Evaluation of the acute scrotum by color-coded Doppler ultrasonography

Long-Term Follow-Up after Testicular Torsion: Prospective Evaluation of Endocrine and Exocrine Testicular Function, Fertility, Oxidative Stress and Erectile Function

Background: This study investigates endocrine and exocrine testicular function, oxidative stress (OS) in semen, and erectile function in patients who underwent surgery for suspected testicular torsion (TT). Methods: We evaluated 49 patients over a mean follow-up of 101 months: n = 25 patients treated with surgical exploration, n = 20 patients treated with detorsion, and n = 4 treated with orchiectomy. We performed semen analysis including Male infertility Oxidative System (MyOxSIS) analysis, physical examination, and evaluation of endocrine and erectile function. Results: OS, erectile function and spermiogram categories did not differ significantly between the groups. The interval from the onset of symptoms to surgery differed significantly between groups (p < 0.001). Preservation of the testes was associated with a higher round cell count (p = 0.002) and follicle stimulating hormone (FSH, p = 0.003). OS showed a significant positive correlation with the spermiogram category (0.337; p = 0.022). A negative correlation was observed between OS and age (p = 0.033), sperm concentration (p < 0.001) and total sperm count (p = 0.006). Conclusions: Endocrine, exocrine and erectile function are not significantly affected by TT in the long term. Orchiectomy results in elevated FSH and a lower round cell count compared to preservation of the testis.

Assessing the Utility of Ultrasound and Urinalysis for Patients with Possible Epididymo-Orchitis - A Retrospective Study

Purpose

Many experts recommend ordering an ultrasound and a urinalysis on all patients with scrotal pain. While the ultrasound may help diagnose a number of potential causes of scrotal pain, the urinalysis primarily has value in assessing for epididymo-orchitis. This study sought to evaluate the utility of these diagnostic tests for patients who presented to the emergency department (ED) with acute scrotal pain and possible epididymo-orchitis.

Patients and Methods

This was a single-center chart review of patients presenting to the ED with scrotal pain. Trained research assistants reviewed charts to obtain urinalysis and ultrasound results as well as diagnoses and treatments provided. Using the final diagnosis as a gold standard, the sensitivity and specificity of ultrasound and urinalysis were calculated for the diagnosis of epididymo-orchitis. Also, through a prespecified definition of “changed management,” we estimated the percentage of cases in which a urinalysis changed management of patients with acute scrotal pain.

Results

We identified 663 adult and pediatric patients who presented with scrotal pain during 2016. All patients had an ultrasound performed, and 458 (69.1%) had a urinalysis done. The sensitivity of urinalysis for epididymo-orchitis was 58.2% (95% CI 48.9% to 67.1%), and the specificity was 85.1% (95% CI 80.8% to 88.7%). For ultrasound, the sensitivity was 78.8% (95% CI 71.4% to 85.0%) and the specificity was 98.1% (95% CI 96.4% to 99.1%). In 24 of 458 cases (5.2% [95% CI 3.4% to 7.7%]) where a urinalysis was obtained, its results may have changed management of the patient.

Conclusion

The diagnosis of patients who present to the ED with scrotal pain is primarily driven by the ultrasound results. While the urinalysis may occasionally provide some benefit in the evaluation of patients with suspected epididymo-orchitis, the reflexive ordering of a urinalysis in patients with scrotal pain may be unnecessary.

Color Doppler Imaging of the Scrotum

Sonographic evaluation of the scrotum provides an accurate method to evaluate normal anatomy and diagnose scrotal pathology. The anatomy, venous and arterial supply as well as the sonographic evaluation are described herein. This review also describes pathologies that may be encountered during sonographic evaluation.

Sonographic findings of typical and atypical scrotal trauma

This review article illustrates sonographic findings in the setting of accidental and nonaccidental scrotal trauma. Although sonographic findings may be irrespective of the type of trauma, the goals of sonographic evaluation are similar in both atypical and typical mechanisms of scrotal injury. Familiarity with findings such as disruption of testicular integrity or vascularity facilitates prompt diagnosis and plays a critical role in clinical management.

