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Torsion of the Appendices and Epididymis Workup

  • Author: Jason S Chang, MD; Chief Editor: Erik D Schraga, MD  more...
 
Updated: Dec 12, 2014
 

Laboratory Studies

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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.

In a retrospective study of 241 boys with acute scrotal pain, the best predictors for epididymitis were dysuria, a painful epididymis on palpation, and altered epididymal echogenicity and increased peritesticular perfusion on ultrasound studies; for appendix testis (AT), the best predictor was a positive blue dot sign.[6]

Color Doppler ultrasonography

Color Doppler sonography (CDS) is the imaging modality of choice for evaluation of the acute scrotum.[7]

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.[8] 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.[9] The test is reported to be 68% sensitive and 79% accurate.[9]

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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, Society for Academic Emergency Medicine, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Additional Contributors

Theodore J Gaeta, DO, MPH, FACEP Clinical Associate Professor, Department of Emergency Medicine, Weill Cornell Medical College; 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: American College of Emergency Physicians, New York Academy of Medicine, Society for Academic Emergency Medicine, Council of Emergency Medicine Residency Directors, Clerkship Directors in Emergency Medicine, Alliance for Clinical Education

Disclosure: Nothing to disclose.

Acknowledgements

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

References
  1. Nason GJ, Tareen F, McLoughlin D, McDowell D, Cianci F, Mortell A. Scrotal exploration for acute scrotal pain: a 10-year experience in two tertiary referral paediatric units. Scand J Urol. 2013 Oct. 47(5):418-22. [Medline].

  2. Even L, Abbo O, Le Mandat A, Lemasson F, Carfagna L, Soler P, et al. [Testicular torsion in children: Factors influencing delayed treatment and orchiectomy rate]. Arch Pediatr. 2013 Apr. 20(4):364-8. [Medline].

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

  4. Boettcher M, Bergholz R, Krebs TF, Wenke K, Aronson DC. Clinical predictors of testicular torsion in children. Urology. 2012 Mar. 79(3):670-4. [Medline].

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

  6. Boettcher M, Bergholz R, Krebs TF, Wenke K, Treszl A, Aronson DC, et al. Differentiation of epididymitis and appendix testis torsion by clinical and ultrasound signs in children. Urology. 2013 Oct. 82(4):899-904. [Medline].

  7. Aydogdu O, Burgu B, Gocun PU, Ozden E, Yaman O, Soygur T, et al. Near infrared spectroscopy to diagnose experimental testicular torsion: comparison with Doppler ultrasound and immunohistochemical correlation of tissue oxygenation and viability. J Urol. 2012 Feb. 187(2):744-50. [Medline].

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

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

  10. Saxena AK, Castellani C, Ruttenstock EM, Höllwarth ME. Testicular Torsion: A 15-Year Single Center Clinical and Histological Analysis. Acta Paediatr. 2012 Mar 3. [Medline].

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

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

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

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

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

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

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

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

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

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

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

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

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

  24. Strauss S, Faingold R, Manor H. Torsion of the testicular appendages: sonographic appearance. J Ultrasound Med. 1997 Mar. 16(3):189-92; quiz 193-4. [Medline].

  25. Watkin NA, Reiger NA, Moisey CU. Is the conservative management of the acute scrotum justified on clinical grounds?. Br J Urol. 1996 Oct. 78(4):623-7. [Medline].

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

  27. Yazbeck S, Patriquin HB. Accuracy of Doppler sonography in the evaluation of acute conditions of the scrotum in children. J Pediatr Surg. 1994 Sep. 29(9):1270-2. [Medline].

 
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