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Torsion of the Hydatid of Morgagni
THE JOURNAL OF UROLOGY
Vol. 91, No. 5 May 1964 Copyright © 1964 by The Williams & Wilkins Co. Printed in U.S.A.
TORSION OF THE HYDATID OF MORGAGNI AUSTINS. LITVAK, IRVING MELNICK
AND
PAUL R. LEBERMAN
From the Division of Urology, Department of Surgery, Division "A", University of Pennsylvania, Philadelphia General Hospital, Philadelphia, Pennsylvania
iMorgagni, 1 in 1761, gave his description of the testicular appendages. Although Morgagni did not illustrate his findings in 10 cases, Jones2 has recently diagrammatically reconstructed the original descriptions and has compared this reconstruction with his observations of 100 testes. All but one of Morgagni's types were present in Jones's series. The most common was a single appendage attached to the groove between the epididymis and the upper pole of the testis which occurred in 36 per cent of his specimens. There has been some confusion as to nomen clature. It is proposed that the clinical picture be called tmsion of the hydatid of Morgagni, regardless of location of the appendage; and that the terms appendix testis and appendix epididymis should be used in anatomical descriptions. The appendix testis is thought by most embryologists to originate as a persistent part of the miillerian duct and the appendix epididymis from the blind end of the mesonephric, or wolffian duct. Since Morgagni's description of these appendages, little had been ascribed to them until 1922, when Colt first described torsion of the hydatid of Morgagni. 3 Shattock,4 also in 1922, reported a case of bilateral simultaneous torsion. Mouchet 5 published a series of articles which outlined the clinical picture. Dix 6 in 1931, and RandalF in 1939 made reports on the subject. In 1962, Jones reviewed the problem. Accepted for publication November 22, 1963. 1 Morgagni, G. B.: Quoted by Jones. 2 2 Jones, P.: Torsion of the testis and its appendages during childhood. Arch. Dis. Childh., 37: 214, 1962.
3 Colt, G. H.: Torsion of the hydatid of Morgagni. Brit. J. Surg., 9: 464, 1922. 4 Shattock, C. E.: A case of torsion of the hydatid of Morgagni. Lancet, 1: 693, 1922. 5 Mouchet, A.: Sur une variete d'orchite aigiie de l'enfance due a une torsion l'hydatide de Morgagni. Presse med., 31: 485, 1923. 6 Dix, V. W.: On torsion of the appendages of the testis and epididymis. Brit. J. Urol., 3: 245,
1931.
7 Randall, A.: Torsion of the appendix testis (hydatid of Morgagni). J. Urol., 41: 715, 1939.
It is our purpose to review the clinical picture, the diagnosis and treatment of 7 cases seen in our institution in the last 5 years and to bring the collective reports up-to-date (table 1). TABLE
Torsion Torsion Torsion Torsion
of of of of
1. Total cases reported
appendix testis .. appendix epididymis. paradidymis ... vas aberrans.
Total.
153 6
l 3
163
In 6 patients, ranging in age from 10 to 42 years, a diagnosis of torsion of the hydatid of Morgagni was made on 7 occasions (table 2). In all but one case, torsion of the appendix testis was found. One patient had an epididymal appendage. Torsion occurred on separate occasions, on differing sides in one patient and spontaneous reduction, then retorsion in another patient. The typical clinical picture in the younger age group in our series may be summarized as 1) insidious onset of pain, at first severe enough to preclude activity; 2) no nausea or vomiting, 3) after 1 to 2 days a small hydrocele develops, which does not become painful or tense enough to hinder examination until 48 to 64 hours after the onset of pain and 4) tenderness and discomfort gradually increase, but temperature remains normal. In 2 of 3 adults in our group, the initial com.plaint was pain in the lower abdominal area, the origin of which was not apparent until the mass was noted. DIFFERENTIAL DIAGNOSIS
The most serious condition which can be confused with torsion of the hydatid of Morgagni is torsion of the testis. The differentiation must usually be made by prompt exploration. Epididymo-orchitis can cause a picture similar to that of torsion of the hydatid of Morgagni which has 574
575
TORSION OF HYDATID OF MORGAGNI
TABLE 2 Patient
Age
Onset
Onset to Operation
Findings
Physical Exam.
