ACUTE SCROTUM

Torsion of testis and appendage

Infection: epididymitis, epididymoorchitis, orchitis
Trauma
Hernia
Idiopathic scrotal edema

Testicular torsion

Torsion occurs when an abnormally mobile testis

twists on the spermatic cord, obstructing its blood
supply.

Patients present with acute onset of severe

testicular pain.

The ischemia can lead to testicular necrosis if not

corrected within 5-6 hours of the onset of pain.

Torsion can be intermittent and can undergo

spontaneous detorsion.

Types: Intravaginal most common, peak incidence

b/w 13-16 years of life.
Extravaginal- less common and confined

TESTICULAR TORSION

 In a child with an acute scrotum, testicular

torsion is not the most common condition
Torsion of testicular appendices represents
the more common cause of scrotal pain with
the peak incidence at 11 years of age.
Typically, it has a more gradual onset than
testicular torsion and patients may endure
pain for several days before seeking medical
attention.
Epididymitis occurs in children with spina bi
fida or infants with imperforate anus with
recto urethral fistula.

CLINICAL PRESENTATION
IN TORSION TESTES

NOT TO MISS TESTICULAR

TORSION

So although torsion of the testicular appendix and epididymitis are more

common, our goal is mainly to detect or exclude a testicular torsion.

Color Doppler
Complete absence of intratesticular blood flow and normal
extratesticular blood flow on color Doppler images is diagnostic, if the
flow is normal in the contra lateral testis. Yet, the presence of flow within
the testis does not exclude the presence of torsion, because incomplete
vascular obstruction can sometimes occur or intermittent torsion.
This case is very obvious because there is no flow on the affected side,
but also a difference in echogenicity.
With prolonged torsion, the testis is typically hypoechoic and
inhomogeneous and is often accompanied by a surrounding hydrocele. By
the time these sonographic findings occur, surgical salvage of the testicle
is unlikely.

TESTICULAR TORSION IN
YOUNG CHILDREN
In the very young child it can be
difficult to examine the testes
because they are very small and
mobile.
The prepubertal testis has a volume
of about 1-2 cc, while the
postpubertal testis has about 30cc.
With age the testis increases in
echogenicity, so in a very young child
the small testis can be difficult to
differentiate from the surrounding fat,
especially if it is retracted into the
inguinal canal

Testicular appendage
torsion
Testicular appendage torsion appears as a lesion of
low
echogenicity with a central hypoechogenic
area adjacent to the epididymis.
Peak incidence at 11 years of age.
Presents with scrotal pain of less severe intensity ,
upper scrotal tenderness and some times with blue
dot sign.
Most of the time however, we don't see it and we
do the US just to exclude a testicular torsion.
We should see torsion of testicular appendices
more as a diagnosis of exclusion.

Epididymitis
Epididymitis is the most common
inflammatory process involving the
scrotum and more common in adults.
Epididymitis also occurs in children,
but is then rare and due to infection
with Streptococcus or Staphylococcus.
In urinary tract abnormalities also
infection with E.Coli is seen.
A sterile chemical epididymitis can
result from reflux of sterile urine
through the ejaculatory ducts, for
instance if the ureter inserts in the
prostatic urethra, this may lead to
increased pressure in the vas
deferens. .

Epididymitis
The case on the left
shows the
typical features of epididymitis.
The epididymis is swollen and
heterogeneous. There is a hydrocele
and scrotal wall thickening. With
color Doppler there is increased flow.
A normal epididymis has only limited color flow.

ORCHITIS
Orchitis is characterized by focal, peripheral,
hypoechoic testicular lesions that are poorly
defined, amorphous, or crescent-shaped.
Orchitis also exhibits testicular hyperemia on
color Doppler sonography images and is
usually accompanied by epididymal hyperemia
due to concomitant epididymitis.
A reactive hydrocele is also frequently
associated with epididymoorchitis.
Focal testicular infarction can occur as a
complication of epididymitis when swelling of
the epididymis is severe enough to constrict
the testicular blood supply.
This appears as a hypoechoic intratesticular
mass devoid of blood flow.
The complications of orchitis are abscess
formation and ischemia.

ORCHITIS
COMPLICATIONS

Trauma
Hematocele
In trauma there is either a hematocele or testicular
hematoma.
In the acute phase the hemorrhage is echogenic and in the
chronic phase it is hypoechoic.
A hematocele results from scrotal or intra-abdominal
hemorrhage.
It represents bleeding between the leaves of the tunica
vaginalis and appears as a complex fluid collection.
With time, this collection can develop loculations, which
appear as thick septations.
It is important to be able to tell sonologically if the testis is
intact, because if there is a rupture, this can sometimes be
treated surgically.

HEMATOCELE

Testicular rupture
Testicular rupture is seen as focal alterations of testicular
echogenicity correlating with areas of intratesticular hemorrhage
or infarction in a patient with a hematocele.
A discrete fracture plane is identified in fewer than 20% of cases,
although visible alterations in the testicular contour are a common
finding sonologically.

STRANGULATED HERNIA
.

Strangulated Hernias in children are common especially in infancy.

Children may present with acute irreducible scrotal swelling,
irritability and symptoms and signs of intestinal obstruction.
Sometimes we can see them on plain films .
If they are filled with bowel, they are easy to detect on ultrasound,
but sometimes these hernias are only filled with soft tissue .

Idiopathic scrotal edema is

seen in school-aged boys.
They present with scrotal skin
swelling which spread to or
from the inguinal region, penis
or perineum so redness is not
confined to hemiscrotum but
spreads to both halves of
scrotum.
Cause is not always apparent
but may be bacterial cellulitis
or a topical allergy.
So the clinical question is, if
there is torsion or infection.
At examination the testes and
epididymis are normal and all
that we see on US is skin
edema.