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Hospital da Criança Conceição - Ministério da Saúde - Brazil, Eca de Queiroz, 384 Apt. 502, Porto Alegre, RS, Brazil, 90.670-020.
Received May 29, 2004;
accepted after revision August 10, 2004.
Address correspondence to M. Baldisserotto
(matteob{at}terra.com.br).
Abstract
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SUBJECTS AND METHODS. Thirty-three patients with acute scrotal pain underwent gray-scale and color Doppler sonography and subsequent surgery. Twenty-two patients had torsion of the appendix testis, six had epididymitis, three had torsion of the testis, and two had torsion of the appendix epididymidis. The testicular appendages of 30 patients and the testes of three were excised and sent to the laboratory for histopathologic examination.
RESULTS. A testicular appendage was identified on color Doppler sonography in 23 patients (21 patients with torsed appendages and two patients with epididymitis). The torsed appendixes testis measured from 4.1 to 16.3 mm, and the normal appendixes in the two patients with epididymitis measured 4.1 and 5.6 mm. With the visualization of an appendix larger than 5.6 mm as the sonographic diagnostic criterion for torsion of a testicular appendage, sensitivity was 68.2% (95% confidence interval (CI), 45.1-85.3%), and specificity was 100% (CI, 74.7-100%). CONCLUSION. The identification of a testicular appendage larger than 5.6 mm is suggestive of torsion. Therefore, depending on the patients' clinical conditions, these cases can be treated conservatively when an appendage larger than 5.6 mm is identified.
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Several authors recommend surgical exploration in all patients with acute scrotal pain because diagnostic imaging techniques do not reach 100% sensitivity [4]. Others, however, have adopted a conservative approach to many cases for which there is a clinical diagnosis of torsion of the appendix testis [5]. However, differentiating between torsion of the testis and of the appendix testis is often impossible. Clinical examination of patients with acute scrotal pain is difficult, and cases of misdiagnosis may reach 45% by general practitioners and 7-10% by pediatric urologists [8]. Surgery textbooks still do not recommend sonography as a useful diagnostic method in the investigation of torsion of the appendix testis although some studies have already described sonographic findings of this disease [9-11]. A study conducted by Hesser and colleagues [12] in 1993 evaluated the accuracy of gray-scale sonography in the diagnosis of torsion of testicular appendages. The sonographic diagnostic criterion adopted in their study was the visualization of a testicular appendage, and their results yielded 88% sensitivity and 75% specificity. They found three false-positive results—that is, testicular appendages that were visualized but that surgical exploration showed to be normal. Therefore, sonographic visualization alone is not a safe criterion to establish the diagnosis of testicular torsion. Torsed appendages measured 3-17 mm in diameter in the study by Hesser et al. Sahni et al. [13], who conducted a study to evaluate the size according to age of normal testicular appendages obtained from medicolegal autopsies, found a mean size of 2.30 ± 1.74 mm for boys 1-14 years old. Considering the findings of these two studies, appendages measuring 3-4 mm may be either normal or torsed. We have not found any other study in addition to the study by Hesser et al., whose purpose was to evaluate the accuracy of sonography in the diagnosis of torsion of testicular appendages. A better definition of the size of normal and torsed testicular appendages as identified on sonography should be useful in the diagnosis of torsion of testicular appendages and provide a safe basis for the adoption of a conservative management.
Color Doppler sonographic findings of torsion of the appendix testis have been described by a few authors [14, 15]. In their studies, the appendixes were visualized as an avascular mass separated from the testis and epididymis, which were enlarged and showed inflammation. However, to our knowledge no study has been conducted to determine the value of the systematic use of color Doppler sonography in the investigation of torsion of the appendix testis.
The purpose of this study was to determine the size and sonographic appearance of torsed and normal testicular appendages at color Doppler examination by establishing the correlation of sonographic findings with surgical and histopathologic findings in children who underwent surgery for an acute scrotum.
