Neonatal Testicular Torsion

Testicular torsion is thankfully rare in male newborns. But what happens if your newborn son is diagnosed with this condition? The following information should help you better understand this serious state of health.

What happens under normal conditions?

The testicles (also called the testes; a single testicle is also called a testis) are part of the male reproductive system. These organs are usually contained within a sac of skin called the scrotum, which hangs beneath the penis.

Late in pregnancy, the testicles descend from the abdomen into the scrotum. At the time of a full-term delivery, all but 3 percent of male babies will have both testicles dropped down into the scrotum. In the process of descent, the testicle is guided by a small attachment known as the gubernaculum testis. After the testicle has moved into the scrotum, it remains there in its normal position because the gubernaculum becomes attached to the surrounding tissues. There are also additional attachments that form between the testicle and its surrounding structures and the inside wall of the scrotum. If the normal attachment process is not yet complete, twisting of the testicular blood supply can occur during pregnancy or around the time of birth.

The testicles are nourished by the blood vessels, which together with the nerves and the sperm channels pass through the spermatic cord from the abdominal cavity to the scrotum. The testicles hang loose in the scrotum and in rare cases they are twisted resulting in a strangulation of the blood supply and the demise of the testicle.

Most often, neonatal testicular torsion is recognized at childbirth. However, it can also occur during the first weeks of life, so the discovery of a firm, enlarged and/or discolored scrotum should lead to an immediate evaluation. Often, such a testicle will not move freely in the scrotum. Sometimes it will have a fluid collection around it, known as a hydrocele. If the hydrocele is large, it can make diagnosis of torsion difficult. Other causes of a firm and/or enlarged scrotum include tumors, which are rare in this age group.

After the baby is born, the testicles will be examined as part of the initial physical examination. If one testicle is missing, the cause may be that it has not dropped down into the scrotum, that it never developed in the first place or that it twisted at some time prior to birth and shrunk in size. On the other hand, if an abnormal scrotum is identified, the likelihood is great that it represents testicular torsion. If so, a nuclear scan or an ultrasound might show a lack of blood flow to that testicle as well as other signs to support the diagnosis. However, these tests are sometimes hard to interpret, thus they are not necessarily required for diagnosis and treatment.

While it has been said by some experts that testicular torsion in babies has no symptoms, we know from older children and adults that this condition is extremely painful. It is possible that the discomfort of torsion of the testicle in a baby is overlooked because the scrotal sac is not examined when he is crying from some source of pain.

For most babies diagnosed with testicular torsion at birth, the testicle cannot be salvaged.  However, in cases where the testicle twists shortly after birth, it may be saved if it is untwisted within a few hours. For this reason, a newly recognized firm, enlarged and/or discolored scrotum following an initial physical examination is an emergency and should be evaluated by a surgeon as quickly as possible. Although the testicle may not be saved if the blood supply has been cut off for too long, there is some evidence that surgery to prevent twisting of the other testicle may be useful. However, not all pediatric urologists agree with the need to operate on the normal opposite testis for fixation. There are multiple considerations, including the likelihood of testicular torsion occurring in the opposite testicle as well as risks associated with anesthesia.

Unlike surgery for torsion in older children or adults, the surgery in babies generally includes two small horizontal incisions slightly higher than and lateral to the penis. This groin incision also allows repair of a hernia if one is encountered.  

What can be expected after treatment for testicular torsion?

Many newborns will need to stay in the hospital overnight after their surgery because of post-anesthesia monitoring of breathing and pulse. The incisions are often painless for several hours because of local anesthetic and afterwards patients need only acetaminophen or ibuprofen for pain. 

Frequently asked questions:

Only one functioning testicle is necessary for normal fertility potential and full masculinization. A single testicle will produce normal amounts of sperm and testosterone. While there has been some experimental evidence to suggest that mechanisms might exist to diminish fertility in these patients, they do not appear to be clinically relevant in the vast majority of men who have had torsion.

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