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Testicular torsion in children: scintigraphic assessment.

Seventy-five patients with suspected testicular torsion who had scintiscans and adequate clinical follow-up were analyzed retrospectively. The scintiscans diagnosed 12/13 cases of surgically proven missed torsion and 3/3 cases of surgically proven acute complete torsion. The scintiscans successfully distinguished all 35 cases of epididymo-orchitis, 14 cases of torsion of the appendix testes and 8 other miscellaneous conditions from testicular torsion. The incidence of testicular torsion in our patients undergoing scrotal scintigraphy was approximately 24%.

Adolescent↗

Physical mapping of the autoimmune disease susceptibility locus, Bphs: co-localization with a cluster of genes from the TNF receptor superfamily on mouse chromosome 6.

An important approach to understanding complex diseases is to reduce them into well-characterized subphenotypes that are under monogenic control. One such example is Bordetella pertussis toxin-induced histamine sensitization in mice, a subphenotype of experimental allergic encephalomyelitis and experimental allergic orchitis. This subphenotype is controlled by a single locus, Bphs, previously mapped to a 33 cM region on mouse Chromosome (Chr) 6. We achieved considerable reduction of this candidate region and constructed a YAC contig across the refined interval. Our results demonstrate that Bphs is located between D6Mit151 and a newly developed marker, EC108RR, a region containing a small cluster of genes belonging to the TNF receptor superfamily. Sequence and quantitative analysis of the candidate gene, tumor necrosis factor receptor 1 (Tnfr1, p55), indicates that it is unlikely to be Bphs. However, the location of Bphs, together with physiologic effects it shares with Tnfr1 activation, suggest that Bphs may prove to be another member of the TNF receptor superfamily.

Animals↗

The incidence and investigation of acute scrotal problems in children.

The true incidence of the various causes of acute scrotum in children is unclear; epididymo-orchitis (EO) is thought to be uncommon. Investigation for underlying urological abnormality in children with EO is recommended. To determine the incidence of the various pathologies in boys presenting to the emergency department with an acute scrotal condition and assess the value of further investigation of the urinary tract in a subgroup of boys with EO, a retrospective review of 100 consecutive patients admitted with a diagnosis of testicular pain was performed. Seventy had torsion of an appendix testis (TAT) and 12 had torsion of the testicle (TT). Ten boys were admitted with 11 episodes of EO; 7 had other pathologies including incarcerated hernia, varicocoele, and idiopathic scrotal oedema. The diagnosis of EO was made at operation in all 11 episodes. Escherichia coli was cultured in 4 patients; none were found to have underlying urinary tract abnormality. TAT was thus commonest causes of the acute scrotum. EO is not rare in infants, the incidence in this study being equal to the of TT. Subsequent urological investigation did not disclose any underlying abnormality. However, based on the current published literature futher investigation is recommended in selected cases.

Acute Disease↗

Cysts of the ejaculatory system: a report of two cases.

We report two cases of rare cystic dilatations of the ejaculatory system. In case 1, a 6-month-old boy was referred to us for the management of recurrent epididymo-orchitis (E-O) complicating open drainage and a colostomy was performed elsewhere for a purulent rectal discharge thought to be rectal duplication. Diagnostic imaging showed a retrovesical cyst. Urethrocystoscopy showed a swelling of the verumontanum. No fistula was seen between the cyst and rectum on colonoscopy. At laparotomy, both ejaculatory ducts and seminal vesicles were found to be fused into a mass with cystic dilatation of the ejaculatory duct. Intraoperative histopathology of the cyst identified a metaplastic epithelial lesion. The cyst was excised with bilateral vasoligation. Since surgery, 8 years ago, urination and defecation have been normal. In case 2, a 4-month-old boy presented with fever and a swollen right scrotum. Ultrasonography showed a retrovesical cyst. Right grade IV vesicoureteral reflux diagnosed on voiding cystourethrography was treated by ureter reimplantation (Cohen) but complicated by recurrent E-O. Urethrocystoscopy with retrograde contrast via the utriculus showed that the cyst opened on the verumontanum, that both ejaculatory ducts opened into the cyst, and there was reflux into the right vas deferens. Right vasoligation alone was performed through a scrotal approach. Although the cyst was not excised, there has been no recurrence of E-O nor enlargement of the cyst for 6 years. Cysts of the ejaculatory system should be considered in the etiology of recurrent E-O in prepubertal children and a high index of awareness is recommended.

