There are a number of urologic conditions that pediatric hospitalists will encounter in their care of pediatric inpatients. Primary urologic emergencies such as testicular torsion and urinary obstruction require prompt diagnosis and intervention to limit morbidity. In addition, several medical entities, such as recurrent urinary tract infection (UTI) and vesicoureteral reflux (VUR), may benefit from urologic consultation. Surgical intervention may be considered or required in some cases such as testicular torsion, high grade vesicoureteral reflux, or high grade ureteropelvic junction obstruction.
Testicular torsion is caused by twisting of the testicle and the spermatic cord resulting in hypoxia to the testicular parenchyma. Depending on the mechanism and degree of torsion, there is a variable period in which the testis is salvageable. Torsion can occur as a result of two mechanisms: extravaginal torsion and intravaginal torsion, terms referring to the tunica vaginalis, a structure that surrounds the testicle. In some regard, this distinction is clinically irrelevant because it cannot be determined clinically, nor does it alter treatment.
Although testicular torsion can occur at any age, it has a predominantly bimodal occurrence, namely, the neonatal and pubertal periods. The precise risk for the development of testicular torsion is not clearly established, but the approximate overall risk of testicular torsion developing by 25 years of age is 1 in 160. Testicular salvage rates have increased over the last 40 years, mainly as a result of early recognition and intervention. The undescended testis is also at risk for testicular torsion, presumably because of abnormal mesorchial attachments. Any child with a nonpapable testis and abdominal pain should be evaluated for intra-abdominal testicular torsion.
CLINICAL PRESENTATION AND DIAGNOSTIC EVALUATION
Neonatal torsion is usually the result of extravaginal torsion in which the testicle twists on the spermatic cord or outside the tunica vaginalis; it accounts for 12% of all cases. Neonatal torsion occurs in the prenatal and postnatal periods. Such occurrence does not appear to be correlated with prematurity, birth weight, method of delivery, or perinatal trauma. The condition is almost always asymptomatic and discovered on routine examination. The examination generally shows an edematous, erythematous hemiscrotum with a firm testis. The hemiscrotum does not usually transilluminate. Current ultrasound technology is very accurate in determining the presence or absence of testicular blood flow in neonatal torsion.1 However, ultrasound results and interpretation can vary due to operator experience and other technical factors and therefore clinical judgment remains relevant. Because of the imprecision of older ultrasound technology, nuclear scans to assess testicular blood flow were common but are now rarely performed. Neonatal torsion is thought to be secondary to the hypermobility of neonatal tissue, which does not firmly fix the testis to the scrotum. Controversy remains over the management of contralateral testis in neonates with torsion. Some ...