testicular torsion in children
Introduction
Introduction to testicular torsion in children Due to torsionofspermaticcord, acute blood flow disorders in the testis and epididymis cause infarction or necrosis, often misdiagnosed as acute orchitis and epididymitis, some unexplained testicular atrophy is also the result of this disease. More common in young people, but in recent years in the number of children, especially newborns, the number of cases increased, clinical is not uncommon, often occurs in congenital testicular mesangial length, testicular dysplasia, cryptorchidism, testicular insufficiency, epididymis and testicular connection Incomplete, epididymis and some spermatic cords are overactive, and the spermatic cord is too long. basic knowledge The proportion of illness: 0.001% Susceptible people: children Mode of infection: non-infectious Complications: male infertility
Cause
Pediatric testicular torsion
(1) Causes of the disease
Testicular torsion is based on the reversal of the spermatic cord and can occur in three locations for the following reasons:
1. The torsion occurs outside the intrinsic sheath and occurs outside the intrinsic sheath. Most of the newborns are of this type, and the testis and the sheath are infarged.
2. Occurrence of intrathecal torsion occurs in the sheath and is more common in young people. Excessive mesangial membrane may be the cause.
3. Occurred between the testis and the epididymis is located between the testis and the epididymis, and the combination between the two is not completely related.
(two) pathogenesis
1. Pathogenesis The pathogenesis of testicular torsion is not fully understood, and may be caused by several factors at the same time.
(1) Developmental abnormality of testicular sheath and spermatic cord: It is the main cause of testicular torsion. Cass (1982) observed that almost all patients have anatomical variations that are prone to testicular torsion. There are 4 categories:
1 testicular sheath mutation: normal testicular sheath and testis, epididymis and scrotum posterior wall adhesion, the attachment is not surrounded by the sheath, so that the position of the testis is relatively stable, when the sheath completely wraps the testicle or expands up to the spermatic cord At the distal end, the testicles were suspended on the spermatic cord and showed a "bell hammer"-like deformity. The testicles were free to rotate in the sheath cavity. 92% of the cases of Cass had this abnormality.
2 The epididymis is attached to the testicle or separated from the testis, or the epididymis is too long, which increases the testicular activity and causes a twist.
3 Neonatal sheath has not been adhered to the scrotum, so it is prone to extracapsular torsion.
4 cryptorchidism, testicular ectopic, multiple testicular disease, the spermatic cord is too long is a good testicular torsion group, it has been found that the decline in the testicular torsion is 21 to 40 times the probability of normal.
(2) cremaster tendon: is the origin of testicular torsion, from the anatomical point of view, the cremaster muscle is oblique or spiral distribution in the spermatic cord, when the cremaster muscle contraction, the testicles rotate from the outside to the inside, Therefore, when the testicular torsion occurs, the left side rotates counterclockwise and the right side rotates clockwise.
Testis on either side can be reversed, occasionally bilateral. According to Watson's experience, the neonatal testicular torsion is often clockwise on the left side and counterclockwise on the right side.
(3) related to heredity.
(4) idiopathic infarct of the testicle is not associated with spermatic cord torsion: often associated with strangulation or incarcerated inguinal hernia in small infants, also seen in postpartum birth, some cases after birth There is testicular infarction, which may be a natural reduction after intrauterine torsion.
2. Pathological changes After testicular torsion, the pathological changes occurred are closely related to the degree of torsion and ischemic time.
Testicular tissue is very sensitive to ischemia. Smith (1955) used dogs for animal experiments and found that testicular ischemia did not affect testicular spermatogenesis and endocrine function for 2 h; ischemia for 4 h, spermatogenic function stopped for 60 days, endocrine no effect; ischemia 6h, spermatogenesis disappeared, endocrine function was partially lost; ischemia 10h, testicular spermatogenesis and endocrine function were completely lost, clinically, this was the case The testicular salvage rate is 80%; the rescue rate is only 50% to 70% for 8-10h treatment; 20% for more than 10h; only 10% after 24h.
