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A Testicular Appendage Presenting as a Mass of the Tunica

Albuginea of the Testicle
Adam J. Singer, MD, Southern California Permanente Medical Group, Woodland Hills

Infect Urol. 2001;14(2)

Introduction

A 33-year-old man found a nontender, hard, 5-mm nodule on the medial surface of the left testicle while toweling off after a
shower. He did not have any urinary complaints and denied genitourinary trauma, infections, and previous surgery. He was
not sexually active. His medical history was significant for schizophrenia and gastroesophageal reflux. His oral medications
were sertraline, 200 mg, in the morning and olanzapine, 50 mg, with ranitidine, 300 mg, at bedtime. His physical examination
was normal except for the asymptomatic nodule on the left testicle.

On ultrasonographic examination, the mass was highly echogenic and extended above the surface of the tunica albuginea
(Figure). Complete blood cell count; liver function tests; urinalysis; and levels of serum electrolytes, a-fetoprotein, and
ß-human chorionic gonadotropin were normal. Exploration of the left intrascrotal contents through an inguinal incision
revealed that the mass was "pearly white" and densely adherent to but separate from the tunica albuginea of the left testicle.
There were no other mass lesions and no testicular and epididymal appendages. The mass was carefully dissected from the
tunica albuginea. Biopsy results of the frozen and permanent sections were consistent with remnants of a testicular
appendage and dystrophic calcification encased by fibrous tissue.

Ultrasonographic examination of the testicle demonstrates a highly echogenic mass that extends above the surface of the
tunica albuginea of the left testicle (arrow).

Which of the following statements is true?

A testicular appendage is a vestigial remnant of the müllerian duct.

Torsion of a testicular appendage is more common in adolescents.

Ultrasonographic examination shows marked variation in appearance and size of testicular appendages.

All of the above.

Discussion

A testicular appendage is a vestigial remnant of the müllerian duct is correct. At approximately 8 weeks of fetal development,
the Sertoli cells of the testicles produce a müllerian-inhibiting substance that causes the müllerian ducts to degenerate,
primarily in a craniocaudal direction.[1] The cranial portion becomes the appendix testis, also known as the hydatid of

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 Morgagni, and the caudal end persists as the prostatic utricle. The hydatid of Morgagni is 1 of 5 testicular appendages. The
other 4 are:

Appendix epididymis, which originates from the head of the epididymis.

Paradidymis (organ of Giraldes), which originates from the caudal portion of the mesonephric tubules (paragenital
tubules) attached to the lower spermatic cord.

Cranial aberrant duct (cranial vas aberrans of Haller), which originates from the body of the epididymis.

Caudal aberrant duct (caudal vas aberrans of Haller), which originates from the tail of the epididymis. [2]

The testicular appendage, a polypoid structure, usually measures 1 to 3 mm in length and is located on the anterior-superior
aspect of each testicle at or near the groove formed by the globus major of the epididymis and the testis. Microscopically, it
consists of a fibrovascular core, occasionally containing dystrophic calcification, covered by an outer layer of columnar,
focally ciliated epithelium.
[3]
It is unknown which events are responsible for torsion of the appendix testis. Several causes for such torsion have been
proposed, including enlargement of the appendix testis at puberty, increased vascularity of the appendix testis, violent
cremasteric reflexes, and trauma.
[4]
During an acute episode of torsion of the appendix testis, it can swell to over 1 cm because of edema, vascular
congestion,hemorrhage, and infarction of the delicate underlying fibrovascular stroma. Following torsion, the appendix testis
may:

Detorse and resume its normal structure and anatomic location.

Undergo varying degrees of atrophy, fibrosis, inflammation, and calcification with or without undergoing detachment.

Slough off and become transformed into an intrascrotal body with a central calcified nucleus covered by concentric
layers of fibrous tissue that is reminiscent of a mobile or fixed scrotal oyster "pearl," as demonstrated in the case
report.[5,6] Holland and coworkers[7] found no credible evidence that an unremoved gangrenous appendage damaged
anything except itself and "like so much rubble strewn about after building an important structure, may cause
unforeseen mischief."

Torsion of a testicular appendage is more common in adolescents is correct. Torsion of the testicular appendage was first
described in 1922 by Colt.
[8]
In 1980, Altaffer and Steele
[9]
found no cases in the literature of torsion of the testicular appendages after the age of 18 years. They cautioned, however,
that it could occur in adults, as evidenced by 6 surgically documented cases at their medical center over a period of 20 years
in patients ranging in age from 20 to 38 years. They cited an extensive review done 10 years earlier of 364 cases in which
the age distribution ranged from 1 to 18 years, with the highest frequency occurring in boys between the ages of 10 and 13
years.
[10]
In a study by Van Glabeke and associates
[11]
of 543 scrotal explorations for acute scrotal pain in boys between the ages of 1 and 16 years, 250 were appendage torsions;
the average age was between 10 and 11 years. Puri and Boyd
[12]
reviewed 22 cases of torsion of the testicular appendage and reported that it was rare after the second decade because of
"local fibrosis"; they recognized that its predisposition for younger patients was unknown.

