Pediatric Scrotal Ultrasound - HD

Introduction

My name is Brian Coley.
I'm the radiologist in chief at Cincinnati Children's
Hospital Medical Center in Cincinnati, Ohio.
And today I'll be talking about scrotal
ultrasound in the child.

Indications for Imaging the Pediatric Scrotum

Regarding why we image the pediatric
scrotum, generally all indications fall into these three
main areas, the undescended, testes, acute scrotal pain,
or a scrotal mass.

Undescended Testes

Regarding undescended testes, approximately 96%
of testes are descended at birth
and 99% are descended by one year.
And in looking at large adult series, there's a prevalence
of only 0.28% In adult patients.
Most of the time in children, an empty scrotum is really due
to a retractile testes.
Although there is a fairly decent percentage
of undescended testes, only about 4%
of testes are truly absent.
And the reason this is important is
that undescended testes can lead to infertility
through abnormal tubular maturation,
and there's a fairly significant risk of neoplasia.
10% of all testicular cancers arise in scended testes.
And these risks, it's important to remember persist
after treatment as well as, these children may present
with testicular torsion of these nodes descended testes.
So in the evaluation, 80% are usual,
usually palpable,
and most of these are in the inguinal canal
as it descends from the abdomen, into the,
into the scrotum.
So in these cases, very few are actually referred by urology
because they can perform a good physical exam.
When we do get asked to look at them, it usually is in,
obese children
or people who are not as comparable with the physical exam.
And ultrasound is great.
When they are referred
to finding these testes within the canal
and pelvis, they're typically a little more hypo coic.
They're a little more ovoid
and they're smaller than the usual testes
beyond the inguinal canal.
It gets a little sketchy as
to whether we should really be doing imaging.
A lot of people have advocated MRI or multi detector ct,
but really with the advent of laparoscopy, most urologists,
if the are, are going straight
to last laparoscopy if they cannot find, the test
that's within the Ola canal.
So what does it look like here
that you'll see there's a hypo coic,
testicular appearance within the inguinal
canal surrounded by fat.
This one is actually up,
near the internal inguinal ring.
You can see adjacent to loops of bowel.
And in this particular image,
you can see here are two testes that are,
along the internal inguinal ring just within the pelvis here
on the right, the bladder, and then here on the left.
So in summary, most of the time this is all we're going
to do to really look for undescended testes,
the inlet canal and around the bladder.
Beyond that ultrasound has a pretty limited role in looking
for undescended testes elsewhere within the abdomen.

