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Pediatrics
Diagnosis
Genitourinary
Scrotal/Testicular Abnormalities
Torsion of Testicular Appendage
Torsion of Testicular Appendage
Sara M. O'Hara, MD, FAAP
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Clinical Issues

          TERMINOLOGY

          • Synonyms

            • Twisted appendage, torsed appendix testis, torsion of appendix epididymis, appendiceal torsion

          • Definitions

            • Spontaneous twisting of pedunculated vestigial remnant along testicle or epididymis, causing ischemia & pain
            • Most common etiology of acute scrotal pain in children
              • Incidence > > epididymoorchitis & testicular torsion

          IMAGING

          • General Features

            • Ultrasonographic Findings

              • MR Findings

                • Nuclear Medicine Findings

                  • Imaging Recommendations

                    DIFFERENTIAL DIAGNOSIS

                      PATHOLOGY

                      • General Features

                        • Microscopic Features

                          CLINICAL ISSUES

                          • Presentation

                            • Demographics

                              • Natural History & Prognosis

                                • Treatment

                                  DIAGNOSTIC CHECKLIST

                                  • Image Interpretation Pearls

                                    Selected References

                                    1. Gopal M et al: Emergency scrotal exploration in children: is it time for a change in mindset in the UK? J Pediatr Urol. 17(2):190.e1-7, 2020
                                    2. Koh YH et al: Testicular appendage torsion-to explore the other side or not? Urology. 141:130-4, 2020
                                    3. Expert Panel on Urological Imaging et al: ACR Appropriateness Criteria® acute onset of scrotal pain-without trauma, without antecedent mass. J Am Coll Radiol. 16(5S):S38-43, 2019
                                    4. Lala S et al: Re-presentations and recurrent events following initial management of the acute paediatric scrotum: a 5-year review. ANZ J Surg. 89(4):E117-121, 2019
                                    5. Sweet DE et al: Imaging of the acute scrotum: keys to a rapid diagnosis of acute scrotal disorders. Abdom Radiol (NY). 45(7):2063-81, 2019
                                    6. Hart J et al: Chronic orchalgia after surgical exploration for acute scrotal pain in children. J Pediatr Urol. 12(3):168.e1-6, 2016
                                    7. Pogorelić Z et al: Management of acute scrotum in children: a 25-year single center experience on 558 pediatric patients. Can J Urol. 23(6):8594-601, 2016
                                    8. Lev M et al: Sonographic appearances of torsion of the appendix testis and appendix epididymis in children. J Clin Ultrasound. 43(8):485-9, 2015
                                    9. Boettcher M et al: Differentiation of epididymitis and appendix testis torsion by clinical and ultrasound signs in children. Urology. 82(4):899-904, 2013
                                    10. Delaney LR et al: Ultrasound of the pediatric scrotum. Semin Ultrasound CT MR. 34(3):248-56, 2013
                                    11. Nicolay L et al: Torsion of the appendix testis in an undescended testis: a case report. Can J Urol. 20(3):6805-7, 2013
                                    12. Yusuf GT et al: A review of ultrasound imaging in scrotal emergencies. J Ultrasound. 16(4):171-8, 2013
                                    13. Sung EK et al: Sonography of the pediatric scrotum: emphasis on the Ts--torsion, trauma, and tumors. AJR Am J Roentgenol. 198(5):996-1003, 2012
                                    14. Park SJ et al: Sonography of intrascrotal appendage torsion: varying echogenicity of the torsed appendage according to the time from onset. J Ultrasound Med. 30(10):1391-6, 2011
                                    15. Singh AK et al: Torsion of testicular appendage. Pediatr Radiol. 40(3):373, 2010
                                    16. Artas H et al: Scrotal calculi. J Ultrasound Med. 26(12):1775-9, 2007
                                    17. Varga J et al: Acute scrotal pain in children--ten years' experience. Urol Int. 78(1):73-7, 2007
                                    18. Baldisserotto M et al: Color Doppler sonography of normal and torsed testicular appendages in children. AJR Am J Roentgenol. 184(4):1287-92, 2005
                                    19. Yang DM et al: Torsed appendix testis: gray scale and color Doppler sonographic findings compared with normal appendix testis. J Ultrasound Med. 24(1):87-91, 2005
                                    20. Ciftci AO et al: Clinical predictors for differential diagnosis of acute scrotum. Eur J Pediatr Surg. 14(5):333-8, 2004
                                    21. Adams BK et al: Tc-99m blood-pool imaging in torsion of an epididymal appendix. Clin Nucl Med. 28(6):526, 2003
                                    22. Sellars ME et al: Ultrasound appearances of the testicular appendages: pictorial review. Eur Radiol. 13(1):127-35, 2003
                                    23. McAndrew HF et al: The incidence and investigation of acute scrotal problems in children. Pediatr Surg Int. 18(5-6):435-7, 2002
                                    24. Johnson DB et al: Mullerian-type epithelial tumor arising within a torsed appendix testis. Urology. 54(3):561, 1999
                                    25. Monga M et al: Metachronous bilateral torsion of the testicular appendices. Int J Urol. 6(11):589-91, 1999
                                    26. Van Glabeke E et al: Acute scrotal pain in children: results of 543 surgical explorations. Pediatr Surg Int. 15(5-6):353-7, 1999
                                    27. Strauss S et al: Torsion of the testicular appendages: sonographic appearance. J Ultrasound Med. 16(3):189-92; quiz 193-4, 1997
                                    Related Anatomy
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                                    Related Differential Diagnoses
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                                    References
                                    Tables

