Is a spiral cremasteric reflex a contributing factor in testicular torsion? A prospective study to determine its incidence in the pediatric urology population.
Donald H. Nguyen, MD, Christopher T. Brown, MD.
Dayton's Childrens Hospital and Nationwide Childrens Hospital, Dayton, OH, USA.
Background: Currently, the main predisposing anatomical abnormality associated with testicular torsion is the "bell clapper deformity" or BCD whereby the testis, epididymis and a portion of the spermatic cord are free floating in the processus vaginalis, hence being more prone to rotational torsion and compression of the vascular flow to the testis. BCD has been observed in much higher incidence of testis torsion, suggesting a co-existing factor which causes the testis to twist, such as an abnormal cremasteric reflex (CR).
Methods: A patient was observed during a routine office visit to have a right spiral cremasteric reflex (SR), where the testis ascends into the upper scrotum from a vertical orientation in a spiral fashion to lie horizontally compared to a linear reflex (LR) on the left side. A prospective study was then launched into searching for other patients to determine the incidence of such "spiral reflex", its laterality (present or absent reflexes and linear or spiral) and age distribution (Group A, birth - 12 months, Group B, 13 -36 mos, and Group C, 37 mos- 21 yrs), with loose and dangling (potentially associated with BCD) or contracted scrota, when they present to the Urology clinic for common referrals.
Results: Over a period of 18 months, 476 boys were referred to the Urology clinic (A=162, B=97, C=217) and examined. A total of 11 boys (2.3%) were found to have a SR (8 on the right, 3 on the left). A loose and dangling scrotum was found in 310 pts (65%) vs a contracted scrotum in 169 pts (35%). All SR pts had loose and dangling scrota. Bilateral absent CR were found in Gp A (104 pts, 64.2%), Gp B (38 pts, 39.2%), Gp C (65 pts, 30%), unilateral reflex only in Gp A (13 pts, 8%), Gp B (12 pts, 12.4%) and Gp C (21 pts, 9.7%), bilateral present LR in Gp A (44 pts, 27.2%), Gp B (46 pts, 47.4%), Gp C (122 pts, 56.2%). In unilateral reflex, the side of the reflex is almost equally distributed (20 R, 26 L).
Conclusion: A spiral cremasteric reflex is present in 11pts or 2.3% of this population and may be the missing contributing component that actually causes the twisting of the testis in a BCD situation. A SR can be explained anatomically by an uneven distribution and insertion of cremasteric muscle fibers surrounding the processus vaginalis circumferentially. The SR patients' families are informed of such finding and instructed to look out for potential future development of testis torsion. Pediatric urologists, primary care physicians and pediatricians should be observant of such spiral cremasteric reflex during routine evaluation of the male patients. A larger and multicenter prospective study would shed better evidenced if SR truly leads to an increased risk of torsion. A significant number of pts are also found to have bilateral absent reflexes (30-64%), which is important to be aware of in the evaluation of testis torsion.
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