Torsion of the Testis or Appendix Testis? An Analysis of Presentation, Management and Outcome of Acute Scrotum in Children

Abstract

Objective:To elaborate clinical predictors to safely distinguish between testicular torsion (TT) and the appendix testis torsion (ATT) and emphasize a diagnostic algorithm to reduce unnecessary exploration rates. TT requires prompt assessment and surgical intervention to achieve tissue function. Torsion of the ATT is the most common differential diagnosis, which can usually be treated conservatively. Colour-Doppler ultrasonography (CDUS) remains controversial for detection of TT.Materials and Methods:Data were retrospectively collected from patients under the age of 20 years admitted to our hospital with acute scrotal pain from 2017 to 2020. The main outcome measures were the onset of symptoms, clinical criteria of absent cremasteric reflex, testicular swelling and high-riding testis, perfusion in CDUS and pathology found during scrotal exploration.Results:Seventy-one patients met the inclusion criteria. Mean age was 10.6 years. 53.2% were diagnosed with TT, 41.6% with ATT, 1.3% with epididymitis and in 3.9%, no pathology was found. Patients with TT were significantly older compared to patients with ATT (p<0.004). TT showed a more frequent onset of symptoms during night-time (p<0.006). 87.8% of TT had two of the three defined clinical criteria, compared with 18.8% of ATT (p<0.001). The limitations of this study were the retrospective design and interobserver variability.Conclusion:Our findings support the safety and importance of clinical criteria to distinguish between TT and ATT. CDUS should not supersede clinical evaluation. The decision to surgically explore should be made on clinical grounds as a standard approach for assessing acute scrotum.

Keywords

• acute scrotal pain
• acute scrotum
• testicular torsion
• torsion of the appendage testis
• scrotal elastography