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ECR 2018 / C-0065
Emergency ultrasound assessment of acute scrotal pain, a pictorial and pathological review.
Congress: ECR 2018
Poster No.: C-0065
Type: Educational Exhibit
Keywords: Education and training, Diagnostic procedure, Ultrasound-Colour Doppler, Ultrasound, Genital / Reproductive system male, Emergency
Authors: M. P. Brassil1, C. O Brien1, P. Govender1, W. Torreggiani2; 1Dublin/IE, 2Dublin 24/IE
DOI:10.1594/ecr2018/C-0065

Findings and procedure details

We carried out a retrospective study of all emergency referrals for testicular ultrasound over a 4 year period to the paediatric and adult ultrasound service in our centre. We examined the initial referrals and clinical details and the ultrasound images were read by two senior radiology specialist registrars under the supervision of a specialist uroradiologist. A wide and varied number of pathologies were identified which we will outline in this exhibit using image examples.

 

Epididymitis

  • The commonest cause of acute scrotal pain.
  • The commonest etiology is bacterial infection, rarely fungal infection may be a causative organism, particularly in the immunocompromised patient. [1]
  • The epididymis is enlarged and hypoechoic compared to the contralateral side, with or without focal hypoechoic regions representing abscesses. Alternatively, haemorrhage may occur and be present as hyperechoic foci or heterogeneity. Vascularity is increased. [2]

Case 1: 3 year old presented to the paediatric ED with a tender and erythematous hemi-scrotum. Fig. 1 Fig. 2

 

 

Orchitis

  • Inflammation of the testis.
  • Usually occurs as a consequence of direct extension of epididymitis.
  • Orchitis may present without epididymitis; however, this usually occurs in the paediatric population with a history of mumps. 
  • Focal or segmental low echogenicity within the testis with hyperaemia. 

Case 1:  14yo presented to ED with 2/7 history of pain and swelling right testis.  Fig. 3

 

 

Pyocoele

  • Purulent fluid collections in the scrotal sac that generally occur in conjunction with epididymo-orchitis. 

  • The purulent fluid collection generally arises from communication between the infected testicle or testicular abscess and an existing hydrocoele, through the mesothelial lining of the tunica vaginalis.
  • Complex, heterogeneous fluid collection in the scrotal sac with septa. Gas may be present causing hyperechoic foci and shadowing.

Case 1:  62yo diabetic with 10 day history of left testicular pain and swelling. Fig. 4 Fig. 5

 

Case 2: 31yo with fever, testicular pain and swelling, CRP 300, WCC 21. Fig. 6 Fig. 6

 

 

Testicular torsion

  • Testicular torsion occurs when a testicle torts on the spermatic cord resulting in the cutting off of blood supply.[3]
  • The most common symptom is acute testicular pain and the most common underlying cause, a bell-clapper deformity.
  • The diagnosis is often made clinically but if it is in doubt, an ultrasound is helpful in confirming the diagnosis.

Case 1: 17yo pain and swelling in left testis 3/7 post trauma in football match. Fig. 7 Fig. 8 Fig. 9

 

 

Testicular fracture

  • Disruption of the tunica albuginea, usually as a result of trauma.
  • The normally smooth tunica may become crinkled or retracted.
  • Hyperechoic or hypoechoic line through the testis.
  • Extrusion of seminiferous tubules may occur which can mimic a complex hydrocoele.[4].
  • Prompt diagnosis may lead to surgical repair.

Case 1: 35yo ED referral with painful , swollen right testis following same day trauma. Fig. 10 Fig. 11 Fig. 12 Fig. 13

 

Case 2: 47yo Trauma 18 months prior with new pain and swelling in right testis. Fig. 14 Fig. 15 Fig. 16 Fig. 17

 

 

Torsion of Hydatid of Morgagni

  • The hydatid of Morgagni is a small embryological remnant at the upper pole of the testis.

  • Torsion of the hydatid is of no consequence in itself except that it presents a similar picture to torsion of the testis which is a surgical emergency.

  • The pain from a torsion of the hydatid is usually less severe and has a longer history than for a torsion of the testis.

Case 1: 10yo ongoing scrotal pain following treatment for orchitis. Fig. 18 Fig. 19

 

 

Thrombosed Varicocoele

  • A varicocele is caused by dilatation of the pamfiniform plexus that drains the testicle, they occur more commonly on the left side due to anatomical drainage.
  • Thrombosis of a varicocele is very rare. Patients may present with acute scrotal pain mimicking a testicular torsion or strangulated hernia.
  • Diagnosis is difficult when based solely on clinical history and examination. Ultrasound with Doppler imaging is the best method of diagnosis.

Case 1: 58 year old man with a painful, palpable scrotal swelling inferior to his left testicle for 6 months.  Fig. 20 Fig. 21

 

 

Testicular Epidermoid

  • Testicular epidermoid cysts account for around 1-2% of all testicular masses and typically present in mid-adulthood (2nd to 4th decades). 
  • The most common type of benign testicular neoplasms.
  • Nonvascular, relatively well-defined intratesticular mass
  • May demonstrate a characteristic lamellated "onion skin" appearance with alternating hyperechoic and hypoechoic rings.
  • Some lesions show a target appearance with a halo of hypoechogenicity and a central hyperechoic region.

Case 1: 13 yo left testicular pain and swelling for 2 weeks. Fig. 22 Fig. 23

 

 

Testicular Seminoma

  •  The most common testicular tumor and accounts for ~45% of all primary testicular tumours. 
  • The most common presentation is with a painless testicular mass although some 45% will report a degree of testicular discomfort.
  •  Diagnosis following trauma is common as it draws the patient’s attention to the lump.
  • Usually appear as a homogeneous intratesticular mass of low echogenicity compared to normal testicular tissue, internal vascularity.

Case 1: 48yo with painful lump for a number of months. Fig. 24 Fig. 25 Fig. 26 Fig. 27

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