Question 4 : Acute left groin pain

Question 4

A 25 year old man presents with acute left groin pain
a) Discuss your US evaluation. Include choices of probe/s, the areas that you would examine and your method
b) What additional clinical information is important?
c) During the examination you cannot find the left testicle in the scrotum
I. Discuss your further ultrasound examination in light of this finding
II. Are there any other imaging tests that you would perform in this setting?

The ultrasound evaluation is prescribed by the potential differential diagnoses in this case. Possibilities include

  • Referred  pain such as  renal colic
  • Hernias : inguinal, direct, indirect,femoral ,strangulated, non strangulated
  • Proximal DVT
  • Lymphadenopathy
  • Testicular causes : orchitis/epididimytis/epidididymo-orchitis,/testicular haemorrhage from a testicular cancer
  • Trauma – haemorrhage /contusion/testicular rupture/scrotal wall haematoma
  • Joint effusion
  • Diverticulitis/colitis/

US evaluation

  • Ensure the patient has adequate analgesia
  • Examine with patient supine unless testing for inguinal or femoral hernia when the patient may need to stand up to look for protrusion of hernia with cough or valsalva manoevre
  • Start with a high frequency linear probe to examine inguinal area. Change to curvilinear probe if patient obese. Look for nodes, DVT, hernias and then scrotum for tortion, epididimyoorchitis, epididymitis, trauma
  • Examine the  joint space of the left hip for effusion
  • Examine the left iliac fossa for bowel wall thickening suggestive of colitis. Look for abscesses or fistulas. Use probe to identify area of maximum tenderness

Additional clinical information

  • Trauma/fever/leg swelling/scrotal swelling/hip pain/back pain/symptoms of UTI

Can’t find right testis

  • To find the testes a method called “tracking the cord” can be used. Obtain a view of the common femoral artery and vein below the inguinal ligament with the probe in the transverse position. The normal spermatic cord is identified anteromedial to the femoral vessels. The spermatic cord is visualised as an  oval echogenic structure with a few round echo-poor areas within it, representing the vas deferens and the vessels. Once this structure is identified the it is tracked along the inguinal canal and beyond to identify the testes.
  • Carefully examine the inguinal canal, pre-inguinal space, pubic tubercle for a homogenous, ovoid hypoechoic structure. It may also have normal echogenicity.
  • If it is atrophic it is hard to distinguish from a  lymph node
  • While the majority of undescended testes are within the inguinal canal (80%) , they may be anywhere along the course of the descent of the testes (from the kidney to the scrotum)and therefore intraabdominal (cann1licular). (2) These are difficult to identify using ultrasound

Other imaging techniques

  • MRI

References

  1. Indian J Radiol Imaging. 2011 Apr-Jun; 21(2): 134–141 Sonographic localization of nonpalpable testis: Tracking the cord technique
    S Boopathy Vijayaraghavan
  2. Radiopaedia :Undescended testicle

 

 

 

 

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