ACUTE SCROTUM
•Torsion of testis and appendage
•Infection: epididymitis, epididymo-orchitis, 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 to perinatal
period.
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
•Color Doppler imaging has limited sensitivity for
detecting blood flow in pediatric patients with a
testicular volume of less than 1cc.
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 schoolaged 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.
•If the child does not have fever or
elevated white count, which can be seen in
cellulitis, than we can make the diagnosis
of Idiopathic scrotal edema.