Cystoscopy↗

Autoimmune interaction measured in a postlabelling microcytostasis assay.

A postlabelling microcytostasis assay was developed to assess primary immune interaction between normal rat lymphocytes and autologous testis cells. In this vitro model of experimental autoimmune orchitis (EAO) unprimed T cells respond to a Sertoli-like subpopulation of testis cells during a 4 day culture period. The T effector cells exert a cytostatic effect on the monolayer-forming target cells. The number of remaining target cells, which inversely correlates with the intensity of the autoimmune reaction, is quantified by 51Cr incorporation. The assay is performed in multiple well plastic plates which allow rapid harvesting by cutting off the bottoms of each well. The attached labelled target cells are directly measured on the bottoms without any further transfer step. The method is adapted for the EAO model but may be useful to study primary T cell interaction with any other monolayer-forming target cells.

Animals↗

Torsion of spermatic cord and testicular appendages.

Forty-seven cases of torsion of the spermatic cord and testicular appendages have been reviewed. Twenty-eight patients with acute spermatic cord torsions underwent surgical correction. Only 10 were treated in time to preserve viability. The other cases were either gangrenous and required orchidetomy or were questionably viable. Acute, painful scrotal swelling with negative e findings on urinalysis is a surgical emergency. Ten patients had warning attacks, but because of delay in diagnosis and treatment, 4 required orchidectomy. Those patients with spermatic cord torsion who were detorsed before twelve hours had elapsed had viable testes. Patients with complaints of intermittent scrotal sweling and pain, with negative urinalysis, may be suffering from intermittent patients were treated in this manner. Six of these had a transverse lie of both testes, which suggested the underlying anatomic defect leading to torsion of the spermatic cord. The diagnosis of epididymitis or epididymo-orchitis is untenable with a negative finding on urinalysis and results in delay incorrect diagnosis and treatment.

Castration↗

Testicular torsion and usefulness of radionuclide scanning.

The usage of the testicular scan to differentiate torsion from epididymo-orchitis in 33 patients is reported. Our results yielded a surgically confirmed accuracy rate of 77 per cent, and a clinical accuracy rate of 100 per cent. The entity of missed torsion has a characteristic appearance, which we have termed the "halo sign."

Adolescent↗

Ultrasound evaluation of scrotum in pediatrics.

Scrotal abnormalities are difficult to assess using clinical criteria alone. Ultrasound provides an accurate means of demonstrating the scrotal contents so that appropriate therapy may be instituted. In a retrospective study, 119 ultrasound examinations of 96 patients (aged 4 days to 23 years) have been compared with the clinical diagnosis, surgical/pathologic findings, and other imaging modalities. The gamut of disease identified included congenital anomalies, neoplasm, trauma, torsion, varicocele, hydrocele, epididymo-orchitis, epididymal cyst/spermatocele, and post-radiation fibrosis. The ultrasound findings correlated well in 93/96 patients. In inconclusive cases, sequential imaging helps differentiate traumatic and inflammatory lesions from neoplastic processes.

Adolescent↗

Technetium 99m scan in acute scrotal lesions.

Scrotal scintigraphy is nearly 100 per cent accurate in identifying testicular torsion and can distinguish that condition, which requires an operation, from torsion of testicular appendages, which often can be treated nonoperatively. The technique is 90 per cent accurate in distinguishing epididymo-orchitis, epididymitis, and testicular abscess and is valuable in the follow-up of testicular torsion or inflammation. It can screen patients for varicocele, identifying possible candidates for spermatic venography and embolization. However, it has nothing to offer in the differential diagnosis of painless testicular masses.

Acute Disease↗

Pyocele of scrotum: consequence of spontaneous rupture of testicular abscess.

We report 2 cases of spontaneous rupture of the testis secondary to suppurative epididymo-orchitis. Both cases presented with pyoceles and were treated conservatively by scrotal incision and drainage of the pyoceles. This prolonged hospital stay and increased morbidity, since both patients ultimately required orchiectomy. We believe that a pyocele is an indication for prompt surgical exploration, and if the testis is ruptured, an orchiectomy should be done.

Abscess↗

Antigens of the basement membranes of the seminiferous tubules induce autoimmunity in Wistar rats.

