Perinatal testicular torsion is a rare condition with an incidence of 1 in 7500 live births. 70% are prenatal and 30% postnatal. Postnatal torsion presents as an acute scrotum, whereas prenatal torsion may be usually missed as it is a non-tender hard mass. Management of prenatal torsion is controversial. We are reporting three such case series presenting within a period of 1 year. Prenatal testicular torsion is usually missed as it is asymptomatic and later presents as cryptorchid. Careful postnatal physical examination and documentation is essential, as a missed case can later present as cryptorchid and may lead to medicolegal issues. In torsion in the immediate perinatal period, the testis may be salvaged if promptly operated

AN, Ashrin

George, Mathan P

James, Jemila

N, Anand

Nair, P M C

Rafi, Muhammed

English

Atharva Scientific Publications (E-Jounals)

Vol 5 | Issue 3 | Mar 2018 Indian J Child Health 213
 Case Series
Perinatal testicular torsion - Not an uncommon entity
Muhammed Rafi, P M C Nair, Jemila James, Anand N, Mathan P George, Ashrin AN
From Department of Pediatrics, Sree Gokulam Medical College, Trivandrum, Kerala, India
Correspondence to: Dr. P M C Nair, Chaithanya, TC 25/1847, Thampanoor, Trivandrum - 695 001, Kerala, India. Phone: +91-9446065070. 
E-mail: drpmc50@gmail.com
Received - 18 January 2018 Initial Review - 09 Februaty 2018 Published Online - 14 April 2018
Perinatal testicular torsion is a rare condition with an incidence of 1 in 7500 live births [1]. Among them, 70% occurs in prenatal period and 30% in the postnatal period. 
Postnatal torsion presents as an acute scrotum, whereas prenatal 
torsion may be usually missed or go undetected as it is a non-
tender hard mass. Management of prenatal torsion is controversial. 
Careful postnatal physical examination and documentation is 
essential, as a missed case can later present as cryptorchid and 
may lead to medicolegal issues. We are reporting three case series 
of such patients presenting within a period of 1 year.
CASE REPORTS
Case 1
Term male baby 3.26 kg born to a 33-year-old G3P2L2 
mother with gestational diabetes by normal vaginal delivery 
was presented. Asymptomatic baby on routine examination 
showed the right hemiscrotum darker with normal rugae. The 
right testis was hard, mobile, non-tender, and larger than the 
left (Fig. 1).
Ultrasonography (USG) of the scrotum with Doppler (Fig. 2) 
showed the right testis to be mildly enlarged, with peripheral 
calcification and no vascularity. The central hypoechoic area 
was showing infarction and necrosis. The left testis was normal. 
Scrotum on exploration showed the right testis atrophic with 
torsion. The right testis was removed and the left orchidopexy 
done.
Histopathology (Fig. 3) showed areas of hemorrhage and 
ischemic necrosis. Only outlines of seminiferous tubules with 
extravasated red blood cells seen. Spermatic cord and epididymis 
showed viable tissues.
Case 2
Term 3.4 kg baby born to a 25-year-old primi mother by normal 
delivery was presented. The right testis was hard, USG Doppler 
showed heterogeneous echo pattern with no vascularity (Fig. 4). 
The left testis was normal with the left-sided hydrocele. The right 
orchidectomy was done in the right testis as it was gangrenous 
(Fig. 5), and in the left testis, orchidopexy was done.
Case 3
Term 2.8 kg baby born to 28-year-old G2A1 mother by normal 
vaginal delivery was presented. The left testis was hard. USG 
Doppler showed heterogeneous echo pattern with no vascularity 
in the left testis (Fig. 6), and the right testis was normal. The left 
orchiectomy (Fig. 7) and right orchidopexy were done.
DISCUSSION
Testicular torsion was first described in 1840 by Delasiauve and 
reported in the newborn by Taylor in 1897 [2]. Prenatal torsion 
produces minimal or no discomfort and presents with only a few 
localized findings. Possible etiologies of perinatal torsion include 
difficult labor, breech presentation, large birth weight, an over-
reactive cremasteric reflex, and multiparty. These factors potentially 
increase intrauterine pressure as well as pressure in the birth canal 
during parturition. Such pressures may stimulate a brisk cremasteric 
response in the setting of loose tunica-scrotal attachment. Usually, 
extravaginal testis, epididymis, and tunica vaginalis twist on the 
spermatic cord. The degree of torsion varies from 180° to more than 
720°. The severity of torsion depends on the degree of twist. Prenatal 
testicular torsion may be unilateral or bilateral, and bilateral torsion 
ABSTRACT
Perinatal testicular torsion is a rare condition with an incidence of 1 in 7500 live births. 70% are prenatal and 30% postnatal. 
Postnatal torsion presents as an acute scrotum, whereas prenatal torsion may be usually missed as it is a non-tender hard mass. 
Management of prenatal torsion is controversial. We are reporting three such case series presenting within a period of 1 year. 
Prenatal testicular torsion is usually missed as it is asymptomatic and later presents as cryptorchid. Careful postnatal physical 
examination and documentation is essential, as a missed case can later present as cryptorchid and may lead to medicolegal issues. 
In torsion in the immediate perinatal period, the testis may be salvaged if promptly operated.
Key words: Perinatal, Prenatal, Testicular, Torsion
Rafi et al. Testicular torsion perinatal
Vol 5 | Issue 3 | Mar 2018 Indian J Child Health 214
Figure 1: Scrotum and testis in Case 1 shows that the 
hyperpigmentation of the right side of scrotum and the right testis 
was hard, mobile, and larger than the left
Figure 2: Ultrasonography scrotum with Doppler of Case 1. The 
right testis mildly enlarged, with peripheral calcification and 
