Testes

Torsion of Testicular Appendage

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Torsion of Testicular Appendage, Torsion of Appendix Testes

  • Epidemiology
  1. Most common in boys under age 3-5 years up to age 12 years old
  • Pathophysiology
  1. Appendix Testicle is a Mullerian Duct remnant on anterosuperior aspect of the Testicle
  2. Appendix Testicle is present in 85% of boys
  • Differential Diagnosis
  1. Testicular Torsion
  2. Epididymitis
  • Symptoms
  1. Insidious or sudden onset of unilateral Scrotal Pain
    1. Pain may be intense, but is typically less severe than with Testicular Torsion
  2. Similar characteristics of Testicular Torsion without the systemic symptoms (e.g. rare Nausea or Vomiting)
  • Signs
  1. Tiny, focally tender, palpable mass at Testis upper pole
  2. "Blue dot" sign (gangrenous appendix Testicle) on scrotal skin early in course
  3. Testicular Inflammation and Hydrocele are late findings
    1. Testicle is typically not tender outside of focal tenderness at appendix Testicle
    2. Cremasteric Reflex is normal
  4. Reactive Hydrocele may be present
  • Differential Diagnosis
  1. See Testicular Torsion
  2. See Testicular Pain
  • Imaging
  1. Scrotal Ultrasound
    1. Diagnosis of Torsion of Testicular Appendage may be made clinically on exam (esp. with blue dot sign)
    2. Critical to distinguish from Testicular Torsion in unclear cases (do not miss Testicular Torsion)
    3. Ultrasound demonstrates a low echogenic appendix (suggesting decreased Blood Flow)
  • Course
  1. Pain resolves in 5-10 days (up to 14 days)
  • Precaution
  1. May be difficult to distinguish from Testicular Torsion, especially in delayed presentation
  • Management
  1. Urology referral indications
    1. Presentation too late to make accurate diagnosis
    2. Unable to exclude Testicular Torsion
    3. Urologists may resect appendix Testes in cases of persistent discomfort
  2. Symptom management
    1. Scrotal support (e.g. tight underwear or jock strap)
    2. NSAIDs
  • References
  1. Mace (2021) Crit Dec Emerg Med 35(9): 14-5
  2. Lewis (1995) J Pediatr Surg 30:277-82 [PubMed]
  3. Hawtrey (1998) Urol Clin North Am 25:715-23 [PubMed]
  4. Ringdahl (2006) Am Fam Physician 74:1739-46 [PubMed]
  5. Sharp (2013) Am Fam Physician 88(12): 835-40 [PubMed]