eMedicine Specialties > Emergency Medicine > Genitourinary

Torsion of the Appendices and Epididymis

Author: Jason S Chang, MD, Clinical Instructor, Department of Emergency Medicine, University of Pittsburgh Medical Center
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Updated: Mar 24, 2009

Introduction

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.
• A retrospective study by Rakha et al demonstrated no evidence of any bacterial or fungal infection in 79 cases of torsion of the testicular appendage. Histologic analysis showed no correlation between degree of inflammatory infiltrate and pyogenic infection.¹  
• Greatest morbidity results from a missed diagnosis of testicular torsion and a subsequent delay in treatment. 

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

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 intact. 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 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.²

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