The following findings are considered indications for manual detorsion: direction of testicular torsion, i.e., inner or outer direction (ultrasonographic accuracy of 70%), and the degree of spermatic cord twist. The following sonographic findings are used to determine whether the treatment was successful: presence of the whirlpool sign and the degree and extent of perfusion of the affected testis. Misdiagnosis of the direction of manual detorsion, a high degree of spermatic cord twisting and insufficient detorsion, testicular compartment syndrome, and testicular necrosis were found to result in treatment failure. The success of manual detorsion is determined based on the symptoms and sonographic findings. Subsequent surgical exploration is recommended in all cases, regardless of the success of manual detorsion.

Association between lower limb spasticity and cryptorchidism in males with cerebral palsy

AIM

To explore the association between presence and severity of lower limb spasticity (LLS) and risk of orchidopexy for cryptorchidism among people with cerebral palsy (CP) and to further define the cremasteric muscle spasticity theory.

METHOD

We queried the Pediatric Health Information System database for male patients with CP, stratified patients into those with/without LLS, and compared groups for orchidopexy occurrence. Comparative statistics were performed using χ2 and Mann-Whitney U tests for categorical and continuous variables respectively. The association between orchidopexy and spasticity type was investigated using logistic regression.

RESULTS

In total, 44 561 males with CP were identified. Of these, 1.6% underwent orchidopexy (median age: 7 years 8 months [interquartile range: 4 years 6 months-11 years 4 months]). LLS presence was significantly associated with higher orchidopexy rate compared to spasticity absence (odds ratio [OR] = 1.33 [1.10-1.59], p = 0.003). Among 7134 patients with LLS, intervention was significantly associated with higher orchidopexy rate (injection procedures: OR = 2.47 [2.27-6.39], p = 0.034; surgical procedure: OR = 2.60 [1.22-6.76], p = 0.026). LLS groin proximity was significantly associated with higher orchidopexy rate (OR = 2.52 [1.42-4.96], p = 0.003).

INTERPRETATION

A strong association exists between LLS presence and severity and orchidopexy risk among people with CP. These findings support a cremasteric spasticity hypothesis as an important factor of cryptorchidism in CP. Providers should continue to examine for cryptorchidism in males with CP as they age.

WHAT THIS PAPER ADDS

Lower limb spasticity (LLS) is associated with higher orchidopexy rate in cerebral palsy. Orchidopexy rate was higher in more severe LLS. Orchidopexy rate was higher in more proximal LLS.

Alterations in testicular positioning after normal descent: acquired cryptorchidism

BACKGROUND

Acquired cryptorchidism or acquired undescended testis (UDT) is defined as the displacement of a testicle outside the scrotal sac after normal descent has been verified. There are still no clear guidelines on its management.

OBJECTIVES

To analyze patients who underwent surgery for UDT in our setting to determine the prevalence of acquired cryptorchidism and to analyze the demographic and clinical characteristics of the population of children diagnosed with both acquired and congenital cryptorchidism, the age of presentation of both entities and the percentage of bilateral involvement.

MATERIALS AND METHODS

This was a retrospective descriptive study using data from the clinical history of patients who underwent surgery for cryptorchidism between 2011 and 2022. The type of cryptorchidism, acquired or congenital, was recorded. Demographic and clinical data were collected.

RESULTS

A total of 367 patients and 442 testicular units were included in the study (75 patients had bilateral involvement). In 54.75% (95% CI: 50.09%-59.40%) of the cases analyzed, cryptorchidism was acquired, and the mean age at the time of surgery was 7.39 years (SD 2.95). Twenty percent (95% CI: 16.29%-24.58%) of the patients presented with bilateral cryptorchidism and 64% (95% CI: 52.88%-75.11%) out of them were acquired on both sides. The diagnosis was metachronous in 42.6% (95% CI: 31.21%-54.12%) of bilateral cryptorchidism cases.