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Color Doppler Sonography
Sonographic examinations were performed with an HDI-5000 (Advanced
Technology Laboratories) system with high-frequency 7-12-MHz linear array
transducers. Examination started with gray-scale sonography, followed by color
Doppler sonography. Color Doppler gain was adjusted to avoid the appearance of
artifacts, and the system was preset to detect low-velocity flows. The routine
examination started with transverse scanning of the scrotum, followed by
longitudinal scanning. Volume, echogenicity, texture, and blood flow were
evaluated for both testes and epididymides. The color Doppler sonographic
criterion to evaluate blood flow in the testis and epididymis was comparison
with the blood flow in the contralateral testis and epididymis. Next, the
upper pole of the testis in the symptomatic side was carefully examined
longitudinally, followed by transverse examination of this region. Whenever a
structure likely to correspond to the testicular appendage was identified, its
location, size, texture, echogenicity, and blood flow were evaluated.
Sonography of testicular appendages was performed only on the symptomatic
side. The larger diameter of the testicular appendage was the criterion used
to determine its size. The volume, shape, echogenicity, and blood flow of the
epididymis and testis were also evaluated. The other side of the scrotum was
scanned using the same routine. Scanning was then extended to the spermatic
cord to assess its thickness and vessels. The full examination took up to 10
min. All sonographic studies were performed by three experienced pediatric
radiologists with qualifications equivalent to certification by the American
Board of Radiology. During daytime, patients underwent sonographic examination
immediately after clinical examination. During the night and on weekends, the
radiologist on call performed sonographic examinations within, at the most, 1
hr after the clinical examination. The sonographic diagnostic criterion for
testicular appendage was the identification of an extratesticular and
extraepididymal mass located at the upper pole of the testis.
Statistical Analysis
Statistical analysis of data was performed with the SPSS (Statistical
Package for the Social Sciences) for Windows (Microsoft) software, version
11.0. Statistical significance was established at a p value of less
than 0.05. Kappa statistics were used to check the agreement of sonographic
findings with clinical and histopathologic findings. Tables of frequency were
used, and specificity, sensitivity, and positive and negative predictive
values were calculated using the Epi Info software (Centers for Disease
Control and Prevention), version 6.0.
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A nodular structure in 25 of the 33 patients examined was identified on gray-scale sonography. Twenty-three of these structures were interpreted as testicular appendages: 22 were located at the upper pole of the testis, 16 were medial to the head of the epididymis, six were either posterior or lateral to the epididymis (Figs. 1A, 1B, 1C, 2A, 2B, 2C, 3A, and 3B), and one was free in the scrotal pouch next to the tail of the epididymis. Surgical and histopathologic findings of these 23 patients showed that the testicular appendages were torsed in 21 patients (Figs. 1C and 2B) and that the two remaining patients had normal appendixes testis and signs of epididymitis (Fig. 3B). In the other two of the 25 patients, the nodular structures were posterolateral to the head of the epididymis and medial to the testis but did not extend from it (Figs. 4A and 4B). Because of the location of the nodule, sonographic results suggested the diagnosis of torsion of an appendix epididymidis. Surgical and histopathologic findings showed that these two structures corresponded to torsed appendixes epididymidis (Fig. 4C). The location, shape, and size determined sonographically for the 21 torsed appendixes testis, the two normal appendages, and the two torsed appendixes epididymidis were in agreement with surgical and histopathologic findings. Only one torsed testicular appendage was not identified during the sonographic examination.
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The largest diameter of each appendage was measured to define its size. The 21 torsed appendixes testis measured 4.1-16.3 mm (mean, 7.7 mm), and the two normal appendixes found in the patients with epididymitis measured 4.1 and 5.6 mm (Table 1). The largest diameters of two torsed appendixes epididymidis were 16.0 and 9.2 mm. The torsed appendix that was not identified on sonography was measured during surgery, and it was 5.0 mm in diameter.
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Of the 21 nodular structures visualized in the patients with torsed appendixes testis, 20 were oval and one was elongated and lobulated. The two normal testicular appendages found in the patients with epididymitis were round. One of the two torsed appendixes epididymidis was oval and the other was round. Eighteen of the torsed appendixes testis were compressing the tunica albuginea at the upper pole of the testis (Fig. 1A).
The nodular structures visualized on sonography in the 21 patients with torsed appendixes testis were hyperechoic to the epididymis in 11 cases, hypoechoic in three, of mixed echogenicity in four, and isoechoic in three. The two normal testicular appendages found in the patients with epididymitis were hypoechoic. The nodular structure was hypoechoic in one of the two patients with appendix epididymidis and of mixed echogenicity in the other.
