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Purpose: Gross testicular heterogeneity on ultrasound has been associated with testis loss following testicular torsion in children. We aimed to quantify the extent of temporal heterogeneity associated with testis loss in testicular torsion cases using a noninvasive technique to determine a HI (heterogeneity index) on ultrasound images., Materials and Methods: We retrospectively studied the records of patients who presented with acute scrotal pain to the Pediatric Emergency Department over a 6-year period. Ultrasound images of the affected testis and the unaffected contralateral testis were examined using a proprietary program to determine the extent of heterogeneity of each image. The difference between the HI of the torsed testis and that of the contralateral normal testis was termed ΔHI. Receiver operating characteristics curve analysis was performed to determine the ΔHI threshold for nonviability., Results: Among 529 patients who presented with acute scrotal pain 147 had testicular torsion based on surgical findings. Of these 147 patients 110 (74.8%) were found to have a viable testis while 37 (25.2%) had a nonviable testis. Using the ΔHI cutoff of 0.394 or greater for nonviability, sensitivity and specificity were 100% and 94.5%, respectively. Positive and negative predictive values were 86% and 100%, respectively., Conclusions: Our results demonstrate that a quantifiable temporal gradation of heterogeneity exists and the heterogeneity index can be used as an objective parameter to determine the viability of a torsed testicle. By developing the technology to measure the heterogeneity index in real time, we could potentially identify which patients with testicular torsion have a nonviable testicle and, thus, would not require immediate surgical exploration., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Testicular torsion is a urological emergency. Failure of timely intervention for this issue leads the testicles to go into necrosis. If left untreated, it can lead to loss of the reproductive organs. The aim of this study was to examine the role of aliskiren in testicular torsion and detorsion injuries., Materials and Methods: Rats were divided into 8 groups of 12 each, including no torsion-detorsion, no torsion-detorsion plus 200 mg/kg aliskiren orally, torsion, torsion-detorsion, torsion plus 100 mg/kg aliskiren orally, torsion plus 200 mg/kg aliskiren orally, torsion-detorsion plus 100 mg/kg aliskiren orally and torsion-detorsion plus 200 mg/kg aliskiren orally. Aliskiren was administered 30 minutes before ischemia and reperfusion, and also 24 hours before the experimental protocol in all treatment groups. Ischemia and reperfusion were each applied for 2 hours., Results: Testicular damage decreased superoxide dismutase and glutathione, and increased malondialdehyde in the testis tissues of rats. Aliskiren administration increased superoxide dismutase and glutathione, and decreased malondialdehyde in the testis tissues. Values were measured by a biochemical autoanalyzer. In addition, this torsion-detorsion damage caused a significant increase in levels of the inflammatory cytokine and agents interleukin-1β and inducible nitric oxide synthase, as examined by real-time polymerase chain reaction. Aliskiren administration decreased these parameters. On pathological evaluation administration of a 200 mg/kg dose of aliskiren was found to protect the testis. Renin-angiotensin-aldosterone system inhibition by aliskiren caused an increase in serum renin levels and a decrease in serum angiotensin II levels., Conclusions: It appears that aliskiren protects the testis from ischemia-reperfusion damage by regulating inflammation and the oxidant-antioxidant balance via renin-angiotensin-aldosterone system inhibition., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We investigated the protective effect of the NADPH oxidase inhibitor apocynin on testicular damage induced by ischemia-reperfusion injury in rats., Materials and Methods: A total of 32 rats were randomly divided into 4 groups. Controls underwent left scrotal exploration only. The 3 groups with ischemia-reperfusion underwent 4-hour torsion followed by 1-hour detorsion. The ischemia-reperfusion only group underwent left testicular torsion and detorsion. The ischemia-reperfusion plus saline group underwent left testicular torsion, received 10 ml/kg saline intraperitoneally at minute 210 of ischemia and then underwent detorsion. The ischemia-reperfusion plus apocynin group underwent left testicular torsion, received 20 mg/kg apocynin intraperitoneally at minute 210 of ischemia and then underwent detorsion. We determined histopathological findings and performed specific biochemical analyses., Results: In the ischemia-reperfusion only and the ischemia-reperfusion plus saline groups malondialdehyde, total oxidative capacity and the oxidative stress index were significantly higher. Superoxide dismutase, catalase, glutathione peroxidase and glutathione were significantly lower. Apocynin significantly decreased malondialdehyde, total oxidative capacity and the oxidative stress index, and significantly increased superoxide dismutase and catalase. There was a significantly increase in the number of giant, degenerated and desquamated cells in the ischemia-reperfusion group. Apocynin significantly improved these histological alterations., Conclusions: These histopathological and biochemical findings show the beneficial effects of apocynin on testicular ischemia-reperfusion injury., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: The correlation between intratesticular pressure during torsion/detorsion and subsequent testicular function and viability has been reported in several recent studies. We assessed the impact of tunica albuginea incision with tunica vaginalis flap coverage on intratesticular pressure and future histopathological parameters in a rat testicular torsion model., Materials and Methods: A total of 21 rats were divided into 3 groups. Group 1 consisted of 7 controls undergoing a sham operation, group 2 consisted of 7 animals undergoing torsion-detorsion, and group 3 consisted of 7 animals undergoing testicular torsion-detorsion followed by tunica albuginea incision and tunica vaginalis flap coverage. Torsion was created by 720-degree counterclockwise rotation of the left testis for 2 hours. By using a compartment monitor, the intratesticular pressure of the torsed testes was measured before torsion (pre-torsion), immediately before torsion repair (pre-detorsion), 5 minutes after detorsion (post-detorsion), and after tunical incision and tunica vaginalis flap application. The correlations between intratesticular pressure values and testicular weight, modified Johnsen score and mean seminiferous tubule diameter were evaluated 4 weeks postoperatively., Results: Median pre-detorsion intratesticular pressure was significantly decreased after detorsion in group 2 (21 vs 7 mm Hg, p <0.001) and group 3 (23 vs 7 mm Hg, p = 0.001). In addition, median intratesticular pressure after tunica albuginea incision and tunica vaginalis flap coverage in group 3 was significantly less compared to median post-detorsion intratesticular pressure in group 2 (5 vs 7 mm Hg, p = 0.025). Overall no significant difference was detected between groups 2 and 3 regarding median modified Johnsen score, mean seminiferous tubule diameter or median testicular weight. The significant reduction of intratesticular pressure in group 3 did not correlate with testicular weight (r = 0.500, p = 0.391), modified Johnsen score (r = -0.205, p = 0.741) or mean seminiferous tubule diameter (r = -0.200, p = 0.747)., Conclusions: Tunica albuginea decompression with tunica vaginalis flap coverage is an effective technique for decreasing intratesticular pressure in torsed testes. However, this technique failed to alter the injury of prolonged arterial occlusion in testicular torsion., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We compared the preventive effects of cyclosporine A combined with prednisolone and melatonin (Sigma-Aldrich) on damage to the contralateral testis after ipsilateral testicular torsion-detorsion between pubertal and adult rats., Materials and Methods: We divided pubertal and adult Sprague-Dawley rats into groups 1-sham operation, 2-detorsion, 3-detorsion plus cyclosporine A with prednisolone and 4-detorsion plus melatonin. After 4 hours of ipsilateral testicular torsion we treated the rats with detorsion only or with detorsion plus drug depending on the group., Results: Seminiferous tubule diameter and germ cell layer thickness were greater in pubertal group 3 and adult group 4 than at each age in group 2 (each p <0.05). The number of spermatids per tubule was greater in pubertal groups 3 and 4, and in adult group 4 than at each age in group 2 (each p <0.05). Of pubertal rats those in groups 3 and 4 had fewer TUNEL positive cells than group 2 (p = 0.061 and 0.057, respectively). Of adult rats the number of TUNEL positive cells was greater in group 3 and significantly lower in group 4 vs that in group 2 (p <0.05)., Conclusions: The preventive effects of cyclosporine A combined with prednisolone on contralateral testicular damage were noted only in pubertal rats while the preventive effects of melatonin were noted in pubertal and adult rats. Results suggest that damage to the contralateral testis induced by an immunological mechanism may be more significant during puberty than during adulthood., (Copyright (c) 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: The lipid lowering agent simvastatin has potent anti-oxidation capacity. We elucidated the potential of simvastatin to attenuate testicular injury induced by testicular torsion-detorsion. We also investigated simvastatin effects on nuclear factor-kappaB expression., Materials and Methods: We allocated 60 adult male Sprague-Dawley(R) rats to testicular torsion-detorsion, torsion-detorsion plus simvastatin (1 or 5 mg/kg), sham operation or sham operation plus simvastatin (5 mg/kg). There were 12 rats per group. Simvastatin was administered immediately after detorsion or immediately after sham operation. Testes were harvested 30 minutes and 24 hours after detorsion to facilitate the evaluation of nuclear factor-kappaB and testicular injury, respectively., Results: Histological findings revealed severe injury in testes of the torsion-detorsion and torsion-detorsion-simvastatin (1 mg/kg) groups while testes in the torsion-detorsion-simvastatin (5 mg/kg) group showed moderate injury. Myeloperoxidase activity, and cytokines, nitric oxide and malondialdehyde in testes in the torsion-detorsion-simvastatin (5 mg/kg) group were significantly lower than in the torsion-detorsion group. Values were comparable in the torsion-detorsion-simvastatin (1 mg/kg) and torsion-detorsion groups. Testicular concentrations of nuclear factor-kappaB in nuclear extracts and phosphorylated inhibitor-kappaB in cytosolic extracts in the torsion-detorsion-simvastatin (5 mg/kg) group were significantly lower than in the torsion-detorsion group. Values were comparable in the torsion-detorsion-simvastatin (1 mg/kg) and torsion-detorsion groups., Conclusions: Simvastatin protected testes from torsion-detorsion injury in a dose dependent manner. Mechanisms may involve attenuating nuclear factor-kappaB activation and decreasing oxidative stress induced by torsion-detorsion., (Copyright (c) 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Intermittent torsion of the spermatic cord is an episode of acute torsion of the spermatic cord that resolves spontaneously. We compared the outcomes in boys with intermittent spermatic cord torsion treated electively with testicular fixation with those in boys with a history of recurrent scrotal pain who required emergent operation for acute spermatic cord torsion without spontaneous resolution., Materials and Methods: A retrospective review revealed 17 boys who required emergency operation for acute spermatic cord torsion and 30 who underwent elective surgery for intermittent spermatic cord torsion. The clinical presentation, number of recurrent painful episodes, lead time to operation, prior alternate diagnoses, intraoperative findings and clinical outcomes were recorded., Results: There was a mean of 2 recurrent painful episodes in the elective group and 3 in the emergency group (p <0.005). In the elective group all boys were cured of pain after bilateral testicular fixation with 100% testicular preservation at a mean of 4 months of followup. In the emergency group at a mean of 10 months of followup the testicular preservation rate was 47% (p <0.01). Intraoperatively an ipsilateral bell clapper malformation was found in 100% of boys in each group. A contralateral bell clapper malformation was noted in 90% and 88% of boys in the elective and emergency groups, respectively., Conclusions: When diagnosed accurately, intermittent spermatic cord torsion can be treated with elective testicular fixation with an excellent outcome. Misdiagnosis may create a cohort of boys with intermittent spermatic cord torsion who are at risk for acute unresolved torsion and potential testicular loss. Urologists should be proactive in recommending elective scrotal exploration when intermittent spermatic cord torsion is a likely diagnosis.