Utility of Real-Time Shear Wave Elastography in the Assessment of Testicular Torsion

Real-time shear-wave elastography (SWE) is a newly developed method which can obtain the stiffness of tissues and organs based on tracking of shear wave propagation through a structure. Several studies have demonstrated its potential in the differentiation between diseased and normal tissue in clinical practices, however the applicability to testicular disease has not been well elucidated. We investigated the feasibility and reproducibility of SWE in the detection of testicular torsion. This prospective study comprised 15 patients with complete testicular torsion. Results obtained from SWE along with conventional gray-scale and color Doppler sonography and post-operative pathology were compared. The results revealed that (i) the size of injured testis was increased and the twisted testis parenchyma was heterogeneous. The blood flow signals in injured testis were barely visible or absent; (ii) The Young’s modulus, including Emean, Emax, Emin and SD values in the border area of torsional testis were higher than those of normal testis (Emean, 78.07±9.01kPa vs 22.0±5.10kPa; Emax,94.07±6.53kPa vs 27.87±5.78kPa; Emin, 60.73±7.84 kPa vs 18.90±4.39kPa; SD, 7.67±0.60 kPa vs 2.30±0.36 kPa, [P<0.05]); The Emax and SD values in the central area of the torsional testis were higher than the corresponding area of the normal testis (Emax, 8.23±0.30 kPa vs 3.97±0.95kPa; SD, 1.5±0.26kPa vs 0.67±0.35kPa,[P<0.05]) and Emin values was lower than those of normal testicles(0.93±0.51kPa vs 1.6±0.36kPa; [P<0.05]); (iii) The Young's modulus measurement between two physicians showed good agreement. The pathological findings were accordance with SWE measurement. SWE is a non-invasive, convenient and high reproducible method and may serve as an important alternative tool in the diagnosis and monitoring the progression of the acute scrotums, in additional to conventional Doppler sonography.

The impact of color Doppler ultrasound on treatment patterns of epididymitis in a university-based healthcare system

INTRODUCTION AND OBJECTIVES

Evaluate the impact of scrotal color Doppler ultrasound (CDUS) on epididymitis treatment patterns in a university-based institution.

MATERIALS AND METHODS

From 1 January 1999 to 30 July 2005, 870 patients from a single institution were diagnosed with epididymitis. A total of 480 men met the inclusion criteria for acute epididymitis. Scrotal ultrasound was included as a part of the diagnostic evaluation in 42.7% of men. Ultrasound reports were available for review in 187 cases. Information regarding patient demographics, diagnostic evaluation, and treatment was reviewed.

RESULTS

Ultrasound findings consistent with epididymitis were identified in 69.3% of men. The four most commonly reported irregularities were scrotal wall thickening (84.2%), abnormal epididymal echotexture (74%), increased epididymal vascularity (72.9%), and an enlarged epididymis (71.5%). Scrotal ultrasound was performed in 67% men under age 20 compared to 36% men between ages 30 and 69. Patients presenting to the Emergency Department underwent sonographic evaluation 57% of the time versus 17.2% men presenting to primary care physicians (P < 0.001). Ninety-five per cent (194/204) of patients who underwent CDUS were treated with antibiotics compared to 96% (263/275) of those who did not receive an ultrasound (P = 0.78).

CONCLUSIONS

CDUS can be helpful in patients with a potential diagnosis of testicular torsion, however, the use of CDUS as a diagnostic adjunct in the evaluation of epididymitis is of limited value. Treatment patterns and antibiotic usage were not significantly altered by ultrasound findings at this institution.

Role of color doppler in scrotal lesions

Color Doppler USG of the scrotum has been demonstrated to be useful in the diagnosis of scrotal lesions. Gray-scale USG characterizes the lesions as testicular or extratesticular and, with color Doppler and power Doppler, flow and perfusion can also be assessed. Color Doppler is particularly helpful in acute painful conditions, where it can differentiate testicular ischemia from inflammatory conditions and thus prevent unnecessary surgical explorations. With color Doppler, useful information can be gained about vascularity in testicular malignancies. Color Doppler also has high sensitivity and high specificity in the diagnosis of lesions like varicoceles.

