Acute Scrotal Pain - HD

Introduction

I do not have any disclosures,

but the presentation comes with a warning.

It does contain sim graphic images, foul smelling

and bloody pathologic conditions,

which may not be suitable for non radiologists.

Assuming they're all radiologists here.

All right, objectives, I'm gonna review the causes

of acute scrotal pain.

Objectives

I'm gonna omit on the basic anatomy.

Assuming everybody's aware of the testicular

and epidermal anatomy, we'll learn how

to identify them in ultrasound

and, look at some of the mimics,

which confuses us often.

The three main categories, for acute scrotal pain,

infection, which includes mitis, and or oras.

Isolated oras is pretty much non-existent now

because the cause of it used to be mumps

and mumps is pretty much non-existent thanks

to the good vaccination.

Most of the times it's either just epi epididimitis in

the early stages or epididymitis.

We look at the complications torsion, complete

and partial torsion.

Partial torsion, which can be sometimes,

very confusing

and difficult to diagnose.

We look at their complications

and of course, trauma, infection

and torsion, usually come with,

a clinical history

of atypical classic clinical history.

Knowing that in advance is extremely essential

to making these diagnosis.

And trauma, of course, does come with that history of either

a motor vehicle crash or,

sports related injuries

or even some,

oddball injuries related to sexual pleasure.

Those histories may be

difficult to dig out from the patient.

But yeah, if you're suspecting it, suggest you do,

this is a classic case of,

an epididimitis.

As you can see, this is the inferior portion

that's the tail of the epididimitis,

which gets involved first in any case of,

epididimitis in, if the patient presents early on,

all you will see is basically this heterogeneous enlargement

of the tail of the epididymus, which will be hyperemic,

and the rest of the epidem will be completely normal.

I've seen some of the,

in the early junior residents calling it a mass also

because it does look like a mass, especially when the rest

of the epi is, is normal.

Looking at the history is extremely important.

These are mostly infectious in the younger males.

Gonorrhea and chlamydia are the culprits in children

and older males.

E coli is usually the culprit.

Yes, the sum of the inferior portion

of the testis here was also involved.

And, very heterogeneous

and hyperemic sometimes,

comparison will be the only key.

As you can see, if you see just the right epidermis here,

it does not quite look very abnormal, right?

It's pretty homogeneous.

But if you compare it with the left,

there is a huge difference in the size of the EPIs

and of course the vascularity.

Yes, comparison. Whenever God has given two size,

I suggest and highly recommend you compare it

because it's free, and,

it'll help you a huge deal in making that diagnosis.

Yes, comparison is always,

very helpful in cases of,

epi dermatitis or testicular torsion as well.

Testes may or may not get involved again, depending on

what stage the patient presents.

This case, the test testes was involved.

And again, the key is in getting this comparison single

field view image of both the testes in the same view.

If you do not, if sometimes a scrotum is really big

and enlarged and you are not able to get it,

I would suggest keeping the same parameters if you're taking

two separate images, because that's very crucial

in determining which side is,

hyperemic

or having less vascularity.

Infection: Epididymitis and Complications

Looking at some of the complications if,

these,

infections are not controlled early on

or the patients do not present,

because, some of the younger males do not want

to lose their stud image and do not wanna come to the ER

because they think it's just a mild pain

that they will get over with.

They may come with something more severe,

such

as just such as abscess formations.

As you can see in this gray scale image,

the entire scrotum or the semi scrotum looks abnormal.

There is enlarged heterogeneous EPIs.

The, the head also looks enlarged.

There is some,

complex looking fluid,

within the scrotal cavity.

The scrotal skin as well looks,

thickened.

And if you put vascularity, if you put color doppler,

you can see is definitely very hypervascular,

excluding this hypovascular area,

which indeed was an epidermal abscess.

Look for the secondary signs of infection.

Look for all these associated features be

cause if the patient has formed an abscess,

it's very likely that he does have an advanced stage of,

epi mitis or so.

Again, the same abscess right there.

And of course you can have testicular involvement as well.

This was a pretty bad case,

which was,

diagnosed pretty late.

The patient presented pretty late,

and you can see

that there was an extra testicular collection as well

as an intra testicular collection.

And the key thing to remember in these cases is try

to keep following up these patients

until they're completely resolved.

You never know when they may flare up again.

