Neonatal unilateral testicular torsion in the first 16 hours of life

Rationale: Neonatal testicular torsion (NTT) is an uncommon but urgent urological condition that predominantly occurs in the prenatal or immediate postnatal period (up to 28 days of life). Diagnosis is often delayed due to subtle clinical signs and the inability of neonates to express discomfort. Early recognition is critical to prevent irreversible ischemic damage and to preserve future endocrine and reproductive function. This case emphasizes the importance of routine detailed neonatal physical examination, even when infants are hospitalized for unrelated conditions or otherwise normal. Patient concerns: A 16-hour-old male neonate was admitted for evaluation and management of early-onset hyperbilirubinemia secondary to ABO incompatibility. The infant demonstrated no systemic symptoms of distress. However, caregivers noted unilateral scrotal swelling during routine examination, without discoloration, fever, or feeding difficulties. Diagnoses: Physical examination revealed an enlarged, firm right hemiscrotum with absence of palpable spermatic cord structures. Doppler ultrasonography demonstrated a heterogeneous, avascular right testis with a focal hypoechoic region suggestive of necrosis, confirming acute right NTT. The left testis showed normal blood flow. Bilateral moderate hydroceles were also observed. Interventions: The patient underwent emergency surgical exploration. Intraoperative findings revealed a 360° extravaginal torsion of the right spermatic cord with a nonviable, infarcted testis. A right orchiectomy was performed. To prevent asynchronous torsion, prophylactic orchiopexy of the left testis was carried out. The neonate received postoperative supportive care, including monitoring, antibiotics, and wound care. Outcomes: The postoperative course was uneventful. The neonate remained hemodynamically stable and was discharged in good condition with arrangements for outpatient follow-up. No complications were noted during early recovery. Lessons: This case highlights the clinical importance of maintaining a high index of suspicion for NTT in any neonate presenting with unilateral scrotal swelling, regardless of admission reason. Routine genital assessment should be an essential part of neonatal examination. Early Doppler imaging and timely surgical intervention are key to preventing contralateral testicular compromise and preserving future fertility. NTT requires prompt recognition and urgent intervention. Thorough clinical examination and rapid diagnostic evaluation can significantly influence outcomes, emphasizing the need for heightened clinical awareness in neonatal care settings.