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Conservative management of intrascrotal appendiceal torsion
CONSERVATIVE
MANAGEMENT
INTRASCROTAL
APPENDICEAL
STEPHEN
OF TORSION
A. KOFF, M.D.*
PAUL DE RIDDER,
M.D.
From the Section of Urology, Department of Surgery, University Hospital, Ann Arbor, Michigan
ABSTRACT -A case is presented of torsion of an intrascrotal appendage which was managed conservatively and may assist in defining the indications jbr operation in this disorder.
The appendages of the testicle and epididymis are vestigial remnants of paramesonephric and mesonephric origin. 1 The most significant pathologic condition affecting these organs is torsion, which is the second most common cause of acute scrotal swelling in children.2 Although appendiceal torsion may at times closely simulate torsion of the spermatic cord, it may be easily diagnosed as a separate entity if seen early in its course. Yet, even when the diagnosis is firmly established, most authors continue to recommend early surgical intervention Except for causing diagnostic confusion and transient morbidity, however, torsion of an appendage has not been shown to be harmful.
skin overlying this nodule (Fig. 1A). The patient was afebrile, the white blood count normal, and the urinalysis acellular and uninfected. A presumptive diagnosis of torsion of an intrascrotal appendage was made, and the patient was treated with mild analgesics and bed rest. Normal activity was resumed on the fourth day, at which time a hydrocele was present (Fig. 1B). The hydrocele was associated with scrotal erythema and mild tenderness, and the intrascrotal contents were obscured. At three weeks follow-up evaluation, the hydrocele was absent; the hemiscrotum was entirely normal except for a residual nontender nodule on the right globus major (Fig. 1C). Comment
Case Report A ten-year-old white male complained of sharp right hemiscrotal pain of ten hours’ duration. No constitutional symptoms, history of dysfunction previous pain, or genitourinary were noted. Physical examination revealed a normal scrotum without edema or erythema. The right testicle was normal. A pea-shaped, 0.5 cm., exquisitely tender nodule was noted arising from the globus major of the right epididymis. A typical “blue dot” could be seen through the scrotal *Present Liverpool,
482
address: England.
Alder
Hey
Children’s
Hospital,
An aggressive surgical approach to the management of acute scrotal swellings is predicated on the difficulties in the differential diagnosis of torsion of the spermatic cord.3 At times the torsion of intrascrotal appendages may present diagnostic confusion which can only be resolved by surgical intervention. Often, however, this entity may be identified before scrotal swelling and edema mask pathognomonic physical signs. Under these circumstances, immediate exploration offers no diagnostic advantages and only trades operative risk and postoperative discomfort for the pain of natural resolution. Although the clinical entity of appendiceal torsion is well described, the natural history of
UROLOGY
/ NOVEMBER
1976 / VOLUME
VIII,
NUMBER 5
FIGURE 1. Acute appendiceal torsion. (A) “Blue dot” sign; (B) development complete resolution, three weeks.
the nonoperated condition has received little attention; and most authors recommend immediate exploration regardless of the certainty of the diagnosis or the degree of discomfort.2,4-6 When seen early, however, appendiceal torsion may present an entirely distinct clinical picture. The constellation of sudden scrotal pain associated with a point tender, pea-sized mass located near but distinct from the upper pole of the testis in an otherwise healthy peripubertal male should immediately suggest the diagnosis. When accompanied by a pathognomonic bluish discoloration seen through the scrotal skin, little doubt exists that this is appendiceal torsion.7 Our patient presented an easily and unquestionably diagnosed intrascrotal appendiceal torsion. As such, no imperative need for exploration existed. When an acute hydrocele developed, had that been his initial presentation, fear of torsion of the spermatic cord rather than any particular symptom would have prompted operation. Knowing the etiology of the reactive hydrocele and observing it resolve was reassuring. It is our contention that conservative therapy may be a tenable alternative in the management of torsion of the testicular appendages, provided that the diagnosis can be made with certainty. In this situation, operation is performed only for symptoms and may not be necessary at all. Ob-
UROLOGY /
NOVEMBER 1976 /
of acute hydrocele;
and (C)
viously when pain is severe or constitutional symptoms are present, operative intervention is necessary. Similarly, when scrotal edema and hydrocele formation occur and present as initial features of the disorder, immediate exploration is necessary. A reactive self-limited hydrocele, however, may be a natural accompaniment to the inflammatory process and alone should not require exploration. Excepting the rare cases of bilateral and recurrent appendiceal torsion, we are aware of no long-term morbidity associated with a nonoperative approach. Ann Arbor, Michigan 48104 (DR. DE RIDDER) References 1. JONES, P.: Torsion of the testis and its appendages during childhood, Arch. Dis. Child. 37: 214 (1962). 2. KAPLAN, G. W., and KING, L. R.: Acute scrotal swelling in children, J. Urol. 104: 219 (1970). 3. LITVAK, A., MELNICK, I., and LEBERMAN, P.: Torsion of the hydatid of morgagni, J. Urol. 91: 574 (1964). 4. FITZPATRICK, R. J.: Torsion of the appendix testis, ibid. 79: 521 (1958). 5. OECONOMOPOULES,C., and CHAMBERLAIN,J.: Torsion of the appendix testis with observations as to its etiology, Pediatrics 26: 611 (1960). 6. RANDALL,A.: Torsion of the appendix testis, J. Urol. 41: 715 (1939). 7. DRESNER, M. L.: Torsed appendage, Urology 1: 63 (1973).
