26.10 Torsion of the Testicular or Epididymal Appendage

•Add to this the fact that these patients are usually healthy of good size and currently the anesthesia is safe.

•Many authors feel that these patients should be managed with early exploration and if the testis is found necrotic, orchidectomy and contralateral orchidopexy is performed. If the testis is found viable, bilateral orchidopexy is performed.

26.10Torsion of the Testicular or Epididymal Appendage

26.10.1 Introduction

•Torsion of testicular appendices is one of the most common causes of acute scrotum.

•It is considered the leading cause of acute scrotum in children.

Figs. 26.27, 26.28, 26.29, and 26.30 Clinical intraoperative photographs of four patients with intrauterine torsion. The testes were found congested and dusky but viable. All underwent bilateral orchidopexy. Early surgi-

Fig. 26.31 Diagrammatic representation of the two common testicular appendages

cal exploration is important in these patients as the exact timing of torsion is not known and in some of these patients, torsion may occur at the time of delivery or shortly after

•This is considered the most common cause of acute scrotal pain in boys aged 7–14 years.

•It can resemble testicular torsion but the onset of pain is more gradual.

•Systemic symptoms are rare.

•Localized tenderness occurs but only in the upper pole of the testis.

•In those with acute scrotal pain, the incidence of torsion of testicular appendage ranges from 46–71 %.

•Torsion of the testicular appendices is virtually a benign condition, but must be

distinguished from testicular torsion (Fig. 26.31).

•The appendix testis and epididymal appendix are commonly pedunculated and because of this are predisposed to torsion.

•Torsion of either appendage (The appendix testis and Epididymal appendix) produces pain similar to that experienced with testicular torsion, but the onset is usually more gradual.

26.10.2 Embryology

•The appendix testis:

–This is a Müllerian duct remnant.

–It is present in 92 % of all testes.

–It is located at the superior pole of the testis in the groove between the testis and epididymis.

–It is the most common appendage to undergo torsion.

•The epididymal appendix:

–This is a Wolffian duct remnant.

–The appendix epididymis is present in 23 % of testes.

–It is usually located on the head of the epididymis.

–It is the second common appendage to undergo torsion.

26.10.3 Clinical Features

•The majority (80 %) of torsion of the testicular or epididymal appendage occurs in boys aged 7–14 years (Mean age 10.6 years).

•The usual presentation is acute scrotal pain but the onset is more gradual. This is important in distinguishing this from testicular torsion.

•The pain is more localized to the upper pole of the testis which is also tender.

•The pain is usually not associated with systemic symptoms, nausea, vomiting or urinary symptoms.

•Localized tenderness occurs but only in the upper pole of the testis.

•Usually, the scrotum appears normal but sometimes there is an associated erythema and edema.

•The cremasteric reflex is usually intact.

•Occasionally, a paratesticular nodule at the superior aspect of the testicle is present. This is called the blue-dot sign which is present in only 20 % of cases (Fig. 26.32).

•This is the appendix of the testis which has become discolored and is noticeably blue through the skin.

26.10.4Investigations and Treatment

•Ultrasonography can be useful in distinguishing torsion of a testis and torsion of an appendix testis.

•Color Doppler ultrasonography is the imaging modality of choice for evaluation of the acute scrotum.