TORSION OF THE SPERMATIC CORD IN THE FIRST YEAR OF LIFE

By THEODORE JAMES, M.B., Ch.B. Duchess of York Hospital fi,r Babies, Manchester

TORSION of the testis or, more correctly, torsion of the spermatic cord, is a surgical emergency which a general surgeon may expect to meet at least once during his career, but the pzdiatric surgeon who devotes himself only to the surgery of infancy and childhood may miss this experience.

In 1901 Scudder (quoted by Donovan, 1930) was able to collect thirty-one cases of torsion of the spermatic cord from the literature. Of these, two, or about 6.4 per cent., had had their onset at less than one year of age-a fair proportion. Between the years 1901 and 1930 another 163 cases were reported and thirteen of these were less than one year old, according to Donovan (1930), who published three cases, two aged 8 months and one aged 10 months which he had met in his own practice. Allen and Andrews (1940) accounted for over 200 more cases published in the preceding decade, but only three more of less than one year of age were added and these were their own. The percentage of such cases remained about the same, or was perhaps a little lower. Campbell (1948) reported two more cases which he regarded as the second and third with the onset within twenty-four hours of birth, and so brought the total number of cases of torsion of the spermatic cord in the first year of life to twenty-four. Since Campbell’s paper 1 have been able to find two more case reports of newborn babies, these making the fourth and fifth cases in which torsion was observed during the first day of life (Biorn and Davis, 1951), and in one of these reason was given for believing that the torsion had its onset during intra-uterine life and had been present for at least two weeks. I can add two more cases from the records of the Duchess of York Hospital for Babies.

One of the twenty-six cases which have already appeared in the literature developed antenatally and five had the onset during the newborn period. These were by Taylor (1897), who was the first to report torsion of the spermatic cord in infancy which he observed four hours after birth; Trillot (1940, quoted by Campbell, 1948) had one case of 3 days old; Campbell (1948) two cases one day old; and the second case of Biorn and Davis observed almost immedi- ately after birth, making a total of six cases observed in the newborn.

In the first case of this paper the torsion was also observed at birth, but it may have occurred before birth as microscopy of the organ suggests. There has been no record of a death due to torsion of the spermatic cord per se, and so it is regrettable that one of the cases described here (Case 1) should have succumbed to a post-operative gastro-enteritis.

CASE REPORTS Case 1 (D. J. R.).-This baby was brought to the Out-patient Department when it was 3 weeks old because

of a swollen left testicle which had been swollen since birth. Family History-Both parents were young and well. The family background was good. The patient was the

result of a second pregnancy, there being a healthy sister aged 24 years. There had been only two pregnancies. Neonatal History.-Gestation had been uneventful for the mother, and birth of the patient had been spontaneous

and normal at term. The birth weight was 8: Ib. (4 kg.), and the patient had been breast-fed for two weeks and then artificial feeding was substituted. The patient behaved like a normal newborn baby. There was no vomiting, diarrhoea, or any other indication that the baby might be unwell. When the infant was born there was present a swelling of the left testicle, but because the infant appeared to be in good condition little notice was paid to this swelling until the third week of life when the mother was up and about and able to attend the Out-patient Department for advice.

Physical Examination.-Temperature and respiration were normal. The pulse was not recorded. The baby was well nourished and well developed ; in no distress. The only abnormal physical findings were in the scrotum. There was a right-sided hydrocele of the tunica vaginalis testis the size of an almond nut, but on the left side there was some edema of the scrota1 skin which was discoloured a dusky red, and it appeared adherent to the underlying structure which was a swollen, heavy, non-tender testicle and as big as a pullet’s egg. Palpation of

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'TORSION O F T H E S P E R M A T I C C O R D I N T H E F I R S T Y E A R OF L I F E 57 the cord revealed it to be swollen, also with loss of definition and individuality of component parts. There was no herniation of abdominal contents along the inguinal canal, and there was no inguinal lymph node hyperplasia or lymph-adenopathy. There was no suggestion of any increased tension in the scrota1 mass when the baby cried, and the baby's bowel movements continued normally.

Laboratory Dam.-The hemoglobin was 124 per cent., the erythrocytes 5.5 million, the leucocytes 32,000,

Photomicrograph of the tezticular tissue of Case 1 showing in heavy black the calcified p;itches H ieniot ox y I i II n n tl eosi n st a i ti.

with a differential reading of polymorphonuclears 27, lymphocytes 66, eosinophils 5 , basophils I . and Turck cells I. Routine urinalysis was essentially normal, and the frecal dejecta showed no parasites, no blood, no salmonella or dysentery-group organisms.

