Ultrasound of Torsion of the Appendix Testis

In this radiology lecture, we review the ultrasound appearance of torsion of the appendix testis and appendix epididymis!
Key teaching points include:
1) Appendix testis is a vestigial appendage usually located between upper pole of testis and head of epididymis.
2) AKA hydatid of Morgagni, the appendix testis is commonly present as a normal finding.
3) Appendix epididymis typically arises from epididymal head.
4) Both scrotal appendages are often pedunculated which increases risk of torsion.
5) Torsion occurs when appendage twists, occluding blood supply.
6) Torsion of the appendix testis is one of most common causes of acute scrotal pain in prepubertal children.
7) Peak age 7-12, but can occur at any age.
8) Normal appendix testis: Oval-shaped, less than 6 mm in size, homogeneously isoechoic to epididymis, and demonstrates little to no blood flow on color Doppler.
9) Torsed appendix testis: 6 mm or larger in size, variable echogenicity, hypoechoic before 24 hours, hyperechoic or heterogeneous after 24 hours.
10) In setting of appendix torsion, hyperemia of surrounding structures with hydrocele and scrotal wall thickening often present.
11) Torsed appendage can detach and become free floating in scrotum.
12) Patients may present with pain localized to upper pole of testis or epididymis.
13) Physical examination may yield the “blue dot” sign: Small, palpable nodule at superior aspect of testis with bluish discoloration of overlying skin due to ischemic appendix.
14) Cremasteric reflex typically intact, and testicle not high riding (unlike testicular torsion).
15) Hyperemia of surrounding structures can be difficult to differentiate from bacterial epididymitis.
16) However, in children, epididymitis usually secondary to inflammation from direct trauma, torsion of a scrotal appendage, or urine reflux into epididymis. Urine dipstick/urinalysis helpful to differentiate from infection.
17) Treatment: Pain management with analgesics, ice, rest. If not recognized, may be treated unnecessarily with antibiotics. Scrotal exploration may be necessary if testicular torsion cannot be excluded.
References:
Baldisserotto M, Ketzer de Souza JC, Pertence AP, Dora MD. Color Doppler sonography of normal and torsed testicular appendages in children. AJR 2005; 184:1287-1292
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[@abdullasarmadal-jamil3718]

Amazing. Thanks from Iraq, Mosul

[@Radquarters]

Thank you, and hello to Iraq!

[@RD-ic1lq]

Though its educational , but you speak too fast with monotonous voice.

[@baranitharan6381]

Thanks for the wonderful lecture sir! I encountered a case, an adult male with focal tenderness near the upper pole of testis. On ultrasound, there was a cyst (approx 3 cm) adjacent to the epididymal head with low level echoes and increased peripheral vascularity. The adjacent epididymal head was inflamed and there was a mild hydrocele as well. Could this be a case of torsion appendix testis or torsion of epididymal cyst or just an epididymitis. Thanks in advance!

[@Radquarters]

Glad you enjoyed the lecture! Torsed appendix testes and appendix epididymides are typically solid in the acute phase. Some theorize that cystic appendages may have undergone prior infarction. Also, torsed appendages are more common in the pediatric population. Epididymal cyst torsion has been described, but it's extremely rare.

[@baranitharan6381]

​@@Radquartersthank you very much for the reply sir!

[@denismingochi4047]

Very useful and helpful. Thanks

[@Radquarters]

Glad it was helpful!

[@immane75]

The best ever . Thanks.

[@Radquarters]

Thanks so much, appreciate that!

[@minetteestrada4639]

Great teaching case

[@Radquarters]

Thank you, and glad you enjoyed it!

[@prosantabarikder978]

nice boss

[@Radquarters]

Many thanks

[@rosiebarajas6741]

Very interesting! What is the urgency for a case like this??

[@Radquarters]

Patients can present with severe pain similar to testicular torsion, but the treatment is conservative once the diagnosis is made.

[@PIYUSHMISHRA-gy9uc]

Hello sir i have little pain always in my right upper testis and in ultrasound they said there are minimal fluid in right testicles so can you tell me is there any serious condition or not ?