儿童间歇性睾丸扭转的临床诊治分析

Clinical analysis of intermittent testicular torsion in children

目的探讨间歇性睾丸扭转(ITT)的临床特点、诊治及预后,以提高对ITT的认识。方法回顾性分析2014年4月至2019年12月复旦大学附属儿科医院收治的9例ITT患儿的临床资料。年龄4.7~13.9岁,平均11.9岁。临床表现为阴囊、睾丸疼痛,疼痛可自行缓解,疼痛次数平均2.4次(1~5次),每次持续1 min^3 d,其中1例伴恶心和左下腹痛。阴囊、睾丸疼痛次数4例为1次,5例反复多次,其中1例多次睾丸扭转手法复位缓解。5例急性发作期患儿,病程为4~24 h,查体均见患侧阴囊红肿伴触痛明显,提睾反射消失;超声检查提示2例睾丸无血供,1例睾丸血供减少,1例睾丸血供正常伴附睾头增大,1例睾丸血供正常伴睾丸上方精索血管扭转。4例慢性期患儿病程为5~24个月,查体见患侧阴囊较对侧松弛,睾丸位置低,提睾反射存在,其中1例伴睾丸横位,1例伴睾丸萎缩发育小;超声检查提示1例存在睾丸萎缩变小,其余3例睾丸正常。9例均行睾丸探查、双侧睾丸固定术,其中5例急性发作期患儿行急诊手术;4例慢性期患儿行择期手术。结果9例手术均顺利完成,无睾丸坏死,睾丸挽救率为100%(9/9)。所有患儿均存在患侧睾丸附睾鞘膜附着异常,为钟摆畸形,其中2例伴健侧睾丸附睾钟摆畸形。所有患儿术后第1天出院。术后随访时间1~69个月,中位时间10个月,均未见睾丸疼痛复发。除1例术前患侧睾丸已存在睾丸萎缩外,所有患儿睾丸均恢复良好,未见睾丸萎缩变小。结论ITT主要临床表现为患侧阴囊、睾丸疼痛,可自行缓解,疼痛持续时间长短不一;查体见睾丸横位或睾丸萎缩、发育小有助于诊断;超声检查因睾丸扭转可自行复位而表现多样。ITT一经诊断,需尽早行双侧睾丸固定术,以防阴囊、睾丸疼痛再次发作及潜在的睾丸缺血损害。

Objective To explore the characteristics of diagnosis,treatment and prognosis of intermittent testicular torsion(ITT)in children.Methods Retrospective review was conducted for the clinical data of 9 ITT cases from April 2014 to December 2019.The average age of all patients was 11.9 years(range 4.7-13.9 years).The involved side was left(n=4),right(n=4)and bilateral(n=1).The main symptoms included severe pain of rapid onset and rapid resolution associated with nausea and lower abdominal pain(n=1).The average number of painful episode was 2.4(1-5).There was a number of 1 painful episode in 4 emergency operative cases and more than 1 in 4 elective operative cases and 1 emergency operative cases.One patient of recurrent scrotal pain was relieved by manual detorsion.Among the five emergency operative cases,scrotal swelling and tenderness were found on the affected side,and the cremasteric reflex disappeared.Ultrasonic examination showed that two had absent testicular flow,one had decreased testicular flow,one had normal testicular flow with swelling epididymis and one with torsion of spermatic cord above testis.While among the 4 elective operative cases,the lie of the affected testis with cremasteric reflex was low on physical examination in all patients,compared with the contralateral testis.Atrophy of the affected testis were found in one case and horizontal lie in another one.The duration of prehospital symptoms ranged 4-24 hours during acute presentation in the 5 emergency patients,and 5-24 months in the 4 elective patients.All patients underwent testicular surgical exploration and bilateral orchidopexy.Results Surgical exploration revealed no testicular ischemic infarction,and the rate of testicular salvage was 100%.A bell-clapper deformity(BCD)was found on all the affected testis and 2 contralateral testis as well.The median time of follow-up time was 10 months(range 1-69 months).No recurrence of testicular pain and other complications was found.Except for one case of testicular atrophy in the affected side before operation,the testicles of all patients recovered well without testicular atrophy.Conclusions Intermittent testicular torsion is mainly manifested as repeated episodes of sudden onset unilateral scrotal pain that could be spontaneously resolved.The positive clinical findings include a horizontal position of the testes while standing and discrepancy in size of the testes.The ultrasonic examination is diversified because testicular torsion can be spontaneously relieved.Although the rate of testicular salvage is high in ITT,surgical exploration and bilateral scrotal orchiopexy should be carried out as early as possible to prevent recurrent painful episodes and testicular ischemic damage.