And as we all know, testis is a precious organ.

You do not want to mess with it.

Do follow up until complete resolution.

I cannot stress on it anymore,

but this is, this is extremely crucial in all

testicular,

diseases.

Venous in fart as a result of venous thrombosis is,

is a very, very important complication of mitis to know of,

to be aware of, because it can mimic testicular torsion

as well, because there's reduced flow in the testis.

But again, how do you differentiate?

How do you prevent this patient from going to the

or is look for those associated signs.

If the patient has developed venous thrombosis

and infarct, it's possible, it's, it's more likely

that patient does have, again, advanced mitis.

As you can see here, there is complex hydro seal.

There's of course edema of the testis and EPIs,

and there is,

thickening of the scrotal wall also.

It's not very well demonstrated here, but I promise it was.

Yes, there will be asymmetric decreased flow,

and as you can see here, again,

there's another patient which basically lost all flow in the

testis and even was necros.

This testis was basically non salvageable by the time,

it was brought to attention.

And you can see the hyper vascularity in the right side

of the EPIs in testis.

And we'll,

we'll talk about it a little little bit later as well.

Gonadal vein thrombosis is another,

complication in this particular case.

Also, the patient came

and presented when he had a palpable cord.

He did not present to us when he actually had epi ditis

and,

when he had the acute onset of it.

When he did feel this palpable cord, that's when he came

to the hospital thinking that this is something,

really concerning.

And, you'll often see the, the elongated,

vessel,

which is completely thrombose.

Of course you have to,

I would highly suggest you go in

whenever a patient presents with a palpable abnormality

to try to palpate it again

and try to put the transducer right there to be able

to identify what the problem is.

IC colitis, a lesser known complication,

IC colitis is actually inflammation of the spermatic cord.

And it's usually occurs as a sequela of epidemo oris.

I have a better case, this one right here

where you can see this heterogeneous appearance

of the spermatic cord with increased vascularity.

And patients present with focal tenderness.

Again, if they do not present at the time of epidemo,

or you can always get that history from them.

Did you have pain?

If, did you, did you have some fever?

Did you have acute pain?

Which,

on that side of the scrotum,

peoe, again, some untreated epididymitis can lead

to dense collection, pus collection in the scrotal cavity.

This patient also had intra testicular abscesses along

with it, which is not surprising when it has reached

that stage that he has formed a huge pus collection.

He has definite hyperemia in the testis as well.

Again, I would say follow up all such lesions,

until resolution, you do not want to lose that testis.

This patient did need surgical evacuation

because,

the pus was way too much

and did not respond to early antibiotics.

This was really in advanced stage of epididymitis

Gran epididymitis is another.

It can be tricky.

And this was a case I saw not too long ago.

Patient presented with acute onset pain,

or acute on chronic pain rather.

And you can see a very heterogeneous epididymus bilaterally

with more granuloma formation right there.

Not too much hyper vascularity as such,

but it definitely looked abnormal.

And obviously, patient did not come

with a known history of bladder cancer

or not on the requisition.

And only when you think about it will you actually try

to find out what's going on.

And since it did not fit into any category,

more,

bread and butter cases, I did think of tuberculosis.

And the patient was not from India

or Turkey had not traveled recently.

And I looked into his charts,

and of course he had history of bladder cancer.

And for those of you who do not know bladder cancer,

among the bladder advanced,

high grade bladder cancers are treated with BCG.

And so here you go, BCG led

to this tuber close tubercle epididimitis in the,

in this patient, other causes of gran

epididymitis could be sarcoid

or broc,

Another case where the epididimitis was not as involved,

but you had this gran lesion in the testis itself

with a lot of vascularity.

And this patient was also,

diagnosed with tuberculous

or, or gran epi neuritis.

Just a little bit of increased

flow compared to the left side.

Always keep that in mind when you see something atypical,

which is not really fitting into any of the, the bread

and butter cases that you have seen.

Think of tuberculosis

and look for a history of bladder cancer, focal neuritis.

This particular case I remember was initially diagnosed

as a testicular neoplasm,

and you all can see why it's very well defined hyper co

occlusion, which is hyperemic.

And somehow I laid my hands on it or laid my eyes on it,

and I'm like, this doesn't look like neoplasm.

