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Nowadays treatment of testicular appendix torsion in children
Abstract
Introduction . Currently, a modern tactics as to the treatment of testicular appendix torsion in children is not an indisputable axiom but it is a subject of discussion in domestic and foreign literature. Modern diagnostic tools, wide implementation of expert-class equipment as well as gaining more experience have reduced, to a minimum , the risk of diagnostic error with fatal consequences for the gonad. So, it impels to revise the existing algorithms and to consider the conservative treatment as the method of choice in uncomplicated testicular appendix torsion.
Objective . To analyze the gained experience in treating testicular appendix torsion and to suggest reasonable algorithms which correspond to modern diagnostic techniques and treatment options.
Material and methods . 2875 cases with testicular appendix torsion have been analyzed. Of these, 2 069 (71.96%) patients were operated on; 755 (26.26%) patients had conservative treatment and 51 (1.78%) had to be operated on despite conservative treatment.
Results . The material obtained in three statistically homogeneous groups has been аnalyzed. When comparing clinical and ultrasound criteria, it was found out that the incidence of orchalgia in the surgical group is slightly higher than in the conservative one. It may indicate that the adhesive process in the scrotal cavity after surgical trauma is more frequent than after a possible aseptic inflammation. Asymmetry of gonad volumes with smaller diseased testicle was seen in all groups. The decrease in testicular volume is minimal in all cases and is not statistically significant. The incidence of heterogeneity in the testicular and appendage echo structure, which indicates sclerotic changes in the parenchyma, is also not statistically significant in the analyzed groups. Patients who were operated despite their conservative care do not have much worse outcomes after long-lasting follow-up period than groups with other curative options.
Conclusion . Torsion of the testicular appendix in children is a challenging problem that is far from being solved. There is no consensus as to the indications for surgical treatment and to the assessment of postoperative outcomes. Modern diagnostic and monitoring techniques allow to dynamically monitor the scrotal organs in conservative treatment. The conservative treatment of testicular appendix torsion is an effective and safe method. The conservative tactics which was changed for surgical one does not lead to gonad deterioration.
Polyorchism is a rare congenital anomaly defined as the incidence of more than two testicles. This pathology is considered to be extremely rare and may remain asymptomatic for a long time. The disease is detected predominantly during the examination of other urologic pathologies such as inflammation, hydrocele, testicular torsion, inguinal hernia, male infertility, and malignant changes. The reported case of polyorchism was confirmed during surgery for left testicular hydatid torsion in a 17-yearold boy. The abnormal testis had its own tunica vaginalis testis, epididymis, common deferent duct, and shared blood supply with the left testis. The testes were preserved during surgery. No impaired spermatogenesis was detected in the patient.
Torsion of the appendix testis is a rare cause of scrotal swelling in the neonatal period. We present a case of torsion of the appendix testis in a one-day-old male. We discuss the physical examination and radiologic studies used to make the diagnosis. Nonoperative therapy was recommended and the patient has done well. Recognition of this condition in the neonatal period can prevent surgical intervention and its associated risks.
Torsion of the appendix testis is not an uncommon cause of acute hemiscrotum. It is frequently misdiagnosed as acute epididymitis, orchitis, or torsion of testis. Though conservative management is the treatment of choice for this condition, prompt surgical intervention is warranted when testicular torsion is suspected. We report a case of torsion of a large appendix testis misdiagnosed as pyocele. Emergency exploration of it revealed a large appendix testis with torsion and early features of gangrene. After excision of the appendix testis, the wound was closed with an open drain. The patient had an uneventful and smooth postoperative recovery.
The acute scrotum is a common emergency department (ED) presentation and can be defined as any condition of the scrotum or intrascrotal contents requiring emergent medical or surgical intervention. Although rarely fatal, acute scrotal pathology can result in testicle infarction and necrosis, testicular atrophy, infertility, and significant morbidity.
Scrotal US is best performed with a linear 7.5- to 12-MHz transducer. In addition to imaging in the longitudinal and transverse planes, it is helpful to obtain simultaneous images of both testes for comparison. Color Doppler is used to evaluate for abnormalities of flow and to differentiate vascular from nonvascular lesions. Attention to appropriate color Doppler settings to optimize detection of slow flow is critical.
The evaluation of acute scrotal pain can be challenging for the clinician initially examining and triaging the patient. Acute scrotal conditions due to traumatic, infectious, vascular, or neoplastic etiologies can all present with pain as the initial complaint. Additionally, the laboratory and physical examination findings in such conditions may overlap; this, coupled with potential patient guarding and lack of collaboration, may result in a limited, non-specific physical examination. Therefore, scrotal ultrasound has emerged to play a central role in the evaluation of the patient presenting with acute scrotal pain.
