Post Orchiopexy problem (Part2)
by roadtrip01, Apr 22, 2010
Hi, i need some follow up advice for my last post about my problem with how i feel my left spermatic cord is still twisted after my orchiopexy surgery. You and another doctor advised me to get a second opinion/discuss a scrotal exploration and rule out possible stones. I decided to go see a senior urologist in another practice and plead my case. I gave him my ultrasound report i had done 1 month after surgery, surgical notes,  and told him my story. He basically didn't believe a word i was saying about intermittent torsion and me rotating my testicle before surgery. He did a short superfical exam where i tried to show him how my left testicle needed to twist to the left which he tried to convince me other wise and he told me my testicle looked funny because thats the way its supposed to look.  He never did a cremaster reflex test and at the end he ordered a MRI scan without contrast of my pelvis and abdomen which I just got word that it that he didn't find anything. Now i'm realy confused on what to do. My prior experience with untwisting my spermatic cord where i was able to get total relief where my cremaster refelx was working properly and my left and right testicles would hang normally and would miror each other and i would have no pain and discomfort. The last time it was like this was a week before surgery but 2 days before surgery it started getting twisted again. And after i looked at the surgical notes where there was no mention of having untwisted the testicle or even an exam of the spermatic cord only confirmed my suspicion. I really would like a trained professional to work with me to correct this problem and a scrotal exploration seems like a good idea but i feel defeated because i keep getting stone walled by the doctors becuase of diagnostic evidence leaving me to needlessly suffer with this. I'm considering other options like piercing my scrotum with small scissor to snip away the sutures so i can rotate my testicle over
by Stephen Liroff, MDBlank, Apr 25, 2010
Let's start with your last comment. Piercing your scrotum to cut the sutures is something that you absolutely do not want to do unless you are trying to get an infection, possibly damage your testicles so that they shrivel up or result in your sterility. An infection could actually be life threatening (i.e., kill you).
Your cremasteric reflex will not function in the future as it had in the past since you had your surgery. There is no sense, from an evaluation standpoint, in a physician testing this. I do not remember if your surgery was done acutely in the face of a torsion or to prevent recurrent torsions,  but not finding a torsion at the time of surgery is certainly not unheard of. A few torsions resolve spontaneously and at the time of surgery, everything appears normal.
I cannot comment on your evaluation; I was not there nor did I review any of your reports. The issue with torsion is that the blood flow to the testis is compromised. The twist itself is not the cause of pain. Thus, if the blood flow (which can be evaluated with a color doppler ultrasound) is normal, then the testis is OK from that standpoint. Could there be a nerve lesion that is the issue say from a suture? Never heard of such, but I assume that it could occur. However, a scrotal exploration may well not help. I would sooner treat by injecting the nerves with a long acting local anesthetic such a bipuvicaine and evaluate your  response.
Sounds as though you'll need another opinion. If the opinions keep coming up with the same answers, a pain center should be your next stop.
Good luck.
S.A.Liroff, M.D.
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Member Comments (6)
by roadtrip01, Apr 28, 2010
Doctor, point taken. Luckally the office that did my mri gave me a copy of the images and i can view them my self and run them with an advanced 3d progam called fiatlux visualize. I looked at all the image studies that contained any detail images of my spermatic cord and found some interesting stuff that looks identical to the images ive seen of twisted spermatic cord. On one image it clearly shows either the vas deferns or spermatic artery going from the back of the testicle then up then half way up to the external inguinal ring it wraps around the front of the spermatic plexus then up into the inguinal canal. I then used a 3d renduring format on the image set and it clearly shows a spiral effect in the spermatic cord. I conpared each image and the 2d image and the 3d image matches at the point of the spiral and the wraping around the plexus.  I printed these images out and brought it to my first urologist and he told me he won't comment because hes not trained to interept the images. So now im going back to the radiologist who interepreted the results to ask him to double check my pelvis mri and to help me interpret what i'm identifying in my mri images. If this proves correct I may have my ticket to get it corrected. Is it possible upload these images so i can show them to you what i'm talking about?
by rmprdl1964, Apr 29, 2010
If I were you I would leave things the way they are. I had a hematoma removed after a vasectomy. After that surgery the testicle was fixed in an uncomfortable position. I was told that If I decided to have surgery I should also be prepared to loose the testicle.
A year later I ended up with an infection in the left testicle and received an emergency orchiectomy to have a necrotic testicle removed.

I believe that it is much better to have tow than one. I did not opt for surgery, I had no choice. Now I have monthly testosterone injections.

All the best.

by roadtrip01, Apr 29, 2010
I don't think you understand, If the spermatic cord is sutured with a twist in it i'm in more danger of losing the testicle. Plus The surgery to fix this or explore the area does not put me at any risk of losing the testicle. The case is weather or not a doctor is willing to take this seriously as an option. The stuggle is from what i understand this diagnosis is not an exact science yet. Only in acute cases is this a definitive diagnosis. Think about it, I had 2 ultrasounds 1 prior and 1 post surgery. All of which rulled out anything else known that would cause pain. Given the fact of my prior history of witnessing my testicle rotate in the scrotum and experiencing all the other known secondary symptoms assocated with it suggest intermittent torsion, Which is what the doctor diagnosed and i feel was the correct decision to get fixed. Now,  Is it possible that the doctor did the surgery and missed seeing a twist along the cord. I would like to think not but human error is a real thing and maybe he over looked observing the whole cord and only looked at the testicle.  
But there arguement is always, if infact there was a twist then the testicle would be dead by now. That makes sense if the twist produced absent blood flow. And from what my second opinion doctor said absent blood flow doesn't happen untill 460 degrees. So the possibility of there being a 360 degree twist or less hasn't been ruled out when pared with my pain sypmtoms and absent cremaster reflex. Now that i have the mri images it only adds more evidence, though it needs to be confirmed by a radiologist. Mri's arn't generally used to diagnos torsion from what i understand so the radiologist could have overlooked what i spoted on the images. So whats going to happen. I don't see any reason why this can't be fixed or explored.
by Shirokuma, May 24, 2010
I had the same issues after orchiopexy, I had a total of 2 the last one was combined with a scrotal exploratory, years later and years of pain later I finally had to have the testicle removed. There was no concrete reasons given for the pain I felt nor the original pain (I was diagnosed with intermittent torsion)

Still have the left and am doing ok.
by Stephen Liroff, MDBlank, May 31, 2010

As I mentioned before, the pain of a torsion is due to the lack of blood flow, not the twist itself. If the pain persists IN THE TETIS and DOES  respond to local anesthetic injections into the cord,  but returns, there maybe a place for removing the nerves to the testis (testis denervation).. This is not a commonly performed procedure and does run the risk that the pain will not be relieved. The urologist doing a scrotal exploration may well want to do both a repeat orchiopexy and this procedure to maximize your chances for relief.. Your testis will be permanently numb. You will, as you know, have some difficulty getting a urologist to re-explore your scrotum. Try a university center.
By the way, there is always the risk of losing the testis as a complication.
Good luck!
S.A.Liroff, M.D.