The testicular blood supply comes from the testicular artery, the spermatic artery and the vas deferens artery. The degree of testicular torsion is different, and the effect on the testicular blood supply is also different. It has been observed that when the testicle is twisted by 90°, testicular necrosis is performed after 7 days; when twisted by 180°, 3 to 4 days testicular necrosis; when twisted 360°, testicular necrosis 12~14h; when twisted 720°, only 2h testicles were necrotic.
The changes in testicular morphology and function in the long-term observations were not consistent. It was observed that the testes that had been rescued after reversal had atrophy, and the atrophy rate was 33% to 68% after 2 years. Some clinical and animal experiments showed that after testicular torsion Due to the release of antigenic substances, causing autoimmune reactions, accumulation of neurotransmitters and toxic substances or endocrine disorders, can damage the testes, affect the spermatogenic function, leading to infertility, it is believed that before the testicular torsion, there is already a general anatomy and internal structure Abnormalities, fertility may have declined, and some scholars believe that testicular torsion does not affect fertility, Puri through IgG immunoagglutination test, no autoantibodies found in all cases, considered testicular reproduction after testicular torsion before puberty The cells are not fully developed, and there is little sympathetic lesion of the contralateral testis due to autoimmunity, which does not affect fertility after adulthood.
Prevention
Pediatric testicular torsion prevention
In daily life, many men have turned their backs on the testicles, and they endured the pain when they endured the treatment. Therefore, others lose their fertility and cause misfortune for life. Therefore, men in adolescence and before and after such as sudden scrotal swelling, pain, especially adolescents, should consider the possibility of testicular torsion, should go to the hospital for urological examination and treatment. In the early stages of testicular torsion, good results can be achieved with a freehand reset. However, the onset time is long and can only be treated surgically.
Complication
Pediatric testicular torsion complications Complications, male infertility
Can go to testicular atrophy, necrosis, affect fertility and endocrine.
Symptom
Pediatric testicular torsion symptoms common symptoms scrotal swelling testicular pain severe pain
1. Clinical manifestations The side of the testicular pain is the first symptom of the disease, often occurs suddenly during sleep or quiet, may be the vagus nerve excitement during sleep, the cremaster muscle contraction increases with the penis erection, the testicles are twisted, and gradually increase, One third of patients with testicular swelling and pain occur slowly. A small number of patients have a history of intense activity before onset. The nature of the pain is initially painful, which in turn exacerbates and becomes persistent severe pain. The testicular does not allow touch, and the pain of a few children The spermatic cord radiates upwards, but also has reflex nausea, vomiting, initial examination of scrotal swelling, tenderness. It is believed that the testicle is slightly enlarged and moved up to the root of the scrotum, and is in a horizontal position, which is a specific sign of the disease. After the torsion occurs, the venous return is blocked, the testicular congestion, followed by arterial occlusion, testicular ischemia and swelling, the testis and epididymis are unclear, and the Prehn sign is positive, that is, the pain is aggravated when the testicle is lifted upward, the crepital reflex disappears, and the scrotum is swollen. Gradually increase and harden.
2. Clinical classification Testicular torsion is basically divided into two types:
(1) Testicular torsion in the sheath: Most of the testicular torsion is clinically common, mostly in adolescence.
(2) external sheath testicular torsion: torsion occurs on the testicular sheath, so it is also called spermatic cord torsion, almost all occur in the neonatal period, not easy to diagnose early, the torsion is more than 360 °, the testicular torsion Local pain, often radiate to the abdomen and waist, and have nausea, vomiting and fever, can be mistaken for testicular and epididymal inflammation, incarcerated hernia, even intra-abdominal disease, scrotal skin congestion, edema, fever, due to cremaster tendon And the shortening of the spermatic cord, the testicles are mentioned in the upper part of the scrotum (Fig. 5), the scrotum is swollen, the skin is edematous, the tenderness is significant, and the mild torsion only causes mild discomfort, accompanied by intermittent hydrops, newborns and small babies. Testicular torsion is often painless, the torsion of the testicles increases, hardens, but no tenderness, the scrotum often adheres to its walls and can be blue through the skin.
