APPENDICITIS WITH ACUTE SCROTUM

1. Simultaneous acute appendicitis with
right testicular torsion
CASE REPORT

2. intro
• 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.

3. • 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.

4. • 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 × 109/L) with predominant neutrophils (80%).
• The urine analysis was normal.

5. • The child was taken up for surgery.
• The right scrotal exploration revealed intravaginal torsion with viable testis [Figure 1], for
which orchid0pexy was done.
• The abdomen was explored through Lanz incision, which showed inflamed, edematous
appendix [Figure 2] with minimal turbid fluid for which appendicectomy was done.
• The child had an uneventful postoperative recovery and was discharged after 3 days.

6. 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.

7. • 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

8. • 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.

9. • 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.

10. • The child that we are reporting was an 12-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.

11. • 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.

14. Acute scrotum masquerading as
acute appendicitis

15. History
A case of male patient, 13 years old.
Complaining from abdominal pain in RIF of 3 days duration.
Associated with vomiting 5 times/ day gastric in nature.
Fever was prominent along course of the disease about 38.2 of low grade fever.
Patient was anorexic with no UTI symptoms or sore throat.

16. Examination
Patient was average in general condition.
Vitally : HR  120 RR 20 Temp  38.2
Abdominal Examination :
By Inspection  No dilated veins or scars or abnormal color with average
contour of the abdomen.
By Palpation  RIF tenderness with rebound tenderness.
Scrotal Examination was normal in day of operation.

17. Investigations
PAUS  average bowel loops with average motility with signs of inflammation in
the form of echogenic fat and mild free fluid collection between bowel loops.
Labs :-
CBC: TLC  7.3 Neut  73% Hb  11.5 Plt  212
Hct  37%
Urine analysis  Free
Patient was ready for operation

18. Operative Details
Patient underwent open appendectomy for acute appendicitis.
During removal of toweling, Scrotal swelling was noted.
O/E:-
By Inspection  Mild Rt. hemiscrotal swelling.
By palpation  Firm swelling confined to Rt. hemiscrotum with transverse
Rt. testis with hotness in comparison to Lt side with induration.

20. Patient then discharged from OR and transferred to do Scrotal duplex  Rt. testis
is enlarged in size with abnormal vascularity in comparison to the Lt. side
surrounded by turbid collection and testicular torsion couldn’t be excluded
suspected early torsion.
Then patient was transferred back to the OR on the same day.

21. Operative Details of scrotal exploration
Rt. hemiscrotal transverse incision.
Exploration of the Rt. hemiscrotum  transverse lie of Rt testis with no torsion
regarding spermatic cord.
Delivery of the Rt. tesits  it was bluish in color.
Hot fomentation of the Rt. testis was done for about 20 mins.
Rt. orcheopexy was done.

22.  Pre hot fomentation
with transverse lie

23.  Pre hot fomentation
with transverse lie

24. Post hot
fomentation

25. Post-operative follow up
Patient discharged from OR with average general condition.
Vital data post-operative was stable.
Patient was NPO for 1 day and started oral feeding in 2nd day post-operative.
Patient discharged home and now receiving his medical treatment in home.

26. Home message
• 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.

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