Acute Scrotal Pain

Testicular Torsion

Now moving on to acute scrotal pain.
The mantra typically is, is that if after clinical exam
and evaluating the patient, a clinician thinks it's torsion,
then you should go straight to surgery.
You should not, bother with any sort of imaging,
examination.
And the reason for this is that rapid diagnosis is vital
and the testicular salvage is related
to time from onset of symptoms.
So if you can get to a patient
before say 12 hours, there's a very good chance
that you'll be able to save the testis if you get to them
after 12 hours.
Often you'll get a, a result like this
where you have an infarcted, necrotic testis
that cannot be salvaged.
However, you've gotta realize that most pediatric patients
with acute testicular pain don't have testicular torsion.
In a clinical review, about 30% do,
but in an imaging reviews, much less than 10%
of children will have it.
In part, that's a sampling bias
because most patients now get imaged
and not, treated just on the basis of physical exam.
So while testicular torsion is a clinical diagnosis,
most children won't have it and thus don't need surgery.
The exam can be unclear even in those
that do have testicular torsion,
and it is of course a very litigious area.
So all that means our clinicians wanna make very sure
that they're not missing something
and that they're not performing a necessary surgery.
So that means that we're going to image these kids.
Ultrasound is certainly the gold standard for this.
Nobody uses, nuclear medicine studies anymore.
So ultrasound with doppler is the standard.
You need to do gray scale examination
and then some sort of color or power doppler.
My opinion is you also should have a waveform
to document a symmetric arterial flow.
Now the gray scale appearance is said to be unreliable.
And that I think is in general true.
However, I think most of you that have much experience
or that start doing this are going to realize
that the gray scale appearance is almost never normal.
So these testes often have a transverse lie.
You may actually see a twisted spermatic cord, you may be,
able to identify a bell clapper deformity,
and there is often a para testicular mass or pseudo mass.
So I think something that's become very clear is that,
you can usually see a cord twist.
So on this image you can certainly see the normal perfuse
test is with powered doppler,
the enlarged relatively hypoechoic testis next to it.
And then if you look, I think I can make you believe
that this swollen cord looks very twisted
and I can detect flow in the cord right down to the level
of the testis itself.
In this other case, again, I think you can see
and appreciate, both on the extended field of view image
and this clip, that the cord is twisted.
You can certainly see there is flow actually in this cord,
but once we get down to the testis itself, there's very,
very poor profusion.
There's been some good work.
This is not my clip, this is from, Dr.
Del Pozo in Madrid
and scanning transversely along the, inguinal area
and down into the scrotum.
I think you can sort of get this kind
of whirlpool appearance, very much like what we see
with a midgut volvulus of the testicular vessel swirling,
in this twisted cord.
There's been some good literature suggests
that this may be one of the most sensitive ways
to diagnose testicular torsion.
The reason testes Taurus is that there's mal fixation
of the testis within the scrotum,
and this is referred to as the bell clapper deformity.
If you think of the, of the testis as the clapper
and then the scrotum as the bell, the testis is free to
to move about within the scrotal sac
and twist upon its vascular pedicle.
This can be a very difficult diagnosis to make,
but if you do have some hydrocele fluid, you might be able
to do it with very light pressure.
You'll be able to see that there is no fixation
of this testes at any point along the scrotal wall.
Now this does require a very light touch.
In this particular case,
the child was having intermittent scrotal pain.
Certainly this is a little bit of a funny looking testes.
It is in enlarged and a little bit hypo coic perhaps
relative to the asymptomatic normal side.
But at this point the child was fairly pain free,
but with a very light touch in scanning around.
You can tell that this is not a fixed testis.
So this child most likely has intermittent torsion
and detorsion, which we know occurs in approximately 50%
of boys who ultimately present with testicular torsion.
So look for that when you have the hydrocele fluid
because even though this child doesn't need surgery tonight,
this child needs urologic consultation
and orchiopexy often with torsion, usually
with torsion, you're gonna have an
abnormal position of the testis.
So even though we are scanning superior
to inferior in a longitudinal fashion related to the body,
on the left testis, we certainly have a,
a transverse view of the testis since it has an
or abnormal high transverse lie within the scrotal sac
as opposed to the normal longitudinal view
of the asymptomatic side.
And of course, when we turn on color,
we've got flow in the asymptomatic side,
no demonstrable flow in the painful side.
And again, that has to be considered torsion.
This para testicular mass
or pseudo mass is usually composed of swollen cord
and enlarged epididymus.
Sometimes there can be some hemorrhage,
but often you'll get this large para testicular mass
adjacent to, the testicle itself.
And of course you still need to put on, doppler,
prove that there's no flow.
And in this case we're not able
to get any flow in the symptomatic side.
And of course you have to prove you can get flow somewhere.
So we can see flow in the normal side again,
indicating acute testicular torsion, Just more images.
Again, I usually always start
with the asymptomatic side, one to gain,
the confidence
and trust of the, the child
before moving to the tender side,
but also to make sure that I've got sufficient technical
parameters to detect flow if it's there.
So once I've detected flow in the asymptomatic side,
move to the other side.
Little doubt about this one.
Very heterogeneous necrotic testis, this one
with a little more heterogeneous echo texture.
But again, I can get flow in para testicular structures,
but no flow within the testis itself.
Neonatal torsion is a little bit different.
These are often pre, birth events.
These testes are rarely viable,
but we do get asked to image them.
In this particular case here,
this is a fairly acute torsion.
This is actually the testis itself
and this is, swelling within the,
walls of the scrotum.
As these, age,
you can start getting calcifications in the tunica ghia
here, as you can see in this testes.
This is the same one over time.
And then when time goes on even further,
these may shrink down
and all you may see is just a little calcified nubbin.
And this is frequently a finding when we're looking
for undescended testes.
And if you actually don't find one, if you find this,
you can be pretty assured that this is a perinatal torsion
and this is all that's left of,
the testicular tissue on that side.
In late torsion, you get in homogeneity of the testis
as it becomes necrotic
or if there's areas of hemorrhage, like in this case,
once you get to this point,
it's pretty clear these are non salvageable testes
that does have some implications for surgical timing.
Depending when the child was NPO
or availability of operating rooms.
Doppler flow will show nothing in the center
and you'll get this intense inflammatory hyperemia
and the soft tissues around the testes, equivalent
to the nuclear medicine, donut sign.
You always have to look at both sides.
Regrettably, sometimes there is bilateral torsion,
as in this case, with non salvageable perinatal, torsions.

