Question 1 : Compare Testicular Torsion, Epididymo-orchitis and Epididymitis

Question 1 

Describe symptoms, historical features and US findings in
• Testicular torsion
• Epididymoorchitis , epididymitis

Ultrasound is an essential tool in differentiating between the different causes of testicular pain however ultrasound alone cannot exclude torsion. Initially ultrasound findings in testicular torsion may be unremarkable and then become heterogeneous or diffusely hypo-echoic, mimicking epididymo-orchitis both on imaging and clinical examination.  The following are some of the salient ultrasound features of testicular torsion, epididymo orchitis and epididymitis.

Symptoms and signs Ultrasound features
Testicular torsion
  1. Acute scrotal pain
  2. Oedema and erythema of testes
  3. Often high-riding testicle
  4. Absent cremasteric reflex. (most sensitive sign of torsion)
  5. Lifting the testes does not abolish pain
  6. Transverse position of testicle
  7. Anterior rotation of epididymis
  8. Nausea and vomiting
  9. History of trauma in 5% of cases
  10. Fever is sometimes present
  11. Abdominal pain
1. Twisting of the spermatic cord 

  • Whirlpool sign
  • twisting or whirling may also be seen on Colour Doppler

2. Altered blood flow

  • Absent Blood flow in complete tortion
  • Reduced and increased Colour flow signal  depending on the stage of torsion.  Hyperaemia in early stages, due to venous dilation or from rebound reperfusion following de-torsion

3. Incomplete torsion

  • sometimes elevated resistive index (RI > 0.75)
  • to and fro flow

4. Complete torsion

  1. Absence of blood flows in  testis and epididymis – check with opposite side
  2. Increase in size of the testis and epididymis(because of venous engorgement). Normal size of testes is 5 X 3 X 2 cm
  3. An early finding is a homogeneous echotexture
  4. A heterogeneous echotexture of the testes is a  late finding (after 24 hours) and implies necrosis.  Hypoechoic regions represent necrosis. Hyperechoic regions represents haemorrhage (if testis is reperfused)
  5. Reactive hydrocoele
  6. Reactive thickening of the scrotal skin with hyperaemia and increased flow on colour Doppler examination 2
  7. Peripheral testicular neovascularisation only seen after a number of days and represents recruiting and enlargement of small peripheral collaterals. Only peripheral and patchy portions of the testis are perfused

 

Epididymitis 1. Usually sexually transmitted chlamydia, Neisseria most important organisms (sexually transmitted), e coli and proteus mirabilis

2. Acute scrotal pain of varying intensity with fever

3. Clinically may be able to differentiate the thickened tender epididymis from the testis

 

  1. Increased colour Doppler flow to the inflamed epididymis (check flow of unaffected side to compare)
  2. Spectral US – high flow low resistance waveform
  3. Reactive hydrocele with septations if a pyocele develops
  4. Scrotal wall swelling
  5. Enlarged epididymis >17 mm
  6. Hypo (abscesses), hyper ( haemorrhage ) or heterogeneous echotexture of epididymis
Epididymo-orchitis 1. Usually sexually transmitted

chlamydia, Neisseria most important organisms (sexually transmitted), e coli and proteus mirabilis

2. Acute scrotal pain of varying intensity with fever

3.  May lead to gangrene and subcutaneous emphysema in some cases

 

  • Increased colour Doppler flow to the inflamed epididymis
  • Spectral US – high flow low resistance waveform
  • Reactive hydrocele with septations if a pyocele develops
  • Scrotal wall swelling
  • Enlarged epididymis >17 mm
  • Patchy /segmental (testicular infarction) hypoechoic  areas  in testes  (difficult to distinguish from a tumour). Venous infarction of the testes in severe infection when localised oedema occludes the venous drainage of portions of the testes. In venous infarction
    – Testis hypoechoic
    – Swollen
    – Absent colour flow
  • Heterogeneous echotexture of testes and epididymis
  • Abscess formation (hypoechoic area with increased colour flow around it)

 

 

References:

  1. Journal of ultrasound 2013 Dec; 16(4): 171–178. A review of ultrasound imaging in scrotal emergencies
    G. T. Yusuf and P. S. Sidhucorresponding author

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