What is the treatment for torsion of the appendix testis (hydatid of Morgi)

From the Guidelines

The treatment for torsion of the appendix testis (hydatid of Morgagni) typically involves conservative management with pain control and supportive care. This approach is based on the most recent evidence from the Journal of the American College of Radiology, which highlights the importance of distinguishing between different causes of acute scrotal pain, including torsion of the testicular appendage, epididymoorchitis, and testicular torsion 1. Initial treatment includes rest, scrotal elevation, ice packs to reduce swelling, and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (400-600mg every 6-8 hours) or naproxen (250-500mg twice daily) for pain and inflammation.

Unlike testicular torsion, which requires emergency surgery, appendix testis torsion is a self-limiting condition that usually resolves on its own within 1-2 weeks. The "blue dot sign", which is visualization of the infarcted appendage through the skin appearing as a blue dot, is pathognomonic for appendage torsion, but it is only seen in 21% of cases 1. Surgical intervention is rarely necessary but may be considered if there is diagnostic uncertainty, persistent severe pain despite conservative measures, or if testicular torsion cannot be ruled out. During surgery, the twisted appendix testis would be removed (appendectomy).

Key considerations in managing appendix testis torsion include:

• Prompt evaluation to rule out testicular torsion, which is a true surgical emergency that can lead to testicular loss if not treated within 4-6 hours
• Conservative management with pain control and supportive care as the primary approach
• Surgical intervention only in cases of diagnostic uncertainty, persistent severe pain, or suspected testicular torsion
• The importance of distinguishing between different causes of acute scrotal pain to ensure appropriate treatment and prevent complications 1.

From the Research

Treatment Options for Torsion of the Appendix Testis

• The treatment for torsion of the appendix testis can vary, with some cases being treated conservatively and others requiring surgical intervention 2, 3.
• Conservative treatment may involve the use of non-steroidal anti-inflammatory agents and can be successful in managing the condition, especially if diagnosed accurately using ultrasonographic and Doppler imaging 3, 4.
• Surgical treatment may be necessary in cases where a diagnosis of testicular torsion cannot be completely ruled out, or if pain recurs after conservative treatment 2.
• Early surgical treatment is recommended for patients presenting with signs of severe inflammation, such as a hard scrotum or scrotal erythema, to minimize the duration of hospitalization 2.
• The role of torsion of the appendix testis as a potential trigger factor for testicular torsion is also being explored, which could have implications for the management of acute scrotum 5.

Factors Influencing Treatment Choice

• The age of the patient, with the incidence of torsion of the appendix testis varying significantly according to age, can influence the treatment choice 2.
• The presence of a tender, mobile mass over the anterior surface of the testis, and Doppler findings of normal blood flow to the testes with increased flow to the adjacent appendix testis, can aid in diagnosis and influence treatment 3.
• Ultrasonographic findings of a pedunculated mass with a central hypoechoic area at the superior aspect of the testis can also support the diagnosis and guide treatment decisions 4.