BJU International (1999), 83, 1023–1025

Intra-uterine testicular torsion: early diagnosis and treatment

A.H. AL-SALEM
Division of Paediatric Surgery, Department of Surgery, Qatif Central Hospital, Qatif, Saudi Arabia

Objective To review the incidence and treatment of
intra-uterine torsion of the testis which although rare
is being recognized with increasing frequency.
Patients and methods From 1988 to 1997, five newborns
(mean birth weight 3.62 kg, range 3.15–4.12) with
unilateral torsion of the testis were treated; all under-
went emergency exploration. The right testis was
aCected in three and the left in two boys.
Results In all except one child, the aCected testis was
enlarged, firm to hard, tender, the overlying skin dark
red and the aCected testis higher than the contralateral
testis. In one child the right testis was enlarged and
higher, but soft to firm, and the overlying skin was
oedematous and red. The exploration revealed extrava-
ginal torsion of the testis which was gangrenous in
four; in one after detorsion there was haemorrhage
and haematoma of the cord and the tunica, and the
testis was slightly congested but not gangrenous. This
testis was preserved and bilateral orchidopexies per-
formed; at 18 months both testes are palpable and of
normal size. In the remaining four children the testes
were frankly necrotic; they underwent orchidectomy
and contralateral orchidopexy. Histology in all four
revealed a totally infarcted testis with extensive haem-
orrhage and vascular congestion.
Conclusion The early diagnosis and treatment of intra-
uterine torsion of the testis is essential.
Keywords Torsion of the testis, intra-uterine, treatment

Table 1 The characteristics of five newborns with intrauterine

Introduction testicular torsion; all were spontaneous normal vaginal deliveries
and all were full-term
Intra-uterine torsion of the testis, a rare condition in the
neonatal period, was first described by Taylor in 1897 Birth weight Status
[1]. Since then, it has been recognized with increasing No. (kg) Side of testis Treatment
frequency, but despite this, controversy and questions
remain over the management of this condition. Although 1 3.57 L Necrotic L orchidectomy
there is now consensus about the need for contralateral R orchidopexy
exploration and orchidopexy, the timing of surgical 2 4.12 R Necrotic R orchidectomy
intervention remains in debate [2–6]. This papers reports L orchidopexy
3 3.15 R Viable Bilateral
five newborns with intra-uterine torsion of testis; pre-
orchidopexy
vious studies are reviewed and aspects of management 4 3.96 L Necrotic L orchidectomy
discussed. R orchidopexy
5 3.32 R Necrotic R orchidectomy
L orchidopexy
Patients and methods
Five newborns with unilateral torsion of the testis were R, Right. L, Left.
treated between 1988 and 1997; their characteristics
and method of treatment are given in Table 1. All were
born after a full-term normal vaginal delivery, and were Results
healthy with good birth weights (mean 3.62 kg, range In all except one patient the aCected testis was enlarged,
3.15–4.12). Their Apgar Scores were 9 and 10 at 1 and firm to hard, tender, with the overlying skin dark red,
5 min, respectively; one was born to a diabetic mother. and the aCected testis higher than the contralateral testis
The right testis was aCected in three and the left in two; (Fig. 1). In patient no. 3, the right testis was enlarged
all underwent an emergency exploration. and higher, but soft to firm with the overlying skin
oedematous and red. Physical examination revealed no
other abnormalities. The emergency exploration revealed
Accepted for publication 23 February 1999 extravaginal torsion of the testis, which was gangrenous