DISCUSSION AND CONCLUSION

Acquired cryptorchidism accounts for more than half of cryptorchidism cases requiring surgery in our setting, with a clearly different age of presentation than that for congenital cryptorchidism. Therefore, it is necessary to monitor the presence of the testes in the scrotal sac until adolescence. It is also important to monitor patients with a history of cryptorchidism, not only for the management of the operated testicle but also for the early identification of patients who will develop metachronous contralateral cryptorchidism.

Point-of-Care Ultrasound for Mimicker Lesions of Incarcerated Inguinal Hernia

Inguinal hernia is the most common surgical disease in pediatric patients, and urgent intervention such as manual reduction is needed for incarcerated inguinal hernia. Torsion of undescended testes, inguinal herniated ovarian torsion, and purulent lymphadenitis are mimickers of this condition. If these mimicker lesions are misdiagnosed as incarcerated inguinal hernia, manual reduction usually fails, and edematous and erythematous changes may occur in these mimicker lesions due to manual reduction. For physicians in the emergency department, prompt decisions and familiarity with the sonographic appearance of different contents within an inguinal hernia are important to accurately diagnose these mimickers. In this case series, we present sonographic images of a typical case of incarcerated inguinal hernia (an 11-month-old male with right incarcerated inguinal hernia) and three cases of mimicker lesions (a 7-month-old female with herniated ovarian torsion, a 7-year-old boy with undescended testicular torsion, and a 2-month-old male with purulent lymphadenitis). The incidence of incarcerated inguinal hernia is reported to be higher in males (80%), on the right side (60%), and in infants and toddlers. This information is important for diagnosing mimicker lesions. In addition, to prevent manual reduction in mimicker diseases, point-of-care ultrasound before manual reduction in suspected cases of incarcerated inguinal hernia is important.

Diagnosis and treatment of cryptorchid testicular torsion in children: A 12-year retrospective study

PURPOSE

To investigate the clinical characteristics, treatment, and prognosis of cryptorchid testicular torsion in children.

METHODS

The clinical data of 25 children who received treatment for cryptorchid testicular torsion between January 2010 and December 2021 were retrospectively reviewed. The median age of the patients was 64.5 months (range: 2 months to 15 years). All patients had unilateral torsion, and the duration of symptoms ranged from 3 to 192 h.

RESULTS

Among the 25 patients, five underwent orchidopexy, while the remaining 20 underwent orchiectomy. After 6 months to 8 years of follow up, the 20 patients who had undergone orchiectomy had a well-developed testis on the healthy side. Four of the five patients who had undergone orchidopexy of the affected testis had well-developed testes bilaterally, while one experienced testicular atrophy.

CONCLUSION

Cryptorchid testicular torsion is a rare urological emergency that displays a delayed presentation and is often misdiagnosed. Clinicians need to carefully review the patient's medical history and ultrasound findings and perform a thorough physical examination to make a correct diagnosis. Active testicular exploration is required for patients suspected to have cryptorchid testicular torsion, and the decision to perform orchidopexy or orchiectomy depends on the intraoperative situation.

Diagnosis, treatment, outcome, and reasons for delayed treatment of cryptorchidism with torsion in children: a 16-year retrospective study in a large pediatric medical center

We describe and summarize the diagnosis, treatment, and reasons for delayed treatment of children with cryptorchidism torsion in Children's Hospital of Chongqing Medical University. The study included 19 cases of cryptorchidism torsion. The age of the children ranged from 16 days to 12 years (median: 6 years). The interval from diagnosis to surgery varied from 4 h to 16 days (median: 3 days). Ultrasound was performed in all cases. Fifteen cases had cryptorchidism torsion, 2 cases had a soft tissue mass in the inguinal region, and 2 cases had an inguinal/abdominal teratoma. Five cases were treated with an orchidopexy, 12 cases were treated with orchiectomy, and 2 cases received resection of a testicular tumor. The 5 children with an orchidopexy were followed up from 1 month to 7 years (median: 3 years), with 1 child having a testis retraction and no blood supply. Of the 12 children who had an orchiectomy, three had delayed diagnosis due to family unawareness of the condition, while other delays were due to delayed referral from primary care facilities. The relative rarity and insufficient awareness of cryptorchidism torsion resulted in a low rate of testicular salvage. Therefore, hospitals of all levels should be fully aware of cryptorchidism with torsion and ensure a male child's genital system and inguinal region are examined to improve the success rate of testicular salvage.

