Appendix Testes Torsion


Article Author:
AJ Pomajzl


Article Editor:
Stephen Leslie


Editors In Chief:
David Wood
Andrew Wilt
Hajira Basit


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
11/6/2019 7:16:08 PM

Introduction

Torsion of the testicular appendages is considered to be the most common cause of acute scrotal pain in prepubertal children and may even be the single most prevalent cause of pediatric orchalgia. [1] It should, therefore, be included in the differential for any male presenting with an acute scrotum but especially in the pediatric age group.[1] There are two testicular appendages that can twist and become symptomatic: the appendix testis and the appendix epididymis. 

The appendix testis, sometimes called hydatid of Morgagni, is a vestigial remnant of the Mullerian duct and is present in 76% to 83% of testes.[2] When present, it is located on the superior pole of the testicle between the testis and epididymis and is the most common testicular appendage to undergo torsion. It is homologous to the fimbriated end of the Fallopian tube in the female.

The appendix epididymis is a vestigial Wolffian (mesonephric) duct remnant and is present in 22% to 28% of the testes.[2] When present, it occurs along the head of the epididymis. It is sometimes considered to be a detached efferent epididymal duct.

Etiology

Both testicular appendages are commonly pedunculated, predisposing them to torsion.[3] Beyond this, the actual cause of torsion is unknown but may be related to trauma and/or prepubertal enlargement, which would explain the peak age of occurrence being in 7 to 12-year-old boys. Some authors have proposed a seasonal etiology for both spermatic cord (testicular) and testicular appendage torsion with low temperatures during the winter leading to more episodes of torsion.[4][5]

Epidemiology

The peak age of occurrence is 7-12 years, although it can occur at any age. More than 50% of boys presenting with acute scrotal pain will have torsion of a testicular appendage.[1][6] In one study of 238 boys aged 19 years and younger who presented to a children's hospital with acute scrotal pain, 46% were ultimately found to have torsion of the appendix testis, while 35% had epididymitis and only 16% demonstrated testicular torsion.[6]

History and Physical

The initial diagnosis is made clinically, although this can be challenging as the presentation is variable, and it is easy to misdiagnose, with 45% of general practitioners making an incorrect initial diagnosis.[7] This frequent misdiagnosis is why imaging is the recommendation for all cases of acute scrotal pain.

Torsion of either testicular appendage commonly produces pain similar to that experienced with testicular torsion, although the onset is usually more gradual. Often, the pain is more localized to the upper pole of the testis or epididymis and does not usually correlate with any urinary symptoms nor with systemic signs such as fever, nausea, or vomiting. 

On initial physical examination of the condition, tenderness can often be localized to the upper pole of the testis or epididymis. There may be a palpable, localized mass in the area of maximum tenderness. The scrotum usually appears normal, and the cremasteric reflex is typically intact. With a normal cremasteric reflex, there would not be any "angel wing or bell clapper deformity" of the opposite testicle.  The "angel wing deformity" is formed when a testicle lies horizontally rather than the usual vertical position, which widens the scrotum inferiorly creating the "angel wing" appearance which is typically caused by inadequate fixation by the gubernaculum of the inferior pole of the testicle to the tunica vaginalis which predisposes to testicular torsion. 

A "blue dot sign" may also be present as a para-testicular nodule noted on the superior aspect of the testicle; this can be identified by stretching the scrotal skin overlying the superior pole of the testicle and is representative of an ischemic testicular appendage. While worth knowing, the "blue dot sign" is only present in about 21% (0 to 52%) of all torsed testicular appendages, and a false positive "blue dot sign" has been reported in the literature in a patient with testicular torsion.[8]

As the condition progresses, worsening inflammation may make physical exam findings less specific. These findings can include scrotal erythema and edema, as well as nonspecific tenderness of the entire testicle and epididymis.