Pitfalls in Ultrasound Examination

So some of the pitfalls in ultrasound examination include
spontaneous detour, intermittent torsion,
and both of these can have increased flow or partial
or incomplete torsion and where flow is present,
but it's going to be, decreased.
So manual detour is a great method for, restoring flow
to the testes as quickly as possible.
This is also the appearance you're going
to get if you have spontaneous detour.
So on the left hand image you can see an enlarged testes
with some reactive hydrocele fluid
and some thickening of the scrotal wall.
Very typical for torsion normal flow in the other side.
After manual detour,
you actually get reactive hyperemia into the previously
ischemic tissues, some fairly high diastolic flow.
And this is the same kind of thing that you're going to see
with spontaneous detour and I'll get to that in a minute.
So this is a cautionary tale of, what can happen
with intermittent torsion.
So this image on the left, it's an older case, was
of a young man who came to, my previous institution
with, scrotal pain over the course
of approximately 14 months.
And every time he had an image that looked like this,
TESIS was a little big, EPIs was a little big,
and he was called epididimitis and treated and sent away.
Now, he was actually followed appropriately by urology,
but never had any laboratory indicators of epididimitis
and importantly, always felt better
by the time he got his imaging done.
So the image here is the same left testis this time
after about seven days of experiencing pain again.
And he didn't bother to come in
because it was always the same.
He got an ultrasound, he got antibiotics,
he went home this time.
However, when he came in, this is clearly a dead testis.
And in one of the clinic notes, again, it said
that every time he'd been imaged
before his pain had resolved.
And that's a good indicator that you're dealing
with intermittent torsion.
So this time he didn't bother to come in, unfortunately,
he did not detour this particular time,
and he had a non salvageable testis.
Partial or incomplete torsion is generally defined
as less than a 360 degree twist.
And importantly, the color flow may be present,
but it's going to be less than the asymptomatic side.
And while waveforms may be abnormal,
you may have higher resistance,
you may have variants in venous outflow.
I've also seen enough cases with normal waveforms
that I don't think you can count on that.
So in this particular case,
certainly not a normal ultrasound appearance.
There's an abnormal lie
of the testes in this longitudinal view of the scrotum.
There is a para testicular mass,
and when you turn on color,
asymptomatic side has a lot more color than
the symptomatic side.
I will tell you these waveforms looked exactly the same.
But if you are relying on a sonographer
or are you have in your mind that this is a binary decision
of flow versus no flow, you are going to miss these cases.
And they're not common, but they're not rare either.
So you have to pay attention to sort
of the semi-quantitative amount of flow
between the symptomatic and asymptomatic side.
If the flow is less
or even equal, you have
to be worried about torsion in a painful testis.

