Torsions of the testicular appendix and epididymis

The appendix of the testis is rudimentary structure of the Müllerian duct, about 3 mm in size, while the appendix of the epididymis is the rudiment of the Wolffian duct. Both are stalked and pendulous, which predisposes them to torsion. Torsion of the appendix in boys has a peak incidence between the ages of seven and twelve and is the most common cause of acute scrotal syndrome in children. It can be and is often accompanied by reactive testicular hydrocele.

Clinical picture
The pain comes on suddenly - as with testicular torsion, but tends to be milder and localized. The testicle itself is usually not sensitive to the touch. In the absence of major edema, a sensitive mass on the upper or lower pole of the testicle can be palpated with a thorough examination. If we stretch the skin of the scrotum between our fingers and move the testicle under it, we can see a migrating bluish point, the so-called blue-dot sign.

A cremaster reflex is often present and a reactive hydrocele can often be palpated.

Diagnosis
The diagnosis is established according to the clinical findings. An ultrasound examination is completed only in unclear cases when we cannot rule out testicular torsion from the clinical findings. Testicular blood flow on Doppler imaging is normal or increased, an echogenic mass with central hypoechogenicity can be seen.

Treatment
Primarily surgical therapy is not recommended. In the vast majority of cases, rest for a week, local cooling and common analgesics are sufficient to treat and relieve symptoms. The condition improves in most patients. In case of failure of conservative treatment or recurrence, surgical revision is already indicated. When a torn appendix is ​​found, it is removed. For non-compliant patients (athletes, adolescents) it is advisable to consider hospitalization.

Although the pain caused by the torquing appendix is ​​resolved immediately by the operation, the pain of the healing wound of the scrotum is added, a longer period of hospitalization is required, the child is burdened by general anesthesia, is exposed to the general risks of surgery ( bleeding, infection, damage to the scrotal structures) and follow-up is necessary postoperative controls.

Related articles

 * Testicular torsion
 * Acute scrotum
 * Acute epididymitis