Acute Appendicitis Masquerading as Acute Scrotum

Abstract

Acute appendicitis presents typically with periumbilical pain that in a few hours settles at the right lower quadrant of the abdomen. Atypical presentations are common but association with acute scrotum is an extreme rarity. A 30-year-old fisherman presented at a rural medical facility with a 2-day complaint of severe pain at the right hemiscrotum followed about 24 hours later with mild diffuse abdominal pain. There was associated mild fever and nausea but no vomiting. There were no urinary symptoms and no recent sexual exposure. Initial physical examination revealed mild generalized tenderness worse at the right lower quadrant but the scrotum was not remarkable, and cremasteric sign was negative. He was admitted as a case of acute abdomen for close observation. Abdominal and scrotal ultrasound scan were normal. By the second day of admission, pain became marked at the right lower abdomen with associated vomiting. There was also marked tenderness at the right lower quadrant with rebound. A diagnosis of acute appendicitis was thus made and appendicectomy done after proper workup. The abdominal and scrotal pain stopped after surgery and the patient was discharged on the seventh postoperative day. Patients with unusual abdominal and scrotal pain should be admitted and closely observed and evaluated to prevent unnecessary scrotal exploration or negative appendicectomy.

Introduction

Acute appendicitis is the commonest abdominal condition requiring emergency surgery (Old, Dusing, Yap, & Dirks, 2005; Paulson, Kalady, & Pappas, 2003; Terawasa, Blackmore, Bent, & Kohlwes, 2004). It was first described in 1886 by Reginald Fitz (1886), a professor of pathologic anatomy at Harvard. The incidence of appendicitis has its peak in the teens and early 20s, becoming quite uncommon after middle age (O’Connell, 2004). The diagnosis to a large extent hinges on the patient’s history and the performance of a thorough physical examination (Fashina, Adesanya, Atoyebi, Osinowo, & Atimomo, 2009). The reliable historical feature of appendicitis is the characteristic sequence of symptoms: periumbilical pain followed by anorexia, nausea, and fever, with the pain settling a few hours later at the right lower quadrant (Fashina et al., 2009; Itskowitz & Jones, 2004; Ohene-Yeboah & Togbe, 2006). Ruggieri (2001), however, reported that fewer than half of all persons with appendicitis present with these symptoms. In fact, it is more common for patients to present without typical symptoms.

The challenges of diagnosis of appendicitis are real since the differential diagnosis is myriad (Anderson, 2004; Clegg-Lamptey, 2002). There is no single sign, symptom, or test that can identify all cases; significant morbidity accompanies diagnostic delay, and debate still swirls around appropriate treatment (Ruggieri, 2001).

Although appendicitis is a common clinical problem with protean manifestation, its association with acute scrotum (acute testicular pain or swelling, the urologist’s equivalent to the general surgeon’s “acute abdomen”) is very rare (Méndez et al., 1998); only 14 cases having been described in the literature. We present a case of acute, nonperforated appendicitis that presented together with severe right hemiscrotal pain.

Case Report

A 30-year-old Andoni fisherman presented to Bethesda Clinic, Port Harcourt, in South Nigeria with a 2-day history of severe pain in the right hemiscrotum. About 24 hours after the onset of the scrotal pain, he developed mild diffuse abdominal pain. There was a history of fever and anorexia with associated nausea but no vomiting. There was neither history of dysuria nor urethral discharge. He denied a recent sexual exposure.

Initial physical examination showed an acutely ill-looking young man in severe scrotal pain. His pulse rate was 92 beats per minute and blood pressure 120/70 mmHg. The abdomen, though generally soft was mildly tender, more at the right iliac fossa. There was neither guarding nor rebound tenderness. The scrotal skin looked normal, and the right hemiscrotum was not swollen but very tender. The cremasteric reflex (elevation of the testicle in response to stroking the ipsilateral upper inner thigh) was absent. Angell’s sign (horizontal disposition of the testis on the opposite side to torsion with the patient examined standing) was negative.

A provisional diagnosis of acute scrotum and appendicitis was made and he was admitted for workup and placed on intravenous ceftriaxone 1 g daily, metronidazole 500 mg 8 hourly, and gentamicin 80 mg 8 hourly.

His hematocrit was 42% and white blood cell count 9.2 × 10⁹ L⁻¹. The urinalysis was normal and HIV status negative. Abdominal and scrotal ultrasound scan showed nothing of significance.