Torsion of Testicular Appendage

The most common thing in the pre pubertal male to cause,
acute scrotal pain is torsion of a testicular appendage.
And there's several of them.
The dominant players are the appendix epididymus present in
roughly a quarter of boys.
And the appendix testis,
which is present in approximately 95% of boys.
And in the normal state,
these are a little bit difficult to see.
They tend not to be too large.
You can see them here, you can see the testis,
or the appendage geus
and testis right next to one another,
which is why clinically you really can't tell them apart.
And when you've got a little bit of fluid,
you can see these little tiny things, floating in,
hydro seal fluid.
So when they tors,
and infarct, they become very, very focal painful.
And if you're a very good examiner, you can determine
that there's focal pain rather than diffuse pain
as in testicular torsion.
But that's non-trivial for,
even a fairly experienced examiner, you may be able
to feel a nodule or see a faint bluish discoloration if you
pull the scrotal skin over the, appendiceal torsion.
And you'll see this sort of blue dot sign I think you can
faintly see in that picture by ultrasound.
If you look for them, you can almost always find them.
There's usually a hydrocele fluid
and sort of non-specific inflammatory response.
There's a lot of hyperemia
and a lot of these kids end up being called epi ditis.
And while that's true, it is inflammation
of the epididymus in surrounding structures.
It's not the typical epi that we think about
in post pubertal in adult patients.
So in this particular case, you can see this enlarged,
tors appendage right here.
They're typically larger than five millimeters.
They often have what's been referred to as a salt
and pepper appearance.
And then you can see the tremendous inflammatory
response around it with color doppler
and absence of flow within the TAUs appendage itself.
Sometimes you can also get increased flow within the,
testis, but typically it's really just the, EPIs
and per appendiceal tissues.
Here's another case again with that sort
of heterogeneous appearance, creating lots
of increased flow in the surrounding tissues and the,
and the testis itself and a companion case.
This child went to the or, not
because, a failure to make the diagnosis, but
because of unremitting pain despite conservative
therapy over seven days.
And so you can see clearly the little infarcted,
testis right here and the tremendous inflammatory response
within the epidermis
and on the surface of the, of the testis itself.
So here's a case that, I missed.
I thought this was going to be a, detour event
of the testis that was tremendous, hyperemia
and inflammatory changes.
And I lost a bet to my urologist.
This child also went to the operating room just
because his pain was not going away as expected.
And probably what this was, was,
a little tors appendage right here.
And when I talked to my urologist afterwards, I asked him,
well, how did you know?
And the reason was is that he said the child's still hurt.
If this was a detour, the child would not have the same kind
of pain as what brought him into the hospital.
This child was having pain, right up
until induction of anesthesia.
So that is not the clinical symptom for, a detour event.
And that's an important thing to keep in mind.
Eventually, these tors appendages will shrink down in size.
They'll become a little calcified nubbin.
They may even become a little,
scrotal lifts moving freely within the
scrotal sac like this one.
And so again, when you see these little scrotal lifts
or scrotal mice, at least in my age population
that I see often, these are due to tourist appendages.

Epididymitis

Now, epi epi minus does still occur.
Typically it's in an adolescent.
And again, with the, the same risk factors as in,
as in young adults or urinary tract infections
and sexually transmitted diseases in the younger child,
you do have to think about structural abnormalities dis
and dysfunctional voiding.
But again, those are pretty uncommon relative
to appendiceal torsion causing at least a similar ultrasound
appearance of appendiceal, I'm sorry, epidermal,
inflammatory changes imaging for epididimitis, again,
non-specific thickening of the scrotal skin,
some reactive hydros, eal fluid
and enlarged, sometimes heterogeneous epididymus.
With increased color flow,
occasionally you can actually get inflammatory changes
and adjacent to infarction in the testis, as in this case.
And in some 10 to 20%
or so cases, you may get a generalized epidermal oris if
inflammatory changes spread to the scrotum itself
or the testicle itself.

