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Obtained images in potentially surgical scrotal
emergencies
a. Testicular torsion: In all pediatric patients that present with
acute scrotal pain, testicular torsion is the most serious condi-
tion that has to be recognized or excluded from the diagnosis, as
soon as possible, since testicular necrosis rate is analogous to
the duration of the consequent ischemia and immediate surgery
has to be considered. Differential diagnosis includes several
conditions that do not represent surgical emergencies. Sono-
graphic alterations reflect the ischemic changes of the tissue
components (alterations in penetration of the echoes). Thus, in
early stages, testis has a normal appearance in gray scale im-
ages. After 4-6 hours from onset of symptoms, the testis ap-
pears enlarged and hypoechoic (edema , increased liquid com-
ponents > increased echoe penetration). In later stages, after
12-24 hours, the testis becomes heterogeneous with mixed
echotexture (vascular congestion, infarcts and hemorrhage >
both echogenic and hypoechoic focal lesions). Sonographic
findings in gray-scale images are not pathognomonic and color
Doppler US has to be performed. Compared with the normal
side, reduction or absence of blood flow signals, even in the
critical early stages of testicular torsion, increases the sensitiv-
ity of US to 80-100% and the specificity to 90-100%.
b. Inflammatory conditions: The symptoms are similar to
those of testicular torsion, but the treatment is conservative. The
primary site of scrotal inflammation is almost always the epidi-
dymis (epididymitis), so, the US examination reveals enlarged
and edematous (diffusely hypoechoic or heterogeneous) epidi-
dymis. When the testis is affected (epididymo-orchitis), differ-
ential diagnosis from testicular torsion is based upon the dis-
covery of increased blood flow signals in the inflammative
tissues in color-Doppler images.
c. Torsion of appendages (testicular or epididymal): It does
not represent a true surgical emergency but usually mimics
acute testicular torsion. US may be normal or reveal a hypere-
choic or hypoechoic small structure (<10mm) between the
epididymal head and the upper pole of the testis with slight hy-
perhaemia adjacent to the appendix at color-Doppler images.
Thus US examination is helpful to avoid an unnecessary sur-
gery.
d. Trauma: Sonographic evaluation of scrotal trauma is of
outmost importance and US should always be performed as
soon as possible. Trauma of the scrotal organs, especially of the
testis, the type of parenchymal injury and tissue viability must
be determined. Resection of ruptured tissue has to be performed
at once, since 72 hours after the trauma occurs, the need for or-
chectomy increases from 7,4% to 55%. Sonographic findings
may be: a) testicular haematomas: focal lesions with variable
appearance depending on their duration b) rupture of testis: tes-
ticular parenchyma appears inhomogeneous, due to edema and
haemorrhagic elements, with irregular margins, due to the ex-
trusion of the testis tissue into the scrotal sac. Occasionally a
fracture may be seen as an echolucent line c) haematocele:
haemorrhagic contents around the testis. Rupture may be
missed in US if hematoma or extrusion of testicular tissue is not
obvious, thus “intact” testicular parenchyma viability must be
confirmed by Color Doppler US. Otherwise, partial or total or-
chectomy is necessary.
e. Scrotal hernia: It is defined as protrusion of intestinal loops
or omentum within the scrotum, through the inguinal channel,
with high risk of incarceration of the hernia’s contents, which
may lead to ischemic necrosis. Immediate surgical reduction is
thus required. US, with the technical features described above,
provides: a) excellent visualization, distinction and measure-
ment of thin structures, such as the intestinal wall width which,
in case of incarceration, exceeds 2-3 mm. b) optimal visualiza-
tion of the increased liquid in the lumen of the incarcerated in-
testine. Real-time sonography provides the ability to observe in-
testinal peristalsis, which, in case of incarceration is absent.
Vascular congestion or absence of blood flow can be demon-
strated by color Doppler sonography.
REFERENCES
Herbener TE (1996) Ultrasound in the assessment of the acute
scrotum. J. Clin. Ultrasound 24: 185 — 205
Meire H, Cosgrove D et al: Abdominal and general ultrasound —
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Middleton W, Middleton M, et al (1997) Sonographic predic-
tion of viability in testicular torsion. J Ultrasound Med 16:
23 27
Raymond H. OyenUltrasound Syllabus ECR 2002 : Scrotal ul-
trasound 280-295
Siegel MJ (1997) The acute scrotum. Radiol Clin North Am 35:
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Strauss S, Faingold R, Manor H (1997) Torsion of the testicular
appendages: sonographic appearance. J Ultrasound Med 16:
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Weber DM, Rosslein R, Fliegel C (2000) Colour Doppler sono-
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diatr Surg 10: 235 - 241
Whittingham T A (1995) Modern developments in diagnostic
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