Torsed appendix testis: gray scale and color Doppler sonographic findings compared with normal appendix testis

A review of multiparametric ultrasound imaging in the clinical setting: scrotal contents

The innovative techniques in ultrasound have added a new dimension to investigating superficially located areas such as the contents of the scrotal sac. High frequency transducers, improved technology with the addition of elastography, contrast enhanced ultrasound and microvascular imaging has resulted in a further improvement in diagnostic capabilities. The ability to clearly demonstrate the presence or absence of vascularity within the area under investigation adds an additional dimension to operator confidence in establishing the presence of infarction, global or segmental, or the walls and cavity of an abscess in the testis or epididymis. Increased vascularity of a tumor aids the differential diagnosis based on the flow dynamics of the microbubble contrast, benign lesions likely to retain contrast. Elastography has the ability to ascertain the stiffness of tissue, and when used in conjunction with other ultrasound methods adds to the understanding of the likelihood of a malignant abnormality being present. All the different techniques come under the umbrella term 'multiparametric ultrasound', with the application in the scrotal sac detailed in this article.

Is Being Overweight a Risk Factor for Torsion of the Appendix Testis in Children?: A Paired Case-Control Study

OBJECTIVE

This study aimed to determine whether being overweight during childhood is a risk factor for torsion of the appendix testis (TAT).

METHODS

We conducted a paired case-control study with all boys surgically treated for TAT, paired by age and sex with patients who were seen in the emergency department for a reason other than acute scrotum. Age and weight were registered, and weight percentile (WP) by age was calculated and compared between groups. Weight percentile was classified into 4 groups (<25, 25-50, 50-75, >75), and a conditional logistic regression analysis was performed to establish the risk of TAT related to the WP.

RESULTS

A total of 980 patients were diagnosed as having TAT in our institution, of which 118 patients (12%) were surgically treated and randomly paired with 118 controls. Mean age was the same in both groups (11.2 years, P = 0.908). Patients with TAT had a higher median of WP (79; interquartile range, 49-94) than the control group (49; interquartile range, 20-79; P < 0.0001). For each WP point increase, risk of TAT raised by 2.2% (odds ratio [OR], 1.022; 95% confidence interval [CI], 1.011-1.032; P < 0.001). Weight percentile >75 increased the risk of TAT: 6-fold compared with WP <25 (OR, 5.9; 95% CI, 2.5-14; P < 0.001), 4-fold compared with WP of 25 to 50 (OR, 4.3; 95% CI, 1.8-10.5; P = 0.001), and 3-fold compared with WP of 50 to 75 (OR, 3.3; 95% CI, 1.5-7.6; P = 0.004).

CONCLUSIONS

Overweight increases the risk of being operated on because of TAT. Because obesity is a rising problem, a greater incidence of TAT remains to be proved.

Contrast-enhanced ultrasonographic findings in torsion of the appendix testis or epididymis in children: a case series

PURPOSE

Torsion of the appendix testis or epididymis is a cause of acute scrotum in children. Ultrasonography with color Doppler is the first-choice modality for diagnosis. However, this method requires skill and experience to make a diagnosis with confidence. Recently, contrast-enhanced ultrasonography for diagnosis in various fields has been reported. However, to our knowledge, there has been no report of this method being used to diagnose torsion of the appendix testis or epididymis. The purpose of this study was to retrospectively examine contrast-enhanced ultrasonographic findings in torsion of the appendix testis or epididymis.

METHODS

Patients who underwent contrast-enhanced ultrasonography for torsion of the appendix testis or epididymis at our institution between April 2010 and April 2023 were enrolled in this study (n = 12). Contrast-enhanced ultrasonography findings of the affected appendage and the testis parenchyma were examined retrospectively.

RESULTS

The parenchyma of the testes was notably enhanced in all the cases. However, 9 of the 12 cases showed that the appendage with torsion was not enhanced at all. In the remaining three cases, only slight enhancement was seen. Nevertheless, it was notably less than that of the parenchyma of the testis.