Idiopathic Scrotal Edema and Vasculitis

Idiopathic scrotal edema is something,
that is fairly unique to the prepubertal, age range,
generally four to seven years.
These children present with pain, edema and erythema.
They generally have a spontaneous resolution.
At ultrasound they will have normal testes,
but you will see scrotal edema
and hyperemia as in this slightly older case.
You can see lots of edema
with these little septations running through it.
And these are vascular channels in the fibrous stroma.
Children can also have their scrotum involved by vasculitis.
In adults, we usually think of poly arteritis, Noosa,
but in kids it's usually heoc choline, perra.
Here's Professor HeLOCK and here's Professor Sheline.
This is a small vessel vasculitis
that can involve multiple organ systems,
but the scrotum is involved in up to 40%.
And what you may see on the scrotum are the
typical peric skin changes.
The testes are usually always normal,
but the epitamy will be swollen and hyperemic.
There's often a hydro seal
and some very severe scrotal wall
thickening due to the skin.
Small vessel vasculitis.
So again, here's a child with tremendous thickening
of the scrotal skin, even some little bit of fluid,
completely normal testes,
but tremendous inflammatory changes within the EPIs.
And this is a pretty typical pattern.

Algorithm for Acute Scrotal Pain

So in terms of the typical things that we see, you know,
a very sort of easy algorithm is that when you have a child
with acute scrotal pain, if there is no flow
or reduced flow that child needs surgery.
'cause you have to presume torsion.
And looking at those cases of, incomplete
or partial torsion, the diagnosis is no longer binary.
You can't just say flow, no flow.
You have to compare amounts of flow side to side.
If there's hyperemia
and pain, pain the same degree as
what brought them into the hospital,
that child doesn't need surgery.
'cause those are always gonna be inflammatory,
conditions or infectious conditions, things
that need medical treatment, not surgical treatment.
Now if you have hyperemia
and reduced pain, you really have to consider detour.
Okay? That's a fairly classic pattern.
So you don't wanna miss those kids who detour
and then come back later, like the case I showed
with a dead testicle.
And just that this is a little bit easier.
This is just from a, a paper,
that I wrote a few years ago just in graphical form.
The same thing that I said again, suspicious torsion,
scrotal pain, reduced flow, go to surgery.

Trauma

We do see kids for trauma, especially in athletic events.
And so there's a variety of, manifestations.
You'll see. Most simple is just a hemato seal.
The appearance of the hemato seal is going
to depend upon the acuity of the injury.
In this case, here's the testis
and this, this large, kind
of echogenic complex fluid around it.
As it ages like blood elsewhere in the body, you'll get,
some breakdown and separation
of blood products into blood fluid levels as well
as septations internally, if there's been more damage
to the testicle itself, you may see heterogeneous,
parenchyma in this case of an intra testicular hematoma.
And really our goal here is to make sure
that it's still perfused and to see if the tunica is intact.
And while it's non-trivial to look for,
this ultrasound is actually pretty good at trying
to diagnose, testicular rupture.
There's been some very good papers,
especially from the San Francisco group.
And in this case you're looking
for disruptions in the white line of the tunica algea
and complex extrusion of,
tubular structures out into the, perticular tissues.
This is important 'cause these patients need to be repaired,
both to try to salvage the testis as well as
to prevent infertility due to the formation
of anti sperm antibodies.
Here's another case, a testicular fracture.
There was interruption of the tunica
and this child had to go to surgery
for a non survival testis.

