Torsion Undescended Testis


Undescended testis (UT) is absence of the testis in the scrotum. Occurs in 2% of the male population. It is more commonly found in babies born prematurely. When diagnosed is done after birth the UT is termed congenital. Acquired UT can occur later in life. 80% of UT are palpable within the inguinal canal, and 20% are non-palpable. Palpable UT are managed with orchiopexy before the age of one year. Imaging studies are not sufficiently reliable to determine presence or absence of a non-palpable UT. Non-palpable UT should undergo laparoscopy early in life to determine if the testis is viable and within an intraabdominal position. UT has a higher incidence than normal testes of infertility, cancer development (seminoma), atrophy, trauma and torsion. The most serious complications of UT are a high rate of infertility and high incidence of testicular cancer. Testicular torsion is 10 times more common in UT than normal positioned testis and 10% of all testicular torsion occur in UT. Most cases of UT torsion occur at an average age of 10 months. Abnormal contractions or spasms of the cremasteric muscle and adduction contractures of the hip called scissor-leg deformity that block entrance of the normal scrotum or forces the testes out are theories of why torsion in UT occurs. This is why is seen a higher incidence of UT torsion in children with cerebral palsy. Diagnosis of UT torsion is more difficult. The clinical symptoms of UT torsion include abdominal pain, groin pain, poor oral intake, vomiting and restlessness. Physical exam might include inguinal swelling and redness if the UT was in an inguinal position, with a painful mass in the inguinal region. Rapid diagnosis of UT torsion or any other gonad torsion is critical to preserve fertility. Doppler ultrasound and technetium scrotal scintigraphy scan studies can be diagnostic with the latter being preferred. US could find decrease or absent flow to the affected testis. Testicular scintigraphy with diffuse increased activity without any photopenic area can be the only sign of torsion in an UT. CT shows a well-circumscribed isodense or heterogenous mass and has fine anatomic detail in locating the affected UT with torsion. The treatment of choice for suspected acute UT torsion is immediate surgical exploration. The rate of testicular loss with UT torsion is very high along with the rate of developing an atrophic testis. With symptoms > 24 hours, no flow and no bleeding of the tunica albuginea orchiectomy is performed.   

References:
1- Artul S, Artoul F, Fahoum B, Nseir W, Nasrallah N, Habib G: Torsion of undescended third testis, as rare cause of painful inguinal mass. Case Rep Urol. 2015;2015:273508. doi: 10.1155/2015/273508. Epub 2015 Jan 26.
2- Shayegani H, Divband G, Tavakkoli M, Banihasan M, Sadeghi R: Torsion of the undescended testis detected by 99mTc testicular scintigraphy: a case report. Nucl Med Rev Cent East Eur. 2016;19(B):24-25. doi: 10.5603/NMR.2016.0034.
3- Naouar S, Braiek S, El Kamel R: Testicular torsion in undescended testis: A persistent challenge. Asian J Urol. 4(2):111-115, 2017
4- Iio K, Nomura O, Kinumaki A, Aoki Y, Satoh H, Sakakibara H, Hataya H: Testicular Torsion in an Infant with Undescended Testis. J Pediatr. 197:312-312, 2018
5- Kargl S, Haid B: Torsion of an undescended testis - A surgical pediatric emergency. J Pediatr Surg. 55(4):660-664, 2020
6- Shin J, Jeon GW: Comparison of diagnostic and treatment guidelines for undescended testis. Clin Exp Pediatr. 2020 Mar 23. doi: 10.3345/cep.2019.01438.


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