Race
J. G. No. 278675
12
Slow
5 days
Hemorrhagic epididymal appendage
N
Right testis 3 times enlarged, mass in superior pole of testis, cord thick
R.F. No. 385851
28
Slow
7 days
Appendix testis hemorrhagic
w
Right testis 2 times enlarged
E.H. No. 378246
10
Sudden
1 day
Epididymal appendage hemorrhagic
N
Left testis very tender
Slow
14 days
No surgery
w
Left epididymal mass, irregular
No surgery
w
Small mass, upper pole right testis, 7 days after onset
Right appendix epididymis Left appendix testis
N
Small mass, upper pole
---
A.R.
30
No. 327702 G.T. No. 276235
No surgery 42
Sudden
7 days
No surgery
------ ---- ---J. J. 11 Gradual 7 days No. 400162 2 days
been allowed to persist. Occasionally the diagnosis of epididymo-orchitis can be made on the basis of infected urine and prostatitis. Torsion of the hydatid of Morgagni can masquerade as ureteral calculus, as was noted in one of our patients, and also as vague suprapubic discomfort.
TREATMENT
The treatment is most often predicated on the differential diagnosis of torsion of the testis. Immediate and prompt exploration is demanded and if torsion of the hydatid of Morgagni is found, ligation and excision should be carried out. It is noteworthy that in one of our cases and in one of Jones's cases,2 torsion of the opposite side occurred on a separate occasion. Therefore, bilateral excision is advocated.
Small mass, upper pole
SUMMARY
A historical and anatomical description of the hydatid of Morgagni and the embryology have been briefly described. A survey of the literature on the subject was made and the clinical description of the disease was described. Seven cases have been added to the literature (table 2). It is felt that torsion of the hydatid of Morgagni is much more common than is usually believed and prompt excision of the affected and unaffected hydatid is the treatment of choice. REFERENCES HowsER, J. W. AND RrvER, L. P.: Torsion and gangrene of the hydatid of Morgagni; review of the literature and case report. Amer. J. Surg., 59: 571, 1943. 0ECONOMOPOULOS, 0. T. AND 0HAMBERLAlN, J. W.: Torsion of the appendix testis with observations on its etiology, an analysis of 26 cases. Pediatrics, 26: 611, 1960. SEIDEL, R. F. AND YEAW, R. C.: Torsion of the appendix testis and appendix epididymis, a report of eight cases. J. Urol., 63: 714, 1950.
Vol. 91, No. 5 May 1964 Copyright © 1964 by The Williams & Wilkins Co. Printed in U.S.A.
TORSION OF THE HYDATID OF MORGAGNI AUSTINS. LITVAK, IRVING MELNICK
AND
PAUL R. LEBERMAN
From the Division of Urology, Department of Surgery, Division "A", University of Pennsylvania, Philadelphia General Hospital, Philadelphia, Pennsylvania
iMorgagni, 1 in 1761, gave his description of the testicular appendages. Although Morgagni did not illustrate his findings in 10 cases, Jones2 has recently diagrammatically reconstructed the original descriptions and has compared this reconstruction with his observations of 100 testes. All but one of Morgagni's types were present in Jones's series. The most common was a single appendage attached to the groove between the epididymis and the upper pole of the testis which occurred in 36 per cent of his specimens. There has been some confusion as to nomen clature. It is proposed that the clinical picture be called tmsion of the hydatid of Morgagni, regardless of location of the appendage; and that the terms appendix testis and appendix epididymis should be used in anatomical descriptions. The appendix testis is thought by most embryologists to originate as a persistent part of the miillerian duct and the appendix epididymis from the blind end of the mesonephric, or wolffian duct. Since Morgagni's description of these appendages, little had been ascribed to them until 1922, when Colt first described torsion of the hydatid of Morgagni. 3 Shattock,4 also in 1922, reported a case of bilateral simultaneous torsion. Mouchet 5 published a series of articles which outlined the clinical picture. Dix 6 in 1931, and RandalF in 1939 made reports on the subject. In 1962, Jones reviewed the problem. Accepted for publication November 22, 1963. 1 Morgagni, G. B.: Quoted by Jones. 2 2 Jones, P.: Torsion of the testis and its appendages during childhood. Arch. Dis. Childh., 37: 214, 1962.
3 Colt, G. H.: Torsion of the hydatid of Morgagni. Brit. J. Surg., 9: 464, 1922. 4 Shattock, C. E.: A case of torsion of the hydatid of Morgagni. Lancet, 1: 693, 1922. 5 Mouchet, A.: Sur une variete d'orchite aigiie de l'enfance due a une torsion l'hydatide de Morgagni. Presse med., 31: 485, 1923. 6 Dix, V. W.: On torsion of the appendages of the testis and epididymis. Brit. J. Urol., 3: 245,
1931.
