The normal and abnormal scrotum in children: evaluation with color Doppler sonography.

The use of color Doppler sonography to evaluate the symptomatic testes in children with scrotal pain or swelling was prospectively studied with a fourth-generation color sonographic unit with a 7-MHz linear transducer. The 32 patients were 1 day to 18 years old (mean age, 8.6 years). Results were correlated with scintigraphic findings in 23 patients, with the final diagnosis established by surgery in 12 patients, and with clinical follow-up in all patients. Eight cases of testicular torsion, including two of acute torsion and six of late torsion, were correctly detected by color Doppler sonography and confirmed surgically. In the remaining patients, perfusion of the testis was correctly detected by color Doppler examination. The final diagnoses in these patients included torsion of the appendix testis (15 patients), epididymitis (five patients), epididymo-orchitis (one patient), yolk sac tumor of the testis (one patient), hydrocele (one patient), and local reaction to an insect bite (one patient). The ability to detect blood flow in the normal contralateral testis was also evaluated in 28 patients. Blood flow was demonstrated in normal testes larger than 1 cm3. Detection of flow in the very small normal prepubertal testis was often difficult, and no flow was identified in one testis. Flow was identified in central arteries in only six of 13 testes smaller than 1 cm3. We conclude that color Doppler sonography is helpful in the initial evaluation of pediatric testes, providing accurate evaluation of the involved hemi-scrotum in our patients and also providing the benefit of both structural and flow information. Until our sensitivity to low-velocity flow improves, we would not suggest the exclusive use of color Doppler sonography in the evaluation of testicular perfusion in the prepubertal patient. We advocate the addition of testicular scintigraphy to corroborate the presence of testicular perfusion when flow in intratesticular arteries cannot be established with certainty by color Doppler sonography.     

Testicular ischemia: color Doppler sonographic findings in five patients

We studied the findings on color Doppler sonography in five men with testicular ischemia (three with acute testicular torsion and two with testicular infarcts after herniorrhaphies). In all five cases, no intratesticular blood flow was identified on the symptomatic side, while normal blood flow was evident on the opposite side. In the three cases of acute torsion, no gray scale sonographic abnormalities were seen, and in the two cases of postoperative infarction, the abnormalities were nonspecific. These findings suggest that color Doppler sonography can be used to show decreased blood flow in cases of acute testicular ischemia and that it may have a role in evaluating patients with suspected testicular torsion.     

Hodentorsion: Diagnose, Differenzialdiagnose und Therapie im Kindesalter

Acute scrotum represents an emergency situation although testicular torsion is present in less than 20% of the cases. Sonography has meanwhile become the definitive modality for diagnosis. Its increasing use before surgical intervention has led to technical improvements in ultrasound diagnostics and critical assessment of ultrasound criteria to exclude testicular torsion as well as standardization of examination procedures. Central arterial and venous perfusion shown to be bilaterally equal on Doppler sonography is the most important criterion for excluding torsion.This article discusses other criteria such as the "resistance index," comparison of parenchymal structure of both testes, evidence for spermatic cord torsion, or differences between the sides in perfusion of the testicular parenchyma and highlights the difficulties involved in partial and intermittent testicular torsion. Alternative investigative methods and the significance of sonography in the differential diagnosis of other underlying causes are addressed. In summary, the combination of interpreting B-mode imaging, color Doppler, and power Doppler sonography and analyzing Doppler flow curves after clinical examination results in successful and conclusive evaluation of the testes in cases of acute scrotum in boys.     

Acute testicular torsion in children: the role of sonography in the diagnostic workup

