ACUTE SCROTUM (PowerPoint download)

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					              ACUTE SCROTUM
•Torsion of testis and appendage
•Infection: epididymitis, epididymo-orchitis, orchitis
•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

•   Types: Intravaginal– most common, peak incidence b/w 13-16
    years of life.
           Extravaginal- less common and confined to perinatal
• 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.
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
     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.
•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
•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 is the most common inflammatory
process involving the scrotum and more common in
•Epididymitis also occurs in children, but is then rare
      and due to infection with Streptococcus or
  •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. .
                  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 is characterized by focal, peripheral, hypoechoic
   testicular lesions that are poorly defined, amorphous, or
 •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
   •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

• 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
                      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
•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.