I think this is just focal, or,

and I had a hard time convincing my colleague,

to change his report and say that, no,

just do a follow up initially.

And the reason why I said was,

yes,

it looks like a very well-defined lesion,

but look for those associated associated

findings that I mentioned.

Again, there's a complex,

complex hydros eal.

There were scrotal wall thickening,

and the rest of the testicle parenchyma also showed some

hyperemia, as you can see here.

The, the, the referring physician actually kind

of agreed because of the symptoms.

And again, as I said, the clinical history will often help

you testicle.

Neoplasms will not always present with an acute pain.

This patient was followed,

and was on antibiotics.

He came back after four weeks.

As you can see, it has,

definitely showed some improvement.

Always look for those findings, correlate

with the clinical history,

that will give you a whole deal of,

information about what's going on.

With the testes, This is an unusual case,

and I apologize, this is a very old case.

I did not find any other case after,

I see this

and it's not even my case.

This was a case of seminoma,

and you can see some scattered micros

and seminoma sometimes can masquerades as oras.

It can infiltrate and obstruct the seminiferous tubules.

And that results in oras.

And this is also one

of the very important reasons why you should always follow

these lesions until complete resolution, because if it's,

or if you just thought it was Oras, gave him antibiotics

and sent him home, he would've had some,

very high stage in metastatic Oma.

This, this patient responded to antibiotics.

The oras got better and the tumor was much more visible.

And, the patient was then worked up

and found to have a seminar.

One of the,

mimics of,

or could be something

of like homogeneous neoplastic infiltrative

involvement such as this.

This was a case of lymphoma.

And, more commonly for lymphoma,

we expect a bilateral involvement.

However, this patient did not

and had a unilateral,

homogeneous hypervascular testis.

And this can be mistaken for,

or if the patient does not have a known history of lymphoma.

Torsion

Moving on to the second category torsion,

I'm pretty sure everybody is aware

of the bell labber deformity, which is one

of the common causes for extra vaginal torsion in

pediatric patients.

This occurs when the tunica vaginalis completely encircles

the epididymus and the spermatic cord and the testis,

and does not attach to the scrotal wall,

which would have fixed the testis in position.

When it's completely surrounding it,

the testis remains like this clapper in a bell,

and it's free to rotate around,

and that's what, which predisposes it to torsion.

Keep in mind this bell clapper deformity.

These are two images. This supposed to be right

and left, but I somehow took both of the right side,

but the left side looked the same,

and you can see the fluid surrounding the entire spermatic

cord and, that there was not much fluid

around the testes, but you could definitely see fluid

around the distal spermatic cord.

Time is of extreme importance in torsion,

if you want to save the testes,

and, if it's diagnosed within six hours,

it has a very high rate of viability of salvageability,

and that is the key point.

You want to make sure,

the test is the torsion is diagnosed as long

as the testes is viable so that they can go

to surgery and detour it.

Five to six hours,

and pretty clearly in the first four hours, you will see

almost a normal appearing testis on gray

scale as you see in this.

However, there was absolutely no flow within the testis.

An EPIs patient went to surgery

and was able to save the testis.

This is the, the first four hours is the most crucial.

And of course, it depends on how soon the patient comes

to the hospital, but, as, as soon as you see it,

the patient needs to be sent to the, or.

This for example, was still within six hours

and the testis could be saved,

but you can see the difference the testis is beginning,

is beginning to become more hypo.

You do not want to wait any longer in such patients.

You do want to send them to the,

or immediately to make them,

to salvage the testis more than 20, 20 hours, of course,

more complications set in.

And, this testis is completely infarcted.

You see some echogenic foci,

we suggest some necrosis has set in as well.

There's absolutely no flow,

and this clearly is a non salvageable testis,

so you do not wanna wait that long.

Hemorrhagic,

complications

or hemorrhagic changes in a torsion gives

this marbly appearance.

Again, it does suggest

or is compatible with a non salvageable testis.

But this is not a tumor which will be easily suggested

by absence of blood flow within it.

But most people sit, look,

expect like a flute collection within the testis.

But many a times when there is hemorrhagic change in a ter

torsion, it gives rise to this marble kind

of an appearance in the testic lachy partial torsion.

Now those are the tricky ones

and many a times,

people are just looking at complete absence of flow to make

that diagnosis of torsion.

