What are the symptoms of perinatal testicular torsion?

Symptoms of Perinatal Testicular Torsion

Perinatal testicular torsion is often asymptomatic and can be easily missed during initial newborn examination, making it a frequently underdiagnosed condition. 1

Clinical Presentation

• Perinatal testicular torsion (PTT) typically presents as an extravaginal twisting of the spermatic cord that often occurs prenatally or perinatally, compromising blood flow to the testicle 2
• PTT is relatively uncommon, accounting for approximately 10% of testicular torsion cases in children 2
• The condition may present with several clinical patterns:
  • A nubbin testis (completely atrophied) 3
  • A small and hard testis 3
  • A normal-sized but hard testis 3
  • Acute scrotal inflammation (in recent-onset cases) 3

Key Physical Examination Findings

• Scrotal erythema and swelling may be present in acute cases 4
• Hydrocele may be observed on the affected side 4
• The affected testicle often appears enlarged, hypoechoic or heterogeneous on examination 2
• Unlike adolescent or adult testicular torsion, perinatal cases are frequently asymptomatic as the infant cannot verbalize pain 1
• Bilateral involvement should be suspected even when only unilateral signs are present, as asynchronous contralateral torsion can occur 5, 4

Diagnostic Considerations

• Ultrasound is the primary diagnostic tool for PTT 2
• Key ultrasound findings include:
  • The "whirlpool sign" (spiral twist of the spermatic cord), which is the most specific ultrasound sign of torsion 2, 6
  • Heterogeneous echotexture and calcifications or cystic areas in prenatal torsion 2
  • Enlarged, hypoechoic or heterogeneous testicle in perinatal torsion 2
  • Decreased or absent blood flow to the affected testicle on Doppler examination 6

Important Clinical Pitfalls

• PTT is frequently missed during initial newborn examination due to its often asymptomatic presentation 1
• The true incidence is likely much higher than reported (6.1 per 100,000 live births) due to underdiagnosis 1
• Physical examination and imaging can be inaccurate in assessing the contralateral testis in cases of perinatal torsion 5
• Delayed diagnosis can lead to complete testicular loss and potential anorchia if bilateral involvement occurs 4
• Even necrotic testes may retain some endocrine function, suggesting consideration for preservation rather than automatic removal 5, 7

Management Implications

• Immediate surgical intervention is recommended when perinatal testicular torsion is suspected 2, 5
• The American Academy of Pediatrics recommends immediate surgical exploration for perinatal torsion occurring after birth 2
• Contralateral orchiopexy should be performed to prevent asynchronous torsion of the unaffected testicle 3
• Non-operative attempts at manual detorsion are not recommended in perinatal cases 1