The volume of the epididymis and testis in the symptomatic hemiscrotum was greater than that in the asymptomatic side in all 33 patients. Epididymal echogenicity was increased in all 33 patients studied. Testicular echogenicity was decreased (n = 2) or heterogeneous (n = 1) in the three patients with testicular torsion; normal (n = 14), decreased (n = 6), or slightly heterogeneous (n = 2) in the patients with torsed appendix testis; normal (n = 6) in all patients with epididymitis; and decreased in the patients with torsed appendix epididymidis (n = 2).
Color Doppler examination did not reveal any flow in the 25 nodular structures identified: 21 torsed appendixes testis (Figs. 1B and 2B), two normal appendixes testis in the patients with epididymitis (Fig. 3A), and two torsed appendixes epididymidis (Figs. 4A and 4B). No flow was observed in the testes in the three patients with testicular torsion. Testicular blood flow was increased in varying degrees in 30 cases: 22 patients with torsed appendixes testis, six patients with epididymitis, and two patients with torsed appendixes epididymidis. Epididymal blood flow was increased in the 33 patients studied: 22 with torsed appendixes testis, six with epididymitis, three with testicular torsions, and two with torsed appendixes epididymidis.
A small hydrocele was found in 18 of the 21 patients with torsed appendages identified on sonography, in four of the patients with epididymitis, in the two patients with torsed appendixes epididymidis, and in one of the patients with testicular torsion. The sonographic findings for one of the patients with epididymitis were interpreted as a thick-walled, trabeculated bladder; this patient reported that he had undergone posterior urethral valve ablation.
Although the purpose of this study was not to evaluate the accuracy of color Doppler sonography in the diagnosis of torsion of testicular appendages, a statistical analysis was conducted to determine accuracy if the sonographic diagnostic criterion for torsion of a testicular appendage were the visualization of the appendix regardless of its size. In this case, sensitivity would be 95.5% (95% confidence interval (CI), 75.1-99.8%); specificity, 81.8% (CI, 47.8-96.8%); positive predictive value, 91.3% (CI, 70.5-98.5%); and negative predictive value, 90.0% (CI, 54.1-99.5%) (Table 1).
Because normal appendixes measuring 4.1 and 5.6 mm were also found, another statistical analysis was conducted considering the visualization of an appendix larger than 5.6 mm as the sonographic diagnostic criterion for torsion of testicular appendages. In this case, sensitivity was 68.2% (CI, 45.1-85.3%); specificity, 100% (CI, 74.7-100%); positive predictive value, 100% (CI, 74.7-100%); and negative predictive value, 61.1% (CI, 36.1-81.7%) (Table 1).
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Several authors have adopted surgery as the procedure of choice to establish the diagnosis of torsion of a testicular appendage, to remove the necrosed testicular appendage, and to relieve pain [4]. Other authors have adopted a conservative treatment for most patients with torsed testicular appendages [5]. However, two factors complicate the adoption of a conservative approach in some patients: the intensity of scrotal pain and the difficulty in establishing a diagnosis of torsion of testicular appendage on clinical findings alone. An accurate presurgical diagnosis of torsion of appendix testis should provide the necessary information for the adoption of a conservative treatment for patients whose pain is bearable.
A study conducted by Hesser and colleagues [12] showed that the identification of a hyperechoic mass adjacent to the upper pole of the testis is an accurate criterion for the sonographic diagnosis of torsion of the appendix testis. In their study, however, three cases were interpreted as torsed testicular appendages at sonography, but pathologic findings showed them to be normal appendages (false-negative cases). The sizes of these appendages were not reported in their study. Their findings were attributed to a possible spontaneous derotation of the appendages.
The statistical analysis in our study showed that when the visualization of any testicular appendage was the sonographic criterion, sensitivity was higher and specificity was lower than when the criterion adopted was the visualization of a testicular appendage larger than 5.6 mm. However, the criterion of visualization of a testicular appendage larger than 5.6 mm had a specificity of 100%. Therefore, identification of a testicular appendage larger than 5.6 mm may be an adequate criterion to establish the diagnosis of torsion of testicular appendage in boys. This criterion may be useful in the adoption of a safe, conservative treatment of patients with torsed testicular appendages.