And even if there's a little bit of flow, they're like,

oh, flow is present.

This is not torsion,

but these are the cases which will take you

to the court most of the time, and you don't wanna do that.

If you see the color,

you can definitely see there's decreased flow compared

to the side, which is the normal side on the left.

And if you do compare the waveforms, which in this case I,

you don't really need to,

this is a very normal waveform compared to this,

which is more like a tortoise parvis, very low amplitude,

low velocity waveform.

This is very highly suggestive

of a partial testicular torsion.

These definitely need to go to the OR

because these are salvageable test definitely,

and you do not want to wait longer

because if it has torsed partially one time,

very high likelihood that it's gonna tors and infarct.

Some of the color flow patterns that we do need

to identify in torsion, of course,

absent flow is a no ble, no brainer.

Increased resistive index on the affected side,

which you can see,

sometimes

because of increased edema, diminished

or reversed diastolic flow

and decreased flow velocity as, as you can see here,

another case in a 16-year-old kid who presented

with acute pain.

This is a left side, which was completely normal,

nice normal waveform on the right side.

As you can see, it was difficult

to obtain any diastolic flow,

and at one point we saw reversal of diastolic flow.

This corresponded to patient's symptoms on this side,

and this was diagnosed as torsion, partial torsion taken

to surgery,

found a 360 degree torsion, salvageable testis.

Another example again,

and this testis had begin to show some heterogeneity,

but still had some flow.

And I can see some people

may just call it normal testis without looking at the

waveform that this is completely abnormal.

This is not what you expect in a testis reversal

of diastolic flow, not once,

but twice in many more incidences that we got.

Yes, these, these testis do need to go to the

or immediately because these are caught.

These are partial towards testis,

and if you are not sure many a times,

you may be lucky if you go just superior to the testis

and look for the spermatic cord twist,

which is also called the word pool sign.

It's been described in several other twisted pathologic

conditions across the body.

It's a very useful sign to keep in mind.

And this one is again, associated with decreased flow,

but still some presence of flow in the testes.

Decreased right-sided pain, go above the testes and voa.

You see this nice whirlpool,

so the testes is still salvageable.

They detours it manually right there,

and you can see the flow coming back in the right testis.

This study in 2014 found a hundred percent specificity

and sensitivity for torsion.

Torsion is not necessarily an all or nothing occurrence

and maybe partial or transient.

Do look for that abnormal flow, as I said earlier.

Also, comparison is the key in scrotal ultrasound,

bilateral torsion, I haven't seen yet.

If you do, please let me know.

Partial torsion does present a, a diagnostic challenge.

Look for the asymmetric flow.

I have seen or heard of a lot of,

radiologists going

to the court because missing,

because of missing a partial torsion,

sonographic findings may vary depending on the degree

and duration of torsion.

Keep that in mind as well.

As for the history when exactly the symptoms started,

and spectral doppler can be helpful in making the

correct diagnosis as well.

Descended testis, we all know

that's also predisposing factor for crypto organism,

so don't just forget about it.

When you do not see the testis try to find the test,

especially if the patient has pain.

And lo and behold, this testis wasn't the,

superior part

of the inguinal canal and looked very different than this

normal testis no internal flow.

This test is at tors and infarcted

and necros, so it was clearly non salvageable

torsion detorsion.

This,

remains somewhat of a confusing entity,

and this again leads to an asymmetric flow,

but I would say the history is the most

helpful in such cases.

You should look for a history of intermittent pain

and relief over past several days.

This patient in particular presented

with pain for two hours.

By the time he came to the ultrasound suite, he said, oh,

I'm feeling good, and the symptoms were on the left side.

You can see the left side is actually more vascular than

the right side, and you may argue, well,

I will call it a bit more otitis.

Well, again, if you look at the history, it's,

it's pretty classic for a distortion detorsion.

And again, if, as I mentioned in the first section, you have

to look for associated findings, if there is oras,

look at epi mitis

because isolated oras is pretty much non-existent.

If it is, or you will have an abnormal EPIs,

you will have a complex hydros seal,

you may have a scrotal wall thickening,

and patients will present with a very classic history

of acute onset pain with fever.

This was another very interesting case.

The urologist was very smart,

and he was pretty short.

This is gonna be a torsion,

decreased flow on the right side.