The Course in Hospitu/.-The apparent well-being of the patient inclined one against a diagnosis of a torsion of the spermatic cord, and the possibility of the condition being malignant, like a teratoma testis, persuaded the surgeon to take immediate action and a left orchiectomy was carried out. When the testis was delivered from the scrotum i t was large, dark red, and rubbery-hard and rotated about the axis of the spermatic cord. There was no naked-eye sign of malignancy when the testis was sectioned a t operation. The patient made a good immediate post-operative recovery but, unfortunately, succumbed to gastro-enteritis which was contracted later.

His/o-putho/ogy.-Dr F. Duran-Jorda reported on the microscopic examination of the specimen of testis : '' The specimen consists of a testis and epididymis, measuring approximately 3 by 2.5 cm. The testis is necrotic and contains a few small calcified patches ; the condition is compatible with a torsion of the testis '' (see illus.).

The presence of the calcified patches inclincd Dr Duran-Jorda to believe that the onset of the twist had taken place before birth.

Case 2 (J. N.).-This baby was brought to the Out-patient Department at the age of 2; months with the complaint that over the preceding five days a swelling had been present in the left groin. This swelling had not been associated with any symptoms or signs of distress. There had been no vomiting, the bowel movements continued normally, and there had been no loss of weight, malaise, or change in disposition, except perhaps for some slight fretfulness.

There had been three siblings, one, a prematurely born baby, had died at 5 weeks of age. The two other siblings, a male aged 5 years and a female of 2 years, were alivc and well.

Furni/.v History.-The parents were well.

58 B R I T I S H J O U R N A L O F U R O L O G Y

Previous History.-The pregnancy had been uneventful except for its termination one month before term. Delivery had been normal and the patient’s birth weight 48 lb. (2.1 kg.).

PhysicalExamination.-Weight, 10 Ib. 2 02. (4.6 kg.) ; head circumference, 184 in. (46.25 cm.) ; length, 224 in. (56.25 cm.) ; temperature, 98” F. (rectal). The baby was rather pale, somewhat fretful, but except for this and a left-sided inguinal swelling which was tender and hard there was nothing else unusual. The parents had not been aware of any deficiency in the scrotum which would have indicated a failure of descent of the testis. The right testis was in the scrotum and clinically normal.

The Course in Hospital.-The probability of an incarcerated inguinal hernia associated with maldescent of the left testis determined immediate operation which disclosed the left testis in the inguinal canal and no hernia. The testis was twisted two or three times about the axis of the spermatic cord, in a clockwise direction. The twists were wholly above the body of the testis which was gangrenous. The testis and epididymis were excised. The baby made an uninterrupted recovery.

Histo-pathology.-To the naked eye the testicular structure was a dark-grey ovoid mass 1.5 cm. long, the sectioned surface was brown, and on microscopy revealed a hzmorrhagic necrosis of the testis.

ETIOLOGY The certain cause or causes of spermatic cord torsion remains unknown, but a working theory

which is generally accepted is one based on a deviation from normal and embryonic development of the attachments of the testis. Donovan (1930) states that almost every author who has operated upon a torsion of the spermatic cord has reported some abnormality of the attachment of the testis to the cord and epididymis, usually associated with a spacious tunica vaginalis with either a long or broad mesorchium. In the two cases reported here the duration of the twist with its attendant morbid changes precluded such detailed analysis of the anatomical structure.

With an unobstructed passage from within the abdomen along its retroperitoneal course the testis enters the scrotum about the eighth or ninth month of fetal life, and with obstruction to its passage Donovan (1930) remarks that “ it is not unusual to find a long mesorchium or a wide separation of testis and epididymis, there being great variation in the attachment of the spermatic cord to the testis. Such are the factors which are regarded as predisposing to torsion.”

Experimental work in dogs has shown that a complete torsion will bring about gangrene of the testis in thirty hours.

Torsion of the spermatic cord does not always take place within the tunica vaginalis testis as appears to be generally believed, and the cases reported by Taylor (1897), Campbell (1948), and Donovan (1930) prove this, but demonstrate an unexplained proclivity in this direction in the very young which may be accounted for by the fact, which Hunter (1926) showed, that in the very young the testis can be removed from its scrotal coverings with very little rupture of the surrounding connective tissue. A testis with a normal mesorchium cannot be twisted (Campbell). A long, lax, or absent gubernaculum which frequently accompanies cryptorchidism may possibly allow abnormal mobility, or an elongation of the globus minor, or abnormal attachment of the mesenteric vessels to the lower pole of the testis and to globus minor, may be factors. Sudden muscular strain is a common atiologic factor, and yet it may occur during sleep (Rigby and Howard, 1907).

