Is Pathological Exam for Disorders of the Appendix Testis Necessary?

Testicular appendages are remnants of embryologic structures commonly encountered during pediatric operations. The literature is vague on the management of incidentally discovered testicular appendages found intraoperatively. We performed a retrospective review of 93 pediatric patients who were found to have an incidental testicular appendage during inguinal hernia repair, cryptorchidism, or testicular torsion cases from December 2017 to June 2020. 100% of the incidental testicular appendage pathology results were benign. All of the specimens were 1.0 cm or less in their largest dimension. Removal of these specimens is considered the standard of care at our institution to help prevent torsion of the testicular appendage, which is one of the leading causes of acute scrotum in children. The authors of this study argue that pathological analysis is unnecessary and may result in excessive use of resources without proven benefit.

Association of antimullerian hormone with the size of the appendix testis, the androgen and estrogen receptors and their expression in the appendix testis, in congenital cryptorchidism

Objectives Antimullerian hormone (AMH) causes regression of the mullerian ducts in the male fetus. The appendix testis (AT) is a vestigial remnant of mullerian duct origin, containing both androgen (AR) and estrogen (ER) receptors. The role of both AMH and AT in testicular descent is yet to be studied. We investigated the possible association of AMH with AT size, the AR and ER, and their expression in the AT, in congenital cryptorchidism. Methods A total of 26 patients with congenital unilateral cryptorchidism and 26 controls with orthotopic testes were investigated, and 21 ATs were identified in each group. AMH and insulin-like three hormone (INSL3) concentrations were measured with spectrophotometry. AR and ER receptor expression was assessed with immunohistochemistry using monoclonal antibodies R441 for AR and MAB463 for ER. For the estimation of receptor expression, the Allred Score method was used. Results AMH concentrations did not present significant differences between patients with congenital cryptorchidism and the controls. Also, no correlation was found between AMH, INSL3, and AT length. Allred scores did not present significant differences. However, expression percentiles and intensity for both receptors presented significant differences. Three children with cryptorchidism and the highest AMH levels also had the highest estrogen receptor scores in the AT. Conclusions No association was found between AMH and the studied major parameters. However, higher AMH concentrations, in combination with higher estrogen receptor scores in the AT, may play a role in cryptorchidism in some children. Larger population samples are needed to verify this observation.

Comparison of demographic and clinical characteristics in distinguishing testicular torsion from torsion of the appendix testis

Purpose The acute scrotum (AS) in the pediatric population is a medical emergency. The most common causes of AS include testicular torsion (TT) and torsion of the appendix testis (TAT). Their distinction may be clinically challenging. The purpose of our study was to compare demographic and clinical characteristics of the pediatric cases of TT and TAT and thus provide clinical evidence for distinguishing these two conditions. Methods We retrospectively analyzed all children ≤ 16 years who underwent surgical exploration for AS. The patients were divided into Group 1 or TT and Group 2 or TAT groups. Results Ninety patients were included in the study (24 with TT and 66 with TAT). Patients with TT were significantly older than those with TAT (p < 0.001). The peak incidence of TT was in the age of 12–16 years (p < 0.001), whereas the peak of TAT was in the age group of 7–11 years (p < 0.001). Scrotal pain was more prevalent in patients with TAT (p = 0.02), whereas systemic signs (nausea/vomiting and abdominal pain) affected more frequently the TT patients (p = 0.003 and p < 0.001, respectively). The mean duration of symptoms was significantly longer in the TAT group than in the TT group (p < 0.001). Color-Doppler Ultrasound (CDUS) findings of absent or decreased testicular blood flow in the affected testis strongly favored the diagnosis of TT (p < 0.001). Conclusion Our data indicate that the older age, shorter duration of symptoms, systemic signs (nausea/vomiting and abdominal pain), and characteristics CDUS findings can help distinguish between the two most common acute scrotum causes.

Association between Testicular Appendix and Undescended Testicle in children: A comparative study

The appendix testis may be involved in the normal testicular descent and there are reports of decreased incidence of appendix testis in children with undescended testis. The aim of this study was to evaluate the incidence of appendix testis in children with undescended testis in comparison to the incidence in children with normally descended testis.