Scrotal emergencies

This review describes the clinical, grey-scale and colour Doppler US findings of different conditions that may be the cause of an acute scrotum. The US appearances of testicular torsion, torsion of the appendix testis, epididymoorchitis, incarcerated hernia and idiopathic scrotal oedema are described. Some of the major studies regarding the sensitivity and specificity of US in the diagnosis of these diseases are reviewed. Grey-scale and colour Doppler US demonstrate high accuracy in the aetiological diagnosis of an acute scrotum and can differentiate between diseases that require immediate surgical intervention and those that can be treated conservatively.

Idiopathic testicular infarction in a boy initially suspected to have acute epididymo-orchitis associated with mycoplasma infection and Henoch-Schönlein purpura

Idiopathic testicular infarction without torsion of spermatic cord is a rare condition. We present a 12-year-old boy originally suspected of acute epididymo-orchitis, but subsequently an orchiectomy was necessary owing to unpredicted testicular infarction not associated with torsion. Elevation of immunoglobulin M against mycoplasma, reduction in serum factor XIII and the presence of sufficient blood flow detected by color Doppler ultrasonography upon initial manifestation suggested that the boy was affected by epididymo-orchitis associated with Henoch-Schönlein purpura or mycoplasma infection. However, progressive testicular enlargement was observed and subsequently testicular blood flow became barely detectable. Our case indicates that the presence of sufficient blood flow upon initial diagnosis in the affected testis does not necessarily exclude infarction and continuous monitoring of blood flow may be required to avoid radical orchiectomy.

Role of spectral Doppler sonography in the evaluation of partial testicular torsion

OBJECTIVE

The purpose of this series was to evaluate the role of spectral Doppler and color flow Doppler sonography in the evaluation of partial testicular torsion.

METHODS

Eight cases of partial testicular torsion, diagnosed on the basis of abnormal spectral Doppler waveforms or abnormal color flow Doppler findings, were retrospectively pooled from 2 teaching hospitals.

RESULTS

The age group ranged from 4 to 85 years. Testicles with partial testicular torsion showed variable spectral Doppler patterns, including increased, similar, or decreased amplitude of the arterial waveform relative to the contralateral testicle. Two cases showed reversal of arterial diastolic flow, and 1 case showed diastolic flow variability within the same testicle. Decreased blood flow was observed on color flow Doppler sonography in 7 of the 8 patients.

CONCLUSIONS

Variability of the Doppler waveform when compared with the contralateral testicle and reversal of diastolic blood flow are indirect clues that aid in the diagnosis of partial testicular torsion.

Testicular Torsion: Twists and Turns

Testicular torsion is one of the common causes of acute scrotal pain. This review discusses the clinical and sonographic findings of intravaginal and extravaginal testicular torsion, including the normal sonographic and vascular anatomy of the testis. The role of color flow Doppler and spectral Doppler is also emphasized in the patient's complete, incomplete, and intermittent testicular torsion. Sonographic features of testicular torsion mimics, such as vasculitis, venous thrombosis, scrotal edema, and technical parameters, are also presented. A brief description of new developments such as contrast-enhanced ultrasound, dynamic contrast magnetic resonance imaging, and near-infrared imaging is included.

Clinical Presentation of Acute Scrotum in Young Males

The purpose of this study was to assess the clinical presentation and ultrasonographic findings of acute scrotum in young males. A total of 87 patients (<or= 25 years old) with presentation of acute scrotum were retrospectively analyzed in Kaohsiung Medical University Hospital. The patients were divided into three groups according to their final diagnosis: 41 patients with testicular torsion (TT), eight patients with torsion of the testicular appendage (TTA), and 38 patients with epididymo-orchitis (EO). The mean ages of the TT group (14.0 +/- 5.7 years) and EO group (16.6 +/- 7.6 years) were higher than that of the TTA group (10.0 +/- 3.5 years) (p = 0.02). White blood cell count (> 10,000 cells/microL) was not found to be statistically different among groups. Pyuria was found in 10 (26%) patients with EO. Color Doppler ultrasound has high sensitivity (87.9%) and specificity (93.3%) rates to differentiate TT from other causes of acute scrotum. In cases with a lower risk of TT, we suggest that a technically adequate color Doppler ultrasound may be arranged to help differentiate diagnoses and prevent needless surgery. The importance of emergent management for acute scrotum should also be impressed upon the public through education to avoid delayed presentation to medical facilities.