Acute testicular torsion in children is an emergency and has to be diagnosed urgently. D oppler sonography is increasingly used in imaging the acute scrotum. Nevertheless, in uncertain cases, surgical exploration is required. In this study, we attempted to define the role of Doppler sonography in the diagnostic workup of the acutely painful scrotum. All patients admitted between 1999 and 2005 with acute scrotal pain were included. After clinical assessment, patients were imaged by Doppler sonography with a ‘‘high-end’’ instrument. In cases of absent arterial perfusion of the testis in Doppler sonography, surgical exploration was carried out. Patients with unaffected perfusion were followed clinically by ultrasound for up to 2 years. Sixty-one infants and children aged 1 day to 17 years (median: 7.9 years) were included. In 14 cases, sonography demonstrated absent central perfusion, with abnormal parenchymal echogenicity in six. Absence of venous blood flow together with reduction of central arterial perfusion was found in one infant. In these 15 patients, surgical exploration confirmed testicular torsion. Among the other 46 patients, we found four cases with increased testicular perfusion and 27 with increased perfusion of the epididymis. In one infant, a testicular tumour was found sonographically, and orchiectomy confirmed diagnosis of a teratoma. Follow-up examinations of the conservatively treated patients showed good clinical outcome with physiologic central perfusion as well as normal echogenic pattern of both testes. No case of testicular torsion was missed. By means of Doppler sonography, an unequivocal statement regarding testicular perfusion was possible in all cases. The initial Doppler diagnosis was confirmed by operative evaluation and follow-up ultrasound. Testicular torsion can therefore be excluded by correctly performed ultrasound with modern equipment. Patrick Gunther and Jens-Peter Schenk contributed equally to this work     

Ischemic orchiditis: review of 5 cases diagnosed by color Doppler ultrasonography

PURPOSE: To study color-doppler ultrasoundfeatures of testicular infarction caused by orchiepididymitis, a severe complication of orchiepididymitis. MATERIAL: and Methods. Five patients were included over a 2 year period. All presented with more than 24 hours of pain. A final diagnosis of testicular infarction caused by orchiepididymitis and color doppler ultrasound was available in all cases. RESULTS: All patients showed doppler ultrasound signs of testicular ischemia. Either vascularisation was not detectable or intratesticular resistive index was increased with a negative diastolic flow. Orchidectomy was performed in all patients. CONCLUSION: Color doppler examination of the scrotum should include measurement of intratesticular resistive index. An elevated RI can be suggestive of ischemia.     

Acute painful scrotum

The ability of US to diagnose the pathogenesis of the acute scrotum is unsurpassed by any other imaging modality. It is the first imaging performed in patients with acute scrotum. Knowledge of the normal and pathologic sonographic appearance of the scrotum and proper sonographic technique is essential for accurate diagnosis of acute scrotum. High-frequency transducer sonography combined with color flow Doppler sonography provides the information essential to reach a specific diagnosis in patients with testicular torsion, epididymo-orchitis, and testicular trauma.     

Recent advances in sonography of the testis and scrotum.

Ultrasonography remains an accurate, rapid, and safe tool in the imaging of disorders of the testes and scrotum. The strengths of gray scale sonography lie in its ability to distinguish intratesticular from extratesticular processes. Improvements in resolution permit greater confidence in the characterization of lesions as representing simple fluid, complex fluid, or solid lesions. The addition of flow information by color Doppler ultrasonography and duplex Doppler ultrasonography represents the most exciting recent advancement, permitting even more diagnostic information in the evaluation of these patients.     

Scrotal sonography in infants and children

In this review we will attempt to summarize the use of scrotal sonography in infants and children. The material is gathered from the literature and from our own experience of 197 sonograms performed on 175 pediatric patients. Included will be information on testicular development and descent, normal sonographic anatomy, classification of scrotal disease, and the final diagnoses of the sonograms. Scrotal sonography has proven useful in evaluating undescended testes in the inguinal canal and just inside the inguinal ring. It is of limited value when the testes are in the abdomen. Sonography can often distinguish the various causes of nonpainful scrotal masses such as tumors, hydrocele, and meconium peritonitis. Sonography is highly accurate in distinguishing normal from abnormal scrotal contents and in separating testicular from extratesticular masses. However, sonography does have limitations in distinguishing benign from malignant neoplasms or from some inflammatory lesions.

Sonography can be successfully used in the differential diagnosis of the painful scrotum especially with color flow Doppler. Inflammatory diseases that often involve the epididymis can be distinguished from torsion. Torsion of the appendages has been diagnosed.

In cases of scrotal trauma, management decisions are often based on the sonographic findings. Conditions that require surgical management such as testicular rupture or large testicular hematomas can be recognized. Information is included on a variety of miscellaneous conditions such as hydrocele, varicocele, and ambiguous genitalia in which sonography has proven valuable.     

