the diagnosis of both is made on clinical grounds , and symptoms can be atypical . a 14-year - old boy was referred by his gp to the paediatric emergency department with a 3-day history of intermittent lower abdominal pain and subsequently a 1-day history of right testicle tenderness and swelling . he had no bowel or urinary symptoms , no fevers or rigors , no history of trauma and denied any sexual activity . on examination , a slight tachycardia of 118 bpm was noted . the parents reported a retractile right testicle in infancy , which had not required surgical correction . the patient was consented for scrotal exploration and taken to theatre with a clinical diagnosis of delayed presentation of testicular torsion . surgery revealed a right - sided purulent hydrocele , a testicular appendage and patent processus vaginalis ( ppv ; fig .  1  ) . figure  1:closed left processus vaginalis and patent right processus vaginalis . closed left processus vaginalis and patent right processus vaginalis . post - operatively , the abdominal pains persisted and repeat examination noted focal right iliac fossa tenderness . blood tests revealed a neutrophilia of 14.48 and a c - reactive protein of 54 . on - call general surgical review led to a diagnostic laparoscopy , aspiration of turbid peritoneal fluid and the removal of an inflamed appendix . an acutely red , swollen and tender scrotum in a male adolescent should raise suspicion of testicular torsion and mandates prompt management . testicular torsion occurs in 1 in 4000 males under the age of 25 years with a peak onset around 714 years of age . with the exception of a high insertion of tunica vaginalis , very few risk factors for testicular torsion other causes of testicular swelling with or without pain include hernias , hydroceles , infection ( epididymitis , epididymo - orchitis , mumps ) and vascular malformations ( e.g. varicocele ) . testicular pain due to intra - abdominal pathology tracking down a ppv is rarely recorded in the literature . the processus vaginalis is an embryonic outpouching of the peritoneum present from the third month of gestation . it precedes the testis in its decent down the inguinal canal from the third month to the seventh month of gestation in males . during the first year of life , the lumen fuses from the internal inguinal ring to the upper pole of the testes , leaving the most distal part to form the tunica vaginalis . the reported incidence in newborns is 7080% , reducing to 3040% by the age of 34 years and persisting to adulthood in 5.1% ( autopsy assessment ) . failure of the fusion can present as a congenital inguinal hernia , a hydrocele or rarely due to intra - abdominal pathology such as appendicitis . it can present at any age but usually presents after the age of 5 years . suppurative appendicitis is caused by luminal obstruction leading to abscess formation and necrosis of the appendix mucosa . furthermore , suppurative appendicitis presenting as testicular swelling and pain is an extremely unusual presentation . abscess formation post appendectomy can lead to intra - abdominal collections , and tracking of these down a ppv causing testicular swelling has been described in the literature ( fig .  2 ) . appendicitis presenting as testicular swelling and pain with no history of intra - abdominal surgery is rarely reported . figure  2:tracking of pus down a closed and open processus vaginalis ( pc , peritoneal cavity ; v , vas deferens ; t , testicle ; tv , tunica vaginalis ; s , scrotum ) . tracking of pus down a closed and open processus vaginalis ( pc , peritoneal cavity ; v , vas deferens ; t , testicle ; tv , tunica vaginalis ; s , scrotum ) . the delay in diagnosis was caused by the clinically appropriate need to explore a patient presenting with an acute scrotum . the medical literature has suggested that patients can be safely observed and imaging utilized if a suppurative appendicitis is suspected , but an urgent scrotal exploration is required if testicular torsion is suspected , thus adding to the clinical dilemma [ 5 , 6 ] . furthermore , as in this case , anatomical variants such as testicular appendages can further confound a complex presentation . alertness of the clinical team to deviation from normal post - operative recovery and re - examination led to an alternate differential diagnosis and appropriate referral and treatment in this case . appendicitis presenting as testicular pain is extremely rare ( fewer than 10 cases in the literature ) and remains a diagnostic challenge . thorough history and examination , both pre- and post - operatively , are key to detecting atypical presentations of such conditions . communication and inter - disciplinary team working remain key to avoid missed diagnoses in such complicated cases .
patients presenting with testicular pain and swelling mandate an urgent urology review and scrotal exploration to prevent testicle loss due to torsion . 
 other pathology masquerading as torsion is extremely rare but can occur . 
 we present one such case . a 14-year - old male presented with a 1-day history of right testicular swelling and tenderness . 
 he was apyrexial and denied any other symptoms . 
 blood tests demonstrated raised inflammatory markers . 
 he had lower left - sided abdominal tenderness with a swollen , erythematous right hemiscrotum . during an urgent scrotal exploration for testicular torsion , 
 a purulent hydrocele with a patent process vaginalis was noted , but no torsion . 
 post - operative abdominal pain mandated a general surgical review and subsequent appendicectomy . 
 the patient made a full recovery . 
 acute suppurative appendicitis presenting as a urological emergency is extremely rare . to make a correct diagnosis and prevent multiple surgeries , a joint urological and general surgical assessment with a high index of suspicion 
 is required .