Torsion of the Appendices and Epididymis Clinical Presentation

Updated: Oct 20, 2016
  • Author: Jason S Chang, MD; Chief Editor: Erik D Schraga, MD  more...
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The patient's history is important in distinguishing torsion of the testicular appendages from testicular torsion and other causes of acute scrotum.

The most common cause of acute scrotum in prepubertal boys is torsion of the testicular or epididymal appendages. [7]

Pain may be present. Onset is usually acute, but pain may develop over time. Typically, it has a more gradual onset than testicular torsion. Intensity ranges from mild to severe. Patients may endure pain for several days before seeking medical attention. The pain is located in the superior pole of the testicle. This is a key distinguishing factor from testicular torsion. A focal point of pain on the testicle is uncommon in complete testicular torsion.

Systemic symptoms are absent. Nausea and vomiting (frequently seen in testicular torsion) are usually not associated with this condition.

Urinary symptoms are absent. Dysuria and pyuria are not associated with torsion of the testicular appendages. Their presence is more indicative of epididymitis.



Physical examination may reveal the following findings [5] :

  • The patient is afebrile with normal vital signs.

  • Although the scrotum may be erythematous and edematous, it usually appears normal.

  • An unreliable marker of pathology, the cremasteric reflex is usually intact. Several studies indicate that the presence of a cremasteric reflex in the acute scrotum is unlikely to be testicular torsion.

  • The testis should be nontender to palpation. If present, tenderness is localized to the upper pole of the testis. Diffuse tenderness is more common in testicular torsion.

  • The presence of a paratesticular nodule at the superior aspect of the testicle, with its characteristic blue-dot appearance, is pathognomonic for this condition. A blue-dot sign is present in only 21% of cases.

  • The combination of a blue-dot sign with clear palpation of an underlying normal, nontender testes allows for the exclusion of testicular torsion on clinical grounds alone.

  • Vertical orientation of the testes is preserved.

  • A study in 2005 scored 3 key historical elements as predictors for testicular torsion. Onset of pain less than 6 hours, absence of cremasteric reflex, and diffuse testicular tenderness. Out of 141 subjects, in the absence of any of these elements, none of the subjects had testicular torsion. With all 3 elements present, 87% were diagnosed with testicular torsion. [8]