Purpose: Bilateral testicular torsion is a rare condition. Most authors present single case reports. Therefore, the clinical and surgical aspects of bilateral torsion in a neonate have not been subjected to detailed analysis. We performed a retrospective analysis of our experience in the management of bilateral perinatal torsion as well as a collective review of the medical literature., Materials and Methods: All cases of neonatal testicular torsion managed at our neonatal surgical center during the last 2 decades (1986 to 2005) were reviewed, and 3 cases of bilateral torsion were identified. In addition, 45 neonatal cases of bilateral torsion were found through the literature search. In all cases data regarding clinical presentation, imaging studies, surgical management, intraoperative and pathological findings, and final outcome were analyzed., Results: Synchronous torsion occurred in 32 of 48 newborns (67%), while asynchronous pathology was reported in 16 (33%), including the 3 presented in this report. All except 1 patient were full-term newborns with normal or above average birth weight. Difficult delivery was noted in 33% of the cases. Despite prompt surgical intervention in 46 infants, the salvage rate was low, with arterial flow confirmed postoperatively in only 3 gonads (3.1%). Four gonads in 3 additional patients were reported to be of normal size on followup., Conclusions: Asynchronous torsion is not as rare an event as previously reported, and it may pose a diagnostic challenge. In the majority of these cases torsion of the left testis seems to occur later than torsion of the right testis. The role of imaging studies in newborns with bilateral torsion seems to be limited, especially in cases of asynchronous pathology. Urgent bilateral exploration is strongly advised in all newborns presenting with either unilateral or bilateral torsion. Such policy carries diagnostic, potential therapeutic and prognostic implications.