Sonographic differential diagnosis of acute scrotum: real-time whirlpool sign, a key sign of torsion

OBJECTIVE

The purpose of this study was to prospectively investigate the role of high-resolution and color Doppler sonography in the differential diagnosis of acute scrotum and testicular torsion in particular.

METHODS

Patients who underwent sonography for acute scrotum between April 2000 and September 2005 were included in the study. Gray scale and color Doppler sonography of the scrotum was performed. The spermatic cord was studied on longitudinal and transverse scans from the inguinal region up to the testis, and the whirlpool sign was looked for.

RESULTS

During this period, 221 patients underwent sonography for acute scrotum. Sixty-five had epididymo-orchitis with a straight spermatic cord, a swollen epididymis, testis, or both, an absent focal lesion in the testis, and increased flow on color Doppler studies along with the clinical features of infection. Three had testicular abscesses. Sonography revealed features of torsion of testicular appendages in 23 patients and acute idiopathic scrotal edema in 19. Complete torsion was seen in 61 patients who had the whirlpool sign on gray scale imaging and absent flow distal to the whirlpool. There was incomplete torsion in 4 patients in whom the whirlpool sign was seen on both gray scale and color Doppler imaging. Nine patients had segmental testicular infarction, and 1 had a torsion-detorsion sequence revealing testicular hyperemia. In 14 patients, the findings were equivocal. There was a complicated hydrocele, mumps orchitis, and vasculitis of Henoch-Schönlein purpura in 1 patient each. Five patients had normal findings. Fourteen were lost for follow-up.

CONCLUSIONS

Sonography of acute scrotum should include study of the spermatic cord. The sonographic real-time whirlpool sign is the most specific and sensitive sign of torsion, both complete and incomplete. Intermittent testicular torsion is a challenging clinical condition with a spectrum of clinical and sonographic features.

Spermatic cord torsion with preserved testis perfusion: initial anatomical observations

PURPOSE

Despite the high sensitivity and specificity of scrotal ultrasonography, there continue to be reports of missed torsion. These "false-negative" scans are attributed to technical factors and intermittent torsions. We hypothesize that patients with specific anatomical configurations maintain testicular blood flow for prolonged periods, and, therefore, will have flow on ultrasound despite concurrent torsion.

MATERIALS AND METHODS

Patient charts and scrotal ultrasounds were reviewed to identify patients younger than 18 years who underwent scrotal exploration between January 1998 and January 2003 for acute scrotum. Patients who underwent radiological evaluation before scrotal exploration were the main focus of this study. Operative reports were reviewed for specific anatomical details.

RESULTS

A total of 61 patients underwent scrotal exploration for acute scrotum during the study period. Of these patients 14 had torsion confirmed intraoperatively and a preoperative scrotal ultrasound available. Four of these 14 patients had normal testicular blood flow on ultrasound but had testicular torsion confirmed intraoperatively. Operative findings suggest that these patients have specific anatomical characteristics.

CONCLUSIONS

Testis perfusion can be maintained for a prolonged period in the presence of testicular torsion. Anatomical variability may account for differences in the duration of viability of the torsed testis. A high index of suspicion must be maintained to avoid missing the diagnosis of testicular torsion in these challenging cases.

Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys

BACKGROUND

Diagnosis of testicular torsion in children is challenging, as clinical presentation and findings may overlap with other diagnoses.

OBJECTIVE

To define the clinical and ultrasound criteria that best predict testicular torsion.

