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Torsion of Testicular Appendages in Men
0022-5347 /80/1241-0056$02.00/0 Vol. 124, July Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1980 by The Williams & Wilkins Co.
TORSION OF TESTICULAR APPENDAGES IN MEN LAWRENCE F. ALT AFFER, III
AND
SAMUEL M. STEELE, JR.
From the Department of Urology, Naval Regional Medical Center, Portsmouth, Virginia
ABSTRACT
Torsion of testicular appendages has never been reported in patients more than 18 years old. We herein review 6 surgically proved cases. The possibility of this condition should be considered in the differential diagnosis of scrotal pain and swelling in men. Torsion of a testicular appendage was first described by Colt in 1922. 1 Since then >300 cases have been reported but one must assume that the frequency of clinical occurrence is much greater than the number of reported cases. There are 4 testicular appendages: 1) the appendix testis or hydatid of Morgagni is found in >90 per cent of men and is a remnant of the miillerian duct, 2) the appendix epididymis (also called the hydatid of Morgagni) is a mesonephric remnant attached to the globus major, 3) the paradidymis or organ of Giraldes' is attached to the lower spermatic cord and is a mesonephric remnant and 4) the vas aberrans or organ of Haller originates at the junction of the body and tail of the epididymis and also is a mesonephric remnant. Torsion of any of these appendages may occur but the appendix testis and appendix epididymis account for the great majority of cases, with torsion of the appendix testis being by far the most common.
MATERIALS AND METHODS
Between January 1, 1959 and December 31, 1978, 6 surgically documented cases of torsion of the testicular appendages in men > 18 years old were seen at our hospital. The records of these 6 patients have been reviewed critically. Several other patients with torsion of the testicular appendages were treated during this period but they are not included in our series because they were not documented surgically. RESULTS
The 6 patients ranged in age from 20 to 38 years old, with only 1 case in a man >30 years old (see table). All patients were white and 5 of the 6 cases involved the right side. Torsion of the appendix testis was noted in 5 of the 6 cases and torsion of the appendix epididymis was noted in 1.
Clinical findings Pt.-Age-Race No. (yrs.) 781716-38-W 470379-20-W 397577-24-W
040990-22-W 741483-29-W 35107-20-W
Side
Appendage
Pain
Hydrocele
Previous Episode
Preop. Diagnosis
Rt.
Testis Epididymis Testis
Pos. Pos. Pos.
Pos. Neg. Pos.
Pos. Neg. Neg.
Epididymitis Epididymitis Torsion of appendix testis
Testis Testis Testis
Pos. Pos. Pos.
Neg. Pos. Neg.
Neg. Neg. Neg.
Orchitis Fibroma Testicular tor-
Rt.
Lt. Rt.
Rt. Rt.
sion
All patients presented with pain and 3 of the 6 patients also had a secondary hydrocele. Only once was a previous similar episode recorded. In only 1 case was the preoperative diagnosis correct. The condition was diagnosed erroneously as epididymitis in 2 cases, and once each as testicular torsion, orchitis and a fibroma.
Patients with torsion of a testicular appendage usually present with mild to severe pain of sudden onset. The pain may be localized to the area of the twisted appendage and physical examination may reveal point tenderness in this area. Frequently, these patients also will present with a secondary hydrocele that may obscure the localized findings. If localization of pain is possible a dark body in the area of the appendage may be seen, which often is referred to as the blue dot sign, and helps greatly to confirm the diagnosis. 2 An extensive review of the literature by Skoglund and associates in 1970 included 321 reported cases of torsion of testicular appendages, to which they added 43 new cases. 3 In these 364 cases the age distribution ranged from 1 to 18 years, with the greatest incidence occurring in patients between 10 and 13 years old. These authors concluded that torsion of testicular appendages was restricted substantially to the age of puberty and found no cases in men > 18 years old. Since their study there have been no reports of torsion of testicular appendages in men > 18 years old.
DISCUSSION
We present 6 cases of surgically proved torsion of testicular appendages in men > 18 years old. These patients demonstrated the typical presentation of universal pain with a secondary hydrocele being present in 50 per cent of the cases. The appendix testis was the appendage most often involved and a previous similar episode usually was not recorded. The preoperative diagnosis was correct only once. There was a predominance for the right side in the series but this is not statistically significant in such a small series. Most assuredly, many similar patients have been treated elsewhere but to date there have been no published cases involving men > 18 years old. Therefore, one might assume that this clinical problem need not be considered once a patient has entered the third decade of life. The intent of our report is to document that torsion of testicular appendages can be a problem in adults. As has been revealed by Skoglund and associates the peak incidence occurs at the time of puberty. 3 Certainly,
Accepted for publication September 28, 1979. Statements or opinions in this article do not necessarily reflect the opinion of the United States Navy. 56
TORSION OF TESTICULAR APPENDAGES IN MEN
adult cases occur much less frequently but they do occur. Therefore, torsion of a testicular appendage should be considered in the differential diagnosis of scrotal pain and swelling in men. REFERENCES 1. Colt, G. H.: Torsion of the hydatid of Morgagni. Brit. J. Surg., 9:
57
464, 1922. 2. Rous, S. N.: Urology in Primary Care. St. Louis: The C. V. Mosby Co., chapt. 10, 1976. 3. Skoglund, R. W., McRoberts, J. W. and Ragde, H.: Torsion of testicular appendages: presentation of 43 new cases and a collective review. J. Urol., 104: 598, 1970.
