What is Appendix Testis Torsion?
Testicular appendage torsion is the main cause of severe scrotum pain in young children before puberty. In fact, it might be the most common reason for testicular pain in children. As such, boys presenting with sudden and intense pain in the testicles should be examined for this condition, especially if they’re prepubertal.
There are two parts inside the testicles that can twist and cause pain: the appendix testis and the appendix epididymis.
The appendix testis, also known as hydatid of Morgagni, is a leftover part from when the person was developing before birth. It can be found in between 76% to 83% of testicles. If it does exist, it is found at the top part of the testicle, placed between the testicle and epididymis. It has a similar structure to the fimbriated end of the Fallopian tube in females. This appendix testis is often the part that gets twisted.
The appendix epididymis is another residual part, from the Wolffian channel, and can be found in between 22% to 28% of testicles. When it is present, it is found near the head of the epididymis, part of the male reproductive system. It’s sometimes thought to be a detached tube leading out of the epididymis.
What Causes Appendix Testis Torsion?
The appendages of the testicles usually have a stem-like structure, which makes them more likely to twist. The exact reason for this twisting, called torsion, is still a mystery. However, it’s thought that factors such as injury and prepuberty growth could be involved. This might be the reason why torsion most commonly happens in boys between the ages of 7 to 12.
Some researchers suggest that colder weather might be linked to more cases of torsion of the testicle and its appendages. They believe that lower temperatures in the winter could lead to an increase in these torsion incidents.
Risk Factors and Frequency for Appendix Testis Torsion
Testicular appendage torsion, a condition which usually causes severe pain, commonly affects boys between the ages of 7 and 12, but it can happen at any age. In fact, it is the leading cause of scrotal pain in boys before they reach puberty. It’s noteworthy that more than half of the boys who have acute scrotal pain are found to have this condition.
In a research study involving 238 boys who were 19 years old or younger, it was found out that:
- 46% of the boys who had sudden scrotal pain were diagnosed with this torsion condition.
- 35% had a condition called epididymitis.
- Only 16% had testicular torsion, a different kind of rotation problem in the testicles.
Signs and Symptoms of Appendix Testis Torsion
Torsion of the testicular appendages, a condition where the small tissues connected to the testicles twist, can be hard to diagnose because symptoms vary and it can be easily mistaken for other conditions. This is so common that almost half of doctors initially misdiagnose this condition. To improve diagnosis accuracy, it’s recommended to use imaging technologies like ultrasound in any cases where sudden testicular pain is a concern.
The pain caused by this condition is often similar to testicular torsion, where the testicle itself twists, but it usually develops more slowly and is focused on the top side of the testicle or the epididymis, which is a tube at the back of the testicles. Other general symptoms like fever, nausea, or vomiting are typically absent.
During physical examination, a doctor will carefully check the patient’s scrotum, testicles, epididymis, groin area, and abdomen. Symptoms related to torsion of the testicular appendages often include:
- Tenderness at the top side of the testicle or epididymis
- Possible presence of a lump where the pain is greatest
- Normal appearance of the scrotum
- A normal cremasteric reflex, which is a quick contraction of the muscles pulling up the testicles when the inner thigh is stroked
This condition doesn’t typically cause the testicles to change their vertical position and stretch out the scrotum, which happens in cases of testicular torsion and makes them look like “angel wings”. However, a “blue dot sign”—a bluish, swollen spot on the top side of the testicle—might be present, though it’s only observed in about one in five cases and therefore is not a reliable symptom.
As the condition advances, the patient may show less specific symptoms, such as redness of the scrotum, swelling, and general tenderness involving the whole testicle and epididymis. A urine test is also recommended for anyone experiencing sudden scrotal pain.
The most common physical findings in patients with torsion of the testicular appendages include:
- No fever or abnormal vital signs
- Normal looking scrotum, possibly with some redness or swelling
- A normal cremasteric reflex
- Testicles in usual position, unlike in the case of testicular torsion
- Pain at the upper part of the affected testicle, typically milder than with testicular torsion
Additionally, there might be a small lump at the top of the affected testicle. A “blue-dot” may also be present but isn’t always indicative of the condition since it’s seen in only about 20% of patients. These physical findings, combined with the lack of other symptoms, can be helpful in diagnosing this condition and ruling out testicular torsion. Nonetheless, it’s crucial to remember that clinical signs alone are not considered reliable enough for a definitive diagnosis and additional tests are usually required.
Testing for Appendix Testis Torsion
Color Doppler ultrasonography, a type of ultrasound test, is the first choice for checking painful conditions in the scrotum for patients of all ages. This tool is better for diagnosing problems than radionuclide imaging (another type of test) and also more readily available in emergency settings. It gives us quick images and allows us to check blood flow to the scrotum.
With ultrasonography, small structures attached to the testicle called appendages usually show little or no noticeable blood flow. Although we might not always see the appendage itself, we can typically confirm that blood flow to the testicle itself is normal, ruling out a condition called ‘testicular torsion’. We often see a low amount of blood flowing to the adjacent epididymis (a tube located at the back of the testicles that stores and carries sperm). If we visualize an appendage, it’s generally less than 5.6 mm in size.
In comparison, a twisted appendage is larger than 5.6 mm and could show different ultrasonography patterns depending on how long it has been twisted. For boys coming in within 24 hours, we may see an oval-shaped shadow area in the image. But after 24 hours, we’re likely to see brighter, mixed textures. We might also see a twisted appendage as a region without blood flow, surrounded by an area with lots of blood flow that appears brighter on the ultrasound. This image can sometimes be hard to distinguish from inflammation of the epididymis based on ultrasound alone. We might need additional clinical information and checks to correctly diagnose what’s going on.