MATERIALS AND METHODS

The records of children hospitalized for acute scrotum from 1997 to 2002 were reviewed. The clinical and ultrasound findings of children who had a final diagnosis of testicular torsion were compared with those of children who had other diagnoses (torsion of the testicular appendix, epididymitis, and epididymo-orchitis).

RESULTS

Forty-one children had testicular torsion; 131 had other diagnoses. Stepwise regression analysis yielded three factors that were significantly associated with testicular torsion: duration of pain < or =6 h; absent or decreased cremasteric reflex; and diffuse testicular tenderness. When the children were scored by final diagnosis for the presence of these factors (0-3), none of the children with a score of 0 had testicular torsion, whereas 87% with a score of 3 did. The ultrasound finding of decreased or absent testicular flow had a sensitivity of 63% and a specificity of 99%. Eight of ten children with testicular torsion and normal or increased testicular flow had a coiled spermatic cord on ultrasound.

CONCLUSION

We suggest that all children with acute scrotal pain and a clinical score of 3 should undergo testicular exploration, and children with a lower probability of testicular torsion (score 1 or 2) should first undergo diagnostic ultrasound. Because the presence of testicular flow does not exclude torsion, the spermatic cord should be meticulously evaluated in all children with acute scrotum and normal or increased testicular blood flow.

ULTRASONOGRAPHY OF THE SPERMATIC CORD IN CHILDREN WITH TESTICULAR TORSION: IMPACT ON THE SURGICAL STRATEGY

PURPOSE

Many surgeons advocate systematic exploration for acute scrotum rather than risking a misdiagnosis of testicular torsion. Study of testicular vascularization with color Doppler sonography (CDS) can be inaccurate, leading to dangerous false-negative results. We determine whether direct visualization of the twisted cord during emergency high resolution ultrasonography (HRUS) is a reliable sign to diagnose the torsion and whether its absence can dispense with unnecessary surgery.

MATERIALS AND METHODS

From 1993 to 2002 an average of 35 patients per year presented with acute scrotum, and 44 patients had spermatic cord torsion. CDS and HRUS were performed in all cases. Transversal and longitudinal scans on both sides of the scrotum permitted comparison of testicular echogenicity, size and vascularization. The spermatic cord was studied along its complete length to detect spiral twist. The surgical findings were correlated with the preoperative results.

RESULTS

Spermatic cord torsion at surgery was confirmed in all 44 cases. The time lost by the examination was never more than 30 minutes. Intratesticular blood flow was absent in the affected testis in 31 cases, and CDS was unreliable in the others. In all cases, regardless of CDS findings, HRUS succeeded in detecting the twist as a snail shell-shaped mass measuring 11 to 33 mm.

CONCLUSIONS

The finding of a twisted spermatic cord is a highly reliable sign for the diagnosis of testicular torsion. Whereas normal intratesticular perfusion does not dispense with emergency exploratory surgery, direct and complete visualization of a nontwisted spermatic cord strongly indicates that surgery is unnecessary. Strict conditions are required, including time spent on HRUS should not exceed 30 minutes, which generally can only be achieved by a senior pediatric radiologist.

Magnetic resonance imaging and ultrasound evaluation of penile and testicular masses

The purpose of this study is to present the role of ultrasonography and MRI in the investigation of testicular and penile masses, as well as to review the literature. This article is based on our experience with 230 patients who presented with acute or subacute scrotal pain or painless enlargement of the scrotum or penis. Gray scale and color Doppler ultrasonography (CDU) were applied in all cases. In 73 cases, the final diagnosis was established by surgery and in 157 cases by follow-up. MRI was performed in 48 cases. Ultrasonography was the initial imaging modality in all cases. It provided detailed anatomic information with high sensitivity and accuracy in cases of torsion, inflammation, varicocele and trauma. In cases of tumor, US showed the presence of the mass in all cases, while it additionally revealed certain characteristic features of tissue constitution and blood supply. In most cases, differentiation between various types of tumors or differentiation between malignant and benign lesions was impossible. MRI, besides the detailed anatomic imaging, also provided a certain degree of tissue specificity. MRI could help in the detection and staging of penile cancer and in the evaluation of testicular and scrotal masses, especially when a diagnostic dilemma occurred on ultrasonographic examination. Ultrasonography, combining gray scale and color techniques, is irreplaceable in the diagnostic work-up of scrotal and penile masses, while MRI can serve as a problem solving diagnostic modality.