A preparation enriched in basement membranes from seminiferous tubules was isolated from rat testes (STBM) and injected with complete Freund's adjuvant into Wistar rats. In 60% of animals a mild multifocal orchitis was observed. In damaged areas, perivascular and peritubular mononuclear cell infiltrates and different degrees of cell sloughing of some seminiferous tubules were observed. Electron microscopy revealed focal thickenings and delamination of the basement membrane of the seminiferous tubules as well as vacuolization of Sertoli cell cytoplasm. Using immunofluorescence discontinuous linear deposits of IgG were detected along the seminiferous tubular wall. Moreover, the same pattern of immunofluorescence was observed when the IgG eluted from the testes of the immunized rats was layered on sections of normal rat testis. Circulating antibodies to STBM were detected using passive haemagglutination in approximately 45% of the immunized rats, with titers ranging from 1:20 to 1:80. Leukocyte migration was inhibited when the spleen cells of the immunized rats were incubated with antigens from the basement membrane of seminiferous tubules, whilst a negative reaction was obtained when the soluble fraction of testis homogenate was used.

Animals↗

Experimental infection of bulls with a genital isolate of bovine herpesvirus-4 and reactivation of latent virus with dexamethasone.

Five 13- to 18-month old Belgian Blue bulls were used in this experiment. Four bulls (Nos. 2, 3, 4 and 5) were inoculated intratesticularly with 10(5) plaque-forming units of bovine herpesvirus-4 (BHV-4) in each testicle (Day 0). The challenge BHV-4 strain was previously isolated from testicle cells of a bull exhibiting orchitis and azoospermia. The fifth bull (No. 1) was used as a control and received the same volume of uninfected cell culture supernatant. For 5 days, beginning on Day 51 post-infection, two bulls (Nos. 4 and 5) and the control bull (No. 1) received 0.1 mg kg-1 of dexamethasone. Unilateral castrations were then performed at regular intervals for viral examination. Treatment with dexamethasone reactivated latent BHV-4, but no clinical signs were observed in treated bulls until the end of the experiment (Day 93). Only Bull 3 showed conjunctivitis and temporary azoospermia. The virus was recovered from various samples showing that: (i) BHV-4 can be present in a latent state in the testicles and mononuclear blood cells; (ii) dexamethasone reactivates the virus; (iii) the virus is excreted by nasal and ocular routes. Each infected bull seroconverted and a booster antibody response appeared after dexamethasone treatment as shown by immunofluorescence. Neutralizing antibodies were detected in each bull by complement-dependent neutralization test with titres higher than those obtained by a classical neutralization test. No booster response of neutralizing antibodies was observed after dexamethasone treatment. The antigenically relevant envelope BHV-4 proteins were identified by Western blotting using sera samples from the animals. DNA restriction endonuclease profiles of viruses reisolated after primary infection and reactivation showed only small differences.

Animals↗

Penile and testicular disorders.

Circumcision, priapism, phimosis, Peyronie's disease, orchitis, epididymitis, and testicular torsion are conditions of the male penis and testicles that warrant increased attention by health care providers in practice. Healthy outcomes for penile and testicular disorders can be achieved through education, enhanced screening, and adequate comprehensive treatment. Penile and testicle disorders provide researchers and clinicians with many opportunities for research and practice that can improve the condition of men's health.

Circumcision, Male↗

Testicular torsion revisited.

Ultrasound is routinely used for the assessment and diagnosis of testicular torsion. It has proven to be a reliable and necessary diagnostic tool for the urologist. Problems, however, can arise in the form of misdiagnosis when the basic pathophysiology and clinical presentation of testicular torsion are not clearly understood. In this pictorial review, we present the spectrum of the appearance of testes with testicular torsion. This includes both complete and incomplete torsion. The critical use of Doppler and the interpretation of the Doppler findings will be presented. Other abnormalities that can be potentially confused with testicular torsion, including epididymitis and orchitis, will be shown. An approach to assessing the testis that stresses the critical role of both Doppler examination and an understanding of the clinical presentation will be presented. In particular, in incomplete torsion, a Doppler examination will still demonstrate flow to the testis, potentially leading to a missed diagnosis if the clinical presentation is not considered. Examples of normal and abnormal anatomy will be presented.

