Untreated Isolated Torsion of the Epididymis in an Adolescent.

Although torsion of epididymis is extremely rare, it should be kept in mind in the differential diagnosis of acute scrotal pain in adolescents. We report here a very rare cause of acute scrotum: torsion of the epididymis.

Introduction

Isolated torsion of the epididymis is an uncommon cause of acute scrotal pain. To the best of our knowledge, only 6 cases of uncomplicated isolated epididymis torsion have been described in the literature. Sonographic images presented only in one of the previous reports. This is the first case of untreated and complicated isolated epididymal torsion in the literature presented with sonographic findings.

Case presentation

A 16 year-old patient presented to our department with acute scrotal pain. The pain had started 36 hours before admission localized mainly in left hemiscrotum and was decreasing in severity. Further anamnesis revealed no abnormalities. On physical examination he was afebrile. Physical examination was within normal limits except for edema and swelling at left hemiscrotum. The right hemiscrotum was normal on exam. Gray scale ultrasonography (US) and Color flow Doppler US (CDUS) was performed with Philips HD 11-XE using a 12 Mhz linear probe. US and CDUS revealed normal echogenicity of right testis and epididymis with a normal vascular flow. The left epididymis was markedly enlarged with a heterogeneous hypoechoic texture on gray scale US and CDUS revealed no vascular flow in the left testis (Fig. 1). Left scrotal wall has thickened. US and CDUS findings were normal in the right testis (Fig. 2). Based on these findings the diagnosis of isolated torsion of epididymis was given. But the patient and his parents refused the surgery. Two weeks later the patient admitted to our clinic with scrotal swelling and a hardness in the left scrotum. Urological examination revealed hard and painless swelling in lower pole of left hemiscrotum. US imaging were revealed a 3 × 2 cm hypoechoic heterogeneous cystic area compatible with necrosis in the left corpus epididymis (Fig. 3). On CDUS a few vascular signal was detected in surrounding head of the epididyms (Fig. 3). There was no vascularity in the center of cystic area and corpus-tail of the epididymis. These findings were thought to be suggestive of an ischemic necrosis caused by untreated isolated torsion of epididymis.

Figure 1

Ultrasonography of left hemiscrotum demonstrates enlarged, thickened, and heterogeneous epididymis. Color Doppler ultrasonography (CDUS) demonstrates no vascular signal in the epididymis.

Figure 2

(a) CDUS image of the right hemiscrotum revealed that the right testis has normal shape and echogenicity with normal vascularity Note the associated thickening of scrotal wall. (b) Longitudinal US image of the left hemiscrotum demonstrates a 3 × 2 cm cystic necrosis area in corpus of epididymis.

Figure 3

(a and b) Transverse US (a) and CDUS (b) image of the left hemiscrotum. US and CDUS scans reveal irregular, shaggy walls, intratesticular heterogeneous cystic lesion. CDUS scan reveals minimal vascularity in surrounding epididymal parenchyma.

Discussion

Isolated torsion of the epididymis is an uncommon cause of acute scrotal pain. It has been extremely rare reported in the literature.1, 2, 3, 4, 5 A long and tortuous epididymis with a long mesorchium or epididymal-testicular dissociation was reported as an underlying anomaly in these cases.3, 4 Anomalies of the vas deferens and the epididymis result from anomalous development of mesonephric duct system and include separation of the vas and epididymis from the testis. Compared to the normal population anomalous attachment of epididymis to the testis is more common in patients with undescended testis.

In our patient, US and CDUS findings included a normal right testis with normal vascular signals, the volume of the left epididymis was markedly increased with heterogeneous hypoechoic texture, without internal blood flow. Two weeks later the area of cystic necrosis was developed due to cutting off blood supply and tissue death in the epididymis parenchyma. The diagnosis of epididymal torsion with US and CDUS is based on detection of changes in echogenicity, enlargement of the epididymis as well as on demonstration of no flow blood in the epididymis. Torsion of the epididymis may be accompanied by presence of a thickened scrotal wall and a reactive hydrocele. If a torsion of epididymis is left untreated for more than six-eight hours, parenchymal necrosis and atrophy ensues. Parenchymal necrosis causes pain and local inflammation of surrounding tissue. In advanced stages of torsion, conventional ultrasound imaging shows inhomogeneities of the tissue and cystic necrosis areas.2, 4, 5 Differential diagnosis of epididymal torsion includes epididymitis and epididymal tumors. Epididymitis may manifest with enlargement of the epididymis, hydrocele and scrotal wall thickening. İncreased vascular signal in epididymal differentiates epididymitis from epididymal torsion. Epididymal tumors may also mimic epididymal torsion with the appearance of epididymal mass and enlargement. Absence of mass like appearance and vascular flow in epididymal torsion distinguish torsion from epididymal tumor.

Conclusion

The isolated torsion of the epididymis should be kept in mind in the differential diagnosis of acute scrotal pain in adolescents.

Conflict of interest

The authors have no conflicts of interest.