Diagnosis and Management of Torsed Epididymal Appendage
In an adolescent male with sudden left scrotal pain, a blue-dot sign, and normal testicular Doppler flow, the diagnosis is torsion of the epididymal appendage, which should be managed conservatively with scrotal support, analgesia, and close outpatient follow-up within 24–48 hours. 1
Immediate Diagnostic Priorities
The first and most critical step is to exclude testicular torsion, which remains a surgical emergency requiring intervention within 6–8 hours to prevent testicular loss. 1, 2 Any acute scrotal pain must be treated as a potential surgical emergency until torsion is definitively ruled out. 1
Key Clinical Features Distinguishing Appendage Torsion from Testicular Torsion
Blue-dot sign: This pathognomonic finding—a visible blue discoloration through the scrotal skin at the upper pole of the testis—is present in only 21% of appendage torsion cases but, when present, strongly supports the diagnosis. 1
Normal testicular perfusion on Doppler: The hallmark of appendage torsion is preserved or normal testicular blood flow, with possible localized hyperemia near the appendage itself. 1 This contrasts sharply with testicular torsion, which shows decreased or absent intratesticular flow. 1
Pain characteristics: While both conditions can present with sudden onset, appendage torsion typically produces less severe pain than testicular torsion and lacks the high-riding testicle or absent cremasteric reflex seen in cord torsion. 1, 2
Diagnostic Imaging Protocol
Urgent duplex Doppler ultrasound is the first-line imaging study when clinical suspicion for torsion exists. 1, 2 The examination should include:
Grayscale assessment: Look for a small hyperechoic or hypoechoic nodule at the upper pole of the testis or head of the epididymis, representing the torsed appendage. 1
Color/Power Doppler: Confirm normal or increased testicular perfusion bilaterally, with possible focal hyperemia adjacent to the appendage. 1 Power Doppler is particularly useful in prepubertal boys who normally have reduced intratesticular blood flow. 1
Comparative assessment: Use the contralateral testicle as an internal control for flow evaluation. 1
Critical Diagnostic Pitfall
A normal ultrasound does not exclude testicular torsion. 2 False-negative Doppler results occur in approximately 30% of cases, particularly with partial torsion, spontaneous detorsion, or very early presentation. 1 When clinical suspicion for testicular torsion remains high despite normal imaging, proceed directly to surgical exploration without delay. 1, 2
Age-Stratified Epidemiology
Torsion of testicular or epididymal appendages is the most common cause of acute scrotal pain in prepubertal boys. 1, 3
In adolescents, the differential shifts toward testicular torsion and epididymitis, though appendage torsion remains possible. 1, 4
The condition occurs primarily in boys aged 7–14 years, with a slight left-sided predominance. 3
Conservative Management Algorithm
Once testicular torsion is definitively excluded and appendage torsion is confirmed:
Scrotal support and elevation: Provide supportive underwear or athletic supporter to reduce movement and discomfort. 5
Analgesia: NSAIDs (ibuprofen) are first-line for pain control and anti-inflammatory effect. 5
Activity restriction: Avoid strenuous activity and contact sports until symptoms resolve. 5
Natural history: The condition is self-limiting and typically resolves within 3–10 days. 5
Mandatory follow-up: Schedule a return visit within 24–48 hours to confirm clinical improvement and ensure no progression. 5
Indications for Surgical Exploration
While most cases resolve conservatively, surgical exploration may be warranted if:
Clinical suspicion for testicular torsion cannot be definitively excluded despite imaging. 1, 2
Symptoms worsen or fail to improve within 48–72 hours. 5
Diagnostic uncertainty persists, as preoperative diagnosis of appendage torsion is correct in only 11% of cases compared to 90% for testicular torsion. 3
Common Clinical Pitfalls to Avoid
Never delay surgical consultation when testicular torsion cannot be excluded. The 6–8 hour window for testicular salvage is absolute, and imaging should never delay exploration when clinical suspicion is high. 1, 2
Do not rely solely on the blue-dot sign, as it is present in only 21% of cases. 1 Its absence does not rule out appendage torsion.
Recognize that appendage torsion is the most commonly misdiagnosed scrotal lesion, with correct preoperative diagnosis in only 11% of cases. 3 Maintain a high index of suspicion for testicular torsion until definitively excluded.
Intermittent torsion/detorsion can produce confusing clinical pictures with wave-like pain patterns and normal Doppler findings. 1, 6 When doubt exists, surgical exploration is safer than observation.
Patient and Family Counseling
Explain that the condition involves twisting of a small developmental remnant (the appendix epididymis), not the testicle itself. 7
Emphasize the importance of immediate return if pain worsens, as this could indicate evolving testicular torsion. 5
Reassure that with appropriate conservative management, complete resolution is expected within 3–10 days without long-term sequelae. 5