Torsion of testicular appendix ……an Ultrasound & Color Doppler Diagnosis

CASE & USG  DETAILS

A boy of 6 years of age  presented clinically with acute painful ,red & swollen left hemiscrotum . USG with color doppler was performed , which showed -  a well defined  echogenic spherical lesion of about 7.5 x 4 x 5 mm size near upper pole of left testis adjacent to head of epididymis. The lesion was extratesticular & extraepididymal , and seen lodged between testis upper pole & epididymal head,  with no internal vascularity on power doppler. Mild adjacent epididymal & periappendiceal soft tissue hyperemia noted , otherwise testis and epididymis appeared normally . No significant hydrocele noted .  On the basis of ultrasound and color doppler findings the diagnosis of torsion of testicular appendix was made , which was confirmed peroperatively . By- Dr. Subhash Tailor, MD, Bhilwara [Rajasthan, India]

Fig.1- TS left hemiscrotum shows a well defined rounded echogenic lesion between upper pole left testis and epididymal head with mild adjacent epidiymal hyperemia .

Fig. 2 – TS and LS scan left hemiscrotum shows torsed appendix lesion [ AP , arrow ] and mild epididymal head hyperemia 

  

Fig. 3 – Per operative photograph shows the torsed appendix of testis [ operative photograph : courtsey – Dr. Gaurav Bahety , M.S. , M.CH. , Pediatric surgeon , Bhilwara , India ] 

LEARNING POINTS & REVIEW LITERATURE

1] Appendix of testis is also known as “Hydatid of Morgagni”, & is remnant of paramesonephric duct. It is attached to upper pole of testis in the groove between head of epididymis and testis.

2] The condition is common in pediatric age group.

2. Clinically present with pain ,erythema & swelling of ipsilateral hemiscrotum . Occasionally ‘Blue Dot Sign’ seen on overlying scrotal wall.

3]Normal appendix of testis is small oval/elongated structure measuring 3 to 5 mm with echotexture like testis. It is well seen when hydrocele is present & occasionally low flow signal detected in it on Doppler.

4] A torsed testicular appendix is usually hyperechoic or mixechogenic or rarely iso to hypoechoic , & spherical in shape ,measuring more than 5.6mm in size. It is avascular on color Doppler, however mild adjacent periappendiceal soft tissue [epididymo-orcheal] hyperemia noted. Mild hydrocele may or may not be present. Rarely a free or isolated echogenic  nodule present in hemiscrotal cavity also suggests torsed & detached appendix.

5] Torsion of appendix of epididymis is rare , & has a long stalk with its location posterolateral to testis,where as testicular appendix is superomedial in location.

6] Treatment options are surgical & conservative methods depending on clinicopathological complexities.

References:

1. Baldisserotto et al, Color Doppler Sonography Of Normal & Torsed Testicular Appendages In Children . AJR 2005,184,1287-1292.

2] Yang at al,Torsed Appendix Testis, J Ultrasound Med 2005, 24:87-91