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Paper text:
spermatic cord torsion ( sct ) is one of the true urological emergencies that mainly develop during puberty and the early adolescent period , with a calculated annual incidence of 1 in 4,000 among those under 25 years old .
the salvage rate of an affected testis largely depends on the duration and degree of torsion .
although sct can be seen at any age , in fact , there have been few reports of older men with sct . because of its rarity in the older age group , the lack of suspicion for sct may lead to delayed diagnosis or misdiagnosis . to the best of our knowledge
, this seems to be the first reported case of sct in an aged patient older than 60 years in korea .
herein , we report this very unusual case of missed sct occurring in a 63-year - old man .
a couple of weeks previously , he had experienced right scrotal pain when he woke up .
he was then seen by a primary care physician . however , the physician failed to find any abnormalities other than epididymal enlargement on scrotal ultrasonography .
the patient was then referred because his symptoms did not improve despite empirical antibiotics use .
he denied having any history of trauma to the testis , strenuous exercise , sexual activity , or febrile illness .
he also had no known sexually transmitted diseases . on physical examination , a swollen , edematous , and erythematous change in the right hemiscrotum was noted .
the right testis was enlarged , hard , consistent , and somewhat tender on palpation compared with the intact left testis .
the results of a complete blood count , chemistry profile , and urinalysis were normal .
gray - scale ultrasonography of the scrotum demonstrated heterogenous echotextures in the right testis that were combined with a thickened scrotal wall and hyperechoic supratesticular mass ( fig .
color doppler sonography revealed that blood flow was present in the asymptomatic left testis , but absent in the right testis .
an increased blood flow in peritesticular structures adjacent to the nonperfused testis was identified ( fig .
although very rare , a few cases of intrascrotal torsion of a testis tumor have been reported .
therefore , we could not absolutely exclude the possibility of a testis tumor and thus planned to perform radical orchiectomy of the symptomatic right testis .
the patient was taken for surgical exploration of the right testis through a right inguinal incision .
the frozen section examination of the right orchiectomy specimen revealed testicular infarction with suppurative inflammation . hence , left transscrotal orchiopexy was done to prevent contralateral torsion at a later date .
an underlying anatomic abnormality , the bell - clapper deformity , was found in the left testis . in the cut section ,
the right testis was 4.3 cm3.2 cm4.2 cm in size and had reddened parenchyma rimmed with several scattered lesions of dirty yellow pus - like exudates .
final histopathological examinations revealed a total hemorrhagic infarct of the testis and diffuse chronic inflammation of the peritesticular soft tissues ( fig .
the causes of acute scrotal pain vary with age , but in all ages , infection and sct are the most common etiology . differentiating sct from infection in the epididymis or testis
is critical . although intravaginal sct is primarily a condition of puberty and early adolescence , it is not exclusive to that population .
the onset of pain in sct is usually acute ; however , up to 25% of patients also have a gradual onset .
thus , delayed presentation or diagnosis may result in patients with gradual onset of scrotal pain .
in addition , age may be another factor that affects the testicular salvage rate . because sct is uncommon and is associated with more severe cord twisting in the older aged group , the prognosis of testicular salvage in this age group
therefore , a high index of suspicion is the first step to determine the presence of sct even if symptoms are equivocal in older patients .
color doppler ultrasound performed by a trained radiologist proved to be a somewhat more desirable modality because it is performed more rapidly and equal to nuclear scintigraphy with respect to sensitivity and specificity .
patients who are very early in the course of torsion may have only minimal enlargement of the testis with normal or slightly decreased echogenicity .
as time goes on , the echogenicity of the testis becomes heterogeneous owing to hemorrhage and necrosis .
a swollen epididymis may be also seen because the deferential artery supplying the epididymis is often involved .
an abrupt increase in the size and alteration of the spermatic cord may be noted below the point of torsion .
this finding of a twisted cord is a highly sensitive and specific sign of sct . in the present case , we suggest some possible reasons for the misdiagnosis during the patient 's first visit at the local clinic . in most cases of sct ,
the epididymal head is only mildly enlarged , whereas the spermatic cord , which passes just superoposteriorly to the epididymal head , is grossly enlarged .
thus , the swollen spermatic cord may be mistaken for an enlarged epididymal head . in cases of missed torsion ,
. this flow may be mistaken for testicular capsular artery flow , thus causing the diagnosis of torsion to be missed .
less likely , a testis with spontaneous detorsion may be hyperemic , simulating epididymo - orchitis . because a missed diagnosis is the most frequent medicolegal concern in our litigious society
clinical symptoms and physical examination are often not enough for prompt diagnosis , especially in cases with delayed presentation . because the adult type of sct is thought to be rare , this rarity may result in missed torsion unless special attention is paid to the possibility of sct .
the present unusual case reminds us to maintain suspicion of sct in males of any age presenting with acute scrotum .
the fate of testicular salvage in spermatic cord torsion depends on the duration of ischemia and the degree of torsion . 
 even though spermatic cord torsion ( sct ) can occur at any age , it is rarely reported in older patients . if the physician does not pay close attention to this unusual situation , the lack of suspicion for sct may result in a missed or delayed diagnosis . 
 we report a very uncommon case of missed sct occurring in a 63-year - old man .