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Age: 14

Sex: Male

Indication: Left testicular pain

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Case #13


Findings

  • Enlarged left testicle relative to the right with absent left testicular and left epididymal vascularity
  • Arterial and venous waveforms are demonstrated in the right testicle
  • Small left hydrocele


Diagnosis

Testicular torsion

Sample Report

Enlarged left testicle and epididymis relative to the right with absent vascularity, consistent with acute left testicular torsion. Small left hydrocele.

Normal appearance of the right testicle and epididymis.


Discussion

  • Ultrasound is the modality of choice when evaluating the scrotum
  • In patients presenting with acute scrotum, make sure you know which side is the symptomatic side as this can be helpful in differentiating cases of epididymo-orchitis from torsion
  • Testicular torsion results from twisting of the spermatic cord, leading to venous obstruction first following by arterial occlusion (the latter of which typically does not occur until there is greater than 360 degrees of twisting)
  • Ultrasound findings supportive of a diagnosis of testicular torsion include:
    • Twisting of the spermatic cord leading to a whirled appearance of the vessels – when present is very useful in identifying both complete and incomplete torsion
    • Absent vascularity on color and power Doppler analysis and absence of discernible arterial and venous waveforms on spectral Doppler tracings
    • Asymmetrically enlarged testicle (usually mildly enlarged initially and progressively enlarges as necrosis occurs)
    • Heterogeneous testicular echotexture on grayscale imaging (usually only a late finding)
    • Increased scrotal wall vascularity on the affected side (usually only a late finding)
    • Reactive hydrocele – a common but very nonspecific finding
  • The common predisposing anatomic variant to testicular torsion is the bell clapper deformity, where the tunica vaginalis has a high attachment on the spermatic cord, leaving the testicle unanchored to the scrotal wall and allowing for free rotation
  • Incomplete torsion can be a difficult diagnosis to make as blood flow (at least arterial) will be preserved to some degree
    • Worry about this if you see twisting of the spermatic cord and/or elevated resistive indices within the symptomatic testicle
  • Torsion-detorsion can also be a diagnostic conundrum as the affected testicle may have reactive hyperemia at the time of imaging
  • The magic time interval to intervention is about 4-6 hours, with testicular salvage likely within the window and unlikely beyond it



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