Today, they requested a consultation for a newborn from the baby room. My pediatrician friend said the baby’s left testicle was firm, dark-colored, and fixed to the skin. We had already diagnosed it over the phone. We inquired about the condition of the other testicle. After confirming it was normal, we examined the baby without panic. The diagnosis was newborn testicular torsion. Since it wasn’t an acute situation, an ultrasound was ordered to rule out other possibilities and ensure the well-being of the other testicle. The parents were informed along with the results, all possibilities were discussed, and the baby was timely operated on to remove the twisted and deceased testicle, securing the healthy one within the scrotum.
In the pediatric surgeon’s journal, I wanted to discuss testicular torsions in newborns with you.
From the prenatal period to the first 30 days of life, the twisting of the testicle around its axis is referred to as “newborn testicular torsion.” The frequency of this condition in newborns is not well-established. Excluding vanished testicles, a rate below 100,000 is given, accounting for about 10% of all childhood testicular twists. However, I don’t consider these figures highly reliable.
Nevertheless, it’s crucial to note that around 70-80% of torsions occur during the prenatal period, meaning most testicles are already nonviable when diagnosed. About 5-15% may involve bilateral torsion.
It’s essential to categorize newborns with testicular torsion into two groups, as our approach varies.
The first group is the prenatal group, i.e., the non-urgent cases. In these cases, the testicles twisted while in the womb, usually without causing noticeable symptoms. It’s necessary to distinguish between those that twisted early and late in prenatal development.
If the testis twisted in the early stages in utero, it gets destroyed over time due to inadequate blood supply. This is termed a vanished or lost testis. It’s crucial to determine whether the twisted testis has disappeared, or if it’s present but located inside the abdomen, or if it never developed at all. I’ll explain how to approach such situations in more detail in the next installment.
If the testis twisted closer to birth, symptoms manifest as I described earlier – swelling, hardness, a higher position within the scrotum, dark color, and a fixed appearance to the skin. Typically, reactive fluid accumulates around the other testicle as well. The chances of saving the twisted testis in these babies are almost 0%; they are usually nonviable during surgery. In such cases, the focus of treatment shifts to preserving the other healthy testis promptly, as torsion might occur in the apparently healthy side soon. This is undesirable, as the baby would require hormone replacement throughout life if there’s no testis. These cases are not urgent, allowing flexibility in the approach. Some surgeons choose not to operate, opting for close monitoring while explaining potential signs of testicular torsion. We don’t fully endorse this because parents might overlook the torsion of the other healthy testis, and leaving a dead testis in place can lead to infection. Additionally, from a medico-legal standpoint, a conservative approach without any intervention is often discouraged. Some surgeons perform surgery at around 1 month to minimize anesthesia risks. If there’s a capable anesthesia team and suitable hospital conditions, it’s not too challenging. Our approach aligns with what I described initially, operating on the baby at the earliest suitable moment, aiming to protect the healthy testis and capitalize on the slim chance of salvaging even 1% of the twisted testis. We remove the dead testis and secure the healthy one within the scrotum. If both testes are twisted, we proceed promptly without delay, correcting the torsion, securing them in the scrotum, even if they appear black and nonviable. Sperm-producing cells die quickly, but hormone-producing cells are somewhat more resilient. We consider the small chance of supporting hormone needs in the future, accepting other risks.
The second group comprises babies in whom the testis twists after birth, within the first 30 days. Initially, their testes appear normal, but later, there’s a rotation, accompanied by redness, swelling in the scrotum, and signs of discomfort and vomiting in the baby. This is a recognizable acute scrotum scenario, similar to testicular torsion seen in older children. We approach these cases like acute testicular torsion, and we can save the testes in about 30-40% of cases.
There’s no need to delve deeply into the surgical technique here, but briefly, we often make a midline incision in the scrotum. Some surgeons use a groin incision, but if we confirm with ultrasound that there are no other reasons, and considering the low risk of hernia or hydrocele in these babies, we don’t find a groin incision mandatory.
Yes, we’ve come to the end of another cruise. I’ve explained a topic where our approach is clear but remains somewhat uncertain in the world of pediatric surgery. If you’d like to listen/watch what I’ve explained, you can click here.
Stay well,
Prof. Dr. Egemen Eroğlu
December 2023