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     

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     

Ultrasonography of scrotal trauma

Ultrasound has emerged as the diagnostic imaging modality of choice in the evaluation of patients with scrotal trauma. Most studies of testicular rupture show great accuracy with virtually no instances of false-positive or false-negative diagnoses. Ultrasonography is capable of differentiating between scrotal hematoma, extratesticular fluid collections, posttraumatic torsion testis, posttraumatic epididymitis, epididymal hematoma, as well as testicular rupture. The differentiation of hematocele from pyocele or exudative hydrocele is generally not possible. In patients with suspected testicular rupture, an accurate diagnosis followed by prompt surgical repair is the key to preservation of testicular function. Ultrasound is an extremely useful adjunct to the physical examination in cases of blunt scrotal trauma both for the differential diagnosis of the enlarged scrotum and for determining the necessity for emergency surgery.     

Ultrasonography of scrotal trauma

Ultrasound has emerged as the diagnostic imaging modality of choice in the evaluation of patients with scrotal trauma. Most studies of testicular rupture show great accuracy with virtually no instances of false-positive or false-negative diagnoses. Ultrasonography is capable of differentiating between scrotal hematoma, extratesticular fluid collections, posttraumatic torsion testis, posttraumatic epididymitis, epididymal hematoma, as well as testicular rupture. The differentiation of hematocele from pyocele or exudative hydrocele is generally not possible. In patients with suspected testicular rupture, an accurate diagnosis followed by prompt surgical repair is the key to preservation of testicular function. Ultrasound is an extremely useful adjunct to the physical examination in cases of blunt scrotal trauma both for the differential diagnosis of the enlarged scrotum and for determining the necessity for emergency surgery.     

Testicular torsion: Evaluation and management

Testicular torsion is described as the twisting of the spermatic cord resulting in acute pain and ischemia. This has a tendency to occur more frequently during adolescence and its cause is unknown. The most common signs and symptoms include red, swollen scrotum and acutely painful testicle, often in the absence of trauma. Nausea and vomiting are common. The most common conditions in the differential diagnosis include epididymitis, strangulated inguinal hernia, traumatic hematoma, testicular tumor, or testicular fracture. Physical examination techniques such as scrotal elevation can be helpful in differentiating between epididymitis and testicular torsion, but emergent imaging with Doppler ultrasound seems to be the most helpful in confirming the diagnosis. Radionuclide testicular scintigraphy with ^99mTc is helpful when past the acute phase (the first 12 hours) and vascular compromise has prolonged. The clinician may attempt to manually reduce the torsion, but many need to be immediately referred to a urologist for a surgical exploration. Long-term prognosis for a functional, nonatrophied testicle is improved the sooner the torsion is diagnosed and treated.     

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.     

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.     

List of Exhibitors

Technical advances in magnetic resonance imaging (MRI), notably in high-resolution MRI, have opened up new diagnostic applications in male pelvic pathology. A major indication is the preoperative staging of prostate cancer, where MRI is more reliable than other imaging modalities in differentiating between localized and advanced disease. In monitoring local recurrence after radical prostatectomy MRI is also valuable in differentiating scar tissue from new growth. In benign prostate disease, MRI effectively displays the congenital cysts that may be associated with infertility. Other disease, however – notably benign prostatic hyperplasia – is generally an incidental finding. Ultrasound remains the imaging modality of choice for evaluation of pathologies of the penis, testis and scrotum, e. g. in differentiating malignant from benign scrotal masses or in diagnosing acute scrotum due to testicular torsion or rupture. In isolated cases, MRI is also a valuable diagnostic aid in conditions of these organs, e. g. in the preoperative localization of ectopic testes in cryptorchidism or if US findings are equivocal. Received 28 May 1998; Revision received 13 July 1998; Accepted 17 July 1998     

急性阴囊闭合性损伤的磁共振成像与彩色多普勒超声诊断

目的探讨磁共振成像（magnetic resonance imaging,MRI）与彩色多普勒超声在急性阴囊闭合性损伤中的诊断价值。方法收集急性阴囊闭合性损伤患者8例,所有病例全部经MRI及彩色多普勒超声检查,回顾性分析及比较MRI及彩色多普勒超声图像。结果8例急性阴囊闭合性损伤患者中,MRI示睾丸损伤出血8例（其中自膜下少量积血2例）,睾丸增大、阴囊肿大皮肤增厚、鞘膜积液8例,白膜毛糙3例,附睾增大5例（其中附睾损伤出血3例）,腹股沟区淋巴结肿大4例。彩色多普勒超声示睾丸损伤出血6例,睾丸增大6例,阴囊肿大、皮肤增厚8例,鞘膜积液6例,白膜异常未见,附睾增大2例,腹股沟区淋巴结肿大未见。结论MRI能清楚显示急性阴囊闭合性损伤,是目前诊断急性阴囊闭合性损伤的精确影像检查方法。     

The acute paediatric scrotum: the role of colour doppler ultrasound

Combined grey scale ultrasound and colour Doppler imaging of the acute paediatric scrotum provides a non-invasive means of assessing the structure and perfusion of the testis. Colour flow ultrasound is a sensitive and specific diagnostic tool for differentiating ischaemic pathology (in which blood flow rate is reduced) from inflammatory disease in which it is commonly increased. Using this technique the number of unnecessary surgical explorations of the scrotum can be reduced. The differential diagnosis of acute testicular pathology and the imaging characteristics of each disorder are described. Close collaboration between paediatric surgeons and radiologists is required to determine the optimal clinical and investigational strategy for each child.     

