ACUTE SCROTUM

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ACUTE SCROTUM

• Torsion of testis and appendage
• Infection epididymitis, epididymo-orchitis,
  orchitis
• Trauma
• Hernia
• Idiopathic scrotal edema

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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.

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TESTICULAR TORSION
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• 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.

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CLINICAL PRESENTATION IN TORSION TESTES
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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.

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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.

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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.

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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. .

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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.

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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.

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ORCHITISCOMPLICATIONS
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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.

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HEMATOCELE
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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.

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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 .

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• 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.