Purpose: The literature concerning undescended testis mainly concentrates on the increased risks of infertility and development of germ cell tumors. Yet the UDT also appears to be at higher risk for torsion compared to the normally descended testis, and this issue is relatively poorly addressed. We reviewed all cases of torsion of UDTs operated on at our hospital during the last 20 years in an attempt to characterize better this condition and its salvageability., Materials and Methods: In this retrospective clinical study we reviewed and analyzed all cases of testicular torsion involving UDT operated on at our hospital between 1984 and 2004., Results: A total of 11 children were operated on at our hospital for torsion of undescended testis between 1984 and 2004. Patient age ranged from 1 month to 18 years (median 7.5 months). In all cases unilateral torsion of undescended testis was diagnosed, with 73% of cases involving the left side. Clinical symptoms included inguinal swelling and erythema associated with a tender, firm mass palpated in the groin area and an empty ipsilateral hemiscrotum. Doppler ultrasound examination was routinely performed in the last 7 patients to confirm the diagnosis. During inguinoscrotal exploration severe ischemia or overt necrosis of the testis was found in 5 of 11 cases. Three of these 5 cases were managed by orchiectomy, while in the other 2 cases the testis subsequently vanished. In the 6 patients who exhibited some improvement following detorsion and warming of the tissue the testes were preserved and orchiopexy was performed. Followup was available in only 5 patients, with vanishing of the torsed testis observed in 4 and a normal testicle detected 21 years postoperatively in 1 patient who was diagnosed early., Conclusions: This series clearly demonstrates poor rates of surgical salvage, which we mainly attribute to delays in parental response and in primary physician referral to the hospital. Parents, who have a pivotal role in early diagnosis, were usually unaware of this urological emergency, and some were surprisingly unaware of the presence of cryptorchidism. By increasing the awareness regarding this entity among members of the medical community and parents, we hope that torsion of the cryptorchid testis (literally, "hidden testis") will no longer necessarily be synonymous with "crypt-torsion" ("hidden torsion").