There was a whirlpool

and the urologist, as soon as he saw it,

he detoured it right there in front of us

and he asked us to image it.

And of course there is a lot of flow.

This is all reactive hyperemia.

After the patient,

after the urologist detoured his testes,

I haven't personally tried detouring it in,

in absence of a urologist.

I don't know if anybody would be courageous enough to do it,

but I don't think it's a bad idea.

If there is, if you suspect

that there's gonna be a huge time interval between,

between the scanning and the patient going to the or,

but yes, I would definitely pick up the phone immediately

and call the urologist.

Many a times again, if the diagnosis is missed either

by a radiologist

or as I said, if the patient does not present,

because these symptoms can be even more,

may make the patient even more reluctant to come

to, the hospital.

He gets intermittent pain and gets relieved.

So he keeps waiting for that symptom to get relieved,

but in the meantime, the testers can get infarcted.

And this was one such case when patient did decide to come

to the hospital one time,

during an acute onset of pain.

And we saw that half of his testers had infarcted.

The patient was taken to surgery.

He had a 360 degree torsion at that time,

and,

underwent an opexy and debridement of this portion.

Mimics of Torsion

Let's look at some of the mimics,

tors appendages,

which could be testicular appendages

or epidermal appendages.

These are basically just useless remnants.

These are mulian deck duct remnants,

which just hang out

as protrusions from the testes and EPIs,

and most of the times they will do nothing,

but occasionally they will tors

and will cause an acute onset pain mimicking the pain

related to acute testicular torsion.

Of course the ultrasound will be able

to differentiate it very easily.

You, you'll see flow within the testes and EPIs

and alongside you will see this elliptical shape,

structure arising from either the testes

or epididymus without flow.

And classically they have this blue dot sign.

Again, I encourage you to go inside the room

and, test where the patient is tender

and right to put your probe right there.

If you don't treat them,

they're usually managed conservatively.

They do not go to the or they will usually just torse

and fall off and then remain in the scrotal cavity

as scrotal pearls.

That's what they are.

If somebody doesn't know, this was

one of a kind case,

patient presented with, again,

acute onset pain, thinking of acute testicular torsion.

The testicular flu was normal, but he had this huge cyst

and if you don't think of it, you will probably not diagnose

it and thinking, oh, patient just overreacted or whatever.

But this is a huge cyst

and it is very possible that the skin tours,

so this was a para testicular cyst,

which had actually torsed

and he was extremely tender at this side.

Point of tenderness, compare it with ultrasound

and then put all the things together

and you will often come to a diagnosis.

The patient was sent to the OR in time

and was correctly treated towards epidermal cyst.

Again, it can be even more difficult to diagnose

because we are so used to seeing large epidermal cyst

and we never really think of them being towards,

but yes, if the patient is really tender,

why would an epidermal cyst

by itself give patient tenderness?

It shouldn't, right? So think of these out

of the box diagnosis.

Don't over diagnose.

Don't start calling all epidermal cyst astors.

But yes, when the patient is in pain

and has presented classically,

do think

of these diagnosis.

One of these cases, this confused me a lot.

This was a typical PM case.

Patient presented with pain.

One of my sonographers, one

of my very good sonographers was scanning it

and said, oh, this is testicular torsion.

I go into the room. Of course there is

no flow in the testes.

How many people would call it?

Torsion comes to the er, nobody calls it torsion. Really?

Am I the only one here? Okay, well, I was thinking

of torsion until I asked.

I talked to the patient and I said, okay,

can you point it out to me like, are you tender here?

And he was very comfortable while we were scanning him.

He said, no, I'm not really tender there.

I'm tender in the unal canal area.

And we scanned it and it looked like a blob there,

like cystic area, some soft tissue.

We couldn't really put things together.

I mean, incarcerated inguinal hernia,

but really, how many times have you seen causing

testicular ischemia?

Patient did go to the or,

and yes, he indeed had an incarcerated inguinal hernia

and they reduced it and the flow was returned.

I looked up literature after that

because I felt terrible.

I was like, really? Did I not know of this?

And there was just one case report,

which caused testicular ischemia because of this.

I mean, it's an artery after all.

I mean, it's very difficult to occlude an artery

because of a hernia, but it was the case.

Another mimic, a very dangerous one. That too.

This was a very famous case by Dr. Dogra.

