Vestigial remnants in the embryology of the scrotum are often found as appendages on the superior portions of the testicle or the epididymis and can occasionally undergo torsion. This most commonly occurs in boys up to 16 years of age but has been reported in adults. The patient complains of sudden pain around the superior pole of the testicle or epididymis as the appendix undergoes necrosis and inflammation. Early in the course, palpation of a firm, tender nodule in this area will confirm the diagnosis.
Management and Disposition
Obtain urologic consultation immediately. Differentiating from the more emergent testicular torsion is the key responsibility. Ancillary studies are generally not helpful in making this diagnosis unless it presents very early in its course. The characteristic physical signs of a small, tender, upper-pole nodule along with a color Doppler ultrasound showing good flow to the testicle may mitigate the need for emergent surgery. With later presentations or an equivocal ultrasound, the diagnosis may not be made with confidence before surgery. If surgery is not deemed necessary by the urologic consultant, analgesics and rest are all that is required. The appendix will involute and calcify in 1 to 2 weeks.
Stretching of the scrotal skin across the necrotic nodule will occasionally reveal a bluish discoloration of the nodule, called the “blue-dot sign.” This is pathognomonic for torsion of the appendix.
A reactive hydrocele may accompany appendiceal torsion. When the hydrocele is transilluminated, the blue-dot sign may be revealed.
Blue-Dot Sign. A blue-dot sign is caused by torsion of the testicular appendix. It is best seen with the skin held taut over the testicular appendix. (Photo contributor: Javier A. Gonzalez del Rey, MD.)
Blue-Dot Sign. A blue-dot sign is seen in an older patient. (Photo contributor: Alan B. Storrow, MD.)