eMedicine Specialties > Emergency Medicine > Genitourinary

Torsion of the Appendices and Epididymis

Jason S Chang, MD, Clinical Instructor, Department of Emergency Medicine, University of Pittsburgh Medical Center

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

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

Treatment

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

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

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.

Ibuprofen (Ibuprin, Advil, Motrin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Dosing

Adult

200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d

Pediatric

<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Ketoprofen (Actron, Orudis, Oruvail)

For relief of mild to moderate pain and inflammation.
Small dosages initially are indicated in small and elderly patients and in those with renal or liver disease.
Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.

Dosing

Adult

25-50 mg PO q6-8h prn; not to exceed 300 mg/d

Pediatric

<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults

Interactions

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Naproxen (Aleve, Anaprox, Naprelan, Naprosyn)

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.

Dosing

Adult

500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d

Pediatric

<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d

Interactions

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Follow-up

Further Inpatient Care

If diagnostic uncertainty for testicular torsion remains, the patient warrants urological consultation and close monitoring of the testicular examination.

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

Medicolegal 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

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

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

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Sean O Henderson, MD, and Gregory Alfred, MD, to the development and writing of this article.

Further Reading