Torsion of the appendix testis

Prognosis

Outcomes

Perinatal Testicular Tortion

Perinatal torsion is a term used to include both prenatal and postnatal events. Most cases are extravaginal torsion in contrast to the usual intravaginal torsion, which occurs during puberty.

The difference between the two types of torsion is important but sometimes may be difficult to determine clinically.

¤ Prenatal torsion classically presents at birth as a hard, nontender mass in the hemiscrotum, usually with underlying dark discoloration of the skin and fixation of the skin to the mass. This picture is characteristic of infarction of the testis caused by previously occurring torsion.

¤ Postnatal torsion presents with more classic, acute inflammation, including erythema and tenderness. A report of a previously normal scrotum at delivery suggests an acute event. The difference is important because postnatal torsion requires emergent exploration and treatment with detorsion and fixation.

In the neonate with torsion at birth or a few days afterward, surgical recommendations are controversial. Although most authorities recommend exploration of the ipsilateral side and fixation of the contralateral testis (because of the risk of asynchronous contralateral testicular torsion in as many as 33% of cases), some have suggested that observation is acceptable because of the negligible salvage rate of the ischemic testis and the low incidence of contralateral torsion. The risk of anesthesia in children younger than 1 year may also factor into decision-making process.

Extravaginal testicular torsion that occurs in newborns cannot be treated by manual detorsion.

Postoperative care in these children is not complicated; however, a torsed testicle may atrophy with time. Long-term follow-up is imperative. Testicular salvage rates are directly proportional to duration of torsion. For torsion less than 6 hours, 85-97% can be salvaged. If the duration of torsion exceeds 24 hours, the chance of salvaging the testes is less than 10%.

Fertility: The results vary and are conflicting.

Androgen levels: Endocrine testicular function remains in the normal range in patients after testicular torsion.

Testicular cancer: There may be a 3.2-fold increased risk of developing a testis tumour 6-13 years after torsion.

(testicular appendages or hydatid of Morgagni)

Torsion of testicular appendages can result in the clinical presentation of acute scrotum. Two such appendages are the appendix testis, a vestigial embryologic remnant of the paramesonephric (müllerian) duct, and the appendix epididymis, a vestigial embryologic remnant of the mesonephric (wolffian) duct.

The müllerian system completely regresses in males, except for its cranial remnant, which persists as the appendix testis, and the extreme lower end remnant, which forms the prostatic utricle. The paradidymis is a remnant structure found at the junction of the epididymis and vas deferens. These remnants serve no known function, except to confound the differential diagnosis of an acute scrotum.

The appendix testis is present in 92% of all testes and is usually located at the superior testicular pole in the groove between the testicle and the epididymis. The appendix epididymis is present in 23% of testes and usually projects from the head of the epididymis, but its location may vary (Image 8.4).

Image 8.4 Testis and epididymal appendages. TA - testicular appendage (appendix testis); EA - epididymal appendage (appendix epididymis); Par – paradidymis – organ of Giraldes; Asterisks - superior and inferior vas aberrans of Haller; T – testis; Ep – epididymis; VD - vas deferens.  

Although it has no physiological function, it can be medically significant in that it can, rarely, undergo torsion (i.e. become twisted), causing acute one-sided testicular pain and may require surgical excision to achieve relief.