Evaluation

Color doppler ultrasonography is the imaging modality of choice for the evaluation of the acute scrotum in all age groups. It has been found to be superior to radionuclide imaging, is readily available on an emergency basis, and can be done more quickly. Rarely will ultrasound identify an appendage itself, but it will typically show normal blood flow to the testicle on the affected side--ruling out testicular torsion--and usually shows hyperperfusion of the associated epididymis. If the appendage does show up on ultrasound, a normal appendix testis will be less than 5.6 mm in size. In contrast, a torsed testicular appendage will be over 5.6 mm and, depending upon the duration of torsion, may appear as an ovoid hypoechoic nodule in boys presenting before 24 hours compared to a hyperechoic or heterogeneous nodule after 24 hours.[9][10]  A large torsed appendage may even give the sonographic appearance of a pyocele, making the clinical history and physical examination even more important.[11]

The normal ultrasonic appearance of a testicular appendage will typically show little or no vascular flow.[12][13]

The affected testicle is often found to be "high riding" in testicular torsion but not in a torsed testicular appendage.

Radionuclide imaging of the scrotum would demonstrate a "hot dot" sign at the site of the torsed testicular appendage but is useful only if the symptoms and torsion have been present for at least 5 hours.  Even after 5 hours, this sign is only found in about 45% of patients ultimately found to have a torsed testicular appendage.[14]  For these reasons, ultrasound imaging is usually the preferred option for the initial evaluation of all acute scrotal pathologies.[15]

If the patient is having voiding symptoms such as dysuria, urgency, or frequency, it will also be important to obtain a urinalysis with culture.

Treatment / Management

Torsion of a testicular appendage is generally a self-limiting condition and, as such, most cases receive conservative therapy. Conservative management includes bed rest, scrotal elevation, ice, nonsteroidal anti-inflammatory drugs, and analgesics. The inflammation and pain usually resolve within one week.

Surgery is rarely indicated for a torsed testicular appendage. A scrotal exploration should only be performed if it is difficult to differentiate from testicular torsion, if the pain is severe and uncontrollable by analgesics or if the pain is prolonged or recurrent. If there is any reasonable doubt about the diagnosis, a scrotal exploration should take place to exclude testicular torsion definitively.  If surgery is ultimately the outcome for a torsed testicular appendage, there is no need to explore the opposite side as is typically done for testicular torsions.

Differential Diagnosis

In a patient presentation of acute scrotal pain, the differential includes ischemia (testicular torsion, torsion of a testicular appendage), infection (acute epididymo-orchitis), or trauma (scrotal contusion, testis rupture). However, the acute scrotum should be considered a surgical emergency until a testicular torsion is ruled out due to the potential catastrophic loss of a testicle. Testicular salvage is time-dependent, and most testicles remain viable if they are surgically detorsed within 6 hours of the onset of symptoms.

Testicular torsion usually has a more acute onset than torsion of an appendage, but this is variable. The cremasteric reflex is almost always absent on the affected side, and on physical exam, an abnormal transverse lie of the unaffected testicle may present. Lifting the affected testicle does not usually relieve pain (negative Prehn sign), but this is not considered a reliable indicator. Doppler ultrasound will show arterial flow to the affected testicle to be absent or minimal. Interestingly, onset during sleep has been found to be an indicator of testicular torsion.[15]  The affected testicle is often found to be "high riding" in testicular torsion but not in a torsed testicular appendage.

Epididymo-orchitis, like torsion of a testicular appendage, will show hyperemia to the affected epididymis on color Doppler ultrasound but is likely to be more pronounced. There will often be associated with voiding symptoms such as dysuria, frequency and urgency, and possibly a history of urinary tract infections. Patients may also present with systemic signs and symptoms of fever, nausea, or vomiting. On physical exam, the epididymis and/or testis on the affected side will usually be enlarged and diffusely tender. Occasionally, elevating the affected testicle will relieve pain (positive Prehn sign).  No "angel wing or bell clapper deformity" will be present.[13]

In doubtful cases, it is essential to perform an emergency scrotal exploration rather than wait and risk losing the testicle.[16]

Prognosis

The prognosis is good for torsion of either testicular appendage as they are both vestigial remnants with no known function. The pain and inflammation associated with the torsion are self-limiting, and the condition typically resolves within one week without the need for surgical intervention. 