THE JOURNAL OF UROLOGY
Copyright© 1980 by The Williams & Wilkins Co.
TORSION OF TESTICULAR APPENDAGES IN MEN LAWRENCE F. ALT AFFER, III
AND
SAMUEL M. STEELE, JR.
From the Department of Urology, Naval Regional Medical Center, Portsmouth, Virginia
ABSTRACT
Torsion of testicular appendages has never been reported in patients more than 18 years old. We herein review 6 surgically proved cases. The possibility of this condition should be considered in the differential diagnosis of scrotal pain and swelling in men. Torsion of a testicular appendage was first described by Colt in 1922. 1 Since then >300 cases have been reported but one must assume that the frequency of clinical occurrence is much greater than the number of reported cases. There are 4 testicular appendages: 1) the appendix testis or hydatid of Morgagni is found in >90 per cent of men and is a remnant of the miillerian duct, 2) the appendix epididymis (also called the hydatid of Morgagni) is a mesonephric remnant attached to the globus major, 3) the paradidymis or organ of Giraldes' is attached to the lower spermatic cord and is a mesonephric remnant and 4) the vas aberrans or organ of Haller originates at the junction of the body and tail of the epididymis and also is a mesonephric remnant. Torsion of any of these appendages may occur but the appendix testis and appendix epididymis account for the great majority of cases, with torsion of the appendix testis being by far the most common.
MATERIALS AND METHODS
Between January 1, 1959 and December 31, 1978, 6 surgically documented cases of torsion of the testicular appendages in men > 18 years old were seen at our hospital. The records of these 6 patients have been reviewed critically. Several other patients with torsion of the testicular appendages were treated during this period but they are not included in our series because they were not documented surgically. RESULTS
The 6 patients ranged in age from 20 to 38 years old, with only 1 case in a man >30 years old (see table). All patients were white and 5 of the 6 cases involved the right side. Torsion of the appendix testis was noted in 5 of the 6 cases and torsion of the appendix epididymis was noted in 1.
Clinical findings Pt.-Age-Race No. (yrs.) 781716-38-W 470379-20-W 397577-24-W
040990-22-W 741483-29-W 35107-20-W
Side
Appendage
Pain
Hydrocele
Previous Episode
Preop. Diagnosis
Rt.
Testis Epididymis Testis
Pos. Pos. Pos.
Pos. Neg. Pos.
Pos. Neg. Neg.
Epididymitis Epididymitis Torsion of appendix testis
Testis Testis Testis
Pos. Pos. Pos.
Neg. Pos. Neg.
Neg. Neg. Neg.
Orchitis Fibroma Testicular tor-
Rt.
Lt. Rt.
Rt. Rt.
sion
All patients presented with pain and 3 of the 6 patients also had a secondary hydrocele. Only once was a previous similar episode recorded. In only 1 case was the preoperative diagnosis correct. The condition was diagnosed erroneously as epididymitis in 2 cases, and once each as testicular torsion, orchitis and a fibroma.
Patients with torsion of a testicular appendage usually present with mild to severe pain of sudden onset. The pain may be localized to the area of the twisted appendage and physical examination may reveal point tenderness in this area. Frequently, these patients also will present with a secondary hydrocele that may obscure the localized findings. If localization of pain is possible a dark body in the area of the appendage may be seen, which often is referred to as the blue dot sign, and helps greatly to confirm the diagnosis. 2 An extensive review of the literature by Skoglund and associates in 1970 included 321 reported cases of torsion of testicular appendages, to which they added 43 new cases. 3 In these 364 cases the age distribution ranged from 1 to 18 years, with the greatest incidence occurring in patients between 10 and 13 years old. These authors concluded that torsion of testicular appendages was restricted substantially to the age of puberty and found no cases in men > 18 years old. Since their study there have been no reports of torsion of testicular appendages in men > 18 years old.
DISCUSSION
We present 6 cases of surgically proved torsion of testicular appendages in men > 18 years old. These patients demonstrated the typical presentation of universal pain with a secondary hydrocele being present in 50 per cent of the cases. The appendix testis was the appendage most often involved and a previous similar episode usually was not recorded. The preoperative diagnosis was correct only once. There was a predominance for the right side in the series but this is not statistically significant in such a small series. Most assuredly, many similar patients have been treated elsewhere but to date there have been no published cases involving men > 18 years old. Therefore, one might assume that this clinical problem need not be considered once a patient has entered the third decade of life. The intent of our report is to document that torsion of testicular appendages can be a problem in adults. As has been revealed by Skoglund and associates the peak incidence occurs at the time of puberty. 3 Certainly,
Accepted for publication September 28, 1979. Statements or opinions in this article do not necessarily reflect the opinion of the United States Navy. 56
TORSION OF TESTICULAR APPENDAGES IN MEN
adult cases occur much less frequently but they do occur. Therefore, torsion of a testicular appendage should be considered in the differential diagnosis of scrotal pain and swelling in men. REFERENCES 1. Colt, G. H.: Torsion of the hydatid of Morgagni. Brit. J. Surg., 9:
57
464, 1922. 2. Rous, S. N.: Urology in Primary Care. St. Louis: The C. V. Mosby Co., chapt. 10, 1976. 3. Skoglund, R. W., McRoberts, J. W. and Ragde, H.: Torsion of testicular appendages: presentation of 43 new cases and a collective review. J. Urol., 104: 598, 1970.