Introduction

Testicular pain is one of the common causes of acute surgical referral(Kastrup, 1952). Testicular pain in teens and children often raises the suspicion of a testicular torsion(Bentley et al., 2004). Many patients with testicular pain often get explored to exclude a torsion. Here, the authors report an unusual case of bilateral clapper bell deformity associated with unusually long, bilateral, cord structures that have not been reported in the literature.

Report of a case

A 25-year-old male presented with a sudden onset of right-sided testicular pain of three-hour duration. He denied any urinary symptoms. There was no significant past medical history. On examination, he appeared well, apyrexial, pulse rate and the blood pressure were within the normal range. Examination of his scrotum showed a high transverse lying right testis (Fig 1), which was exquisitely tender to touch. His left testis was also transversely oriented but at a lower level. His abdomen proper was unremarkable. Urine dipstick was normal and white cell count was elevated (14 X 10⁹/L) with a neutrophilia.

He was taken to theatre and the scrotum was explored. Right-sided testis and cord structures were congested and there was a hydrocele containing 15 ml of straw colored fluid. The testis was transversely oriented and partially twisted. The cord was unusually long and redundant. The cord was 4 cms longer than the distal end of the scrotum. There was a clapper-bell deformity. The left testis also showed 4 cms excess cord with a clapper-bell deformity (Fig 2). Right testis was detorted, standard orchidoxpexy was performed on both sides with prolene stitches and the scrotal wound was closed with an undyed vicryl in two layers. The patient’s symptoms disappeared after the operation.

Figure 1

Figure 1

Preoperative picture showed high lying right testis

Figure 2

Figure 2

Intra operative picture showing left sided redundant cord (4cms) and transversely oriented testis with clapper-bell deformity. The right testis (not shown) showed similar finding.

Discussion

Common causes of testicular pain include torsion of testis, torsion of appendage of testes and epididymis and epididymo-orchitis. Aetiology and precipitating factors of a testicular torsion include clapper-bell deformity, undescended testis, sexual activity, trauma, cremasteric reflex, and cold weather(Oeconomopoulos and Chamberlain, 1960). Torsion can run in families and may occur while the patient is sleeping(Okeke and Ikuerowo, 2006). Clapper-bell deformity is a well known-cause of testicular torsion in which there is failure of normal posterior adherence of testis, epididymis and gubernaculum to the inside of the scrotal wall. Therefore the testis is free to rotate like a clapper inside a bell leading to torsion. We report a new cause of testicular torsion, which is a redundant long cord as shown in Fig 2. It was bilateral and associated with bell-clapper deformity and it led to transverse orientation of both testes. Even after orchidopexy, redundant cord structures were lying very lose with serpigenous kinks because of the surplus length.

Radionuclide scan and duplex ultra sound may be useful in evaluation of testicular torsion(Pinthus et al., 1999). When there is strong suspicion of testicular torsion, the scrotum should be explored immediately without waiting for an imaging because testis may not be viable after 6 hours. Duplex scan cannot exclude a torsion in all cases(Bentley et al., 2004) and is not useful in diagnosing torsion of undescended testis(Bentley et al., 2004). Differential diagnosis for torsion of testis is epididymo-orchitis, torsion of testicular and epididymal appendages(Rashid et al., 2007) and torsion of epididymal cyst(White et al., 2006). Anatomical deformity is the commonest cause of a testicular torsion and there fore both testis should be fixed in a case of testicular torsion(Halland and Jonler, 2005).