© 1999 BJU International 1023

1024 A.H. AL-SALEM
Fig. 1. The enlarged left scrotum, dark red and higher than the
left side.
in four patients (Fig. 2). In patient no. 3 after detorsion
there was haemorrhage and haematoma of the cord and
the tunica; the testis was slightly congested but not
gangrenous (Fig. 3). This testis was preserved and bilat-
eral orchidopexies undertaken. Postoperatively, the
patient fared well and was discharged home after 7 days.
Currently he is 18 months old, and both testes are
palpable and of normal size. In the remaining four
patients, the testes were frankly necrotic and orchidec-
tomy and contralateral orchidopexy were undertaken in
Fig. 2. Intraoperative photograph showing an enlarged necrotic
testis.
Fig. 3. Intraoperative photograph showing a healthy but congested
and slightly enlarged testis. Note the congested oedematous cord
after detorsion.
each. The histology in all four revealed totally infarcted
testes with extensive haemorrhage and vascular
congestion.
Discussion
Intra-uterine torsion of the testis can aCect the right side
as often as the left and is occasionally bilateral [2,7,8];
when bilateral it can be synchronous or asynchronous
[8]. It is commonly seen in full-term infants with birth
weights above the mean; the reported mean (range)
birth weight in such patients is 3.6 (2.9–4.2) kg [2]. All
five patients in the present series had birth weights of
> 3 kg (Table 1). The cause of the relationship between
high birth weight and the occurrence of intra-uterine
torsion is unknown, although higher pressures in the
uterus or birth canal have been proposed as predisposing
factors [4].
The precise aetiology of intra-uterine torsion of the
testis is unknown. A higher birth weight, trauma from
diBcult labour or breech presentation, and an overactive
cremasteric reflex have been implicated, but the most
commonly accepted theory is that extreme mobility of
the neonatal tunica vaginalis within the scrotum allows
torsion to occur in the presence of an active cremasteric
reflex [7]. Most authors propose that torsion is usually
a prenatal event, but the exact timing of torsion is not
known. Tripp and Homsy [9] reported a case of bilateral
neonatal torsion diagnosed prenatally at 34 weeks’
gestation and Hubbard et al. [10] reported a case of
unilateral torsion at 35.5 weeks’ gestation. Most cases
are apparent at birth but there are reports of torsion
occurring after delivery or within the first week after
birth [2,7].
Although the aCected testis is almost invariably nec-
rotic at surgery, emergency exploration is advocated.
This is clearly shown in patient no. 3, where the testis
© 1999 BJU International 83, 1023–1025

would not have survived if emergency surgery had been
omitted or delayed. The torsion in this patient probably
occurred during or immediately before delivery. This is
supported by the softer consistency of the aCected testis
in this patient compared with that in the other four. In
two other previous reports, the testes were salvaged as
a result of early exploration [2,3]. Not uncommonly,
either the diagnosis or referral of these cases for surgical
evaluation is delayed; the median reported time for a
diagnosis was 22 h after birth [8]. This underlines the
importance of a thorough clinical examination of all
newborns at birth, by paediatricians and/or obstetricians,
and not after their discharge from the hospital. Early
diagnosis and emergency exploration may increase the
salvage rate of these testes. Based on a very low salvage
rate of testes, some authors advocate a nonoperative
approach to these patients, or treating them electively
after the neonate is medically stable [4–6]. The argument
for delayed elective surgery is that it obviates the risks
of anaesthesia and surgery in the newborn; however,
this is not a valid argument because unless there is a
clear contraindication to surgery, these patients are
usually healthy with no other associated anomalies, and
of good birth weight. In addition, the recent advances
in anaesthetic techniques further minimize the risk of
anaesthesia, although the risk cannot be eliminated
during the first few days of life [4–6]. Although such an
approach of delayed exploration and contralateral
orchidopexy may be adopted in patients with a prolonged
torsion that is supported clinically by a hard testis,
induration and erythema of the scrotum, early explo-
ration eliminates the potential immunological eCects of
torsion on the contralateral testis, albeit that the occur-
rence of this is controversial [11]. It also establishes the
diagnosis, excludes other causes (e.g. hydrocele, mec-
onium peritonitis, irreducible hernia, haematocele, tor-
sion of appendix testis and benign or malignant
neoplasms) and may increase the salvage rate of these
testes.
Previously there was disagreement about the need for
contralateral testicular exploration and fixation, but
currently there is a general consensus. Contralateral
exploration and fixation is advocated not only because
it is easy to carry out and adds no or minimal morbidity,
but also obviates the potential risk of torsion on the
other side, potentially rendering the patient anorchidic
[5].
To date, 28 cases of bilateral intra-uterine torsion of
the testes have been reported, most being synchronous
[5,7–9,12–16]. Although asynchronous bilateral neo-
natal torsion is rare, with only four cases reported, the
© 1999 BJU International 83, 1023–1025
INT RA-UTER INE TEST ICU LAR TORS ION 1025
exact incidence is diBcult to estimate because of the
progressive tendency to perform early contralateral
orchidopexy. Asynchronous bilateral torsion can occur
at any time and as early as 48 h after torsion on the
other side [8]. This calls for early recognition of this
condition, expeditious exploration, and contralateral
exploration and orchidopexy.
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Author
A.H. Al-Salem, FRCSI, FICS, FACS, Consultant Paediatric
Surgeon, PO Box 18432, Qatif 31911, Saudi Arabia.