On the second day of admission, the right lower abdominal pain became worse and he started vomiting. The tenderness at the right iliac fossa was associated with guarding and rebound tenderness. A diagnosis of appendicitis was made, and he was scheduled for emergency appendicectomy. At surgery, a visibly inflamed appendix at retrocaecal position was found. This was removed and the stump buried with vicryl suture. The appendix was sent for histopathology and the result came as acute suppurative appendicitis. The scrotal pain stopped after the surgery. His recovery was uneventful and he was discharged on the seventh postoperative day.

Discussion

Acute appendicitis has many differential diagnoses because of its protean manifestations. Unusual presentations are due to variations in the location of the vermiform appendix or its sharing of the same nerve supply with other organs. It has been reported by Fukukura and Chang (2005) and Luchs, Halpern, and Katz (2000) that 0.13% of all cases of acute appendicitis occur in various external hernia sacs. These include Amyand’s hernia and de Garengeot’s hernia. In Amyand’s hernia, between 0.08% and 1% of cases of acute appendicitis occur in the right inguinal canal (Carey, 1967; D’Alia et al., 2003). About 0.08% of cases of acute appendicitis were found in the femoral canal in de Garengeot’s hernia (Nguyen & Komenaka, 2004).

Acute scrotum has been described by Cochlin (2005) as usually because of acute epididymo-orchitis or torsion of the testis. Diagnosing the causes of testicular pain from physical examination and historical clues can be very challenging. An important test is the cremasteric reflex. A positive or normal test is seen when the testicle retracts after light stroking of the inner ipsilateral thigh. This was negative in this patient. It is typically present in epididymitis but absent in testicular torsion as the testis is already elevated (Trojian, Lishnak, & Heiman, 2009). Ciftci, Senocak, Tanyel, and Büyükpamukçu (2004) demonstrated that an absent cremasteric reflex has a 92% sensitivity in diagnosing testicular torsion. In addition, patients with torsion are more likely to present earlier and have an abnormal testicular orientation than patients with epididymitis (Ciftci et al., 2004; Karmazyn et al., 2005). Ultrasonography (US) has been used by some clinicians in the diagnosis of testicular pain. The published sensitivity of color Doppler US for diagnosing testicular torsion has a wide range of 63% to 100% with a specificity of 80% to 100% (Gunther et al., 2006; Kalfa et al., 2007; Karmazyn et al., 2005).

The absence of recent sexual exposure and typical physical signs, negative urinalysis, and unremarkable ultrasound findings largely ruled out the possibility of epididymo-orchitis and torsion in this patient. Although David, Yale, and Goldman (2003) suggested that prompt diagnosis and scrotal exploration is essential in torsion to enhance testicular salvage rate, exploration was not contemplated in this case as there was no strong or compelling indication for it.

The occurrence of testicular pain as the initial manifestation of acute appendicitis has been reported by Clarkson and Pradhan (2008) as extremely rare, but it can occur as referred pain (Romanes, 1986). This is because the testes share the same nerve supply as the appendix from the T10 segment of the spinal cord. Other atypical symptoms of acute appendicitis such as genitourinary complaints arising from an inflamed retrocaecal appendix irritating the urinary bladder or ureter, acute scrotum resulting from intraperitoneal fluid from a perforated appendix entering the scrotal sac through a patent processus vaginalis, and spurious diarrhea from an inflamed pelvic appendix irritating the rectum have been reported by Rabinowitz and Hulbert (1995) and Yasumoto et al. (1998).

The use of diagnostic imaging in cases of suspected appendicitis has also increased in recent years, with computed tomography (CT) and US being the most commonly used modalities. Paulson et al. (2003) and Old et al. (2005) have observed that CT is more accurate than US for diagnosing appendicitis in adults and adolescents. The overall accuracy of CT ranges from 93% to 100% and that of US from 71% to 97% (Paulson et al., 2003; Terawasa et al., 2004). These facilities are not commonly available in developing countries but even when available, they are often not affordable. CT and US also have some limitations; results are often influenced by variations in patients’ age, ability to cooperate, body habitus, the presence of pregnancy, and the availability and skill of trained operators (Old et al., 2005; Paulson et al., 2003; Terawasa et al., 2004).

The atypical presentation of this index case warranted admission and repeated clinical evaluations, which led to the eventual decision to operate. This is not unusual in acute abdomen. Repeated clinical evaluation in bizarre cases of acute abdomen enhances early diagnosis and prevents delayed surgery and the attendant morbidity and mortality (Clarkson & Pradhan, 2008; Paulson et al., 2003). The disappearance of testicular pain postappendicectomy in this patient confirmed its relationship with the appendix.

In conclusion, a patient with an unusual clinical presentation of an acute scrotum with associated history of lower abdominal pain should be carefully evaluated and closely observed to avoid unnecessary scrotal exploration or negative appendicectomy.