Ultrasonographic examination shows marked variation in appearance and size of testicular appendages is correct. Cohen
and coworkers[13] reported on the ultrasonographic features of 3 cases of torsion of the appendix testis ranging from 18
hours' to 10 days' duration, in which all masses were variably hypoechoic centrally with a thick or thin echogenic periphery.
The degree of echogenicity did not correlate with any temporal delay between symptoms and diagnosis. Johnson and
Dewbury[5] prospectively studied scrotal ultrasonographic scans of 51 consecutive men, between the ages of 22 and 82
years, for the assessment of possible testicular masses or chronic testicular pain and to obtain the imaging characteristics of
the appendix testis and epididymis. There was marked variation in size (0.18 to 0.74 cm) of the appendix testis as well as

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 inconsistencies in echogenicity and amount of solid and cystic components.

The decision to surgically explore calcifications of the tunica albuginea depends primarily on the clinical index of suspicion for
a malignant lesion and the attainment of a definitive tissue diagnosis of indeterminate lesions. [14] Look-alike lesions usually
include teratomas, tunica albuginea cysts, adenomatoid tumors of the tunica albuginea, fibromas, solitary fibrous tumors,
fibrous pseudotumors, adrenal rests, splenic gonadal fusion, and calcifications of tunica albuginea from sutures used for
orchidopexy.[15-17]

One year later, the patient has not had a recurrence and is asymptomatic.

Sidebar

This is a dilemma that each of us faces all too frequently. With the much higher public awareness of testicular malignancy
than in the past, men will often present with processes about which they are significantly worried but about which we, as
physicians, are less concerned. An ultrasonographic examination, which demonstrates no intrinsic or parenchymal pathology,
is often reassuring to the physician. The patient, however, is often "cancer-phobic," and exploration may be warranted to
ease a patient's mind. I am sure that each of us has seen patients who have self-referred because a physician has been
unsuccessful in reassuring them that a process is benign.

S. Lee Guice III, MD, Charlotte, NC

References

1. Maizels M. Normal and anomalous development of the urinary tract. In: Walsh PC, Retik AB, Vaughan ED Jr, Wein
AJ, eds. Campbell's Urology. 7th ed. Philadelphia: WB Saunders Co; 1998:1545-1600.

2. Ulbright TM, Amin MB, Young RH. Atlas of Tumor Pathology: Tumors of the Testis, Adenexa, Spermatic Cord, and
Scrotum. Third Series, Fascicle 25. Bethesda, Md: Armed Forces Institute of Pathology; 1999:1-39.

3. Weiss MA, Mills SE. Vestigial intrascrotal structures, ectopias, and appendages. In: Weiss MA, Mills SE, eds. Atlas of
Genitourinary Tract Disorders. Philadelphia: JB Lippincott; 1988:17.18-17.19.

4. Dresner ML. Torsed appendage. Diagnosis and management: blue dot sign. Urology. 1973;1:63-66.

5. Johnson KA, Dewbury KC. Ultrasound imaging of the appendix testis and appendix epididymis. Clin Radiol. 1996;51:
335-337.

6. Wilhelm E. The wandering testicular pain. Eur Urol. 1977;3: 76-77.

7. Holland JM, Graham JB, Ignatoff JM. Conservative management of twisted testicular appendages. J Urol. 1981;125:
213-214.

8. Colt GH. Torsion of the hydatid of Morgagni. Br J Surg. 1922;9:464.

9. Altaffer LF, Steele SM Jr. Torsion of testicular appendages in men. J Urol. 1980;124:56-57.

10. Skoglund RW, McRoberts JW, Ragde H. Torsion of testicular appendages: presentation of 43 new cases and a
collective review. J Urol. 1970;104:598-600.

11. Van Glabeke E, Khairouni A, Larroquet M, et al. Acute scrotal pain in children: results of 543 surgical explorations.
Pediatr Surg Int. 1999;15:353-357.

12. Puri P, Boyd E. Torsion of the appendix testis. Clin Pediatr. 1976;15:949-950.

13. Cohen HL, Shapiro MA, Haller JO, Glassberg K. Torsion of the testicular appendage: sonographic diagnosis. J
Ultrasound Med. 1992;11:81-83.

14. Mitcheson HD, Sant GR, Doherty FJ. Scrotal ultrasound. AUA Update Series. Baltimore: American Urological
Association; 1985;4:1-7.

15. Singer AJ. A tunica albuginea cyst. Infect Urol. 1999;12(6): 173-175.

16. Ulbright TM, Amin MB, Young RH. Atlas of Tumor Pathology: Tumors of the Testis, Adenexa, Spermatic Cord, and
Scrotum. Third Series, Fascicle 25. Bethesda, Md: Armed Forces Institute of Pathology; 1999:235-342.

17. Ward JF, Cilento BG Jr, Kaplan GW, et al. The ultrasonic description of postpubertal testicles in men who have
undergone prepubertal orchidopexy for cryptorchidism. J Urol. 2000; 163:1448-1450.

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 Infect Urol. 2001;14(2) © 2001 Cliggott Publishing, Division of CMP Healthcare Media

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