This was a patient from Saudi Arabia who presented

with pain, no flow, flow, present CLI torsion sent to the,

or got an orchiectomy, but found to have lupus vasculitis.

I said, okay, we couldn't diagnose.

He came back again after a few days

and had the same appearance on the other side.

And of course, this time we were smarter.

We said, no, this is lupus. This is not torsion.

Unfortunately, he infarct it,

developed infection and hematoma.

He lost that testes too, and he changed his mind

and decided to sue us.

And of course, it was a multimillion dollar,

deal.

I always say is don't mess with an Arab, it's,

it'll put you in trouble.

Another complication that I saw, this happens when,

liver transplant surgeons decide

to do hernia surgeries,

and this was one of the liver transplant surgeon who tried,

who was doing hernia surgeries.

And he, he, it was, it was supposed to be a simple surgery,

but no, he tied it too str too tight,

and patient infarcted his testes just

because of a simple hernia repair complication.

Be aware of these complications.

Venous infarct I already talked about.

It can mimic,

torsion because of reduced flow

or absence flow, but if you look at the associated findings,

you may be able to diagnose it, that this is in fact a sicka

of for,

acute extrinsic compression,

by a fluid collection can also lead to decreased flow

or abnormal flow, as you can see here.

This was the right side.

This is a normal left side,

and this was an acutely developed,

hydros eal post hydros return of flow.

This is something like a page kidney

or a compartment syndrome, kind of a appearance quickly,

Trauma

run through trauma as I have two minutes.

Again, the, the role of radiologist in trauma is

to tell if the patient needs to go to surgery or not, right?

Right. So you have to find out if the test is intact or not,

because if there is testicular rupture,

he needs to go to the or.

One of the most common findings,

however, in trauma is a hemato seal.

But hemato seal can occur even without testicular injury.

And that may make things difficult looking at the testes.

But, especially when the hemato seal is that big.

Always try to look for the testicular tunica albia

and the continuity of it.

If it is disrupted, most likely it is gonna be a rupture.

This was a case of an MBC.

The first time he presented it looked somewhat abnormal

heterogeneous, but did not show any acute,

discreet lesions.

But patient came for follow up.

That's why another follow up is always necessary in

these trauma cases.

And he developed more discrete hematoma.

These were only contusions at this time,

which became more discreet hematomas,

sports related injury.

Intra testicular hematoma.

Again, very, very important to follow up all these lesions

until resolution because they may get infected

and you may land up losing the testers.

Any intra testicular lesion that you do not,

intend

to take out, you have to follow them to complete resolution.

You may get trauma induced torsion in a red number of cases.

That's because of the contraction of the cre matric muscles.

And sometimes you may see a nice fracture line,

often associated with a rupture.

As you can see here, this disruption of the NIC Algea

with contour abnormality, a lot of hemato seal

as well needs to go to the or.

Okay. That was a gross,

image.

From the surgery he was able to save some of his testes.

Again, a sports related injury, rupture of the testis,

but part of the testis here is viable, as you can see

with color doppler.

Again, you can debride this part of the testis,

and that's the role of color doppler to tell the surgeon

that, okay, you do,

have some viable testis.

Bilateral rupture just

suggests a very severe grade of injury.

And this is just another example of bilateral trauma

with complete loss of this testes.

And he landed up losing both the testers

because of bad ruptures.

These are some scrotal wall hematomas.

Again, resolution is extremely important.

They landed up becoming abscesses

and, that's not good.

It was still in the scrotal wall,

so at least he did not lose his testis.

Spermatic cord hematoma can be seen with trauma, can be seen

with hernia repairs,

and can be managed conservatively if it's causing symptoms,

needs to be taken to surgery.

And if it's not treated, may result in abscess.

Just another penetrating trauma.

This could be a little more devastating.

A lot of, this is a testicular rupture there

and there's a large hemato seal.

I'm gonna stop here since we're running out of time.

Spontaneous testicular hemorrhage.

I do wanna just say,

a few things about it.

This is not very well described in literature.

It's just a few case reports,

and it's often misdiagnosed as a neoplasm,

which has hemorrhaged.

This is a rare entity.

Patient do not have any history of trauma.

And if you do need a high index of suspicion for this,

because there's no real sonographic finding to tell you

that this is spontaneous testicular hemorrhage.