Evaluation of testicular viability by power Doppler ultrasonography in experimentally induced acute testicular torsion

RATIONALE AND OBJECTIVE: We sought to determine whether torsed testis viability can be evaluated by ultrasonography (US) including power Doppler US in an experimental model of acute testicular torsion. METHOD: Eighteen rats underwent unilateral 540 degrees testicular torsion and contralateral orchiopexy. Gray-scale and power Doppler US were performed 24 hours later. We evaluated echogenicity, intratesticular vascular flow, and testis size. Echogenicity and intratesticular vascular flow were quantitatively analyzed by using a visual scale and computer-based analysis. After US, detorsion was performed in torsed testes, and 6 days after detorsion testes were excised to determine testicular viability, which was determined using gross and microscopic findings. US findings before detorsion were correlated with testicular viability. RESULTS: At US performed 24 hours after testicular torsion, all viable testes (n = 7) were homogeneous and isoechoic versus contralateral testes. In nonviable testes (n = 11), lower (82%) and heterogeneous (73%) echogenicities were seen on gray-scale US. Intratesticular vascular flow was preserved in 86% of viable testes. In nonviable testes, no intratesticular vascularity was observed in 82%, and intermittent, peripheral blood flow was detected in the remaining 18%. Intratesticular focal lesions were observed in 45% of nonviable testis. Quantitative analysis showed a statistically significant difference between viable and nonviable testes in terms of testicular echogenicity and intratesticular vascular flow. CONCLUSION: Preoperative US including power Doppler examination can predict testicular viability in testicular torsion. Echogenicity of nonviable testes was found to be hypoechoic and inhomogeneous. Power Doppler examination showed no or intermittent peripheral blood flow in nonviable testes.     

Using color power Doppler ultrasound imaging to diagnose the acute scrotum. A pictorial essay

Acute nontraumatic scrotum represents one of the most important emergencies in the male population. Etiology of the acute scrotum greatly varies, but the most common causes include testicular torsion and inflammatory disease. Currently, the most successful diagnostic imaging is ultrasound integrated by the application of color power Doppler. A very important finding is the detection of presence/absence of intratesticular blood flow for the early identification of testicular torsion. This pictorial essay aims to illustrate the various causes of acute nontraumatic scrotum by using color power Doppler ultrasound imaging, based on a retrospective analysis of 768 cases performed at our Level I trauma center between January 2005 and June 2006.     

Continuous arterial spin-labeling perfusion magnetic resonance imaging of the human testis

RATIONALE AND OBJECTIVES: The purpose of this study was to determine if continuous arterial spin-labeling perfusion magnetic resonance imaging could be used to detect testicular perfusion in human subjects. MATERIALS AND METHODS: Continuous arterial spin-labeling magnetic resonance perfusion imaging was performed in seven normal male volunteers and in one patient with a painful scrotum following vasectomy. RESULTS: Normal testicular blood flow was demonstrated in 14 of 14 normal testes in seven volunteers, as well as in two normally perfused testes in the post-vasectomy patient. A change in the steady state magnetization was observed in all of the normally perfused testes of the seven volunteers. CONCLUSION: It is possible to detect blood flow to the normally perfused testes using noninvasive spin-labeling perfusion magnetic resonance imaging. This modality could potentially, in future investigations, be used to image patients with suspected testicular torsion and resultant testicular ischemia.     

Epididymoorchitis mimicking testicular torsion in Henoch-Schönlein purpura

Henoch-Sch?nlein purpura, although being a systemic vasculitis, mostly involves skin, gastrointestinal system, joints, and kidneys. Testicular involvement is a rare occurrence. A 7-year-old boy with Henoch-Sch?nlein purpura developed acute scrotum and was referred to rule out testicular torsion. On gray-scale ultrasonography, the testes and epididymis were slightly enlarged, and had heterogeneous and hypoechoic echotexture. The scrotal wall was thickened as well. Color and power Doppler ultrasonography revealed increased vascularity in scrotal contents. Testicular torsion was excluded and the diagnosis of testicular involvement of Henoch-Sch?nlein purpura was established. Color Doppler US, together with gray-scale findings, can be useful in the evaluation of Henoch-Sch?nlein purpura with acute scrotum, excluding testicular torsion and preventing unnecessary surgery.     