A multicenter review of undescended testis torsion: A plea for early management

INTRODUCTION

Torsion of an undescended testis (UT) is a surgical emergency, difficult to diagnose, whose prognosis depends on a quick management.

AIM OF THE STUDY

To evaluate the management and outcome of these patients.

STUDY DESIGN

We retrospectively analyzed all cases of UT torsion operated in nine French hospitals between 1997 and 2017. We divided patients in two groups: patients referred less than 6 h after the onset of symptoms (group A) or more than 6 h (group B).

MAIN RESULTS

We collected 60 cases (17 in group A and 43 in group B). Median age was 2.2 years [IQR = 0.7-7.8] (2.3 y in group A and 2 y in group B, p = 0.76). Eleven patients (10 in group B) had neurological disorders (p = 0.15). The main reason for absence of UT treatment was the absence of surgical consultation in a normal delay (n = 44, 73%). Symptoms were pain (n = 58, 97%), inguinal mass (n = 55, 92%) and vomiting (n = 16, 27%). An inguinal mass with no palpable testis in the ipsilateral hemiscrotum was seen in 55 patients (92%). An ultrasound scan performed in 27 patients led to the diagnosis in 16 patients (59%). At surgery, an orchiectomy was performed in 4 patients (23%) of group A and 24 patients (56%) of group B (p = 0.04). After a median follow-up of 11 months [IQR = 4-23], 11 patients of group A (65%) and 7 patients of group B (16%) had a clinically normal testis (p = 0.03). The salvage rate among patients with conservative treatment was 85% for group A and 37% for group B (p = 0.01).

DISCUSSION

Our study reveals that although UT torsion is an emergency, 72% of patients are referred more than 6 h after the onset of symptoms. We mostly found classic clinical presentation of UT torsion: a painful inguinal mass with an empty ipsilateral scrotum. Ultrasound was performed in half cases, and even if the result was not significant, it still seemed to be associated with a higher rate of orchiectomy especially in group B because of the delay in care. However, when ultrasound was realized early, it led to diagnosis in all cases. This dilemma poses the problem of the role of imaging in diagnostic management.

CONCLUSIONS

Early clinical diagnosis in front of a painful inguinal mass with an empty scrotum is essential to improve the salvage rate of testis in UT torsion. Early management of UT should have avoided 68% of testis loss.

Is Testicular Torsion a Real Problem in Pediatric Patients With Cryptorchidism?

Purpose: To present management and outcomes of patients with cryptorchidism suffering from testicular torsion. Methods: This is a retrospective review of pediatric patients with torsion of undescended testes, who were treated between 2009 and 2019. We recorded: the age, symptoms, duration of torsion, results of physical examination, surgery findings, and additional treatment. Additionally, an extensive online literature search, from 2015-2020, was performed to identify other similar case series. Results: We identified 9 boys with torsion of the undescended gonad, which represented 4.7% of all 192 boys with testicular torsion. The mean age of boys with torsion of undescended testis was 8.7 years. The mean duration of symptoms in our study group was long and it was up to 28.5 h. All patients had inguinal canal exploration. In eight cases, testicular necrosis and primary orchidectomy was performed. Furthermore, 45 cases were identified in the literature and reviewed. Conclusion: According to clinical experience and available studies, torsion of male undescended gonads is a comparatively rare condition. Nevertheless, diagnosis is still delayed and connected with inevitable orchidectomy.