Purpose: We determined the time course of malondialdehyde, a measure of free radical damage, in patients undergoing standard surgical treatment for testicular torsion., Materials and Methods: Patients presenting with testicular torsion were studied prospectively. Blood samples were obtained after administering general anesthesia but before surgical incision, and 10 minutes, 30 minutes and 24 hours after detorsion. Orchiopexy was performed in patients with viable testes (group 1) and orchiectomy was performed in those with nonviable testes (group 2). Further blood samples were obtained 1 and 3 months after surgery. Similar blood samples were taken from controls, including patients younger than 40 years undergoing other operations involving manipulation of the testis, such as hydrocelectomy or orchiopexy (group 3). The level of malondialdehyde in each serum sample was determined by the thiobarbituric acid reaction., Results: A total of 65 patients were studied, including 56 with testicular torsion and 9 controls (group 3). Of the 56 patients 11 (19.6%) with testicular torsion underwent ipsilateral orchiectomy and contralateral orchiopexy (group 2). The remaining 45 patients (80.4%) underwent bilateral orchiopexy (group 1). However serum malondialdehyde was estimated in only 34 of the 56 patients with torsion. Mean malondialdehyde at 0, 10 and 30 minutes, 24 hours, and 3 and 6 months was 3.3, 3.69, 3.69, 2.9, 2.65 and 2.39 nmol./ml. on the 24 group 1 patients, 3.53, 4.56, 3.87, 2.87, 2.82 and 2.64 nmol./ml. in the 10 group 2 patients, and 3.6, 3.08, 3.18, 2.95, 2.88 and 2.65 nmol./ml. in the 9 group 3 controls, respectively. The highest serum malondialdehyde was at 10 minutes after detorsion in groups 1 and 2. There was a statistically significant difference in malondialdehyde between groups 1 and 2 compared with group 3 at 10 minutes (p <0.04). Serum malondialdehyde returned to baseline at 24 hours in all patients., Conclusions: The results of this study indicate that testicular torsion and its treatment with detorsion is an example of ischemia-reperfusion injury, producing measurable changes in malondialdehyde in humans. Thus, serum malondialdehyde could be used to determine the extent of injury.