Imaging of the acute scrotum

The scrotum is a superficial structure and clinical examination is frequently not enough for making a specific diagnosis. In acute scrotal pain US can confirm the presumptive clinical diagnosis and provide additional relevant information. In testicular torsion, color-Doppler imaging has a central role since it has become possible to identify it at early stage by showing absence of perfusion in the affected testis before any gray-scale abnormality. Scintigraphy remains a satisfactory alternative in evaluating testicular torsion and should be used when color Doppler is inadequate, raising doubts about the suspected torsion. Diagnosis of torsion of testicular appendages is particularly difficult. Ischemic infarction shows a characteristic pattern at gray-scale and color-Doppler imaging, whereas hemorrhagic ischemia may require MRI. Inflammatory diseases of the scrotum can be easily investigated by echo color Doppler and conventional radiography, and CT can be particularly useful in the detection of gas bubbles. In scrotal trauma, scrotal hematoma, hematocele, intratesticular hematoma, and testicular rupture can be identified using gray-scale US with very good reliability. Magnetic resonance imaging is indicated when a small tear of tunica albuginea is suspected but not visualized on US. Received: 3 May 2000/Accepted: 8 June 2000     

Color Doppler sonography of normal and torsed testicular appendages in children

OBJECTIVE: The purpose of our study was to determine the size and appearance of normal and torsed testicular appendages on color Doppler sonography. SUBJECTS AND METHODS: Thirty-three patients with acute scrotal pain underwent gray-scale and color Doppler sonography and subsequent surgery. Twenty-two patients had torsion of the appendix testis, six had epididymitis, three had torsion of the testis, and two had torsion of the appendix epididymidis. The testicular appendages of 30 patients and the testes of three were excised and sent to the laboratory for histopathologic examination. RESULTS: A testicular appendage was identified on color Doppler sonography in 23 patients (21 patients with torsed appendages and two patients with epididymitis). The torsed appendixes testis measured from 4.1 to 16.3 mm, and the normal appendixes in the two patients with epididymitis measured 4.1 and 5.6 mm. With the visualization of an appendix larger than 5.6 mm as the sonographic diagnostic criterion for torsion of a testicular appendage, sensitivity was 68.2% (95% confidence interval (CI), 45.1-85.3%), and specificity was 100% (CI, 74.7-100%). CONCLUSION. The identification of a testicular appendage larger than 5.6 mm is suggestive of torsion. Therefore, depending on the patients' clinical conditions, these cases can be treated conservatively when an appendage larger than 5.6 mm is identified.     

Does color Doppler sonography improve the clinical assessment of patients with acute scrotum?

INTRODUCTION AND OBJECTIVES: Our experience concerning the use of color Doppler sonography (CDS) in the differential diagnosis of acute scrotum is reported. MATERIAL AND METHODS: From July 2000 to July 2005, 155 patients (median 17.2 years) were admitted with a diagnosis of acute scrotum (unilateral in 150 cases, bilateral in 5). Along with a careful anamnesis and the physical exam, all patients underwent a CDS study of the scrotal content using a sonograph GE Logiq 500 with a multifrequency (7.5-10 MHz) linear probe Small Part. The following CDS parameters were evaluated: intensity of the color-power signal on the testicular parenchyma and on the epididymis; systolic peak velocity (SPV) and telediastolic velocity (TDV) in correspondence of the gonadal hilum. Ultrasound and flowmetry parameters registered on the painful testis were compared with those registered on the healthy controlateral testis. The reduction/absence versus the increase of color-power signal in the parenchyma and the reduction/absence versus the increase of SPV and TDV in the centripetal intratesticular arteries were considered presumptive of testicular torsion versus orchiepididymitis. RESULTS: The results only refer to the 150 patients (300 testis) with acute monolateral scrotum. The clinical picture and the physical exam suggested a torsion of the spermatic cord in 40 cases, a spontaneous de-torsion in 5, an orchiepididymitis in 80, a blunt scrotal trauma in 15, a bulky epididymal cyst or a hydrocele in 4 and a testicular pain of unknown etiology in the remaining 6 cases. Standard US was pathological in 95 patients (63.3%); CDS was pathologic in 70 patients and in 42 of them suggested a testicular torsion. Fifty-three patients underwent surgical exploration: among 42 patients with a presumptive diagnosis of testicular torsion, the diagnosis was confirmed in 22 cases, no anomaly was found in 16 cases and in 4 patients a torsion of testicular appendix was found. The rupture of the tunica albuginea was present in six out of seven patients submitted to surgical exploration for previous blunt trauma and the sonographic diagnosis of hematocele was documented in all cases. The single false-negative diagnosis of testicular torsion in CDS occurred in an 18-month-old child. In presence of funicular torsion, the sensitivity and specificity of physical exam and CDS were 100% versus 95.7% and 86.5% versus 85.3%, respectively; sensitivity and specificity of SPV, TDV and color-Doppler signal on the testis were 100% and 94.8% versus 100% and 90.1% versus 95.7% and 90.8%. In the pre-operative assessment of scrotal trauma, the B-mode US showed a sensitivity and specificity of 100% and 90%, respectively; the color Doppler analysis has not supplied with additional elements for planning a surgical exploration. In presence of orchiepididymitis, the sensitivity and specificity of the physical exam in association to CDS was equal to 100%. In all patients with torsion of the testicular appendix, physical exam and CDS parameters were within normal limits. DISCUSSION AND CONCLUSIONS: In our experience CDS is an indispensable imaging modality for the clinical assessment of patients with acute scrotum; however, the informations it can afford are operator-dependent and have to be supported by the history and physical exam of the patient. CDS findings constitute probably an important medico-legal support when the necessity of surgical exploration is excluded; anyway, in presence of a clinical suspicion of testicular torsion, even with an apparently normal CDS, the surgical exploration is recommended.     