Diagnostic Errors↗

Testicular ultrasound.

Acute scrotal pain makes up approximately 0.5% of all complaints presenting to an emergency department. Some of the most com-mon diagnoses for this complaint are testicular torsion and epididymitis. Misdiagnosing testicular torsion can lead to organ loss,cosmetic deformity, and compromised fertility. Modem ultrasound examination of the scrotum is the test of choice for acute scrotal pathology and yields high accuracy compared with surgical exploration. A key component of the testicular examination is use of power and spectral Doppler ultrasonography. Examination of the acute scrotum should not be undertaken unless Doppler capability is available because the evaluation of blood flow is such an important part of diagnosis of testicular torsion, orchitis, epididymitis,trauma, and hemorrhage into a mass.

Acute Disease↗

Tissue microcircumstances for leukocytic infiltration into the testis and epididymis in mice.

Spermatozoa do not appear in the seminiferous epithelium until puberty, when immune tolerance has already been established. Therefore, they contain various autoimmunogenic materials which are recognized as foreign by the self immune system. However, the testis and epididymis are known as immunologically privileged organs. In particular, the blood-testis barrier (BTB) formed by Sertoli cells and the blood-epididymal barrier formed by epididymal epithelial cells protect autoimmunogeneic spermatozoa from attack by the self immune system. The immune privileged circumstances in the testis and epididymis have been demonstrated by many studies to involve a local transplantation system. We review here the immune privileged status of these organs from the viewpoint of induction of inflammatory cell responses in mice. The testicular interstitium in mice is resistant to vasculitis, lymphangitis, spermatic granuloma and polymorphonuclear cell infiltration: however, the epididymal interstitium is vulnerable to them. Therefore, the testicular tissue outside BTB is also protected from inflammatory cell infiltration, although many resident macrophages are normally present in the testis. In sharp contrast, subcutaneous injection of viable syngeneic testicular germ cells (TGC) alone induces autoimmune orchitis with no involvement of the epididymitis in mice. In the testes of TGC-immunized animals, severe lymphocytic infiltration with aspermatogenesis was seen in spite of no use of adjuvants. Unexpectedly, injections of viable epididymal spermatozoa (ES) did not evoke any autoimmune inflammation in the epididymides. Therefore, the testis rather than the epididymis may easily become an unprivileged organ as to autoimmunity under some special conditions.

Animals↗

Acute painful scrotum.

The ability of US to diagnose the pathogenesis of the acute scrotum is unsurpassed by any other imaging modality. It is the first imaging performed in patients with acute scrotum. Knowledge of the normal and pathologic sonographic appearance of the scrotum and proper sonographic technique is essential for accurate diagnosis of acute scrotum. High-frequency transducer sonography combined with color flow Doppler sonography provides the information essential to reach a specific diagnosis in patients with testicular torsion, epididymo-orchitis, and testicular trauma.

Acute Disease↗

Intra-abdominal sepsis attenuates local inflammation-mediated increases in microvascular permeability at remote sites in mice in vivo.

BACKGROUND: Given that leukocyte delivery to remote sites is diminished in states of systemic inflammation, such as sepsis, and activated leukocytes may be responsible for endothelial injury leading to vascular leakage, we hypothesized that intra-abdominal sepsis would diminish microvascular leakage at remote sites by altering leukocyte-endothelial interactions. METHODS: Using a murine intravital microscopy model, we examined leukocyte-endothelial interactions and vascular leakage at a peripheral site in the presence of local and/or systemic inflammation. Forty mice were randomized to 1 of 4 study groups: local infection (orchitis), systemic infection (intra-abdominal sepsis by cecal ligation and puncture), local and systemic infection, and control. Postcapillary venules of the cremaster muscle were examined by bright light and fluorescence intravital microscopy. Microvascular leakage was determined after intravenous administration of fluorescent albumin. RESULTS: Systemic infection attenuated the increases in both leukocyte adherence and local infection-induced microvascular permeability. Neutrophil cell-surface expression of L-selectin, as determined by flow cytometry, diminished with both local and systemic infection, whereas expression of CD11b increased with systemic, but not local, infection. CONCLUSIONS: These data suggest that systemic (intra-abdominal) sepsis diminishes local inflammation-mediated vascular leakage by attenuating leukocyte adherence.

Abdomen↗