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Desai C, Raghuvanshi K, Panesar H, Murali V. Importance of Touch: Managing Testicular Torsion in a 28-Year-Old With Duchenne Muscular Dystrophy. Cureus 2022; 14:e22775. [PMID: 35371864 PMCID: PMC8971100 DOI: 10.7759/cureus.22775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2022] [Indexed: 11/10/2022] Open
Abstract
This case report highlights a case of testicular torsion in a man over the age of 25 with Duchenne muscular dystrophy (DMD), who presented with an atypical pain history, and a Testicular Workup for Ischaemia and Suspected Torsion (TWIST) score negative for exploration. However, based purely on the examination findings, scrotal exploration was performed and a torted testis was found. The report demonstrates that in this cohort of patients, a higher index of suspicion is needed to ensure early recognition of the condition. Furthermore, scrotal exploration can be safely conducted under local anaesthesia given the multiple cardiovascular and spinal co-morbidities attributed to DMD.
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The bell-clapper deformity of the testis: The definitive pathological anatomy. J Pediatr Surg 2021; 56:1405-1410. [PMID: 32762939 DOI: 10.1016/j.jpedsurg.2020.06.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 06/16/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The bell-clapper deformity (BCD) predisposes to intravaginal torsion (IVT) and is classically bilateral. The precise pathological definition of what constitutes a BCD is not clear. The current study aims to clarify the specific anatomic details of this anomaly. METHODS A systematic review was performed utilizing the PRISMA principles. Studies are presented chronologically based on their level of evidence. They are further divided into study types: autopsy and operative studies of acute torsion, intermittent torsion and studies of the contralateral testis in vanishing testis. RESULTS The bell-clapper deformity is best defined by complete investment of the testis, epididymis and a length of the spermatic cord by the tunica vaginalis. Based on autopsy studies the rate of BCD in scrotal testis varied from 4.9% to 16%; with bilaterality in 66%-100%. In cases of acute IVT bilaterality was noted in 54%-100%. The most disparate results were in cases of testicular regression syndrome where contralateral BCD was noted in 0%-87% of cases. CONCLUSION We suggest future studies employ the strict anatomical definition above. As there is evidence of age-dependent investment of the testes, it will be important to develop age-standardized measurements of intravaginal length of spermatic cord. This critical morphometric measurement will allow a better understanding of the risk of IVT. LEVEL OF EVIDENCE Systematic review of diagnostic studies: lowest level of evidence of included manuscripts Level IV (case-control studies with a poor reference standard).
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Zheng WX, Hou GD, Zhang W, Wei D, Gao XL, Chen MH, Huang LG, Yan F, Zhang G, Yu L, Liu F, Zhang B, Yuan JL. Establishment and internal validation of preoperative nomograms for predicting the possibility of testicular salvage in patients with testicular torsion. Asian J Androl 2021; 23:97-102. [PMID: 32687070 PMCID: PMC7831831 DOI: 10.4103/aja.aja_31_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This study aimed to establish nomograms to preoperatively predict the possibility of testicular salvage (TS) in patients with testicular torsion. The clinical data of 204 patients with testicular torsion diagnosed at Xijing Hospital and Tangdu Hospital (Xi'an, China) between August 2008 and November 2019 were retrospectively analyzed. Univariate and multivariate logistic regression analyses were used to determine the independent predictors of TS. Based on multivariate regression coefficients, nomograms to predict possibility of TS were established. The predictive ability of the nomograms was internally validated by receiver operating characteristic (ROC) curves and calibration plots. The duration of symptoms ranged from 2 h to 1 month, with a median of 3.5 days. Thirty (14.7%) patients underwent surgical reduction and contralateral orchiopexy, while the remaining 174 (85.3%) underwent orchiectomy and contralateral orchiopexy. Finally, long symptom duration was an independent risk predictor for TS, while visible intratesticular blood flow and homogeneous testicular echotexture under color Doppler ultrasound were independent protective predictors. Internal validation showed that the nomograms, which were established by integrating these three predictive factors, had good discrimination ability in predicting the possibility of TS (areas under the ROC curves were 0.851 and 0.828, respectively). The calibration plots showed good agreement between the nomogram-predicted possibility of TS and the actual situation. In conclusion, this brief preoperative prediction tool will help clinicians to quickly determine the urgency of surgical exploration.
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Affiliation(s)
- Wan-Xiang Zheng
- Department of Urology, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Guang-Dong Hou
- Department of Urology, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Wei Zhang
- Department of Urology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China
| | - Di Wei
- Department of Urology, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Xue-Lin Gao
- Department of Urology, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Mei-Hong Chen
- Department of Urology, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Lu-Guang Huang
- Information Center, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Fei Yan
- Department of Urology, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Geng Zhang
- Department of Urology, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Lei Yu
- Department of Urology, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Fei Liu
- Department of Urology, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Bo Zhang
- Department of Urology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China
| | - Jian-Lin Yuan
- Department of Urology, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
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Syed MK, Al Faqeeh AA, Othman A, Hussein AA, Hussain S, Almas T, Alsufyani R, Alaeddin H, Syed S, Syed SK. The Spectrum of Testicular Pathologies Upon Scrotal Exploration for Acute Scrotum: A Retrospective Analysis. Cureus 2020; 12:e10984. [PMID: 33209540 PMCID: PMC7667721 DOI: 10.7759/cureus.10984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background The term acute scrotum encompasses a plethora of testicular pathologies that are detrimental to the survival and sustenance of testes. The aim of the present study is to determine the spectrum of these testicular pathologies upon scrotal exploration performed in the aftermath of acute scrotal pain in the pediatric population. Methods This multicenter retrospective cross-sectional study was conducted at the department of pediatric surgery at two hospitals. During the study period, the clinical characteristics of the 76 patients that underwent scrotal exploration for acute scrotum were assessed. These included age, duration of symptoms on presentation, and identification of the etiology underlying scrotal pain. The data obtained was eventually analyzed using the Statistical Package for the Social Sciences (SPSS) 23.0 software (IBM Corp., Armonk, NY). Results A total of 76 scrotal exploration procedures were performed. The involvement of the left side of the scrotum was more common than the right side. Most of the patients who presented were older than five years of age. A majority of the patients presented after 24 hours of the commencement of their symptoms. Of the included participants, 36 patients (47.47%) were found to have an underlying torsion of appendix testes that was appropriately managed. Testicular torsion was observed in 15 patients, out of which eight viable testes were salvaged with a subsequent orchidopexy while seven torsions required orchiectomy owing to their non-viability. Other findings included epididymo-orchitis and infected hydrocele. A total of 19 testes appeared completely normal upon scrotal exploration. Conclusion Scrotal exploration should be considered as part of the medical and surgical workup and in the management of acute scrotum, as it divulges the specific underlying testicular pathology. Prompt scrotal exploration can aid in ascertaining the underlying etiology and is, therefore, pivotal in the apt management of the underlying pathology.
