Blue Scrotum Blues: A Case of Neonatal Testicular Torsion

Introduction: Neonatal testicular torsion (NTT) is a rare condition that occurs during the perinatal time period. The incidence is about 6 per 100,000 live births, with the majority of cases consisting of unilateral testicular torsion. Timing of torsion can impact testicle viability and ultimate organ salvage during urologic surgical intervention as vascular compromise can result in ischemic injury. The current literature regarding NTT describes both typical and atypical presentations, with a focus on the controversies in surgical management. With this case presentation, we attempt to highlight aspects of clinical findings in a neonate with NTT and identify key components of immediate management for the pediatrician.

Case Description: A newborn male born via cesarean section at 36 4/7 weeks of gestation with an uneventful delivery was noted to have blue discoloration to the right hemiscrotum immediately after birth (Figure 1). A large, firm, non-tender, scrotal mass was palpated on the right side. Initial testicular ultrasound with Doppler revealed that the right testicle was asymmetrically enlarged with heterogeneous echotexture and striated hypoechoic interior. Doppler demonstrated hyperemia surrounding the right testicle, but no signal was visualized within the right testicular parenchyma (Figure 2). The urology team was consulted, and on day of life 2, the infant had right orchiectomy and left orchiopexy under general anesthesia. During surgery, the right testicle was necrotic in appearance. The patient tolerated anesthesia without adverse events. At the two week follow up visit, the incision site showed appropriate healing and the left testicle was a normal size to palpation.

Discussion: We report a case of NTT in a preterm infant with successful early surgical management. While risk factors such as term gestation, breech delivery, and traumatic delivery have been proposed in NTT, no definitive cause has been identified. The initial differential diagnosis in a patient with similar findings could include testicular torsion, birth trauma, hydrocele, intestinal hernia, epididymitis, appendicitis, and rare solid malignancies. Physical examination findings of a firm, non-tender, frequently discolored scrotal mass in the neonate has been suggested to be pathognomonic for torsion. Doppler ultrasonography with absent signal within the testicular parenchyma is suggestive of torsion. Regarding surgical management, the benefit of testicular salvage and prevention of future torsion events must be weighed against the potential risks of exposure to anesthesia.

Conclusion: Pediatricians should consider NTT in any newborn presenting with scrotal swelling, discoloration of the scrotum, and scrotal mass. The appropriate initial test in these patients is a scrotal Doppler ultrasound. Prompt involvement of the pediatric urologist is key as it allows for determination of timing of surgical management. Early surgical management can lead to possible organ salvage and prevention of anorchia from contralateral torsion.