This is Not the Appendix You're Looking For

Case

A previously healthy 11 year-old male presents to the ED with three days of lower abdominal pain. The patient was evaluated at an urgent care center prior to arrival and was sent to the ED to “rule out appendicitis.” The patient reports intermittent “stabbing” pain that was initially suprapubic, but moved to the right lower quadrant today. The patient states the pain comes and goes without a clear trigger, but he has been able to eat normally and go to school. His mom became concerned today when they were about to eat dinner and the patient had an episode of severe pain that caused him to lie down. His mom gave him acetaminophen with some relief. He has not had fever, nausea, vomiting, or diarrhea. He has no sick contacts. He denies dysuria and penile discharge. 

In the ED, vitals are normal. Physical exam is significant for very mild right lower quadrant and suprapubic tenderness on palpation. The patient does not have guarding, rebound, or express grimacing on exam. He is able to jump up and down without abdominal pain. Genitourinary exam is notable for significant discomfort while palpating the superior portion of the right testicle over the epididymis. No discoloration is noted and the cremasteric reflex is intact. The patient reports that palpating the superior portion of the right testicle recreates his abdominal pain.

A point-of-care urinalysis was unremarkable. A testicular ultrasound was obtained:

Image 1: The image above shows enlargement of the right epididymal appendage, containing numerous dilated tubules.

Video 1: Right epididymal appendage with numerous dilated tubules.

Diagnosis

Acute torsion of the right appendix epididymis.

Discussion

Young, male patients with testicular pathology may complain of abdominal pain. It is important to perform a genitourinary exam for every male pediatric patient with abdominal pain.

 The appendix of the epididymis, also known as the epididymal appendage, or the appendix epididymis, is a small vestigial structure found at the head of the epididymis (Image 2).

Image 2: From Wikimedia Commons (https://commons.wikimedia.org/wiki/File:Grant_1962_116.png)

It is a remnant of the Wolffian duct and has no known physiologic function. It is, however, capable of torsion, as is the appendix testes, and the spermatic cord (i.e. testicular torsion). Unlike testicular torsion, however, torsion of the testicular or epididymal appendage are not dangerous. Systemic symptoms such as nausea and vomiting, which are classically seen in testicular torsion, are not usually present in appendageal torsion. Patients will usually have tenderness over the upper pole of the epididymis or testis. Early torsion of the appendix testis or epididymis may present with a pathognomonic “blue dot sign” which is a bluish discoloration seen through the scrotal skin.  

Surgical treatment for appendageal torsion is usually unnecessary, although color Doppler US should be obtained to confirm blood flow to the testes. Torsion of the appendix epididymis (and appendix testis) is often self-limited and managed with supportive care including NSAIDs, rest, scrotal support and reassurance. Most patients will have resolution of their symptoms within a week.

 The differential for acute scrotal pain varies by age, but includes hydrocele, hernia, or child abuse in infants; hernia, torsion or the appendix testes, torsion of the epididymal appendix, testicular torsion, or trauma during childhood; and epididymitis, torsion of the appendix testes, torsion of the epididymal appendix, testicular torsion, trauma, or orchitis in adolescents.

Resolution

The patient was treated in the ED with ibuprofen and discharged with a prescription for NSAIDs and a scrotal sling (supportive underwear styles like traditional briefs work just as well).  At the time of discharge, the patient was feeling better.

Take Home Points

• Young patients with testicular pain may present complaining of abdominal pain

• A genitourinary exam is necessary in every male pediatric patient presenting with a chief complaint of abdominal pain

• Torsion of the testicular appendages is not dangerous

• Diagnosis is made via color doppler ultrasound

• Treatment is NSAIDs, scrotal support, and reassurance

Faculty Reviewer: Dr. Jessica Smith

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References:

1. Fujita N, Tambo M, Okegawa T, Higashihara E, Nutahara K. Distinguishing testicular torsion from torsion of the appendix testis by clinical features and signs in patients with acute scrotum. Res Rep Urol. 2017;9:169–174. Published 2017 Aug 28. doi:10.2147/RRU.S140361

2. Lev, M. , Ramon, J. , Mor, Y. , Jacobson, J. M. and Soudack, M. (2015), Sonographic appearances of torsion of the appendix testis and appendix epididymis in children. J. Clin. Ultrasound, 43: 485-489. doi:10.1002/jcu.22265

3. https://www.uptodate.com/contents/causes-of-scrotal-pain-in-children-and-adolescents?search=epididymal%20appendage&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

4. Lewis AG, Bukowski TP, Jarvis PD, et al. Evaluation of acute scrotum in the emergency department. J Pediatr Surg 1995; 30:277.

5. Nicks, Bret A., and David E. Manthey. “Chapter 96. Male Genital Problems.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. Eds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2011

6. Pillai SB, Besner GE. Pediatric testicular problems. Pediatr Clin North Am 1998; 45:813.

7. http://www.emdocs.net/testicular-torsion-pearls-and-pitfalls/

8.  Vasdev N, Chadwick D, Thomas D. The acute pediatric scrotum: presentation, differential diagnosis and management. Curr Urol. 2012;6(2):57–61. doi:10.1159/000343509