Purpose: Poly (adenosine diphosphate [ADP]-ribose) polymerase inhibitors have been used successfully to decrease ischemia-reperfusion injury in several organ systems. We evaluated the efficacy of poly (ADP-ribose) polymerase inhibitors on biochemical changes in testicular ischemia-reperfusion injury., Materials and Methods: Adult male Wistar rats were divided into 9 groups of 6 each. One group served to determine baseline values of biochemical parameters, 1 that underwent sham operation served as a control, 1 underwent 2 hours of testicular torsion and 4 hours of detorsion, 2 received pretreatment with vehicle (saline or dimethyl sulfoxide) before detorsion and 4 received pretreatment with the poly (ADP-ribose) polymerase inhibitor nicotinamide, 3-aminobenzamide, 1,5-dihydroxyisoquinoline or 4-amino-1,8-naphthalimide before detorsion. Lipid peroxidation products, nitric oxide content and myeloperoxidase activity, an indicator of neutrophil accumulation, were assessed in testicular and renal tissues., Results: Testicular torsion-detorsion caused a significant increase in lipid peroxidation products, nitric oxide content and myeloperoxidase activity in ipsilateral testes (p <0.01) but not in the contralateral testes or kidneys. Animals treated with poly (ADP-ribose) polymerase inhibitors had a significant decrease in these biochemical parameters compared with vehicle treated animals (p <0.01)., Conclusions: These data emphasize that poly (ADP-ribose) polymerase may have a role in testicular damage caused by ischemia-reperfusion and the inhibition of poly (ADP-ribose) polymerase may be a novel approach to therapy for ischemia-reperfusion injury of the testis.

Purpose: Unilateral testicular torsion is common and leads to bilateral testicular injury. Spermiography is abnormal in 70% of patients after testicular torsion. Histological changes in the contralateral testis at the time of torsion have been previously interpreted as the consequence of a predisposing testicular pathology or a noxious effect of the twisted testis. We hypothesized that increased apoptosis in the contralateral testis in unilateral testicular torsion is a consequence of a breakdown in the blood-testis barrier of the twisted testis, which may increase the risk of infertility., Materials and Methods: A total of 17 patients 14 to 34 years old (mean age plus or minus standard deviation 20.7+/-6.1) underwent surgery to alleviate unilateral testicular torsion. Mean time from the first symptoms of torsion to surgery was 4.2+/-3.0 hours (range 0.5 to 11). Bilateral testicular biopsy was performed in all patients, and apoptosis was analyzed by terminal deoxynucleotidyl transferase mediated S-deoxyuridine triphosphate nick end labeling., Results: Compared with controls, the incidence of apoptosis was increased in the contralateral testes in all patients. Apoptosis occurred predominantly in spermatocytes, early and late spermatids, and Sertoli's cells. In contrast, spermatogonia, peritubular connective tissue (fibroblasts and myofibroblasts) and endothelial cells seldom underwent apoptosis. Leydig cells were affected less often than spermatocytes. The extent of apoptosis and necrotic changes within the twisted testicle directly correlated with the duration of torsion., Conclusions: Extensive apoptosis is a phenomenon that occurs regularly in the germinal epithelium of the contralateral testis in testicular torsion. Specifically primary and secondary spermatocytes are predominantly affected. Notably spermatogonia, capillary endothelium, connective tissue and peritubular fibroblasts are rarely involved. A selection strategy has seemingly evolved that precludes the possibility of the perpetuation of genetic mutations. We hypothesize that trauma to the blood-testis barrier initiated by testicular torsion induces the release of apoptotic activating factors (cytokines), which subsequently cause extensive apoptosis in the germinal epithelium of the contralateral testis. Therefore, it is probable that repeat apoptotic episodes may explain the high incidence of infertility in these patients.