no vascularity. Central hypoechoic area showing infarction and 
necrosis; the left testis normal
Figure 3: Microscopy of Case 1 showing areas of hemorrhage 
and ischemic necrosis with outlines of seminiferous tubules and 
extravasated red blood cells on H and E stain
Figure 4: In Case 2, ultrasonography scrotum showing smaller right 
testis
Figure 5: Atrophic testis in Case 2
Figure 6: In Case 3, ultrasonography scrotum showing smaller and 
avascular left testis
can be synchronous (67%) or asynchronous (33%). Antenatal 
ultrasound is not that sensitive for such cases. A careful routine 
postnatal physical examination can diagnose it [3]. Salvageability 
depends on the time elapsed since torsion.
Torsion in the prenatal period several weeks back presents as 
a regular, firm, painless scrotal mass, often in the upper part of 
the hemiscrotum, smaller than the contralateral normal testis, very 
much attached to the scrotal wall, without acute inflammatory 
signs, and it does not transmit the light. When torsion occurs in 
Rafi et al. Testicular torsion perinatal
Vol 5 | Issue 3 | Mar 2018 Indian J Child Health 215
the prenatal period near birth (several days), a firm and painless 
scrotal mass, bigger or similar in size than the contralateral normal 
testis, is seen without acute inflammatory signs and it does not 
transmit light. Torsion in the prenatal period very near to birth (few 
days or several hours) will present with acute inflammatory scrotal 
signs: A painful, enlarged, bluish, or reddish hemiscrotum and an 
enlarged and sometimes elevated testis - not transmitting light, 
thickened, and painful cord. Doppler USG is 89.9% sensitive, 
98.8% specific; USG alone is equivocal. USG will show enlarged, 
heterogeneous testis, and thickened tunica albuginea with rim-like 
hyperechoic reflections (calcifications) at the transitional zone 
between testis and tunica albuginea in case of prenatal torsion. 
The hypoechoic central area may also be evident which shows 
necrosis. A short duration of torsion is characterized by mixed 
echogenicity. Prolonged intrauterine torsion shows calcification 
and a hypervascular ring of tunica with a hypodense center.
Technetium-99 m pertechnetate of dose 5 mCi is the agent 
of choice in such cases. Typically, immediate radionuclide 
angiograms are obtained, with subsequent static images as 
well. In the healthy patient, images show symmetric flow to the 
testes, and delayed images show uniformly symmetric activity. 
The appearance of testicular torsion on scintigraphy depends on 
the chronicity. In acute torsion (usually <7 h): Blood flow may 
range from normal to absent on the involved side, and a nubbin 
sign may be visible. The nubbin sign is a focal medial projection 
from the iliac artery representing the reactive increased flow 
in the spermatic cord vessels terminating at the site of torsion. 
Static images show photogenic area in the involved testis. In 
the subacute and late phases of torsion (missed torsion), often 
increased flow to the affected hemiscrotum through the pudenda 
artery with a photogenic testis and a rim of surrounding increased 
activity on static images - described as a rim, doughnut, or bull’s 
eye sign [4,5].
In all the 3 cases reported here, scrotal exploration was done 
in immediate postnatal period, but testes were not salvageable. 
For long-standing intrauterine torsion, there is no urgency; these 
neonates should be operated on electively when the child is in 
optimal clinical status to confirm the suspected diagnosis, to 
remove the affected testis, and to explore the contralateral normal 
one. If torsion occurs in the prenatal period very near to birth or 
in the postnatal period within the 1st month of life immediate 
exploration should be carried out. Early surgical exploration may 
detect asynchronous torsion and allows its correction. Whether 
contralateral orchidopexy is justified is controversial. Postnatal 
torsion will be presenting with considerable tenderness and 
swelling of a previously normal testicle. Testicular salvage rate 
in acute torsion: 85–97% – when operated within 6 h, 55–85% @ 
6–12 h, 20–80% @ 12–24 h, and <10% if >24 h [3,4].
CONCLUSION
Prenatal testicular torsion is not so rare but usually missed as it is 
asymptomatic and later presents as cryptorchid. Careful postnatal 
physical examination and documentation is essential, especially 
in avoiding future medicolegal complications. Also note that 
in torsion in the immediate prenatal period, the testis may be 
salvaged if promptly operated.
REFERENCES
1. Gatti JM, Pettiford J. The Acute Scrotum. In: Holcomb GW 3rd, Murphy JP, 
Ostlie DJ, editor. Ashcraft’s Pediatric Surgery. 6th ed. Amsterdam: Elsevier 
Health Sciences; 2014. p. 702-4.
2. Taylor MR. A case of testicle strangulated at birth: Castration, recovery. Br 
MedJ 1897;1:458.
3. Lissauer T. Physical Examination of newborn. In: Martin RJ, Fanaroof AA, 
Walsh MC, editor. Fanar off and Martin’s Neonatal-Perinatal Medicine. 
10th ed. Philadelphia, Saunders; 2014. p. 396.
4. Riaz-Ul-Haq M, Mahdi DE, Elhassan EU. Neonatal testicular torsion; a 
review article. Iran J Pediatr 2012;22:281-9.
5. Callewaert PR, Van Kerrebroeck P. New insights into perinatal testicular 
torsion. Eur J Pediatr 2010;169:705-12.
Figure 7: In Case 3, the left gangrenous testis
Funding: None; Conflict of Interest: None Stated.
How to cite this article: Rafi M, Nair PMC, James J, Anand N, 
George MP, Ashrin AN. Perinatal testicular torsion - Not an 
uncommon entity. Indian J Child Health. 2018; 5(3):213-215.


Perinatal testicular torsion - Not an uncommon entity

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Perinatal testicular torsion - Not an uncommon entity

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