Acute scrotal pain will always grab both patient’s and providers’ attention, appropriately.  We have already discussed the most feared cause of acute scrotal pain – Testicular Torsion. While there are many other causes of inguinal and scrotal pain (ex, varicocele, inguinal hernia), one of the common causes is Torsion of the Appendix Testis.

Appendix Testis: What is that?

• There are actually 4 identified testicular appendages, but appendix epididymis and  appendix testis or the most commonly encountered.
• Appendix testis is located in the groove between testis and the epididymal head at the upper pole of the testis.
• The appendix testis is pedunculate and susceptible to torsion.
• Torsion of the appendix testis is a common cause of acute scrotal pain in children. [Boettcher, 2013; Sakellaris, 2008]

Appendix Testis: Don’t Get it Twisted

• Etiology of torsion is unknown.
• Usually occurs in boys 7-14 years of age.
• More common than epididymitis in children.
• Torsion of the appendix testis can lead to necrosis of it.
  • The necrotic tissue will lead to local inflammation and, thus, mimic epididymitis.  [Boettcher, 2013]
  • Inflammatory cells infiltrate the twisted appendix testis and are a marker of progression of the disease, not infection. [Rakha, 2006]

Diagnosis

• Clinical History and Exam are helpful, but not conclusive
  • “Classic” signs:
    • Localized tenderness at the superior pole
    • Blue Dot sign
    • Preserved cremasteric reflex
  • Findings that favor Epididymitis: [Boettcher, 2013]
    • Dysuria
    • Painful epididymis

• Ultrasound can be helpful in making the diagnosis. [Lev, 2014; Yang, 2005]
  • Findings consistent with torsion of appendix testis:
    • Size of 5 mm or greater
      • May see hyperechogenic mass between epididymal head and upper pole of the testis.
      • Often associated with enlarged epididymis and hydrocele.
    • Spherical shape
    • Increased periappendiceal blood flow
  • Findings more consistent with epididymitis:  [Boettcher, 2013]
    • Altered epididymal echogenicity
    • Increased peritesticular perfusion on the affected side
  • Often used as means to evaluate for testicular torsion.
    • Ultrasound is not perfect in ruling-out testicular torsion.
    • Recall that normal blood flow does not completely exclude the possibility of testicular torsion. [Sakellaris, 2008]

Treatment

• NSAIDs
• Restricted activity (“Sorry, no soccer or football this weekend boy.”)
• Cool Sitz baths
• Antibiotics are not required.
  • Obviously, this seems intuitive, but often the U/S may indicate findings consistent with epididymitis/orchitis so you may be inclined to give abx.
  • Antibiotics for epididymitis can be reserved for boys with: [Boettcher, 2013; Halachmi, 2005]
    • Recurrent infection history
    • Underlying urinary tract abnormality
    • Signs of puberty
• Very rarely will surgical excision be required for pain control.

References