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 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. •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.