Complications

The primary complication of torsion of a testicular appendage is a misdiagnosis resulting in the loss of testis due to a missed testicular torsion. Ultrasonography can help avoid such misdiagnosis and is, therefore, the recommended diagnostic approach in all cases of acute scrotal emergencies.

Pearls and Other Issues

  • The "blue dot sign" is a classic physical exam finding unique to testicular appendix torsion. However, it is often absent in the setting of testicular appendix torsion and can be falsely positive in cases of true testicular torsion.
  • Because of their lack of function and potential to torse, the appendix testes and epididymal appendix are commonly removed if encountered during an elective scrotal exploration for other purposes. 
  • Often, testicular appendage torsion in prepubertal boys gets misdiagnosed as epididymitis based on scrotal ultrasound imaging, as both can demonstrate epididymal hypervascularity. Epididymitis should be considered highly unlikely in a pre-sexual boy with no urologic abnormalities, recent catheterization, or history of UTIs.
  • If a testicular appendage is more than 5.6 mm on ultrasound, it should be considered suspicious for torsion of the appendage.
  • Patients with testicular appendage torsion are likely to be younger than those with testicular torsion. They also will lack the "angel wing deformity" and not demonstrate the "high riding" testicle position usually associated with testicular torsion.[15]
  • Rare causes of an acute scrotum can include incarcerated hernias and traumatic testicular ruptures. 
  • There have been reported cases of simultaneous testicular torsion with testicular appendage torsion.
  • It is possible to have torsion of a testicular appendage in an undescended testicle.

Enhancing Healthcare Team Outcomes

Management of the acute scrotum is a surgical emergency until proven otherwise. As patients with this condition usually present to the emergency department, the first person to encounter the patient is a triage nurse who must be cognizant of the urgency potential testicular torsion demands and immediately contact the clinical interprofessional team. The patient should be placed in a room promptly, and the physician alerted of the patient's presence and chief complaint. Early history and physical exam should give the physician some guidance and direction, usually necessitating a color Doppler ultrasound and promptly read by a radiologist.

Once testicular torsion can safely be ruled out, other potential causes of acute scrotal pain, including testicular appendage torsion, can come under consideration and the patient appropriately treated. 

Management of pre-pubescent scrotal pain requires a coordinated interprofessional effort between physicians, specialists, and nursing staff to lead to accurate and prompt diagnosis resulting in appropriately directed treatment. [Level V]


  • Image 11380 Not availableImage 11380 Not available
    Image courtesy O.Chaigasame
Attributed To: Image courtesy O.Chaigasame

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Appendix Testes Torsion - Questions

Take a quiz of the questions on this article.

Take Quiz
A 5-year-old male presents with gradual onset of right scrotal pain. His family denies fever or trauma. On examination, the testis and epididymis are tender and swollen, and there is discoloration of the scrotal skin on the same side. He denies dysuria. The urinalysis is completely normal. A Doppler ultrasound shows increased blood flow. What is the most appropriate treatment?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following are mullerian duct remnants one could expect to find in a male?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 10-year-old boy presents to the emergency department with complaints of acute onset, left testicular pain. A left cremasteric reflex is not appreciated. The right cremasteric reflex is normal. He has a palpable blue nodule in the upper pole of his left testicle when the overlying scrotal skin is stretched. Color duplex Doppler shows no arterial flow to the left testicle. What is the next step?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
In males younger than 16 years of age, what is the etiology of the most common cause of acute scrotal pain?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 16-year-old male presents to the emergency department at with severe and acute-onset left scrotal pain. Scrotal ultrasound and urinalysis are ordered. Which of the following, if present, would most strongly warrant an urgent urologic consultation?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 16-year-old male, who was recently admitted to the hospital for an overnight laparoscopic appendectomy, returns to the emergency department with acute, right scrotal pain. A color doppler is obtained which demonstrates normal arterial blood flow to both testicles but hyperemia to the area of the right epididymis. Which of the following is the next best test to confirm the diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 10-year-old boy is brought to the emergency department with a 3-hour history of severe, acute right-sided scrotal pain that woke him from sleep. The opposite testicle is normal to examination and is non-tender. The affected testicle is very tender to touch. No obvious testicular swelling or erythema is present. Urination is normal, and there is a normal urinalysis. No fever, nausea, or vomiting is reported. What is the best initial therapy for this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Appendix Testes Torsion - References