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Affiliation(s)
| | | | - Alsayed Othman
- Pediatric Surgery, Al-Azhar University - Assuit Branch, Assuit, EGY
| | | | - Salman Hussain
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Talal Almas
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Reema Alsufyani
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Hasan Alaeddin
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Saifullah Syed
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Sabahat K Syed
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
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Tokuda B, Kiba M, Yamada K, Nagano H, Miura H, Goto M, Yamada K. The split sign: The MRI equivalent of the bell clapper deformity. Br J Radiol 2019; 92:20180312. [PMID: 30604623 DOI: 10.1259/bjr.20180312] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
METHODS: The cases of eight patients who underwent MRI and surgery for acute scrotum between January 2010 and January 2017 were evaluated. We recorded whether hyperintense fluid on T2 weighted images existed between the posterior aspect of the epididymis and the scrotal wall ("split sign") and investigated if it correlated with BCD in surgical findings. RESULTS: In one patient without hydrocele, readers were unable to evaluate the anatomy of the tunica vaginalis. Among seven patients with hydrocele, five had the split sign and all were surgically confirmed as BCD. In two patients with hydrocele but no split sign, one had normal scrotal anatomy and the other had a BCD with a necrotic testis adherent to the scrotal wall. CONCLUSION: The split sign on MRI corresponded well to the lack of fixation of the epididymis to the scrotal wall and detected BCD with high sensitivity (5/6). ADVANCES IN KNOWLEDGE: A hyperintense area on T2 weighted image between the posterior aspect of the epididymis and scrotal wall ("split sign") is a useful MRI finding for diagnosing BCD.
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Affiliation(s)
- Bunta Tokuda
- 1 Department of Radiology, Kyoto Prefectural University of Medicine , Kyoto , Japan
| | - Maki Kiba
- 1 Department of Radiology, Kyoto Prefectural University of Medicine , Kyoto , Japan
| | - Kaori Yamada
- 1 Department of Radiology, Kyoto Prefectural University of Medicine , Kyoto , Japan
| | - Hitomi Nagano
- 1 Department of Radiology, Kyoto Prefectural University of Medicine , Kyoto , Japan
| | - Hiroshi Miura
- 1 Department of Radiology, Kyoto Prefectural University of Medicine , Kyoto , Japan
| | - Mariko Goto
- 1 Department of Radiology, Kyoto Prefectural University of Medicine , Kyoto , Japan
| | - Kei Yamada
- 1 Department of Radiology, Kyoto Prefectural University of Medicine , Kyoto , Japan
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West JM, Goates AJ, Brown JA. A 26-Year-Old Male with a 14-Year History of Left Intermittent Testicular Torsion Treated with Self-Manual Reduction. Curr Urol 2018; 11:166-168. [PMID: 29692698 DOI: 10.1159/000447213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 12/06/2017] [Indexed: 11/19/2022] Open
Abstract
Intermittent testicular torsion presents with recurrent episodes of severe unilateral testicular pain with resolution of symptoms between episodes. We present a case of a 26-year-old man with a 14-year history of intermittent testicular pain presenting to the urology clinic for elective surgical evaluation. He reported monthly symptoms for many years and had learned to manually reduce the torsion with each episode. Diagnosis of intermittent testicular torsion was made based on patient history and treatment with bilateral orchiopexy resulted in complete symptom resolution and without any loss of testicular function.
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Affiliation(s)
- Jeremy M West
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Andrew J Goates
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - James A Brown
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Tatem A, Kovac JR. Chronic scrotal pain and microsurgical spermatic cord denervation: tricks of the trade. Transl Androl Urol 2017; 6:S30-S36. [PMID: 28725615 PMCID: PMC5503921 DOI: 10.21037/tau.2017.05.17] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Every practicing urologist encounters patients complaining of chronic scrotal content pain (CSCP). This condition can be equally frustrating for both patients and clinicians as there are no clear treatment guidelines, or pathways, for urologists to follow. As a result, most patients typically seek out multiple providers without improvements in their symptoms. Fortunately, microsurgical spermatic cord denervation (MSCD) is becoming an accepted, reliable and reproducible technique for definitively addressing CSCP in select patients. This manuscript reviews the background, effectiveness and current practice guidelines for scrotal pain in general, and MSCD in particular. Technical insights into how this technique can be performed both safely, and efficaciously, are provided. Finally, the manuscript presents a simple, yet detailed, easy to follow treatment algorithm to aid all urologists in the management of patients presenting with chronic pain.
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Affiliation(s)
- Alex Tatem
- Department of Urology, Indiana University, Indianapolis, IN, USA
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