Intravaginal spermatic cord torsion without whirl pool sign before adolescence

Spermatic cord torsion in children is a urological emergency that requires operation and fixation within 6 h. Ultrasound sonography allows for the diagnosis of torsion in the early stages; however, some cases are sometimes overlooked and necrotize. While two peaks of onset have been reported (in the neonatal period and adolescence), attention must be paid to prepubertal children as well. Torsion manifests in two ways: as extravaginal torsion (EVT) and intravaginal torsion (IVT). EVT is common in newborns, and IVT is common in adolescents. Bell clapper deformity is thought to be a major cause of IVT. The bell clapper theory describes an anatomical anomaly wherein the testis is freely suspended, leading to its rotation. In EVT, spermatic cord twisting occurs outside of the tunica vaginalis because of a loose connection of the testis to the scrotum in newborns. However, we highlight the fact that IVT can also occur in prepubertal children. A one-year-old and three-year-old boy were admitted to our hospital with testicular pain as the chief complaint. Ultrasonography did not reveal any whirlpool sign. A physical examination showed apparent symptoms of testicular torsion; we therefore performed an emergency operation. We found both boys to be suffering from IVT-type torsion. We corrected the rotation and attempted an ultimately unsuccessful reperfusion. Both testes had bell clapper deformity and were torn in a narrow space. This small space can induce a steep and narrow pitch of torsion far beyond the detectability of ultrasonography. In prepubertal cases, we must pay attention to cases of torsion with no signs of whirlpools after ultrasonography.