What is the management approach for prenatal versus perinatal testicular torsion?

Management of Prenatal vs. Perinatal Testicular Torsion

For prenatal testicular torsion, surgical intervention should be performed as an elective procedure, while perinatal testicular torsion requires immediate surgical exploration due to the potential for testicular salvage.

Definitions and Timing

• Prenatal (antenatal) testicular torsion occurs in utero and is present at birth 1
• Perinatal testicular torsion occurs around the time of birth (during delivery or shortly after) 2
• Prenatal torsion is typically extravaginal (outside the tunica vaginalis) and has extremely poor salvage rates (<1%) 1, 3

Diagnostic Approach

• Color Doppler ultrasound is the recommended initial imaging modality for suspected testicular torsion 4
• Ultrasound findings include:
  • Abnormal testicular blood flow
  • Altered testicular architecture
  • Possible reactive hydrocele 5
• The "whirlpool sign" on ultrasound indicates a twisted spermatic cord with high sensitivity (96%) and specificity (99%) 4

Management of Prenatal Testicular Torsion

• Elective surgical intervention is appropriate as testicular salvage is extremely unlikely (<1%) 1, 3
• Recommended approach includes:
  • Inguinal exploration of the affected side 3
  • Ipsilateral orchiectomy for the necrotic testis 1
  • Contralateral prophylactic orchiopexy to prevent future torsion 1, 3
• Surgery can be scheduled when anesthetic risks are minimized rather than as an emergency 5

Management of Perinatal Testicular Torsion

• Immediate surgical exploration is recommended due to potential for testicular salvage 2, 6
• Surgical approach includes:
  • Detorsion of the affected testis
  • Assessment of testicular viability
  • Orchiopexy if viable, orchiectomy if necrotic
  • Contralateral orchiopexy to prevent future torsion 6

Special Considerations for Bilateral Torsion

• Bilateral asynchronous torsion occurs in approximately one-third of bilateral cases 6
• Physical examination and imaging can be inaccurate in assessing the contralateral testis 6
• Emergent surgical exploration is recommended for all cases of perinatal torsion to identify potential contralateral involvement 2, 6
• Preservation of testes should be attempted whenever possible as some endocrine function may be retained even in compromised testes 2

Common Pitfalls to Avoid

• Delaying surgical intervention for perinatal torsion, which reduces chances of testicular salvage 4, 6
• Failing to perform contralateral orchiopexy, which puts the remaining testis at risk 1, 3
• Relying solely on physical examination or imaging to rule out bilateral involvement 6
• Assuming all neonatal torsions are prenatal and therefore unsalvageable 2, 6