Scrotal Mass

Testicular Tumors

So the last big category is a scrotal mass.
So clearly it's,
it's alarming when anyone finds a scrotal
mass in examination.
The good news is that ultrasound has an extremely high
sensitivity, for diagnosing these.
So it can tell you whether it's present
or absent, whether it's an intra testicular
or an extra testicular lesion.
And also fortunately in children,
it's much less common than adults.
Testicular tumors account for only 1% of childhood cancer,
and there are peaks in the very young childhood,
less than five years, and in the immediate
post pubertal period.
So unlike in adults, seminomas are very,
very uncommon in children.
Most are of germ cell origin, either teratomas, both benign
and malignant, or endodermal sinus or yolk sac tumors.
And then approximately 10% are strodel stromal tumors,
either late cell or sertoli cell.
So with imaging, certainly we'll be able
to determine if a mass exists,
but for most lesions,
ultrasound is not histologically specific.
Doppler as well is more size dependent than histology.
Dependent with, larger tumors
tended to be more vascular.
There is some suggestion
that you can help differentiate, enlargement from tumor,
from inflammation, but that's, not terribly reliable.
And while there's been a lot written on MRI in adult
patients, the role in pediatric patients is unclear again,
because seminomas are not very common.
And that's, the role of advanced imaging
for most adult disease.
So just some images of testicular tumors, again,
just a large mass yolk sac carcinoma.
This more heterogeneous mass ended up being a mixed in
bridal and choriocarcinoma.
Here's another yolk sac tumor.
Nothing particularly distinctive about its appearance.
This is actually the tumor with a compressed rim
of testis around it.
And you can see on this fairly large lesion that it's very,
hyperemic with, color doppler.
Testicular teratomas are one of those lesions
that you can start to, consider as a diagnosis.
You can often see mixed solid and cystic tumor.
Sometimes you can see the calcifications within it.
These are always benign in pre-pubertal patients,
but when you have a patient in puberty,
there's a much higher incidence of having some mixed,
malignant elements.
Testicular epidermoids have a fairly character
characteristic appearance of this sort of laminate
or onion skinned world appearance.
They can be multiple as in this case.
Again, these are one of the few lesions you can suggest.
A specific histologic diagnosis
with ultrasound lading cell tumor.
This is a small one that was very hyperemic.
And again, nothing specific about its appearance.
There is a specific, tumor,
calcifying serato cell, which is unique to,
pediatric patients.
As you can see here, this large rocklike mass within the,
superior part of the testis.
One thing I think when you're scanning kids,
especially pre pre kids, is you have to consider, trying
to make a diagnosis when you can
because you can offer these children testa sparing surgery.
So ultrasound is nearly a hundred percent accurate in
determining whether a mass is present.
And like I said, the histologic specif
specificity is generally poor.
However, some lesions do have some pretty characteristic
appearances, cysts, epidermoids, and teratomas.
And like I said,
pre pubertal teratomas have always been benign.
There has never been a reported case
of a malignancy in a pre pubertal teratoma.
So when you have a case like this, it's fairly typical.
There's a thin rim of parenchyma here
and this is a large cystic mass with sort
of little dermoid plugs.
So when you suggest that diagnosis, the surgeon can offer,
testa sparing surgery and courtesy of my friend Dr.
Rama Enthi. Here is a particular case that he did.
You have to treat these like a cancer operation.
So this is done through the inguinal canal with delivery of,
scrotal contents and surgical control.
In this case, he's sliced open the thin rim
of testicular tissue
and he was able to shell out in its entirety this cystic
mass, and you can actually see the little soft tissue wall
or the soft tissue nodule here through the wall,
and then he sews up the testicle.
Now you might be thinking, is this really worth doing?
But I'll tell you one year later here, is that testis
and there's a little post-surgical calcification,
but this testis is normal in size
and is symmetric to its counterpart.
So this is definitely worth doing if you can preoperatively
make the suggestion that this is a benign diagnosis
and that your surgeon is willing to take the extra time
to try to perform testa sparing surgery.

Secondary Tumors

Secondary tumors are not very common in kids.
Most all of them are leukemia and lymphoma.
Lesser, frequency of neuroblastoma
and rhabdomyosarcoma test testicular leukemia can present
as either, an enlarged testes, diffusely enlarged
and sort of mixed heterogeneity, echogenicity.
Or you can have little focal areas typically
of hypo echogenicity.
And these testes are almost always very, very hyperemic.
And Dr. Siegel has described,
these abnormal vessels.
Normally when you do doppler studies,
the vessels are very straight and regular and linear.
And here you can see they don't really have a very organized
pattern, probably from leukemic infiltration.
That's a fairly characteristic sign.
Very similar appearance with testicular lymphoma.
Again, in large testes, they tend
to be hypo coic can be focal or diffuse,
and doppler can help you if you're unclear whether a little
area of heterogeneity is abnormal or not.
Certainly the more diffusely involved testes,
there's tremendous hyperemia in this one.
There was a question of,
heterogeneity in the inferior pole.
And when you turn on color,
certainly there's something very abnormal going on,
and that was biopsy proven to be lymphoma as well.

