Presentation
Sudden onset of severe left scrotal pain. Testis high riding on examination and very tender.
Patient Data
- Absence of flow into the left testis, including on power Doppler
- Small (2 x 2 cm) supernumerary testis inferior to the main (larger) left testis within the left scrotum
- Left hydrocoele
- Swirling of the left spermatic cord was seen on real-time scanning (images not saved)
- Normal flow demonstrated to the solitary right testis
Ultrasound findings are consistent with left testicular torsion.
Given the time-critical nature of the diagnosis, limited ultrasound views were saved and the findings were urgently conveyed to the treating medical team to facilitate urgent surgical exploration.
Case Discussion
The patient in this case proceeded to urgent surgical exploration, where torsion of the left (main) testis was confirmed. The left (main) testis was detorted, resulting in return of good color and appearance. The smaller supernumerary testis (separate spermatic cord) was not torsed and had normal appearance. Orchidopexy was performed on both the left (main) testis and left supernumerary testis, as well as the right testis. The patient had an uneventful recovery and follow up period.
Polyorchidism is a rare congenital anomaly describing the presence of three or more testes. Left sided supernumerary testis is more common than right, and there is more commonly a single spermatic cord. Polyorchidism is asymptomatic and commonly diagnosed incidentally with torsion, inguinal hernia, or testicular tumor. Undescended testis and microlithiasis are commonly present in association with polyorchidism1,2.
Testicular torsion is a time-critical diagnosis, and if strongly suspected on clinical history/examination, the patient should proceed directly to surgical exploration and management, bypassing ultrasound. The role of ultrasound is in differentiation of equivocal presentations, where a diagnosis such as epididymo-orchitis is considered more likely. Even if no features of testicular torsion are demonstrated on ultrasound, an intermittently torting / untorting testis cannot be excluded 3.