7 Randall, A.: Torsion of the appendix testis (hydatid of Morgagni). J. Urol., 41: 715, 1939.
It is our purpose to review the clinical picture, the diagnosis and treatment of 7 cases seen in our institution in the last 5 years and to bring the collective reports up-to-date (table 1). TABLE
Torsion Torsion Torsion Torsion
of of of of
1. Total cases reported
appendix testis .. appendix epididymis. paradidymis ... vas aberrans.
Total.
153 6
l 3
163
In 6 patients, ranging in age from 10 to 42 years, a diagnosis of torsion of the hydatid of Morgagni was made on 7 occasions (table 2). In all but one case, torsion of the appendix testis was found. One patient had an epididymal appendage. Torsion occurred on separate occasions, on differing sides in one patient and spontaneous reduction, then retorsion in another patient. The typical clinical picture in the younger age group in our series may be summarized as 1) insidious onset of pain, at first severe enough to preclude activity; 2) no nausea or vomiting, 3) after 1 to 2 days a small hydrocele develops, which does not become painful or tense enough to hinder examination until 48 to 64 hours after the onset of pain and 4) tenderness and discomfort gradually increase, but temperature remains normal. In 2 of 3 adults in our group, the initial com.plaint was pain in the lower abdominal area, the origin of which was not apparent until the mass was noted. DIFFERENTIAL DIAGNOSIS
The most serious condition which can be confused with torsion of the hydatid of Morgagni is torsion of the testis. The differentiation must usually be made by prompt exploration. Epididymo-orchitis can cause a picture similar to that of torsion of the hydatid of Morgagni which has 574
575
TORSION OF HYDATID OF MORGAGNI
TABLE 2 Patient
Age
Onset
Onset to Operation
Findings
Physical Exam.
Race
J. G. No. 278675
12
Slow
5 days
Hemorrhagic epididymal appendage
N
Right testis 3 times enlarged, mass in superior pole of testis, cord thick
R.F. No. 385851
28
Slow
7 days
Appendix testis hemorrhagic
w
Right testis 2 times enlarged
E.H. No. 378246
10
Sudden
1 day
Epididymal appendage hemorrhagic
N
Left testis very tender
Slow
14 days
No surgery
w
Left epididymal mass, irregular
No surgery
w
Small mass, upper pole right testis, 7 days after onset
Right appendix epididymis Left appendix testis
N
Small mass, upper pole
---
A.R.
30
No. 327702 G.T. No. 276235
No surgery 42
Sudden
7 days
No surgery
------ ---- ---J. J. 11 Gradual 7 days No. 400162 2 days
been allowed to persist. Occasionally the diagnosis of epididymo-orchitis can be made on the basis of infected urine and prostatitis. Torsion of the hydatid of Morgagni can masquerade as ureteral calculus, as was noted in one of our patients, and also as vague suprapubic discomfort.
TREATMENT
The treatment is most often predicated on the differential diagnosis of torsion of the testis. Immediate and prompt exploration is demanded and if torsion of the hydatid of Morgagni is found, ligation and excision should be carried out. It is noteworthy that in one of our cases and in one of Jones's cases,2 torsion of the opposite side occurred on a separate occasion. Therefore, bilateral excision is advocated.
Small mass, upper pole
SUMMARY
A historical and anatomical description of the hydatid of Morgagni and the embryology have been briefly described. A survey of the literature on the subject was made and the clinical description of the disease was described. Seven cases have been added to the literature (table 2). It is felt that torsion of the hydatid of Morgagni is much more common than is usually believed and prompt excision of the affected and unaffected hydatid is the treatment of choice. REFERENCES HowsER, J. W. AND RrvER, L. P.: Torsion and gangrene of the hydatid of Morgagni; review of the literature and case report. Amer. J. Surg., 59: 571, 1943. 0ECONOMOPOULOS, 0. T. AND 0HAMBERLAlN, J. W.: Torsion of the appendix testis with observations on its etiology, an analysis of 26 cases. Pediatrics, 26: 611, 1960. SEIDEL, R. F. AND YEAW, R. C.: Torsion of the appendix testis and appendix epididymis, a report of eight cases. J. Urol., 63: 714, 1950.