Paratesticular Tumors

Para testicular tumors are usually malignant kids.
The most common is, rhabdomyosarcoma,
although occasionally you can get neuroblastoma in lymphoma
leukemia lesions as well.

Non-Malignant Masses: Hydroceles

So non-malignant masses,
the most common one are hydros EALs.
In an infant, you have
to be concerned about patent processes, vais
and accompanying hernias.
In the older child, you may see, new hydros seal
with inflammation or trauma,
testicular torsion or even with tumor.
And there's three main types, the scrotal
or common garden variety, hydros eal,
an insisted hydros eal to the cord,
and then an abdominal scrotal, hydros eal.
So garden variety, hydros, eal to patent processes.
Vaginalis, you've all seen that fluid comes
and surrounds the testis.
Again, there's normal fixation of the testis against,
the scrotal wall.
The insisted hydros, eal
or funiculus seal, some people call them,
is really a ated fluid within the inguinal canal.
Testis is below, abdominal cavity is up above.
These can often be mistaken for incarcerated hernias
or even lipomas.
Lipomas are very uncommon in pediatric population,
whereas an insisted hydro seal is actually fairly common.
And then lastly is, the abdominal scrotal hydro seal
where you have this large fluid collection filling the
scrotum, extending up often as an abdominal mass in,
one of the lower quadrants.
And here you can see the, the lone testicle, you know,
amidst this, sea of fluid.
These require a different surgical approach.
As you might imagine for complete excision.

Hernias

Hernias are very common and they may contain bowel
or omentum, within the, inguinal canal
or even extending down into the scrotum.
It's important that you have to have some sort
of pressure in the abdomen, either with a Val Salva
or if it's a young child that can't cooperate.
I've even scanned these children standing to try
to increase abdominal pressure to, make a hernia appear.
If you see hyperemia of the bowel, you need
to think about incarceration.
If there's bowel but has no peristalsis, you need
to think about ischemia.
Omental hernias can be a little trickier.
They look like a complex mass, often very echogenic
because of the fat, but typically you can follow vessels
down and make this diagnosis.
So this particular patient, had an incarcerated,
hernia probably with early strangulation.
We could follow bowel loops
through the inguinal canal down into the, scrotum.
And here you can see there's good blood flow up
until the point of this fairly tight, narrow,
hernia ring
and then no flow in the bowel beyond, you know,
the importance again of, some sort
of provocative maneuver.
In this case, we have a normal test as hydro seal
and some unclear mass with Val Salva.
This large fatty mass increases greatly in size.
Another way of looking within the,
inguinal canal here,
you wouldn't say there is anything going on,
but with Val Salva, you get this protrusion
of abdominal contents.
Again, in this case, omental fat.
And again, just in this short video clip,
you can see if you took the image at this
point, you would see nothing.
But with Val Salva, you get protrusion
of abdominal contents, down superior to the testis.

Summary

So in that quick review, in summary, you have
to remember with acute scrotal pain
that the color Doppler diagnosis is not binary.
Partial torsion and detour, certainly exist.
You have to correlate it with the status of pain.
If the patient still hurts as much as what, caused 'em
to come to the hospital,
and they have hyperemia, you have
to consider inflammatory infectious conditions.
If they have that hyperemic appearance,
but their pain is better, you really have
to think about detour
and that child still needs surgical consultation.
Tors appendage is the most common cause
of acute scrotal pain before puberty,
and it can look very much like epididimitis if you don't
take the extra care to look around
and actually find the tors appendage.
Scrotal masses. Ultrasound is highly sensitive,
but not terribly specific.
Germ cell tumors are the most common.
And when you do see those few specific, cases
that you can provide some specificity like testicular cyst,
like pre-pubertal, teratomas like epidermoid cyst,
you can just suggest to your surgeons
that test a sparing surgery is a good option.
And again, we start with undescended testes and honestly,
after a good physical exam,
there's probably little role for imaging.
Thank you very much for your time.
I hope this has been useful for you.