At the same time, testicular appendages with diameters smaller than 5.6 mm may be indicative of either a normal or a torsed appendix. In two patients with epididymitis, normal testicular appendages, measuring 4.1 and 5.6 mm, were seen at sonography. The histopathologic examination showed that they were both normal. These results are in disagreement with those reported by Sahni and colleagues [13], who found a mean value of 2.0 ± 1.34 mm for the largest diameter of testicular appendages obtained from medicolegal autopsies in boys 1-14 years old. In these cases, sonographic findings should be correlated with the following clinical findings to establish a diagnosis: a blue dot seen through the scrotal skin, a black dot shown by transillumination, or a tender palpable nodule found at the upper pole of the testis. If the diagnosis is still unclear, surgical exploration should be conducted to establish a definite diagnosis.
Therefore, it may be concluded that the identification of a testicular appendage of any size on sonography is not a safe criterion for the establishment of a diagnosis of torsed appendix testis. A testicular appendage must be larger than 5.6 mm—the size of the largest normal appendix found in our study—to be considered unequivocally enlarged. This value is greater than the upper limit of the normal range for the age reported in the study conducted by Sahni et al. [13]. However, small appendages—measuring 3-5.6 mm and thus within the normal range for the age—may also be torsed, as our results and those reported by Hesser et al. [12] have shown. Torsed testicular appendages of a normal size for the age represent 27% of all cases.
Our sonographic studies accurately identified 21 of the 22 torsed appendixes testis, two normal appendixes testis, and two torsed appendixes epididymidis. The presence of a hydrocele was useful in some cases for the differentiation of an appendix testis from adjacent structures. It was color Doppler sonography, however, that provided the differentiation of the avascular appendix testis from the epididymis and hypervascularized adjacent tissues in most cases. Hesser et al. [12] reported that, of 42 patients with torsion, five torsed appendixes testis were not identified. Of the 22 torsed appendixes testis in our study, only one was not identified on sonography. This greater percentage of appendixes identified in our study may be because we used color Doppler sonography. However, color Doppler findings were not useful in the differentiation of normal and torsed appendixes testis. The absence of flow was observed both in the patients with torsed appendixes and in the two patients with epididymitis with normal appendixes, one of which measured 5 mm.
Gray-scale sonographic findings for normal and torsed testicular appendages were different. Hesser et al. [12] reported that torsed appendixes testis were hyperechoic or had mixed echogenicity. Strauss et al. [18], however, in a study of five patients with testicular appendages, reported that three were hyperechoic and two were isoechoic with the adjacent epididymis. In our study, echogenicity of the torsed testicular appendages with the epididymis was varied: hyperechoic, hypoechoic, heterogeneous, or isoechoic. For some of the torsed appendixes that were isoechoic with the epididymis and testis, transverse sonography and color Doppler sonography were especially useful in differentiating the torsed appendix from the head of the epididymis. A sonographic study of the entire scrotum should be conducted because the torsed appendix testis may be free in the scrotum. The identification of a free nodule inside the scrotum is useful for the establishment of a diagnosis of torsion of appendix testis. Compression of the tunica albuginea by the enlarged appendix testis was observed in 18 of the 21 torsed appendixes identified on sonography but did not occur in the two patients with normal appendixes. To our knowledge, similar findings have never been reported in studies of sonographic findings of torsion of testicular appendages.
The torsion of the appendix epididymidis in patients with acute scrotum is a rare event, and only few cases have been reported in literature [13]. No case of torsion of the appendix epididymidis has been reported in studies of large series of patients with an acute scrotum [3, 4, 7]. In our series of 33 patients, we found two patients with torsion of the appendix epididymidis (6.1%). We do not know why such a high occurrence of torsion of the appendix epididymidis was found in our smaller number of patients. To our knowledge, ours is the first report of color Doppler sonographic findings of patients with torsion of the appendix epididymidis. The torsed appendixes epididymidis in our study were seen as round or oval, avascular, heterogenous nodules located posterolateral to the head of the epididymis, measuring 16.0 and 9.2 mm, and not associated with the testis. Differently from the cases of torsed appendixes testis reported, the appendix epididymidis had an isoechoic stalk projecting from the epididymis. The normal size of the appendix epididymidis in adults ranges from 3 to 8 mm [16]. Our review of literature did not yield any studies about the size of the normal appendix epididymidis in children.
In conclusion, the identification of a testicular appendage larger than 5.6 mm is suggestive of torsion, and, depending on clinical conditions, conservative treatment can be adopted for these patients. Testicular appendages measuring 3-5.6 mm may be either normal or torsed. In this case, treatment should be decided after considering clinical and physical examination findings and sonographic results.
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