彩色多普勒超声在小儿睾丸扭转诊断中的价值

目的探讨彩色多普勒超声对小儿睾丸扭转的诊断价值。方法对44例临床疑诊睾丸扭转男孩(年龄1岁～15岁,平均8岁)首先用二维超声显示双侧睾丸附睾形态、结构及内部回声,再用彩色多普勒观察血流情况,所有病例经手术证实。结果44例中的41例睾丸扭转患者患侧睾丸血流减少或消失。结论彩色多普勒诊断睾丸扭转有很高的特异性,简便无创,应作为诊断睾丸扭转的首选方法。     

Color Doppler US of the scrotum.

Color Doppler ultrasonography (US) is an increasingly important tool in the evaluation of the scrotum, especially in acute scrotal disorders. With this modality, arterial flow is readily detected in the normal spermatic cord and testis but is not seen in the epididymis; venous flow is not seen anywhere in the normal scrotum. Scrotal inflammatory lesions appear as hypervascularity of the epididymis or testis, even though gray-scale findings may be normal or nonspecific. Testicular torsion is demonstrated by an absence or marked decrease in the number of visible vessels. Small tumors (less than 1.5 cm) are hypovascular, and larger tumors (greater than 1.5 cm) are hypervascular. The modality also demonstrates Valsalva maneuver-induced venous flow augmentation in varicoceles and altered flow in testicular tumors. Color Doppler US allows for evaluation of morphologic findings and perfusion and enables accurate diagnosis of most scrotal disorders.     

睾丸扭转35例临床分析

目的探讨睾丸扭转的诊治方法。方法回顾性分析35例睾丸扭转病例的临床资料。患者年龄14～29岁,发病至确诊时间7h～45d。入院前误诊为急性睾丸附睾炎抗炎治疗23例,误诊时间3～45d,误诊为急性阑尾炎行阑尾切除术1例。结果所有患者均行彩色多普勒超声检查,33例确诊。4例试行手法复位均失败。手术探查示精索鞘膜内型扭转34例,鞘膜外形扭转1例;扭转度数360°～720°。2例行患睾复位和固定术,其余患者均切除患睾。所有患者同时行健侧睾丸固定术。结论对于非外伤性阴囊急症,尤其对青壮年患者,临床医生要考虑到睾丸扭转的可能,有条件者应立刻行CDFI等辅助检查以帮助诊断和鉴别,高度怀疑睾丸扭转者应早期果断行手术探查以最大限度地提高睾丸的挽救率。     

Prenatal testicular torsion: sonographic appearance in the newborn infant

The prenatal diagnosis of spermatic cord torsion is often really difficult and the diagnosis is usually retrospective. Herein, we report a case of a male newborn baby who presented at delivery with an enlarged, swollen and tender scrotum. US showed an enlarged right testis, with dishomogeneous texture, fluid collection between the testis and the tunica vaginalis and large hydrocele. Differential diagnosis included hydrocele complicated by infection or hemorrhage, testicular tumor or postnatal testicular torsion. Color and power Doppler did not reveal any flow signal, and the diagnosis of antenatal torsion with initial necrosis was made. The role of color Doppler US is emphasized in directing the patient to emergency surgical exploration, when testicular salvage may be possible. Delayed surgical treatment can be proposed, when the diagnosis of antenatal torsion has a high degree of certainty. However, the Doppler examination of a newborn baby's testis is a very difficult challenge even for an experienced radiologist. Electronic Publication