Because the disease has no specific performance, it is not easy to confirm the diagnosis at an early stage. We have collected 232 cases in China, and the misdiagnosis rate is nearly 60%. It is emphasized that when the scrotal emergency in childhood does not include urinary system symptoms, it should be diagnosed before other diseases are diagnosed. Considering testicular torsion, Doppler ultrasound blood flow measurement and ECT are helpful for diagnosis, and others have used B-ultrasound and MRI for preoperative diagnosis.
In recent years, it has been reported that ultrasound blood flow map, ultrasound stethoscope and radionuclide 99mTC scan to diagnose testicular torsion, intermittent hydrocele with mild tenderness may have incomplete torsion.
Examine
Pediatric testicular torsion examination
There are no abnormal findings in laboratory tests.
1. Doppler ultrasound blood flow measurement can sensitively detect changes in testicular blood flow, is a fast, simple, non-invasive, painless and repeatable examination method, the diagnostic accuracy is as high as 81% to 90% During the examination, the Doppler ultrasound stethoscope head is placed directly on the scrotum, and the probe is moved along the longitudinal axis of the testicle to detect the vascular sound of the testicle, and the vascular sound is detected as negative; the spermatic blood vessels are oppressed, and the vascular sound disappears to be positive, and two Side contrast, when the testicles are twisted, blood flow is reduced or disappeared; blood flow increases during acute epididymitis; blood flow is normal or increased when the testicular attachment is reversed, but this method also has a certain false negative, often due to congestion or incompleteness. When twisted (within 180°), the blood flow is not completely blocked, the arteries are still weakly beaten, the venous congestion, and the probe position is too high to interfere with the pulsation of the spermatic vessels.
2. Radionuclide examination before the patient to take oral potassium chloride to protect and block thyroid function, intravenous injection of 185 ~ 740MBq potassium, the first minute for the development period, after 5 to 10 minutes for the testicular parenchyma development period, the -sweet camera Align the scrotum and testicles once every 5 seconds. The patients with testicular torsion showed a decrease in vascular phase, a decrease or disappearance of the parenchyma, and a pregnancy ring reaction. Patients with epididymitis showed enhanced vascular and parenchymal development. The accuracy of radionuclide scanning in the diagnosis of testicular torsion is 87% to 100%, but there are also false negative or false positives, mostly caused by long torsion time and testicular tissue congestion. The advantage of this method is painless, non-invasive and rapid. 10 to 15 minutes can be completed without affecting the emergency operation time, but the examination cannot be repeated within 24 hours.
Diagnosis
Diagnosis and diagnosis of testicular torsion in children
Testicular torsion has no typical history and unique signs. Differential diagnosis is difficult. It is often misdiagnosed in the early stage of the disease. It should be differentiated from the following diseases before surgery: 1. The difference between orchitis and epididymitis and testis and epididymitis is that the latter is slow. When lifting the scrotum, the pain is relieved. Conversely, when the testicle is twisted, the pain is aggravated when moving or lifting the scrotum. In childhood, it can exist alone or in the presence of mumps. The scrotal swelling and pain are slow, many have fever, and the blood is high. Sexual manifestations, epididymitis can more clearly touch the enlarged epididymis outline, testis often drooping, Prehn sign negative.
1. Testicular attachment torsion testicular attachment generally refers to the remnant of the middle kidney tube. After the testicular accessory is twisted, the symptoms are similar to testicular torsion. It is often difficult to identify clinically, but the principles of surgical treatment are the same, sometimes above the testicle or For lateral painful lumps and large pea masses, first consider the testicular attachment torsion.
2. Others should also be differentiated from other diseases such as testicular abscess, inguinal hernia, trauma, tumor, testicular infarction, etc. The difference between testicular swelling and testicular tumor is that the disease is painful, and the skin is red and swollen.
