AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Torsion of testicular appendages can result in the clinical presentation of acute scrotum. Two such appendages are the appendix testis, a remnant of the paramesonephric (müllerian) duct, and the appendix epididymis, a remnant of the mesonephric (wolffian) duct.

The appendix testis is present in 92% of all testes and is usually located at the superior testicular pole in the groove between the testicle and the epididymis. The appendix epididymis is present in 23% of testes and usually projects from the head of the epididymis, but its location may vary. Most acute presentations of scrotal pain and swelling can be attributed to epididymitis, testicular torsion, or torsion of a testicular appendage. The presentations of these conditions can typically be distinguished by history and examination. However, in many cases, torsion of a testicular appendage, although a benign condition, may present identically to testicular torsion, a true urologic emergency.

Pathophysiology

The vestigial tissues forming the appendices are commonly pedunculated and are structurally predisposed to torsion. Torsion of an appendage leads to ischemia and infarction. Necrosis of appendices causes pain and local inflammation of surrounding the tunica vaginalis and epididymis (acute hemiscrotum). Torsion of the testicular appendage may also be accompanied by presence of a thickened scrotal wall, a reactive hydrocele, and enlargement of the head of the epididymis.

Frequency

United States

Torsion of testicular appendices is one of the most common causes of acute scrotum; it is the leading cause of acute scrotum in children.

In several retrospective reviews of pediatric patients who presented to the emergency department with acute scrotal pain, the incidence of torsed testicular appendage ranged from 46-71% and represented the most common cause of scrotal pain.

International

Occurrence rates appear similar to rates in the United States.

Mortality/Morbidity

Torsion of the testicular appendices is virtually a benign condition, but again, must be distinguished from testicular torsion, which can have permanent consequences on testicular viability.

• Necrotic tissue is reabsorbed without any sequelae in almost all cases.
• The literature contains only one case report of a scrotal abscess secondary to tissue necrosis.

  Some cases of persistent pain due to torsion of the testicular appendix have required surgical excision for relief or often for diagnostic surgical exploration.

• Little evidence supports the suggestion that scrotal calculi can form because of calcification of the necrotic appendix.

Race

No racial or ethnic predilection exists.

Age

Age ranges vary from infancy to adulthood with more than 80% of cases occurring in children aged 7-14 years. Mean age is 10.6 years. This condition rarely presents in adulthood (probably due to local fibrosis). Torsion of testicular appendices is the leading cause of acute scrotum in children.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

The patient's history is important in distinguishing torsion of the testicular appendages from testicular torsion and other causes of acute scrotum.

• Pain may be present.
• • Onset is usually acute, but pain may develop over time. Typically, it has a more gradual onset than testicular torsion.
  • Intensity ranges from mild to severe.
  • Patients may endure pain for several days before seeking medical attention.
  • The pain is located in the superior pole of the testicle. This is a key distinguishing factor from testicular torsion. A focal point of pain on the testicle is uncommon in complete testicular torsion.
• Systemic symptoms are absent. Nausea and vomiting (frequently seen in testicular torsion) are usually not associated with this condition.
• Urinary symptoms are absent. Dysuria and pyuria are not associated with torsion of the testicular appendages. Their presence is more indicative of epididymitis.

Physical

Physical examination may reveal the following findings:

• The patient is afebrile with normal vital signs.
• Although the scrotum may be erythematous and edematous, it usually appears normal.
• An unreliable marker of pathology, the cremasteric reflex is usually present. Several studies indicate that the presence of a cremasteric reflex in the acute scrotum is unlikely to be testicular torsion.
• The testis should be nontender to palpation. If present, tenderness is localized to the upper pole of the testis. Diffuse tenderness is more common in testicular torsion.
• The presence of a paratesticular nodule at the superior aspect of the testicle, with its characteristic blue-dot appearance, is pathognomonic for this condition. A blue-dot sign is present in only 21% of cases.
• The combination of a blue-dot sign with clear palpation of an underlying normal, nontender testes allows for the exclusion of testicular torsion on clinical grounds alone.
• Vertical orientation of the testes is preserved.
• A recent study in 2005 scored 3 key historical elements as predictors for testicular torsion. Onset of pain less than 6 hours, absence of cremasteric reflex, and diffuse testicular tenderness. Out of 141 subjects, in the absence of any of these elements, none of the subjects had testicular torsion. With all 3 elements present, 87% were diagnosed with testicular torsion.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Urinalysis
• CBC with differential

