Torsion of the Testicular Appendices and Epididymis Clinical Presentation

Updated: Feb 02, 2022
  • Author: Jason S Chang, MD; Chief Editor: Erik D Schraga, MD  more...
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Patient 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. [16]

Pain may be present. Onset is usually acute, but pain may develop over time. 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 in the testicle is uncommon in complete testicular torsion.

Systemic symptoms are absent. Nausea and vomiting (frequently seen in testicular torsion) usually are 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 [12] :

  • 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 have found that a cremasteric reflex in the acute scrotum is unlikely to indicate 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.

  • 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 underlying normal, nontender testes allows for exclusion of testicular torsion on clinical grounds alone.

  • Vertical orientation of the testes is preserved.

In one study, researchers identified 3 key historical elements that serve as predictors for testicular torsion: duration of pain less than 6 hours, absence of cremasteric reflex, and diffuse testicular tenderness. None of the 141 study participants had testicular torsion in the absence of any of these elements. When all 3 elements were present, testicular torsion was diagnosed in 87% of patients. [17]