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Fourty-eight patients were operated on for unilateral intravaginal testicular torsion at Yokohama Red Cross Hospital during the period between July 1976 and December 2001. Orchiopexy was carried out on 20 out of 48 patients. Only 8 patients could receive orchiopexy within 8 hours after the onset of symptoms. Although, 24 of the 48 patients had visited a medical doctor within 8 hours after the onset. Therefore, the less the testes might be sacrificed if these patients could be immediately sent to a clinic with an urologic speciality. The contralateral uninvolved testis has been said to require orchiopexy because it has an anatomical structure similar to the testis with torsion. However, the contralateral testes in 5 out of 20 patients with ipsilateral orchiopexy turned out to have a normal anatomical structure according to our classification of intravaginal testicular torsion. This suggests that no orchiopexy is necessary if the contralateral uninvolved testis has a normal anatomical structure from the standpoint of torsion type.

Objective: The purpose of this study was to illustrate the spectrum of sonographic findings in testicular torsion in a large series of neonates and infants. These patterns and their evolution have, to our knowledge, not been described previously., Conclusion: The sonographic appearance of testicular torsion in neonates and infants can be divided into three types. We believe that the findings represent different stages in the evolution of testicular torsion.

Painful scrotum is a clinical entity that includes a variety of diseases, such as torsion of the spermatic cord, infectious conditions, injuries and oncology. This condition is more common in infants or youths. It is extremely important to recognize this condition and treat it promptly if the testicle is to be saved.

With the aim of describe a typology that will result in a more precise diagnostic which in turn will permit the selection of the most direct method approach, an analysis was made of the clinical characteristics of patients we treated due to the presence of torsion of the testicular and epididymal appendages. A retrospective review was made of 91 patients, taking into account this age, time of appearance, time of evolution, symptoms, physical examination, histological study and effects. The average age was 9.47 years with a greater incidence occurring between the eight and twelve years old. No influence due to a seasonal phase was detected. The time span between the initial appearance of the symptoms and the time of admittance was 39.5 hours, being somewhat less in patients below the age of six. The common symptom was pain. In addition, 58.2% of the patients also suffered scrotal affectation. In 31 patients the hydatid was palpable and in 19 the "blue dot sign" rendered positive. In 83 cases, surgery was done via the scrotum, resulting in the confirmation of the initial diagnosis. The affectation of the left side was more frequent (62.5%). The hospital discharge was possible in less than 48 hours with no visible long-term effects. Thus, we believe that it is possible to almost always make a diagnosis based on the clinical data, and the type of treatment to be applied should be the extirpation of the hydatid to be carried out via the scrotum.

Histological investigation of 63 biopsies taken during surgical detorsion of twisted testes reveals 3 morphologically different degrees of damage. In grade 1 injury the testicular parenchyma shows edema of interstice, slight blood extravasation and a desquamation of the germ cells. The grade 2 injury is characterized by a diffuse hemorrhagic saturation of the interstice and partial necrosis of germ cells. The grade 3 injury corresponds to a fully developed hemorrhagic infarction of the testis. The biopsies taken within the first 4 h after onset of symptoms show a relatively high number of minor changes (grade 1) which hold out hope for restitutio ad integrum. Grade 2 injury predominates in the period between 4 and 8 h, but it can appear also in the first 4 h. Only after 24 h all the testes examined are completely necrotic. This study shows that the amount of time that elapses between onset of symptoms and surgical detorsion is not the only factor to predict the outcome of the injured testis.

We have developed a new classification for intravaginal testicular torsion by comparing the testes in 36 cases of intravaginal torsion with those of 30 cases undergoing castration for prostatic cancer. The classification was made by our new criteria as follows: bell-clapper type (type III) in which torsion very easily occurs; intermediate type (type II), which can be further divided into two subtypes, type IIb in which torsion easily occurs and type IIa in which torsion hardly occurs, and normal type (type I) in which torsion never occurs. We believe that our new classification is simple and useful for definite clinical understanding.

As a surgical therapy for intravaginal testicular torsion, we developed a testicular fixation method considering the testis in intravaginal testicular torsion in comparison with the normal one. With our method, the lower part of the testis is fixed in a ring form around the testicular long axis to show the wide extravaginal area similar to that of a normal testis. We believe that this method is simple, logical and effective to fix the testis in intravaginal testicular torsion.

Testicular torsion was evaluated by B-scan ultrasound in one experimental animal and in 12 patients. The clinical findings were categorized as acute, subacute, or chronic depending on the amount of time that had elapsed since the onset of pain (less than 24 hours, 1 to 10 days, and more than 10 days, respectively). A consistent pattern of sonographic parenchymal changes for each of these stages is described. The ultrasound textural changes were found to be diagnostically useful when correlated with the clinical findings. Scrotal ultrasound also complements radioisotope studies, locating the testicle when it cannot be found by palpation, and may detect testicular torsion that is not suspected clinically. When physiologic blood flow studies are normal in the clinical setting of possible torsion, ultrasound is more accurate than other imaging modalities in demonstrating pathology.