Fig. 29.13 An intraoperative photograph showing already necrotic testes in a newborn with bilateral intrauterine testicular torsion

29.3Torsion of the Testicular or Epididymal Appendage

29.3.1 Introduction

•Torsion of testicular appendices is one of the most common causes of acute scrotum (Fig. 29.16).

•There are two types of testicular appendices:

–The appendix testis

–The epididymal appendix

•Torsion of testicular appendices is considered the leading cause of acute scrotum in children.

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

•Torsion of the testicular appendices is virtually a benign condition, but must be distinguished from testicular torsion.

•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.

29.3.2 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.

29.3.3 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 which presents with sudden acute scrotal pain.

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

Fig. 29.17 An intraoperative photograph showing torsion of the appendix testis

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

•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. 29.17).

29.3.4 Investigations and Treatment

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

analgesics.

–Torsion of a testicular appendage may be misdiagnosed as epididymitis but if the urinalysis is normal, no antibiotic therapy is required.

–The inflammation usually resolves within a week.

acute scrotum secondary to severe epididymo-orchitis with intrascrotal abscess formation

•It has been shown that 47 % of prepubertal boys and 75 % of infants with epididymitis have an underlying urogenital anomaly.

29.4Epididymitis, Orchitis, and Epididymo-orchitis

29.4.1 Introduction

•Acute epididymo-orchitis is a clinical diagnosis consisting of pain, swelling and inflammation of the epididymis, with or without inflammation of the testes.

•It is an important cause of acute scrotum in children (Fig. 29.18).

•Orchitis (infection limited to the testis) is much less common and commonly caused by mumps.

•Chronic epididymitis refers to inflammation that lasts for more than 6 months.

•Epididymitis is considered the most common cause of acute scrotum in older boys, and it is important to differentiate this from testicular torsion.

•There is an increased incidence of genitourinary abnormalities in prepubertal boys with epididymitis.

29.4.2 Etiology

•The exact etiology of acute epididymitis is unknown.

•Acute epididymitis is believed to be caused by the retrograde passage of urine from the prostatic urethra to the epididymis via the ejaculatory ducts and vas deferens.

•There are however several contributing causes for acute epididymitis including:

–Genitourinary abnormalities in infants and young boys.

–In older boys, acute epididymitis is often idiopathic.

–Epididymitis can also be secondary to systemic diseases, such as:

•Sarcoidosis.

•Kawasaki disease.

•Henoch-Schönlein purpura.

–Inflammation of the epididymis may be also reactive secondary to trauma or torsion of an appendix testis.

–Chemical irritation from sterile reflux of urine into the seminal tract.

–Epididymitis in children can also be druginduced (amiodarone-induced epididymitis)

•Bacterial epididymitis is caused by several organisms including:

–Coliforms,Pseudomonasspecies,Ureaplasma, Mycoplasma species, Staphylococcus, Proteus species, and Haemophilus influenzae.

–In sexually active patients, Chlamydia and/ or Neisseria gonorrhoeae may be the causative organism.

–Viral causes include paramyxovirus, Coxsackie virus, echovirus, and adenovirus.

–Granulomatous epididymitis is very rare in children and can be secondary to tuberculosis.

29.4.3 Clinical Features

•The usual presentation is with unilateral scrotal pain and swelling of relatively acute onset.

•Acute epididymitis is usually unilateral but it is bilateral in 5–10 % of the patients.

•There may be a history of a urinary tract infection.

•Tenderness on the affected side.

•The epididymis will be enlarged and tender or the whole testis and epididymis will be tender.

•There may also be erythema and/or edema of the scrotum on the affected side.

29.4.4 Investigations and Treatment

•Urinalysis with culture and sensitivity.

•Blood culture.

•Infants and children with epididymitis have a high incidence of associated urogenital abnormalities, and thus require full urological evaluation.

•Renal ultrasound, a voiding cystourethrogram and urodynamic studies are necessary investigations in prepubertal boys with acute epididymitis. This is specially so in the presence of urinary tract infection (Figs. 29.19, 29.20 and 29.21).

•In patients with signs of urinary tract infection, treatment includes empiric antibiotic therapy until the results of a urine culture are known.

•Treatment should start with an oral or I.V broad-spectrum antibiotic depending on the presence or absence of signs of systemic infection. Treatment should be continued for 10–14 days and the antibiotics modified according to the culture result.

•Patients with underlying genito-urinary abnormalities usually require surgical intervention.

•In the absence of urinary tract infection, treatment is supportive including:

–Bed rest and scrotal elevation.

–Non-steroidal anti-inflammatory drugs and analgesics.