CLINICO-HISTOPATHOLOGIC PRESENTATION OF A NIGERIAN CHILD WITHTORSION OF A TESTICULAR APPENDAGE: A CASE REPORT

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K.I Egbuchulem¹, A. A Ishola², C.O Onwurah³.

1. Division of Paediatric Surgery, Department of Surgery, University College Hospital, Ibadan.
2. Division of General Surgery, Department of Surgery, University of Ibadan, Ibadan.
3. Final year Medical Student, College of Medicine, University of Ibadan, Ibadan.

Abstract

Torsion of hydatid of Morgagni (appendix testis) is one of the causes of acute scrotum. However, it can be distinguished from testicular torsion by its insidious onset and localizable tenderness. In addition, colour doppler ultrasonography has characteristic findings in torsion of hydatid of Morgagni. We present a case of torsion of hydatid of Morgagni which was of sudden onset, and had clinical features mimicking testicular torsion which warranted immediate scrotal exploration. Intra-operative finding was torsion of appendix testis as against the clinical presentation suggestive of testicular torsion. Acute scrotum being a time dependent emergency may not allow time for doppler ultrasonography which will differentiate torsion of appendix testis from testicular torsion thus preventing unnecessary scrotal exploration.

Introduction

The appendix testis and the appendix epididymis are the two testicular appendages that can also undergo torsion mimicking testicular torsion. The appendix testis or hydatid of Morgagni is a vestigial remnant of the Mullerian duct which is present in about 76 to 83% of testes.^1,2 It is located on the superior pole just between the testis and epididymis, and it is the most common appendage to undergo torsion.^1,2 Torsion of hydatid of Morgagni is a common cause of acute scrotal pain in prepubertal boys.^1–3

Torsion of hydatid of Morgagni commonly causes pain similar to that of testicular torsion.^4,5 Physical examination in torsion of testicular appendage may reveal a normally appearing scrotum with intact cremasteric reflex and tenderness localized to the upper pole of the testis or epididymis with a palpable localizable mass in the area of maximum tenderness. However, reactive inflammation of surrounding structures may cause a more diffuse pain making torsion of appendix testis indistinguishable from testicular torsion.⁶

Colour doppler ultrasonography is the imaging modality of choice for the evaluation of the acute scrotum in all age groups. Treatment of torsion of a testicular appendage is usually non-operative, and symptoms usually resolve within a week. A scrotal exploration usually is performed when there are doubts about the diagnosis. Scrotal exploration is recommended without delay for a scrotal scan to improve chances of testicular salvage in patients with very high risk of having of testicular torsion as determined by the Testicular Workup for Ischaemia and Suspected Torsion (TWIST) score.⁶ TWIST score is a 7-point tool for evaluating acute scrotal pain. It consists of testicular swelling (2 points), hard testis (2 points), high-riding testis (1 point), absent cremasteric reflex (1 point) and nausea/vomiting (1 point).⁷ A score of 5 and above is concerning for testicular torsion for which delays should be avoided, and urgent scrotal exploration recommended.^7,8

We report a case of torsion of hydatid of Morgagn in 9-year-old Nigerian male who presented with sudden onset acute scrotum.

CASE PRESENTATION
A 9-year-old male presented with a sudden onset left scrotal pain few hours prior to presentation. The pain was dull in nature and relieved transiently by the use of analgesics. There was no history of fall or trauma to the scrotum. There was no history of dysuria, urinary frequency, pus or blood in the urine. He had no history of recent urethral catheterization or previous episode of scrotal pain. There was no associated fever, nausea or vomiting.

At presentation, he was afebrile and well hydrated. His vital signs were normal while genital examination revealed a swollen left hemi-scrotum which was warmand tender. Cremasteric reflex was absent and Prehn sign was negative. He had a TWIST score of 5 (left testicular swelling; 2, absent cremasteric reflex; 1, hard left testis; 2) which necessitated immediate scrotal exploration.

Intra-operative finding was an inflamed tiny polypoid tissue in 630Ú anticlockwise torsion at the superior pole normal left testis close to the groove between was detorsed, ligated at its base and excised (Figure 2). Scrotal incision was closed with subcuticular vicryl 2/0 stitches, and patient was discharged on 2nd postoperative day. He was seen at surgical outpatient clinic at 2nd post-operative week with no complaints and the testis and epididymis (Figure 1). The appendage satisfactory wound healing. Microscopy of excised surgical specimen revealed sections of polypoid tissue partly lined by pseudostratified columnar epithelium(Figure 3). There were ducts lined by similar
pseudostratified epithelium and were within the underlying loose fibromyxoid stroma. Also seen were congested blood vessels. Features are in keeping with an epididymal appendage (Figure 4).