In conclusion, we are firmly convinced that a scrotal ultrasound should always be performed in the presence of acute scrotal pain. Moreover, urologist should be able to perform a scrotal ultrasound but, if imaging does not supply a clear diagnosis, surgical exploration is still mandatory.
The acutely painful scrotum is a common urologic emergency. The primary objective of management is to avoid testicular loss. This requires a high index of clinical suspicion and prompt surgical intervention. In our series conducted between January 1996 and December 2005, 119 patients (age range: 4-62 years) underwent emergency operative exploration for acute scrotal pain. The most common finding was torted cyst of Morgagni (63/119, 52.9%), followed by testicular torsion (41/119, 34.4%). The majority of testicular torsions occurred in the pubertal group (22/41, 53.6%). Only one patient in this group had an unsalvageable testis necessitating orchidectomy, a testicular loss rate in torsion of 2.4%. There were no postoperative wound infections or scrotal haematomas. Testicular salvage depends critically on early surgical intervention, so the delay incurred in diagnostic imaging may extend the period of ischaemia. Furthermore, all radiological investigations have a certain false-negative rate. We advocate immediate surgical exploration of the acute scrotum. We report a low orchidectomy rate (2.4%) in testicular torsion.
Selective scrotal exploration of only those boys believed to have testicular torsion (TT), relying on history and clinical examination for diagnosis, can result in a missed or delayed diagnosis of TT. To minimise testicular loss we propose early scrotal exploration in all boys with acute scrotum (AS). To validate our approach we investigated the accuracy of clinical diagnoses of all boys with AS admitted to our unit. Clinical features and diagnoses were correlated with operative findings.
A retrospective review of the records of all boys (1-16 years of age) presenting with AS between 2003 and 2007 was done. Overall, 138 boys were seen during this period. Three boys were treated conservatively. The 135 boys who underwent scrotal exploration were divided into three groups: Group A (47 boys) with a history and clinical features considered preoperatively to be consistent with torsion of appendix of testis (TAT); Group B (46 boys) whose characteristics were thought to be more consistent with TT; and finally Group C (42 boys) in whom a preoperative definitive diagnosis could not be made. The preoperative clinical features and diagnoses of the 135 boys were correlated with the operative findings.
In Group A, exploration confirmed TAT in 37 (78%) boys, but in 7 (15%) boys it revealed TT. In Group B, exploration confirmed torsion in 31 (68%) boys, but 13 (28%) had TAT. In Group C, exploration revealed 39 (93%) cases of TAT and 3 (7%) cases of TT.
Surgical exploration in all cases of paediatric AS offers an accurate diagnosis and treatment, thus minimising the risk of testicular loss.
The true incidence of the various causes of acute scrotum in children is unclear; epididymo-orchitis (EO) is thought to be uncommon. Investigation for underlying urological abnormality in children with EO is recommended. To determine the incidence of the various pathologies in boys presenting to the emergency department with an acute scrotal condition and assess the value of further investigation of the urinary tract in a subgroup of boys with EO, a retrospective review of 100 consecutive patients admitted with a diagnosis of testicular pain was performed. Seventy had torsion of an appendix testis (TAT) and 12 had torsion of the testicle (TT). Ten boys were admitted with 11 episodes of EO; 7 had other pathologies including incarcerated hernia, varicocoele, and idiopathic scrotal oedema. The diagnosis of EO was made at operation in all 11 episodes. Escherichia coli was cultured in 4 patients; none were found to have underlying urinary tract abnormality. TAT was thus commonest causes of the acute scrotum. EO is not rare in infants, the incidence in this study being equal to the of TT. Subsequent urological investigation did not disclose any underlying abnormality. However, based on the current published literature futher investigation is recommended in selected cases.
Ultrasonography (US) with a high-frequency (7.5-10-MHz) transducer has become the imaging modality of choice for examination of the scrotum. US examination can provide information valuable for the differential diagnosis of a variety of disease processes involving the scrotum that have similar clinical manifestations (eg, pain, swelling, or presence of mass). The pathologic condition that may be at the origin of such symptoms can vary from testicular torsion to infection to malignancy. The ability of color and power Doppler US to demonstrate testicular perfusion aids in reaching a specific diagnosis in patients with acute scrotal pain. This review covers the anatomy of the scrotum and the scanning protocol for scrotal US, as well as detailed descriptions of disease processes and their US appearances. Newly described conditions such as intratesticular varicoceles and other benign intratesticular cystic lesions are also discussed.
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