Differential Diagnosis of Acute Scrotum in Childhood and Adolescence with High-Resolution Duplex Sonography

Acute testicular pain in childhood can be caused by testicular torsion, torsion of the appendix testis, or epididymo-orchitis. Quick and reliable diagnosis is essential for determining the further course of action (surgery or conservative approach). The diagnostic tool of choice is high-resolution sonography with a linear transducer (> 10 MHz) combined with color and spectral Doppler sonography. The Doppler device settings should include a low pulse repetition frequency (< 4 cm/s), a low wall filter (< 100 Hz), and adequate gain. Comparison with the unaffected healthy testis is essential. The most important of the three diseases is torsion of the spermatic cord because it requires immediate surgical intervention and detorsion. The affected testis is enlarged and has an inhomogeneous echotexture with hypoechoic and hyperechoic areas as well as an associated hydrocele. In testicular torsion, color Doppler shows reduced or absent intratesticular vessels in comparison with the healthy contralateral testis. Spectral Doppler shows decreased flow velocities especially during diastole in intratesticular arteries and an increased resistance index. The investigation should always include imaging of the spermatic cord from the outer inguinal ring to the upper pole of the testis. In contrast to a normal finding, the vessels and the ductus deferens are not displayed as linear tubular structures but in form of a spiral twist. Ultrasound shows a target-like structure with multiple concentric rings. Color Doppler sonography shows the typical whirlpool sign. In torsion of the appendix testis, the appendix testis is enlarged in the groove between the testis and epididymis. The longitudinal diameter of the appendix testis can be greater than 5 mm. The echogenicity of the torsed appendage can vary between hypoechoic (acute torsion) and hyperechoic (prior torsion). An associated hydrocele of varying size is usually seen. Color Doppler sonography reveals a lack of perfusion of the enlarged appendix testis and increased vascularity of the testis and primarily the epididymis. Epididymo-orchitis is characterized by an enlarged epididymis and/or testis with inhomogeneous echogenicity (hypoechoic – hyperechoic). Color Doppler sonography shows increased vascularity in comparison with the unaffected testis. Spectral Doppler reveals increased diastolic flow velocities and a decreased resistance index. Idiopathic scrotal edema and an incarcerated inguinal hernia must be ruled out in the differential diagnosis.

Testicular Torsion and Contralateral Torsion of the Appendix Testis

Testicular torsion is a urological emergency that results in deterioration of the blood supply of the testicle and ischemia as a result of the rotation of the spermatic cord around itself. It may show a wide clinical variety with inflammatory manifestations varying from mild abdominal pain to severe scrotal pain. Orchiectomy may be required in cases which are delayed and cannot be operated urgently. Torsion of the testis and epididymis are other frequently seen causes of acute scrotum in children. Growth of masses and hormonal stimulation in the adolescent age cause an increase in the tendency of the torsion of appendix testis which have a small pedicle and epididymis. In the presence of sudden scrotal pain, testicular torsion should be considered, if there is clinical suspicion, patients should be evaluated with color doppler ultrasound (CDUS) and scrotal exploration should be performed immediately. A 20-year-old male whose clinical picture, and scrotal ultrasonography suggested the presence of testicular torsion is presented in this case report.

New insights into the expression of androgen and estrogen receptors of the appendix testis in congenital cryptorchidism

BackgroundThe appendix testis (AT) is the most common vestigial remnant of the human testis. Variations in the presence and expression of AT androgen receptor (AR) and estrogen receptor (ER) have been reported in cryptorchidism. We studied the possible association of AR and ER expression of the AT with cryptorchidism.MethodsATs were resected from 40 boys who underwent inguinoscrotal surgery, (20 patients with congenital unilateral cryptorchidism [UC] and 20 controls with orthotopic testes and hydrocele). AR and ER expression was evaluated with immunohistochemistry, and the percentage and intensity of AR and ER expression were evaluated by the Allred scoring method. AT length was compared between the two groups. Correlation of AR and ER expression was evaluated independently in patients and controls.ResultsThe Allred score for AR trended toward lower values in UC compared to controls (p = 0.193), while ER scores presented statistically significant lower values in UC compared to controls (p = 0.017). No significant difference or trend was found in the expression of both receptors between high and low cryptorchidism (p = 0.981 for AR, p = 0.824 for ER) and for the appendiceal length between UC and controls (p = 0.369).ConclusionsThe findings of a trend for lower AR expression and a statistically significant lower expression of ER in UC may suggest an association of AR and ER with cryptorchidism and may provide an insight into the process of testicular descent.