Epididymitis, Testicular Torsion, and Torsion of Appendix Testis

ABSTRACT & COMMENTARY

Source: Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics 1998;102:73-76.

When a pediatric patient presents with scrotal pain or swelling, it can be difficult to distinguish the causes. Investigators at the Primary Children’s Medical Center in Utah report on a retrospective review of patients younger than 18 years of age with these conditions who recently presented to their hospital. Ninety patients were included—64 with epididymitis, 13 with testicular torsion, and 13 with torsion of appendix testis.

The peak incidence of all three conditions was during ages 9-14 years. Incidence of testicular torsion peaked at 12-16 years. Patients with torsion of appendix testis were evenly distributed between 1-14 years, and patients with epididymitis were seen in all age groups, with a peak incidence of 8-12 years. Historical features, such as fever, nausea, vomiting, dysuria, sexual activity, and history of trauma, were not helpful discriminators. Compared with epididymitis, patients with testicular torsion and torsion of appendix testis were more likely to present within 12 hours of the onset of symptoms. All patients with testicular torsion had an absent cremasteric reflex and a tender testicle, compared, respectively, with 14% and 69% of patients with epididymitis, and 0% and 31% of patients with torsion of appendix testis. The testicular lie was normal in all patients with epididymitis and torsion of appendix testis, yet was normal in only half of the patients with testicular torsion. Ninety-seven percent of patients with epididymitis had a tender epididymis, compared with only 23% of patients with testicular torsion. Only patients with torsion of appendix testis had isolated tenderness at the superior pole of the testis. In the 38 patients who had a color Doppler ultrasound, the sensitivity was 100% and the specificity was 97% for identifying testicular torsion.

Comment by Leonard Friedland, MD

There are some take-home messages from this retrospective review. In contrast to the history, the physical examination is very helpful when attempting to distinguish between testicular torsion, epididymitis, and torsion of appendix testis. Think testicular torsion when you note an absent cremasteric reflex, tender testicle, or abnormal testicular lie. Isolated tenderness at the superior pole of the testis is highly characteristic of torsion of appendix testis. Color Doppler ultrasound can be helpful in distinguishing among the causes; however, missed cases of testicular torsion have been reported. The practice at my institution mimics that of Kadish and associates: urology consultation is obtained in all uncertain cases. I was taught that epididymitis was a disease of sexually active patients, yet this paper confirms my experience that it occurs in children as well as adolescents. Epididymitis was observed across all age ranges; only 15% of patients with epididymitis had an abnormal urinalysis, and in those patients none cultured had a STD. Add epididymitis to your differential of the acute scrotum, even in young children.