Imaging Studies

• Ultrasonography
• • Testicular appendage torsion appears as a lesion of low echogenicity with a central hypoechogenic area.
  • The presence of a large appendix adjacent to the epididymis (in the absence of clinically detectable inflammation) may signify testicular involvement.
  • If the edematous appendix and the head of the epididymis are close enough, this condition will have the "Mickey Mouse" appearance on transverse view.
  • Ultrasonography can be useful in distinguishing torsion of a testicle and torsion of an appendix testis.
• Color Doppler ultrasonography
• • Color Doppler sonograms show normal blood flow to the testis, with an occasional increase on the affected side that possibly is due to inflammation.
  • In prepubertal patients, this method of imaging is somewhat controversial because the prepubertal testis has low-velocity blood flow, and color Doppler ultrasonography is less accurate in these instances.
  • A recent study using formal color Doppler ultrasonography reported 90% sensitivity and 98% specificity in diagnosing acute testicular torsion. However, variability exists in the sensitivity of color Doppler ultrasonography. As a result, a negative ultrasonographic result does not necessarily exclude testicular torsion. In high clinical suspicion, surgical exploration may be warranted.
• Radionuclide imaging
• • The positive sign for testicular appendix torsion is the hot-dot sign, which is an area of increased tracer uptake.
  • This sign is pathognomonic for testicular appendix torsion.
  • Radionuclide images do not show a positive result if symptoms have been present for fewer than 5 hours. Positive results are seen in only 45% of patients whose symptoms have lasted 5-24 hours.
  • The test is reported to be 68% sensitive and 79% accurate.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Emergency Department Care

• Necrotic tissue of the testicular appendices causes no damage other than damage to itself. Most cases, therefore, are treated conservatively.
• Pain usually resolves within 1 week but may persist for several weeks.
• NSAIDs and ice are the mainstays of therapy for inflammation.
• Reduced activity and scrotal support are indicated.
• Provide symptom relief.
• Uncontrolled pain can be relieved by surgical excision of the appendix.

Consultations

If the diagnosis is unclear and testicular torsion cannot be ruled out or if pain persists, surgical exploration is warranted.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Drug Category: Nonsteroidal anti-inflammatory drugs

These agents have anti-inflammatory and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Complications

• No recognized complications of this condition warrant attention.

Prognosis

• The prognosis is excellent.
• Long-term sequelae to this condition do not exist. Virtually all patients have uneventful recoveries.

Patient Education

• For excellent patient education resources, visit eMedicine's Men's Health Center. Also, see eMedicine's patient education article Testicular Pain.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Torsion of testicular appendices is a diagnosis of exclusion in patients presenting with acute hemiscrotum.
• A false-positive diagnosis of this condition (ie, missed testicular torsion) is a major medical/legal pitfall. A negative color Doppler ultrasonography result is not 100% sensitive in ruling out testicular torsion, especially in the case of intermittent testicular torsion.
• Immediate surgical exploration is appropriate in cases of doubtful diagnosis.
• Missed testicular torsion may lead to the loss of spermatogenesis in the affected testicle within 4-6 hours.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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• Holland JM, Graham JB, Ignatoff JM. Conservative management of twisted testicular appendages. J Urol. Feb 1981;125(2):213-4. [Medline].
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• Strauss S, Faingold R, Manor H. Torsion of the testicular appendages: sonographic appearance. J Ultrasound Med. Mar 1997;16(3):189-92; quiz 193-4. [Medline].
• Watkin NA, Reiger NA, Moisey CU. Is the conservative management of the acute scrotum justified on clinical grounds?. Br J Urol. Oct 1996;78(4):623-7. [Medline].
• Williamson RC. Torsion of the testis and allied conditions. Br J Surg. Jun 1976;63(6):465-76. [Medline].
• Yazbeck S, Patriquin HB. Accuracy of Doppler sonography in the evaluation of acute conditions of the scrotum in children. J Pediatr Surg. Sep 1994;29(9):1270-2. [Medline].

Article Last Updated: Jul 12, 2006