                                    Tables

                                    KEY FACTS

                                    • Terminology

                                      • Imaging

                                        • Top Differential Diagnoses

                                          • Clinical Issues

                                            TERMINOLOGY

                                            • Synonyms

                                              • Twisted appendage, torsed appendix testis, torsion of appendix epididymis, appendiceal torsion

                                            • Definitions

                                              • Spontaneous twisting of pedunculated vestigial remnant along testicle or epididymis, causing ischemia & pain
                                              • Most common etiology of acute scrotal pain in children
                                                • Incidence > > epididymoorchitis & testicular torsion

                                            IMAGING

                                            • General Features

                                              • Ultrasonographic Findings

                                                • MR Findings

                                                  • Nuclear Medicine Findings

                                                    • Imaging Recommendations

                                                      DIFFERENTIAL DIAGNOSIS

                                                        PATHOLOGY

                                                        • General Features

                                                          • Microscopic Features

                                                            CLINICAL ISSUES

                                                            • Presentation

                                                              • Demographics

                                                                • Natural History & Prognosis

                                                                  • Treatment

                                                                    DIAGNOSTIC CHECKLIST

                                                                    • Image Interpretation Pearls

                                                                      Selected References

                                                                      1. Gopal M et al: Emergency scrotal exploration in children: is it time for a change in mindset in the UK? J Pediatr Urol. 17(2):190.e1-7, 2020
                                                                      2. Koh YH et al: Testicular appendage torsion-to explore the other side or not? Urology. 141:130-4, 2020
                                                                      3. Expert Panel on Urological Imaging et al: ACR Appropriateness Criteria® acute onset of scrotal pain-without trauma, without antecedent mass. J Am Coll Radiol. 16(5S):S38-43, 2019
                                                                      4. Lala S et al: Re-presentations and recurrent events following initial management of the acute paediatric scrotum: a 5-year review. ANZ J Surg. 89(4):E117-121, 2019
                                                                      5. Sweet DE et al: Imaging of the acute scrotum: keys to a rapid diagnosis of acute scrotal disorders. Abdom Radiol (NY). 45(7):2063-81, 2019
                                                                      6. Hart J et al: Chronic orchalgia after surgical exploration for acute scrotal pain in children. J Pediatr Urol. 12(3):168.e1-6, 2016
                                                                      7. Pogorelić Z et al: Management of acute scrotum in children: a 25-year single center experience on 558 pediatric patients. Can J Urol. 23(6):8594-601, 2016
                                                                      8. Lev M et al: Sonographic appearances of torsion of the appendix testis and appendix epididymis in children. J Clin Ultrasound. 43(8):485-9, 2015
                                                                      9. Boettcher M et al: Differentiation of epididymitis and appendix testis torsion by clinical and ultrasound signs in children. Urology. 82(4):899-904, 2013
                                                                      10. Delaney LR et al: Ultrasound of the pediatric scrotum. Semin Ultrasound CT MR. 34(3):248-56, 2013
                                                                      11. Nicolay L et al: Torsion of the appendix testis in an undescended testis: a case report. Can J Urol. 20(3):6805-7, 2013
                                                                      12. Yusuf GT et al: A review of ultrasound imaging in scrotal emergencies. J Ultrasound. 16(4):171-8, 2013
                                                                      13. Sung EK et al: Sonography of the pediatric scrotum: emphasis on the Ts--torsion, trauma, and tumors. AJR Am J Roentgenol. 198(5):996-1003, 2012
                                                                      14. Park SJ et al: Sonography of intrascrotal appendage torsion: varying echogenicity of the torsed appendage according to the time from onset. J Ultrasound Med. 30(10):1391-6, 2011
                                                                      15. Singh AK et al: Torsion of testicular appendage. Pediatr Radiol. 40(3):373, 2010
                                                                      16. Artas H et al: Scrotal calculi. J Ultrasound Med. 26(12):1775-9, 2007
                                                                      17. Varga J et al: Acute scrotal pain in children--ten years' experience. Urol Int. 78(1):73-7, 2007
                                                                      18. Baldisserotto M et al: Color Doppler sonography of normal and torsed testicular appendages in children. AJR Am J Roentgenol. 184(4):1287-92, 2005
                                                                      19. Yang DM et al: Torsed appendix testis: gray scale and color Doppler sonographic findings compared with normal appendix testis. J Ultrasound Med. 24(1):87-91, 2005
                                                                      20. Ciftci AO et al: Clinical predictors for differential diagnosis of acute scrotum. Eur J Pediatr Surg. 14(5):333-8, 2004
                                                                      21. Adams BK et al: Tc-99m blood-pool imaging in torsion of an epididymal appendix. Clin Nucl Med. 28(6):526, 2003
                                                                      22. Sellars ME et al: Ultrasound appearances of the testicular appendages: pictorial review. Eur Radiol. 13(1):127-35, 2003
                                                                      23. McAndrew HF et al: The incidence and investigation of acute scrotal problems in children. Pediatr Surg Int. 18(5-6):435-7, 2002
                                                                      24. Johnson DB et al: Mullerian-type epithelial tumor arising within a torsed appendix testis. Urology. 54(3):561, 1999
                                                                      25. Monga M et al: Metachronous bilateral torsion of the testicular appendices. Int J Urol. 6(11):589-91, 1999
                                                                      26. Van Glabeke E et al: Acute scrotal pain in children: results of 543 surgical explorations. Pediatr Surg Int. 15(5-6):353-7, 1999
                                                                      27. Strauss S et al: Torsion of the testicular appendages: sonographic appearance. J Ultrasound Med. 16(3):189-92; quiz 193-4, 1997