SYMPTOMATOLOGY In the older infant and child, as in the adult, the onset of torsion of the spermatic cord is

announced by sudden, sickening pain, which may be accompanied by a systemic disturbance usually gastro-intestinal, but as in Taylor’s case by convulsive seizures.

A maldescended testis in the inguinal canal will suggest an incarcerated hernia. With the testis in the scrotum a hlemorrhagic infarction of the testis may be thought of, and with gangrene or complete infarction the testis becomes insensitive.

On the other hand, in infants, as in the two cases of Donovan, a case 7 months old of Edington (quoted by Rigby and Howard, 1907) and in the two cases reported in this paper, there may be a complete absence of symptoms, and the awareness of some local pathology be incidental to the routine management of the infant by the mother. The signs which suggest torsion of the spermatic cord may include cedema of the inguinal or scrotal areas, perhaps an

T O R S I O N O F T H E S P E R M A T I C C O R D I N T H E F I R S T Y E A R O F L I F E 59

inguinal mass, the testis being absent from the scrotum, or there may be a change of colour of the skin of the scrotum as in Case 1, in which the colour was a dusky red, or there may be fluid in the tunica vaginalis, usually blood. The testis may “ weigh ” heavily, and this could simulate a syphilitic gumma of the testis of prenatal origin or a malignant teratoma.

DlAG NOSIS The diagnosis of torsion of the spermatic cord requires to be differentiated from the conditions

already mentioned, namely, gumma, teratoma, hydrocele, testicular infarction, acute inguinal lymphadenitis, strangulated inguinal hernia, and the final diagnosis can be made only by surgical intervention. Acute epididymo-orchitis which is very rare in childhood should not be diagnosed in infancy, but in young boys it has been confused with torsion of the cord. A history of sudden agonising pain which may draw attention to local pathology in or about the scrotum is not always to be expected, as the two cases of Donovan and the two cases reported here testify.

PROGNOSIS The evidence goes to show that the testis will stand a chance of survival if it is released from

its predicament within thirty hours of the onset of the torsion, but even then, although it may survive the torsion, it is likely to suffer atrophy. Care should be exercised to distinguish a torsion of the appendix testis from a “ torsion of the testis.” The former does occur, and in the past in older patients orchiectomy has mistakenly been carried out (Fosher, 1932 ; Rhodes, 1935). The other appendage which may suffer a twist and so simulate a torsion of the cord is the hydatid of Morgagni (Lambert and Smith, 1938).

Most pzdiatricians have had at some time or other to consider a diagnosis of orchitis in a young child or infant, and may have made a diagnosis of “ non-specific orchitis.” It is the ‘‘ non-specific orchitis ” which not seldom is a partial torsion of the spermatic cord with enough of a twist to interfere with the health of the testis but not enough to produce symptoms of an acute surgical emergency, and to which later in life an atrophy of the testis is attributed.

TREATMENT It is as well, therefore, that the pEdiatrician or pzdiatric surgeon bear in mind the possibility

of a torsion of the spermatic cord when a baby or child presents with a swelling in the scrotum, with or without pain, and should i t not be possible unequivocably to make a diagnosis other than that of torsion, the surgeon should make operative exploration, for the literature holds cases where procrastination has resulted in unnecessary castration.

SUMMARY A brief review of torsion of the spermatic cord as it has occurred in the first year of life

serves as an introduction to two reports of cases with onset at or possibly before birth in one and at 2A months in the other.

A recapitulation of factors considered to be of xtiologic significance follows, and the diagnosis, prognosis, and treatment are summarised.

REFERENCES ALLEN, P. D., and ANDREWS, T. H. (1940). BIORN, C. L., and DAVIS, J . H. (1951). J . Amer. mecl. Ass., 145, 1236. CAMPBELL, M. F. (1948). J . Pediut., 33, 323. DONOVAN, E. J. (1930). Ann. Surg., 92, 405. FOSHER, C. H. (1932). J . Amer. med. Ass., 99, 269. HUNTER, R. H. (1926). Brit. J . Surg., 14, 125. LAMBERT, J., and SMITH, R. E. (1938). Brit. J . Surg., 25, 553. RHODES, J . S. (1935). New Engl. J . Med., 213, 1005. RIGBY, H. M., and HOWARD, R. J. (1907). Lancet, 1, 1415. TAYLOR, M. R. (1897). Brit. meri. J., 1, 458.

Amer. J . Dis. Child.. 59, 136.