Acute painful scrotum

The ability of US to diagnose the pathogenesis of the acute scrotum is unsurpassed by any other imaging modality. It is the first imaging performed in patients with acute scrotum. Knowledge of the normal and pathologic sonographic appearance of the scrotum and proper sonographic technique is essential for accurate diagnosis of acute scrotum. High-frequency transducer sonography combined with color flow Doppler sonography provides the information essential to reach a specific diagnosis in patients with testicular torsion, epididymo-orchitis, and testicular trauma.

Assessment of acute scrotum by Doppler color flow imaging: A report of four cases

We used an Aloka SSD-2000 ultrasound unit with a 5 MHz convex scanner to assess one case of torsion of the spermatic cord, one case of orchitis, and two cases of epididymitis. Color flow imaging showed absence of blood flow signals in the testis in the case of torsion of the spermatic cord, while blood flow signals in the scrotum were significantly increased in the cases of orchitis and epididymitis. Blood flow signals decreased after chemotherapy. Color flow imaging may thus prove useful in the diagnosis and follow-up of patients with acute scrotum.

Sonography of the scrotum

Ultrasonography (US) with a high-frequency (7.5-10-MHz) transducer has become the imaging modality of choice for examination of the scrotum. US examination can provide information valuable for the differential diagnosis of a variety of disease processes involving the scrotum that have similar clinical manifestations (eg, pain, swelling, or presence of mass). The pathologic condition that may be at the origin of such symptoms can vary from testicular torsion to infection to malignancy. The ability of color and power Doppler US to demonstrate testicular perfusion aids in reaching a specific diagnosis in patients with acute scrotal pain. This review covers the anatomy of the scrotum and the scanning protocol for scrotal US, as well as detailed descriptions of disease processes and their US appearances. Newly described conditions such as intratesticular varicoceles and other benign intratesticular cystic lesions are also discussed.

Torsion of the spermatic cord: sonographic diagnosis

This article describes the ultrasound guidelines for evaluating patients with spermatic cord torsion, including gray-scale, Doppler with spectral analysis, and color and power Doppler sonography. The sonographic and Doppler features of acute, subacute, and chronic torsion of the spermatic cord are demonstrated and discussed.

Escroto agudo

Este artigo pretende fazer uma revisão geral do tema, com ênfase em conceitos atuais e/ou controversos no manejo das situações clínicas em questão, em especial conceitos ainda polêmicos quanto à fisiopatologia e ao manejo diagnóstico. Também é feita uma revisão extensa quanto aos aspectos clínicos e terapêuticos da torção de testículo neonatal e quanto aos aspectos de diagnóstico diferencial na síndrome do escroto agudo. São citadas informações estatísticas derivadas dos principais estudos clínicos publicados nos últimos 20 anos em literatura médica ocidental.

Testicular torsion: time is the enemy

BACKGROUND

The acute scrotum is a diagnostic dilemma, and testicular torsion is of primary interest because of its fertility problems for the patient and medico-legal issues for the surgeon. The present study aimed to correlate operative findings of patients with suspected testicular torsion with certain clinical variables and investigations to see if diagnosis and outcome could be improved.

METHODS

A total of 99 patients underwent scrotal exploration for suspected testicular torsion at the Royal Brisbane Hospital between 1990 and 1995. Colour Doppler ultrasound, white blood count and urine microscopy results were documented, along with the patient's age and duration of testicular pain.

RESULTS

Fifty-six patients were found to have torsion, and the testicular loss rate was 23%. Patients who experienced testicular pain for longer than 12 h had a testicular loss rate of 67%. A negative urine microscopy was suggestive of testicular torsion, but was not diagnostic. The white blood count did not aid in the diagnosis. Colour Doppler ultrasound of the scrotum was used on nine occasions with three false negative results and a sensitivity of only 57%.