Purpose: Testicular torsion is a urologic emergency representing a form of ischemia-reperfusion (IR) injury that requires prompt care to achieve tissue salvage and a reduction in post-torsion morbidity. Hyperbaric oxygen (HBO) has shown benefits in previous musculoskeletal models of IR. We evaluated the efficacy of HBO treatment in a rat testicular torsion model., Materials and Methods: Four groups of male Wistar rats were included in this study: 1) Sham (n=16), spermatic cords exposed but not occluded; 2) Control (n=16), 4 hours of bilateral spermatic cord occlusion; 3) HBO during ischemia (n=18), 4 hours of occlusion and administration of HBO during the last 90 minutes of ischemia; and 4) HBO on reperfusion (n=8), HBO administered immediately upon reperfusion of the testes. The animals were sacrificed at two weeks and architecture and germinal epithelial cell thickness were determined by histological examination on each testicle. Average thickness (in cell layers) of each group was compared with control using Student's t test., Results: Control testicles showed a significant reduction in germinal cell thickness compared with sham (1.7 versus 6.3, p <0.05). The animals treated with HBO during ischemia showed a significant increase in epithelial cell thickness compared with control (2.8 versus 1.7, p <0.05). Hyperbaric oxygen treatment during reperfusion had the greatest beneficial effect compared with control (5.1 versus 1.7, p <0.05)., Conclusions: Adjunctive HBO therapy administered during ischemia or reperfusion significantly reduced injury to the testicle in this animal model. These results suggest a potential benefit of HBO treatment in clinical situations of testicular torsion.

Purpose: We assessed the significance of the clinical presentation of boys who underwent surgical exploration for acute scrotum., Materials and Methods: We retrospectively analyzed the records of 115 consecutive boys who underwent surgical exploration for acute scrotum between October 1986 and January 1996. We divided the children into group 1-83 with spermatic cord torsion a mean of 14.4 years old, group 2-27 with torsion of a testicular appendage a mean of 9.4 years old and group 3-5 with epididymo-orchitis a mean of 14.1 years old. Particular attention was given to nausea and vomiting, patient age and duration of pain., Results: Nausea and vomiting occurred in 69 and 60% of the boys in group 1, 8 and 4% in group 2 and none in group 3. Nausea and vomiting had positive predictive values of 96 and 98%, respectively, for spermatic cord torsion. Only 6 of the 83 boys (7%) with spermatic cord torsion were younger than 11 years, whereas 15 of the 27 (56%) with torsion of a testicular appendage were younger than 11 years. Of the 83 boys with spermatic cord torsion the testes were salvaged in 51 (61%) and the duration of pain was 40 minutes to 12 hours (mean 4 hours). The testes were not salvaged in any patient with greater than 12 hours of pain., Conclusions: We believe that any boy 11 years old or older with scrotal pain less than 12 hours in duration that is associated with nausea or vomiting should be considered to have torsion of the spermatic cord. In this day of cost-effective medical management it is not necessary to perform imaging in this subset of boys before surgical exploration.

We report on an 8-year-old boy with a unilateral testicular mass and bilateral diffusely echogenic testes on sonography. At inguinal exploration torsion of an appendix testis with a reactive phlegmon was found and testis biopsy revealed significant testicular microlithiasis. To our knowledge our case demonstrates a previously undescribed presentation of testicular microlithiasis. The literature is reviewed and this disease entity is discussed.

Testicular torsion affects prepubertal males and causes testicular infarction and subfertility. Animal models of spermatic cord torsion have been used in an attempt to study the mechanism of testicular injury from torsion. Although standardized animal models of torsion have been proposed, their reliability in producing testicular ischemia has not been documented. Dynamic enhanced magnetic resonance imaging (MRI) of the testis was used in a rat model with surgically induced, unilateral, 720 degrees torsion to quantify the severity of ischemia. Intravenous dysprosium diethylenetriaminepentaacetic acid-bis methylamide (Dy-DTPA-BMA) was injected as a bolus followed by serial dynamic Turbo GRASS images. Region of interest (ROI) measurements were obtained within the testicular parenchyma during contrast enhancement and washout. Perfusion abnormalities ranging from minimal delay in contrast enhancement in the torqued testicle to complete absence of intraparenchymal blood flow were documented with dynamic enhanced MRI. Reperfusion scans 1 hour after surgical reduction of torsion showed normalization of testicular blood flow in all animals. Dynamic enhanced MRI appears to be a useful method of documenting the perfusion deficit arising from torsion of the testis. Standard animal models of torsion produce inconsistent results because they do not reliably reproduce testicular ischemia. The ability of MRI to quantify perfusion abnormalities in the testis may provide additional information in the evaluation of human patients with symptoms of testicular torsion.