References

Murphy FL,Fletcher L,Pease P, Early scrotal exploration in all cases is the investigation and intervention of choice in the acute paediatric scrotum. Pediatric surgery international. 2006 May     [PubMed]
Park SJ,Kim HL,Yi BH, Sonography of intrascrotal appendage torsion: varying echogenicity of the torsed appendage according to the time from onset. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine. 2011 Oct     [PubMed]
Mushtaq I,Fung M,Glasson MJ, Retrospective review of paediatric patients with acute scrotum. ANZ journal of surgery. 2003 Jan-Feb     [PubMed]
Jacob M,Barteczko K, Contribution to the origin and development of the appendices of the testis and epididymis in humans. Anatomy and embryology. 2005 Apr     [PubMed]
JONES P, Torsion of the testis and its appendages during childhood. Archives of disease in childhood. 1962 Apr     [PubMed]
Lyronis ID,Ploumis N,Vlahakis I,Charissis G, Acute scrotum -etiology, clinical presentation and seasonal variation. Indian journal of pediatrics. 2009 Apr     [PubMed]
Molokwu CN,Somani BK,Goodman CM, Outcomes of scrotal exploration for acute scrotal pain suspicious of testicular torsion: a consecutive case series of 173 patients. BJU international. 2011 Mar     [PubMed]
Kim JS,Shin YS,Park JK, Clinical features of acute scrotum in childhood and adolescence: Based on 17years experiences in primary care clinic. The American journal of emergency medicine. 2018 Jul     [PubMed]
Melekos MD,Asbach HW,Markou SA, Etiology of acute scrotum in 100 boys with regard to age distribution. The Journal of urology. 1988 May     [PubMed]
Baldisserotto M,de Souza JC,Pertence AP,Dora MD, Color Doppler sonography of normal and torsed testicular appendages in children. AJR. American journal of roentgenology. 2005 Apr     [PubMed]
Meher S,Rath S,Sharma R,Sasmal PK,Mishra TS, Torsion of a large appendix testis misdiagnosed as pyocele. Case reports in urology. 2015     [PubMed]
Johnson KA,Dewbury KC, Ultrasound imaging of the appendix testis and appendix epididymis. Clinical radiology. 1996 May     [PubMed]
Boettcher M,Bergholz R,Krebs TF,Wenke K,Treszl A,Aronson DC,Reinshagen K, Differentiation of epididymitis and appendix testis torsion by clinical and ultrasound signs in children. Urology. 2013 Oct     [PubMed]
Melloul M,Paz A,Lask D,Luttwak Z,Mukamel E, The pattern of radionuclide scrotal scan in torsion of testicular appendages. European journal of nuclear medicine. 1996 Aug     [PubMed]
Fujita N,Tambo M,Okegawa T,Higashihara E,Nutahara K, Distinguishing testicular torsion from torsion of the appendix testis by clinical features and signs in patients with acute scrotum. Research and reports in urology. 2017     [PubMed]
    [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Pediatrics-Medical Student. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Pediatrics-Medical Student, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Pediatrics-Medical Student, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Pediatrics-Medical Student. When it is time for the Pediatrics-Medical Student board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Pediatrics-Medical Student.