eMedicine Specialties > Emergency Medicine > Genitourinary

Torsion of the Appendices and Epididymis: Differential Diagnoses & Workup

Author: Jason S Chang, MD, Clinical Instructor, Department of Emergency Medicine, University of Pittsburgh Medical Center
Contributor Information and Disclosures

Updated: Mar 24, 2009

Differential Diagnoses

Epididymitis
Henoch-Schonlein Purpura
Hernias
Hydrocele
Orchitis
Testicular Torsion

Workup

Laboratory 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 sonography (CDS) is the imaging modality of choice for evaluation of the acute scrotum. 
    • In torsion of the testicular appendage, CDS shows 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 CDS is less accurate in these instances.
    • Some studies suggest that CDS has 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.
    • A study by Pepe et al demonstrated that CDS specificity may not be as high as previously reported for testicular torsion.3  In a subset analysis of 42 adolescents with diagnostic suspicion of testicular torsion by CDS, only 22 had surgical confirmation of this diagnosis, while 16 were found to be normal and 4 had torsion of the testicular appendage. In fact, clinical examination alone had sensitivity and specificity of 100% and 50%, respectively, while CDS had sensitivity and specificity of 95.7% and 48.7%, respectively. In a patient presenting with an acute scrotum, a negative CDS result may provide supportive evidence that the patient has a benign condition like torsion of an appendage, but it does not exclude the diagnosis of testicular torsion. In high clinical suspicion, surgical exploration may still 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.4
    • The test is reported to be 68% sensitive and 79% accurate.4

More on Torsion of the Appendices and Epididymis

Overview: Torsion of the Appendices and Epididymis
Differential Diagnoses & Workup: Torsion of the Appendices and Epididymis
Treatment & Medication: Torsion of the Appendices and Epididymis
Follow-up: Torsion of the Appendices and Epididymis
References
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References

  1. Rakha E, Puls F, Saidul I, Furness P. Torsion of the testicular appendix: importance of associated acute inflammation. J Clin Pathol. Aug 2006;59(8):831-4. [Medline].

  2. Karmazyn B, Steinberg R, Kornreich L. Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys. Pediatr Radiol. Mar 2005;35(3):302-10. [Medline].

  3. Pepe P, Panella P, Pennisi M, Aragona F. Does color Doppler sonography improve the clinical assessment of patients with acute scrotum?. Eur J Radiol. Oct 2006;60(1):120-4. [Medline].

  4. Melloul M, Paz A, Lask D, et al. The pattern of radionuclide scrotal scan in torsion of testicular appendages. Eur J Nucl Med. Aug 1996;23(8):967-70. [Medline].

  5. Barloon TJ, Weissman AM, Kahn D. Diagnostic imaging of patients with acute scrotal pain. Am Fam Physician. Apr 1996;53(5):1734-50. [Medline].

  6. Fisher R, Walker J. The acute paediatric scrotum. Br J Hosp Med. Mar 16-Apr 5 1994;51(6):290-2. [Medline].

  7. Holland JM, Graham JB, Ignatoff JM. Conservative management of twisted testicular appendages. J Urol. Feb 1981;125(2):213-4. [Medline].

  8. Hormann M, Balassy C, Philipp MO, Pumberger W. Imaging of the scrotum in children. Eur Radiol. Jun 2004;14(6):974-83. [Medline].

  9. Johnson KA, Dewbury KC. Ultrasound imaging of the appendix testis and appendix epididymis. Clin Radiol. May 1996;51(5):335-7. [Medline].

  10. Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics. Jul 1998;102(1 Pt 1):73-6. [Medline].

  11. Kogan SJ, Hadziselmovic F, Howards SS. Pediatric andrology: congenital and acquired scrotal abnormalities. In: Adult and Pediatric Urology. Vol 3. 4th ed. 2002:2570-2581.

  12. Lewis AG, Bukowski TP, Jarvis PD, et al. Evaluation of acute scrotum in the emergency department. J Pediatr Surg. Feb 1995;30(2):277-81; discussion 281-2. [Medline].

  13. McAndrew HF, Pemberton R, Kikiros CS. The incidence and investigation of acute scrotal problems in children. Peditric Surg Int. Sept 2002;18:435-437. [Medline].

  14. Rabinowitz R, Hulbert WC Jr. Acute scrotal swelling. Urol Clin North Am. Feb 1995;22(1):101-5. [Medline].

  15. Ravichandran S, Blades RA, Watson ME. Torsion of the epididymis: a rare cause of acute scrotum. Int J Urol. Oct 2003;10(10):556-7. [Medline].

  16. Sahni D, Jit I, Joshi K, Sanjeev. Incidence and structure of the appendices of the testis and epididymis. J Anat. Oct 1996;189 ( Pt 2):341-8. [Medline].

  17. Siegel MJ. The acute scrotum. Radiol Clin North Am. Jul 1997;35(4):959-76. [Medline].

  18. 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].

  19. 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].

  20. Williamson RC. Torsion of the testis and allied conditions. Br J Surg. Jun 1976;63(6):465-76. [Medline].

  21. 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].

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Further Reading

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Keywords

acute scrotum, acute scrotum in children, testicular torsion, testicular pain, acute scrotal pain, appendix epididymis, appendix of epididymidis, pedunculated hydatid, appendix testis, nonpedunculated hydatid, ovarium masculinum, sessile hydatid, torsion of appendices, torsion of epididymis

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Contributor Information and Disclosures

Author

Jason S Chang, MD, Clinical Instructor, Department of Emergency Medicine, University of Pittsburgh Medical Center
Jason S Chang, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Theodore J Gaeta, DO, MPH, FACEP, Clinical Associate Professor, Department of Emergency Medicine, Joan and Sanford Weill Medical College at Cornell University; Vice Chairman and Program Director of Emergency Medicine Residency Program, Department of Emergency Medicine, New York Methodist Hospital; Academic Chair, Adjunct Professor, Department of Emergency Medicine, St George's University School of Medicine
Theodore J Gaeta, DO, MPH, FACEP is a member of the following medical societies: Alliance for Clinical Education, American College of Emergency Physicians, Clerkship Directors in Emergency Medicine, Council of Emergency Medicine Residency Directors, New York Academy of Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
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