急诊阴囊疼痛患者核素阴囊显像的临床研究

目的 评价放射性核素阴囊显像用于鉴别急性睾丸蒂扭转和急性睾丸附睾炎的临床应用价值。方法 对４９例主诉急性阴囊疼痛患者的核素阴囊显像结果进行临床分析,并与超声检查结果相比较。“弹丸”式静脉注射Ｎａ＾９９Ｔｃ＾ｍＯ４后,分别行动态和静态采集,得到睾丸血流灌注像和静态血池像。结果 阴囊显像患侧阴囊放射性分布呈扭转表现的３７例患者中,经临床手术证实为睾丸蒂扭转者３５例,余２例为患侧腹股沟斜疝;３５例确诊为     

Imaging of the scrotum in children

Clinical examination of the scrotum is difficult due to the small size of the testes and the epididymis in infants and young children, and eliciting patients history is challenging. Therefore imaging of the scrotum in childhood bears great importance. Ultrasound is the standard imaging technique of choice providing the clinicians with a definitive diagnosis in most cases. However, in conditions of testicular torsion and epididymo-orchitis—the most common differential diagnosis of scrotal pain—ultrasound findings can be inconclusive and further evaluation is required. Since there is a large overlap between paediatric and adult pathology, differences from adults in anatomy and pathology must be considered when evaluating the paediatric scrotum.     

Clinical study of scrotum scintigraphy in 49 patients with acute scrotal pain: A comparison with ultrasonography

The significance of scrotum scintigraphy in differentiating acute testicular torsion from acute orchiepididymitis was evaluated. In this report, 49 patients with acute scrotal pain were examined with radionuclide scrotum scintigraphy and ultrasonography in parallel for comparison. Of 37 patients with decreased radioactivity in the abnormal side scrotum, 35 were diagnosed with testicular torsion surgically and the other 2 were diagnosed with indirect inguinal hernia. Only 17 among the 35 patients were diagnosed by ultrasonography as having testicular torsion. The remaining 12 patients with increased radioactivity in the abnormal side of the scrotum were all diagnosed with orchiepididymitis through conservative treatment and clinical follow-up, but only 8 of the 12 were correctly and exactly diagnosed by ultrasonography. In the process of diagnosing acute scrotal pain, radionuclide scrotum scintigraphy has obvious advantage over ultrasonography. It also has the advantage of being simple, fast and accurate but without any detrimental effect on the human body.     

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.     

Reliability of radionuclide scintigraphy for detection of testicular torsion: an animal study

Sodium pertechnetate Tc99m scintigraphy is a valuable technique for the evaluation of acute testicular torsion in postpubescent males. However, in neonates and children with small testicles, the method is less reliable. Since the testicles of adult rats and young children are of similar size, the reliability of testicular imaging for detecting torsion was evaluated in this species. The utility of the radionuclide angiogram (RA) and static images were determined in 17 anesthetized animals before, 2 h after and 20 h after ligation of the left spermatic cord. The preligation RA was asymmetric in 27% of animals, while the static images were abnormal in 18%. Postligation flow and static images were abnormal in 57% and 82% of the animals (localized to the correct side, 38% and 36%), respectively. The animals with vascular occlusion failed to show any statistically significant greater incidence of decreased radionuclide accumulation on the ligated side. To determine the influence of relative perfusion and extracellular fluid space of the scrotum and testicles on the images, additional studies were performed with 201Tl (representing perfusion) and 99mTcO4- (representing ECF space). Perfusion was approximately equal in the testis and epididymis but significantly higher in the scrotum. These results suggest that scrotal scintigraphy is unreliable for detecting acute torsion of small testicles.     

Testicular infarction secondary to acute inflammatory disease: demonstration by B-scan ultrasound

Acute epididymitis can lead to obstruction of the adjacent testicular blood supply, resulting in focal or diffuse infarction of the testis or epididymis in the absence of torsion. Four cases are presented to demonstrate the spectrum of B-scan ultrasound findings, ranging from focal necrosis of the epididymis and ischemic infarction of the testis to diffuse testicular infarction. Epididymal enlargement and skin thickening are consistently seen on ultrasound as well as swelling and decreased echogenicity of the testicle. The authors suggest a protocol for acute scrotal symptoms, incorporating clinical findings and (where appropriate) radionuclide scans.     

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.     

Differential diagnosis of scrotal masses by ultrasound

Ultrasound is the mainstay for imaging of the scrotum. It is used primarily for determining the location and nature of palpable lesions and to demonstrate nonpalpable lesions. Scrotal US is characterized by high sensitivity in the detection of intrascrotal abnormalities and is a very good mode for differentiating testicular from paratesticular lesions. However, scrotal US is limited in determining whether a focal testicular lesion is benign or malignant. The limitations of gray-scale US in the assessment of an acute scrotum and in particular of testicular torsion have now been overcome by color-coded duplex sonography and power Doppler.