CONCLUSIONS

Time is the enemy when managing the acute scrotum. No investigation substantially improves clinical diagnosis enough to warrant any delay in definitive surgical intervention.

An analysis of clinical outcomes using color doppler testicular ultrasound for testicular torsion

OBJECTIVES

To delineate the clinical outcomes of color Doppler ultrasound (US) in the equivocal torsion patient.

METHODS

From 1992 to 1997, 130 patients (<23 years old) from 2 institutions underwent US imaging using a 7.5-mHz linear transducer to evaluate an acute scrotum equivocal, or of low suspicion, for torsion. The US reports and hospital charts of these patients were retrospectively reviewed.

RESULTS

After clinical and radiologic evaluation, torsion was excluded in 110 patients without surgical exploration. In 3 patients, intermittent testicular torsion was diagnosed and in 17 patients, emergent exploration was performed for US diagnosis of testicular torsion. Twenty-five patients (22.7%) were subsequently lost to follow-up. Follow-up of 85 patients with US negative for torsion (mean length of follow-up = 466.9 days) revealed no testicular atrophy in 83. Two patients underwent delayed orchiectomy/contralateral orchiopexy for missed testicular torsion. Of 17 patients with US positive for torsion, 9 underwent orchiectomy for a necrotic torsed testis, 7 viable torsed testes were found, and 1 torsed appendix testis was found. Therefore, color Doppler US for the equivocal acute scrotum yielded a 1% false-positive rate, sensitivity of 88.9%, and specificity of 98.8%.

CONCLUSION

When faced with ruling out testicular torsion, it is necessary to integrate the multiple pieces of patient data, knowing that each piece of data may have inaccuracies. With this in mind, this analysis of outcomes verifies that color Doppler US is an excellent adjunctive study in the clinically real situation in which the clinical evaluation is equivocal or low suspicion.

Acute scrotal pain

The diagnosis of acute scrotal pain can be difficult. The most common causes include torsion of a testicular appendage, epididymitis, and testicular torsion, which account for 85% to 90% of all cases. These entities may be clinically indistinguishable because characteristic symptoms and signs for each overlap, whereas pathognomonic features are uncommon. Diagnostic accuracy without delay is required to avoid the loss of testicular function in testicular torsion cases and to avoid unnecessary surgery in other cases. A thorough understanding of the key clinical features of each entity, coupled with an understanding of the appropriate use of perfusion imaging studies, will equip the emergency physician with the tools to accomplish this task.

Doppler sonography in testicular and scrotal imaging

The primary role of Doppler ultrasound of the acute testicle and scrotum is for the diagnosis of spermatic cord torsion or epididymitis. The utility of Doppler in other conditions such as testicular neoplasm is limited, and in general does not increase diagnostic specificity. The application of color Doppler imaging and power Doppler imaging increases sensitivity for the detection of orchitis and testicular neoplasms in which the gray scale findings may be subtle. Power Doppler imaging is more sensitive for the identification of slowly flowing blood than color Doppler imaging. As a result, power Doppler imaging may be particularly helpful for the diagnosis or exclusion of spermatic cord torsion as a cause of acute scrotal pain in the prepubescent male.

The acute scrotum

Every boy with acute onset scrotal pain and swelling requires an immediate evaluation. Our protocol (Fig. 6) for the evaluation of these children is based on the history and physical examination combined with the selective use of imaging studies. When used appropriately, this protocol facilitates the rapid identification of children with torsion and minimizes the number of unnecessary scrotal explorations. When the duration of the pain is brief, and history and physical examination suggest that torsion is the most likely diagnosis, urgent surgical exploration without additional imaging studies is recommended. When it is not possible to definitely diagnose or exclude the diagnosis of testicular torsion, or when the duration of pain is greater than 12 hours, then diagnostic imaging can provide significant information. Color Doppler sonography is, in the authors' opinion, preferable to nuclear imaging for the evaluation of children with acute scrotums. When normal or increased blood flow is present, scrotal exploration is not required. When the study demonstrates decreased blood flow or does not provide a definite diagnosis, scrotal exploration is recommended. The authors recommend this approach because less than one third of these children have testicular torsion, and if routine scrotal exploration is performed for all boys with acute scrotums, a significant number of unnecessary surgical procedures will result.

