Disease Description (Causes and Symptoms)
- Definition: A condition caused by twisting (torsion) of an intrascrotal appendage (e.g., a lobule of the testicular appendage or an appendage of the epididymis), in which the blood flow to the testicle itself is unaffected but ischemia and inflammation of the appendage cause pain and localized swelling.
- Causes/Pathophysiology: A small intrascrotal appendage twists due to structural factors (such as a long stalk or broad mobility), blocking blood flow and leading to ischemia -> necrosis and inflammation.
- Main symptoms: Localized scrotal swelling and redness, localized tenderness (pain mainly palpable in the upper part of the testicle or on the surface of the scrotum), typically without severe tenderness of the entire testicle or reduced blood flow. A “blue dot sign” may sometimes be observed when visible through the skin. Fever and urinary symptoms are usually absent (except when infection is also present).
Treatment Methods and Precautions
- Initial diagnosis and treatment
- Imaging: It is most important to confirm with scrotal ultrasound (color Doppler) that testicular blood flow is normal (to distinguish it from testicular torsion). The torsed appendage often appears as an avascular small nodule.
- Conservative treatment (in most cases):
- Pain control with analgesics and anti-inflammatory drugs (e.g., nonsteroidal anti-inflammatory drugs)
- Rest and scrotal support (wearing a supporter), cold compresses
- Observation (checking whether the pain improves within several days)
- Surgical treatment when indicated:
- Scrotal exploration and removal (excision) of the affected appendage may be performed when the pain is severe, does not improve with conservative treatment, or the diagnosis is uncertain and testicular torsion cannot be ruled out.
- Medications and procedures
- Analgesics/anti-inflammatory drugs: Use for a short period
- Antibiotics: Use only when infection (such as epididymitis) is clinically and laboratory-suspected
- Precautions / Risk of complications
- Delayed diagnosis may result in mistaking the condition for testicular torsion, or conversely, missing testicular torsion, which can cause testicular damage. Immediate emergency evaluation is needed if sudden, severe pain occurs.
- Surgical evaluation is needed if pain persists or worsens despite conservative treatment.
- The prognosis is generally good with appropriate treatment, and the long-term risk of infertility is very low (when there is no testicular damage).
Checklist Before an Outpatient Visit (Including Sample Questions)
- What to prepare (bring)
- A list of currently used medications (including prescription and OTC medications)
- A record of when the symptoms recently began and how they have changed (when they started, pain severity and frequency, factors that improve or worsen them)
- Whether fever, nausea/vomiting, or urinary symptoms (painful urination, frequent urination, etc.) are present
- History of trauma (whether there has recently been a bruise or injury to the scrotal area)
- Medical history: undescended testicle, previous scrotal surgery, history of epididymitis, etc.
- Results of any previously performed scrotal ultrasound (original images or report, if available)
- Photos (if changes in pain, redness, or swelling are visible) — a guardian should accompany pediatric patients
- Examinations and evaluations at the outpatient visit
- Physical examination (inspection and palpation of the scrotum, checking the cremasteric reflex)
- Color Doppler ultrasound (checking testicular blood flow and the appendage)
- Blood tests (inflammatory markers) and urinalysis (evaluation for accompanying infection) if necessary
Examples of General Questions to Ask the Doctor
- What exactly is this condition? (Question about diagnostic certainty)
- How long is this pain expected to last? What is the prognosis?
- What are the side effects of the medication I am currently taking? Are there any interactions with other medications?
- How likely is surgery to be necessary? If surgery is performed, what will recovery be like?
- Could this condition affect long-term reproductive function (sperm production and fertility)?
Examples of Condition-Specific Questions
- How do you distinguish whether these symptoms are torsion of an intrascrotal appendage or testicular torsion (an emergency)? Which tests can confirm this?
- When is additional treatment (surgical exploration) necessary even if testicular blood flow appears normal on color Doppler findings?
(Emergency warning) If sudden severe pain occurs, the pain rapidly worsens, or nausea/vomiting or a change in testicular position (elevation) is observed, go to the emergency room immediately.