Unilateral spermatic cord torsion has been shown to cause damage to the contralateral testis in humans and animal models. In an attempt to explain conflicts among various laboratories concerning the extent of this contralateral effect and to determine the importance of the extent of torsion, prepubertal rats (35 to 40 days) were subjected to unilateral spermatic cord torsion of various degrees (zero to 1440 degrees). Sham surgeries were performed and served as controls (0 degrees of torsion). The animals were allowed to recover from the surgeries and to attain puberty before a period of fertility testing. Fertility, fecundity, organ weight and testicular histological data were obtained after the breeding period. Our data indicate that animals undergoing 360 degrees of torsion exhibited no changes in the parameters studied. However, if 720 degrees, 1080 degrees or 1440 degrees of torsion was induced, a significantly lower percentage of fertile males and pregnant females resulted for each of these experimental groups when compared to those values for the 0 degrees controls. These data indicate that the extent of contralateral testicular degeneration is dependent upon the degree of spermatic cord torsion to which the ipsilateral testis is subjected. The induction of unilateral spermatic cord torsion at 720 degrees or more causes a significant reduction of subsequent fertility while torsion of a lesser degree has little or no effect in the development of this phenomenon.

The ischemic effects of prolonged testicular torsion have been well documented; however, prevention or arrest of the damaging effects of prolonged ischemia has been incompletely studied. Two groups of Sprague-Dawley rats were subjected to varying lengths of bilateral testicular ischemia. Group I underwent normothermic ischemia for two, four, and six hours. Likewise, Group II underwent similar time periods of ischemia, however, after thirty minutes of normothermic ischemia the scrotum of each animal was placed into an ice bath maintained at 4C. Two weeks postoperatively, bilateral orchiectomy was performed. Histology of the testes of the two groups was compared. Neither group revealed significant destruction of the germinal epithelium after two hours of ischemia. Group I revealed only 25% preservation of the germinal epithelium at four hours and only 8% preservation at six hours of ischemia. In contrast, Group II which received ice showed 90% preservation of germinal epithelium at four hours and 85% preservation at six hours of ischemia. We conclude that external ice application significantly preserves seminiferous tubules at four and six hours of ischemic injury in the rat testicle.

A patient with duplication of the testis who presented initially with torsion of a right inguinal testis is described. Subsequently, a malignant teratoma of the trophoblastic type (choriocarcinoma) developed in the scortal testis on the right side. This scrotal testis was impalpable initially but a normal testis was present on the left side. The patient died of cerebral and pulmonary metastases of the teratoma.

The correlation between the presence of the ipsilateral cremasteric reflex and the absence of testicular torsion was 100 per cent in a 7-year evaluation of 245 boys with acute scrotal swelling. The presence of the cremasteric reflex was the most valuable clinical finding in ruling out testicular torsion and the absence of this reflex increased the suspicion of testis torsion.

We report 2 cases of torsion of scrotal malignant tumors of the testis. A review of the literature disclosed several instances of torsion of intra-abdominal testicles with malignant tumors and only 1 case of a scrotal testis. The association of torsion and tumor in these cases may represent 2 manifestations of a dysplastic gonad.

A review of 100 boys less than 15 years old who were hospitalized for an acute scrotum revealed that the most common causes of the disorder were testicular torsion, including torsion of the spermatic cord (42 per cent) and torsion of the appendages (32 per cent). The remaining 26 per cent of the cases were owing to idiopathic scrotal edema (8 per cent), epididymitis and orchitis (6 per cent each), and incarcerated hernia and acute hematocele (3 per cent each). The age distribution of these children was biphasic, with the highest frequency in newborns (with exclusively extravaginal torsion) and in boys 13 years old, whereas in boys with appendiceal torsion the single peak frequency was at age 10 years. While idiopathic scrotal edema occurred in children less than 7 years old and orchitis in patients more than 12 years old, epididymitis was observed in young boys and those of pubertal age.