Imaging in pediatric urology

A multitude of disorders of the genitourinary tract can occur in children. Although some entities may be diagnosed clinically, radiologic imaging is often necessary for diagnosis and management. The radiologic work-up has been discussed using a problem-oriented approach in five clinical situations: urinary tract infection, hydronephrosis or hydroureter, trauma, swollen scrotum, and hematuria. This discussion provides some general guidelines, although the evaluation of each child may need to be individualized depending on their specific clinical symptomatology.

Critical analysis of the clinical presentation of acute scrotum: a 9-year experience at a single institution

PURPOSE

We assessed the significance of the clinical presentation of boys who underwent surgical exploration for acute scrotum.

MATERIALS AND METHODS

We retrospectively analyzed the records of 115 consecutive boys who underwent surgical exploration for acute scrotum between October 1986 and January 1996. We divided the children into group 1-83 with spermatic cord torsion a mean of 14.4 years old, group 2-27 with torsion of a testicular appendage a mean of 9.4 years old and group 3-5 with epididymo-orchitis a mean of 14.1 years old. Particular attention was given to nausea and vomiting, patient age and duration of pain.

RESULTS

Nausea and vomiting occurred in 69 and 60% of the boys in group 1, 8 and 4% in group 2 and none in group 3. Nausea and vomiting had positive predictive values of 96 and 98%, respectively, for spermatic cord torsion. Only 6 of the 83 boys (7%) with spermatic cord torsion were younger than 11 years, whereas 15 of the 27 (56%) with torsion of a testicular appendage were younger than 11 years. Of the 83 boys with spermatic cord torsion the testes were salvaged in 51 (61%) and the duration of pain was 40 minutes to 12 hours (mean 4 hours). The testes were not salvaged in any patient with greater than 12 hours of pain.

CONCLUSIONS

We believe that any boy 11 years old or older with scrotal pain less than 12 hours in duration that is associated with nausea or vomiting should be considered to have torsion of the spermatic cord. In this day of cost-effective medical management it is not necessary to perform imaging in this subset of boys before surgical exploration.

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.

Ultrasound in the assessment of the acute scrotum

Color Doppler imaging (CDI) has become the study of choice in evaluation of the scrotum due to technological advances resulting in superior resolution and sensitive Doppler systems. CDI has become particularly helpful in evaluating the scrotum in the setting of acute disorders, such as torsion of the spermatic cord, epididymal and testicular inflammation, and scrotal trauma. CDI should be the study of choice to evaluate for torsion of the spermatic cord and demonstrates a high degree of accuracy. CDI in such a setting, however, does require operator experience, sensitive Doppler ultrasound equipment, and operator knowledge of the limitations of CDI. With epididymitis or epididymo-orchitis, CDI has proven to be quite helpful in evaluating the scrotal contents for the presence of inflammation and associated complications. In scrotal trauma, CDI's utility remains somewhat controversial, but with further investigation its appropriate application in this situation may become clear.

Acute scrotum: Analysis on 333 cases

Treatment of acute scrotum is becoming increasingly more common in urological surgery. The aim of this work was to analyse all the cases of acute scrotum subjected to surgical exploration in the last 20 years. Funicular torsion was found in 51% of patients, appendicular testis torsion in 26%, alterations compatible with previous funicular torsion in 15%, while findings were negative in 7%. Surgery to relieve funicular torsion and eversion of the vaginal was performed in 82% of cases, while the testis was fixed in 12% and in 11 cases orchiectomy was necessary. The contralateral testis was never fixed. No recurrence of funicular torsion has been found during follow-up, but in 9% of patients contralateral funicular torsion occurred at a later date.