VOLUME VIII. NUMBER 5
483
MANAGEMENT
INTRASCROTAL
APPENDICEAL
STEPHEN
OF TORSION
A. KOFF, M.D.*
PAUL DE RIDDER,
M.D.
From the Section of Urology, Department of Surgery, University Hospital, Ann Arbor, Michigan
ABSTRACT -A case is presented of torsion of an intrascrotal appendage which was managed conservatively and may assist in defining the indications jbr operation in this disorder.
The appendages of the testicle and epididymis are vestigial remnants of paramesonephric and mesonephric origin. 1 The most significant pathologic condition affecting these organs is torsion, which is the second most common cause of acute scrotal swelling in children.2 Although appendiceal torsion may at times closely simulate torsion of the spermatic cord, it may be easily diagnosed as a separate entity if seen early in its course. Yet, even when the diagnosis is firmly established, most authors continue to recommend early surgical intervention Except for causing diagnostic confusion and transient morbidity, however, torsion of an appendage has not been shown to be harmful.
skin overlying this nodule (Fig. 1A). The patient was afebrile, the white blood count normal, and the urinalysis acellular and uninfected. A presumptive diagnosis of torsion of an intrascrotal appendage was made, and the patient was treated with mild analgesics and bed rest. Normal activity was resumed on the fourth day, at which time a hydrocele was present (Fig. 1B). The hydrocele was associated with scrotal erythema and mild tenderness, and the intrascrotal contents were obscured. At three weeks follow-up evaluation, the hydrocele was absent; the hemiscrotum was entirely normal except for a residual nontender nodule on the right globus major (Fig. 1C). Comment
Case Report A ten-year-old white male complained of sharp right hemiscrotal pain of ten hours’ duration. No constitutional symptoms, history of dysfunction previous pain, or genitourinary were noted. Physical examination revealed a normal scrotum without edema or erythema. The right testicle was normal. A pea-shaped, 0.5 cm., exquisitely tender nodule was noted arising from the globus major of the right epididymis. A typical “blue dot” could be seen through the scrotal *Present Liverpool,
482
address: England.
Alder
Hey
Children’s
Hospital,
An aggressive surgical approach to the management of acute scrotal swellings is predicated on the difficulties in the differential diagnosis of torsion of the spermatic cord.3 At times the torsion of intrascrotal appendages may present diagnostic confusion which can only be resolved by surgical intervention. Often, however, this entity may be identified before scrotal swelling and edema mask pathognomonic physical signs. Under these circumstances, immediate exploration offers no diagnostic advantages and only trades operative risk and postoperative discomfort for the pain of natural resolution. Although the clinical entity of appendiceal torsion is well described, the natural history of
UROLOGY
/ NOVEMBER
1976 / VOLUME
VIII,
NUMBER 5
FIGURE 1. Acute appendiceal torsion. (A) “Blue dot” sign; (B) development complete resolution, three weeks.
the nonoperated condition has received little attention; and most authors recommend immediate exploration regardless of the certainty of the diagnosis or the degree of discomfort.2,4-6 When seen early, however, appendiceal torsion may present an entirely distinct clinical picture. The constellation of sudden scrotal pain associated with a point tender, pea-sized mass located near but distinct from the upper pole of the testis in an otherwise healthy peripubertal male should immediately suggest the diagnosis. When accompanied by a pathognomonic bluish discoloration seen through the scrotal skin, little doubt exists that this is appendiceal torsion.7 Our patient presented an easily and unquestionably diagnosed intrascrotal appendiceal torsion. As such, no imperative need for exploration existed. When an acute hydrocele developed, had that been his initial presentation, fear of torsion of the spermatic cord rather than any particular symptom would have prompted operation. Knowing the etiology of the reactive hydrocele and observing it resolve was reassuring. It is our contention that conservative therapy may be a tenable alternative in the management of torsion of the testicular appendages, provided that the diagnosis can be made with certainty. In this situation, operation is performed only for symptoms and may not be necessary at all. Ob-
UROLOGY /
NOVEMBER 1976 /
of acute hydrocele;
and (C)
viously when pain is severe or constitutional symptoms are present, operative intervention is necessary. Similarly, when scrotal edema and hydrocele formation occur and present as initial features of the disorder, immediate exploration is necessary. A reactive self-limited hydrocele, however, may be a natural accompaniment to the inflammatory process and alone should not require exploration. Excepting the rare cases of bilateral and recurrent appendiceal torsion, we are aware of no long-term morbidity associated with a nonoperative approach. Ann Arbor, Michigan 48104 (DR. DE RIDDER) References 1. JONES, P.: Torsion of the testis and its appendages during childhood, Arch. Dis. Child. 37: 214 (1962). 2. KAPLAN, G. W., and KING, L. R.: Acute scrotal swelling in children, J. Urol. 104: 219 (1970). 3. LITVAK, A., MELNICK, I., and LEBERMAN, P.: Torsion of the hydatid of morgagni, J. Urol. 91: 574 (1964). 4. FITZPATRICK, R. J.: Torsion of the appendix testis, ibid. 79: 521 (1958). 5. OECONOMOPOULES,C., and CHAMBERLAIN,J.: Torsion of the appendix testis with observations as to its etiology, Pediatrics 26: 611 (1960). 6. RANDALL,A.: Torsion of the appendix testis, J. Urol. 41: 715 (1939). 7. DRESNER, M. L.: Torsed appendage, Urology 1: 63 (1973).
VOLUME VIII. NUMBER 5
483