A big twisted appendage might even look like a pyocele, which is why it’s so important to know the patient’s medical history and perform a thorough physical check-up. The brightness of a twisted testicular appendage on ultrasound can vary based on things like the size of the appendage and how much time has elapsed since symptoms began.
In cases of testicular torsion, the affected testicle often appears to be lifted high due to the twisting of the spermatic cord. But if a testicular appendage is twisted, the testicle doesn’t show this characteristic. The testicle’s position might appear normal or slightly lifted, but it won’t show the major upward shift that comes with testicular torsion.
Another kind of image test, radionuclide imaging, may show a “hot dot” sign at the site of a twisted testicular appendage. But the test is not useful unless symptoms have been present for at least five hours. In fact, even after five hours, this sign shows up for just about 45% of patients diagnosed with a twisted testicular appendage. Also, radionuclide imaging takes a long time. Therefore, ultrasound is usually the best first choice for quickly evaluating sudden scrotum pain or other issues.
If a patient with scrotum pain also has problems like pain on urination, or feels like they need to urinate a lot or urgently, a urine test could be necessary. A twisted testicular appendage is less likely to cause urinary symptoms or show problems in the urinalysis than other conditions.
If we aren’t sure of the diagnosis after these evaluations, we may recommend an urgent surgical exploration for a detailed checkup.
Treatment Options for Appendix Testis Torsion
When it comes to testicular appendage torsion – a condition where a small tissue attached to the testicle twists – it usually takes care of itself. Most of the time, it just needs simple measures like bed rest, lifting the scrotum high, applying ice, and taking medication for inflammation and pain. Usually, these steps help reduce the inflammation and pain within a week, but in some cases, it might take longer. If the pain continues for a long time, removal of the tissue through surgery could be an option.
But it’s rare that surgery would be needed for a twisted testicular appendage. Doctors only consider surgery in certain situations such as struggles differentiating from a more serious condition called testicular torsion, severe pain that medication can’t control, or if the pain won’t stop or keeps coming back even after following simple care measures.
If doctors can’t confirm the diagnosis and there’s reasonable suspicion that it might be testicular torsion, a more serious condition, surgery is likely to be suggested. This is to make sure that it’s not testicular torsion. If surgery does become necessary to treat a twisted testicular appendage, there’s usually no need to explore the other side as is typically done for testicular torsion. However, some experts might suggest examining and potentially removing the testicular appendages on the other side during the surgery. They suggest this because there’s a small chance of about 4.2%, of the testicular appendage on the other side twisting in the future.
What else can Appendix Testis Torsion be?
When a patient has a sudden pain in their testicles, the cause could be due to a range of issues, including lack of blood supply to the testicles (testicular torsion or torsion of a testicular appendage), infections (acute epididymo-orchitis), or injuries related to trauma (like bruising or rupture of the testis). However, if a patient experiences an abrupt pain in the testicles, it should be handled as a surgical emergency until testicular torsion is ruled out. This is because not addressing it urgently can potentially lead to the loss of a testicle. Quick treatment is vital to save the testicle and it’s usually possible if surgery to untangle the testicle is performed within 6 hours after the pain starts.
Testicular torsion typically comes with sudden and severe pain. During the physical examination, the doctor might find that a specific reflex (cremasteric reflex) is absent in the affected side and that the other testicle is lying in an unusual position. However, these signs may not always be present or reliable.
Doctors can use a special type of ultrasound (Doppler ultrasound) to see if there’s blood flow to the affected testicle. Additionally, if the symptoms began during sleep, this could point more towards testicular torsion. The testicle usually stands higher in the scrotum in cases of testicular torsion.
Epididymo-orchitis, which is similar to testicular torsion, shows increased blood flow to the affected part of the testicle in the ultrasound. It’s also typically associated with symptoms linked to urination like discomfort, needing to pee frequently, and urgency. A history of urinary tract infections can also be indicative. Fever, nausea, or vomiting may be present, but it’s less common.
In uncertain cases where testicular torsion or other severe conditions are suspected, it’s crucial to quickly operatively explore the scrotum rather than delaying treatment. Prompt surgical intervention is necessary to prevent any loss to the testicle and reduce any additional negative outcomes.
What to expect with Appendix Testis Torsion
The outlook is usually good for cases of twisted testicular appendages. These appendages are seen as remnants leftover from evolution and they don’t seem to have a specific function. The pain and swelling that come with this condition naturally lessen over time. Typically, this problem gets better on its own within a week, without needing surgery.
Possible Complications When Diagnosed with Appendix Testis Torsion
The main problem with a twisted testicular appendage is that it can be misdiagnosed, which could lead to losing a testicle if a twisted testicle is missed. To prevent these kinds of mistakes, ultrasound scanning is the suggested method for diagnosing all sudden cases of scrotal emergencies.
Preventing Appendix Testis Torsion
If a person is diagnosed with torsion or twisting of their appendix testis, it’s vital that they follow all the doctor’s treatment guidance. This usually includes staying in bed, raising the testicles, applying ice to the area, and taking specific medications such as pain relievers and anti-inflammatory drugs.
Additionally, it’s important for these individuals to keep a close eye on their symptoms. If they notice their symptoms getting worse or if there’s no improvement within a week, they should contact a healthcare professional for a check-up.
