Diagnostic Considerations

Torsion of the cryptorchid testis can be very challenging to diagnose. Many patients present with scrotal pain, but only a fraction of these have torsion.^{[29, 30]}This condition may be mistaken for incarcerated hernia, appendicitis, or other causes of acute abdomen. Intra-abdominal testicular torsion is often associated with malignant degeneration.^[31]

Testicular torsion can occur in boys who have undergone prior orchidopexy, though this is unusual. Hence, testicular torsion should be suspected and considered in the differential diagnoses of acute scrotum in this group.^{[15, 32]}

Torsion of the appendix testis may present similarly to testicular torsion. The age of the patient may be helpful, in that torsion of the appendix testis is more common in prepubertal boys.^[6]These boys are less likely to have nausea and vomiting than boys with testicular torsion.

Upon examination, a classic "blue-dot sign" (ie, a tender nodule with blue discoloration on the upper pole of the testis) may be seen; this finding on the upper scrotum is a typical finding in torsion of the appendix testis (see the image below). However, in the acute setting, differentiating testicular torsion from torsion of the appendix is often impossible, and scrotal exploration should be performed whenever the diagnosis is uncertain. (See Torsion of the Appendices and Epididymis.)

Torsion of appendix testis.

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Other problems to consider in the differential diagnosis of testicular torsion include the following:

Hydatid of Morgagni
Idiopathic scrotal edema (dermatitis, insect bite)
Scrotal abscess/cellulitis
Tumor
Obstructed or incarcerated hernia
Furuncle
Hemangioma
Abdominal trauma with hemiscrotum
Splenogonadal fusion
Adrenal neuroblastoma
Meconium peritonitis
Antenatal Meckel diverticulum perforation
Hernial sac torsion
Pyocele
Ventriculoperitoneal shunt migration

Differential Diagnoses

Adrenal Hemorrhage
Epididymitis
Henoch-Schonlein Purpura (IgA Vasculitis)
Orchitis
Pediatric Appendectomy
Pediatric Hydrocele and Hernia Surgery
Varicocele in Adolescents

Workup

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Media Gallery

Perinatal testicular torsion.
Intravaginal testicular torsion with ischemia in adolescent boy.
Torsion of undescended testis.
Torsion of testis, with cord twist clearly demonstrated.
Torsion of appendix testis.

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