|Year : 2012 | Volume
| Issue : 2 | Page : 82-83
Simultaneous acute appendicitis with right testicular torsion
Tanveer Akhtar, Pranjal Kumar Das, Nitin Singh, Haralappa Paramesh
Department of Pediatric Surgery and Pediatrics, Lakeside Institute of Child Health, Lakeside Medical Center and Hospital, Bangalore, Karnataka, India
|Date of Web Publication||17-Mar-2012|
5/2-1, 3rd Floor, Benson Cross Road, Benson Town, Bangalore - 560 046, Karnataka
| Abstract|| |
We present a child with both acute appendicitis and torsion of the right testis presenting at the same time. Testicular torsion possibly occurring due to vomiting in acute appendicitis so far has not been reported in the literature.
Keywords: Acute appendicitis, painful scrotum, testicular torsion
|How to cite this article:|
Akhtar T, Das PK, Singh N, Paramesh H. Simultaneous acute appendicitis with right testicular torsion. J Indian Assoc Pediatr Surg 2012;17:82-3
|How to cite this URL:|
Akhtar T, Das PK, Singh N, Paramesh H. Simultaneous acute appendicitis with right testicular torsion. J Indian Assoc Pediatr Surg [serial online] 2012 [cited 2013 May 22];17:82-3. Available from: http://www.jiaps.com/text.asp?2012/17/2/82/93974
| Introduction|| |
Acute appendicitis in children can rarely present with a tender swollen scrotum due to gravitation of the inflammatory intraperitoneal fluid into the scrotal sac via a patent processus vaginalis, raising the possibilities of epididymitis, scrotal abscess or testicular torsion. It is, therefore, extremely important to be aware of this unusual clinical scenario of association of an acute scrotum in a case of acute appendicitis, as only a high index of suspicion will enable prompt and successful management of both the appendicitis and the testicular torsion.
| Case Report|| |
An 11-year-old boy presented with a 12-h history of pain in the right lower quadrant of the abdomen followed by vomiting 2 h later. The child complained of sudden onset of pain in the right side of the scrotum immediately after vomiting. On examination, there was severe tenderness over the right iliac fossa with guarding and rebound tenderness. The right hemiscrotum was red and edematous. The right testis was in the high scrotal position, which was enlarged and extremely tender. The cremasteric reflex was absent. The child was started on intravenous fluids and antibiotics. An ultrasonography of the abdomen demonstrated tender and distended appendix with minimal free fluid around it. Doppler ultrasonography of the right testis showed absent blood supply. There was leukocytosis (12.9 × 10 9 /L) with predominant neutrophils (80%). The urine analysis was normal.
The child was taken up for surgery. The right scrotal exploration revealed intravaginal torsion with nonviable gangrenous testis [Figure 1], for which orchidectomy was done. In addition, prophylactic left orchidopexy was performed. The abdomen was explored through Lanz incision, which showed a severely inflamed, edematous appendix [Figure 2] with minimal turbid fluid for which appendicectomy was done. In addition, a Meckel's diverticulum was detected that was normal on appearance. Because it was broad based with no palpable nodules in it, it was left in situ. The child had an uneventful postoperative recovery and was discharged after 3 days.
| Discussion|| |
It is rare for a pediatric surgeon to come across a case of an acute appendicitis with scrotal pain and swelling. Satchithananda et al. reported a case of a 3-year-old Caucasian boy with acute appendicitis and epididymitis where inflammatory fluid from the inflamed appendix tracked down into the scrotal sac via a patent processus vaginalis and resulted in an inflamed epididymitis.  Shehzad et al. reported a 16-year-old boy who presented with a few hours history of a painful, red and swollen right hemiscrotum in addition to mild lower abdominal pain and vomiting, in whom the examination revealed a tender, red and edematous hemiscrotum with minimal abdominal signs. With a possible diagnosis of testicular torsion, urgent scrotal exploration was done, which revealed pus tracking through a patent processus vaginalis and a normal testicle. The abdominal exploration revealed a perforated retrocecal appendix with pus tracking down into the scrotum.  Méndez et al. and Singh et al. reported one case each with a history of scrotal pain secondary to acute retrocecal nonperforated appendicitis where surgical exploration showed a patent processus vaginalis and tracking down of pus into the scrotum. , The other abdominal condition that can present with pain in the inguinoscrotal region is Amyand's hernia, where the content of the inguinal hernia is an appendix, whether inflamed or noninflamed. The incidence of having a normal appendix within an inguinal hernial sac is about 1%, whereas only 0.1% of all cases of appendicitis present in an inguinal hernia, further underscoring the rarity of the condition. 
The child that we are reporting was an 11-year-old, who presented to us with acute appendicitis and torsion of the right testis occurring at the same time, which has not been reported before. We support the dictum of not to support two different diagnoses at the same time. We find it difficult to explain this unusual presentation. There is an ambiguity as to whether the presence of both acute appendicitis and testicular torsion represent a coincidence or related entities. The only plausible explanation is that the violent bout of the vomiting, secondary to appendicitis, could have generated cremasteric reflex to trigger off a torsion, which was very well supported by the history of events. This is supported by the fact that the cremasteric muscle surrounds the spermatic cord in a spiral manner, and contraction of this muscle has a rotational effect on the testicle. A strong contraction of this muscle can therefore rotate a predisposed, freely mobile testicle, which may undergo torsion.  We advocate a prompt and urgent Doppler ultrasonography of the scrotum in a child with an unusual clinical presentation of lower abdominal pain with an acute scrotum to rule out testicular torsion.
| References|| |
|1.||Satchithananda K, Beese RC, Sidhu PS. Acute appendicitis presenting with a testicular mass: Ultrasound appearances. Br J Radiol 2000;73:780-2. |
|2.||Shehzad KN, Riaz AA. Unusual cause of a painful right testicle in a 16-year-old man: A case report. J Med Case Reports 2011;5:27. |
|3.||Méndez R, Tellado M, Montero M, Ríos J, Vela D, Pais E, et al. Acute scrotum: An exceptional presentation of acute nonperforated appendicitis in childhood. J Pediatr Surg 1998;33:1435-6. |
|4.||Singh S, Adivarekar P, Karmarkar SJ. Acute scrotum in children: A rare presentation of acute, non-perforated appendicitis. Pediatr Surg Int 2003;19:298-9. |
|5.||Logan MT, Nottingham JM. Amyand's hernia: A case report of an incarcerated and perforated appendix within an inguinal hernia and review of the literature. Am Surg 2001;67:628-9. |
|6.||Seng YJ, Kevin M. Trauma induced testicular torsion: A reminder for the unwary. J Accid Emerg Med 2000;17:381-2. |
[Figure 1], [Figure 2]