CONCLUSION

Our findings indicated that contrast-enhanced ultrasonography may be an easy and reliable method for diagnosing torsion of the appendix testis or epididymis.

Pearls and Pitfalls of Pediatric Scrotal Imaging

Ultrasonography (US) is the primary imaging modality for the evaluation of pediatric scrotal disease. The ability to obtain exceptional anatomical detail and testicular perfusion information without ionizing radiation makes it the essential tool for evaluating scrotal pain and palpable masses. Challenges arise in both the performance and interpretation of scrotal US in the child. Optimizing imaging parameters and recognizing key differentiating US features help minimize misinterpretations that can lead to poor patient outcomes. Key pearls and pitfalls in pediatric scrotal ultrasound methods and diagnoses are reviewed. Knowledge of what is normal for the various ages of childhood from neonate through adolescence is necessary for accurate US analysis. Imaging evaluation of key causes of the acute painful scrotum including testicular appendage torsion, epididymitis, and testicular torsion are discussed. Sonographic features for the diagnosis of benign and malignant scrotal masses, microlithiasis, and cryptorchidism are reviewed.

Ultrasound evaluation of inguinoscrotal pain: an imaging-based review for the ultrasonographer

Emergencies involving the inguinal region and scrotum are common and can be caused by a plethora of different causes. In most cases, such conditions have nonspecific symptoms and are quite painful. Some inguinoscrotal conditions have high complication rates. Early and accurate diagnosis is therefore imperative. Ultrasound is the method of choice for the initial evaluation of this vast range of conditions, because it is a rapid, ionizing radiation-free, low-cost method. Despite the practicality and accuracy of the method, which make it ideal for use in emergency care, the examiner should be experienced and should be familiarized with the ultrasound findings of the most common inguinoscrotal diseases. On the basis of that knowledge, the examiner should also be able to make an accurate, direct, precise report, helping the emergency room physician make decisions regarding the proper (clinical or surgical) management of each case. Here, we review most of the inguinoscrotal conditions, focusing on the imaging findings and discussing the critical points for the appropriate characterization of each condition.

Torsed appendix epididymis in an adult: misdiagnosis as tumor of tunica vaginalis on sonography

We report the sonographic findings in a case of torsed appendix epididymis that occurred in an adult, which was misdiagnosed as a tunica vaginalis tumor such as cystic mesothelioma. Scrotal gray-scale sonography revealed an ovoid-shaped, heterogeneously hypoechoic mass with multiple tiny cystic foci and thick septa in the sac of the right tunica vaginalis, which abuts to the right epididymal head. Color Doppler sonography showed no blood flow within the mass. Pathological examination revealed torsion of the appendix epididymis.

Sonographic appearances of torsion of the appendix testis and appendix epididymis in children

PURPOSE

The most common cause of acute scrotum in prepubertal boys is torsion of the testicular or epididymal appendages. The purpose of this retrospective study was to characterize the features of these lesions as viewed on sonographic (US) and color Doppler US examination.

METHODS

During a 220-week period, 527 male patients 0-17 years old had been referred from the pediatric emergency department for scrotal US evaluation. Torsion of the appendix testis or appendix epididymis had been diagnosed in 19 (3.6%) patients, 3-14 years old (mean, 9.4 years); those patients became our study cohort. The clinical diagnoses in 15 of those patients had been suspected testicular torsion (n = 7), trauma (n = 4), suspected epididymitis and/or orchitis (n = 3), and suspected hydrocele (n = 1). The remaining four patients had been referred owing to nonspecific pain. None of the 19 patients had had the "blue-dot sign" on physical examination.

RESULTS

In the 19 patients diagnosed with torsion of the intrascrotal appendages, color Doppler US demonstrated a round or oval avascular lesion with heterogeneous echotexture (n = 18), posterior enhancement (n = 13), and hyperemia of the surrounding structures (n = 15). All lesions (appendages) were adjacent (n = 16) or in close proximity (n = 3) to the upper pole of the testis. Fifteen of the appendages were adjacent to both the testis and the epididymis, four were adjacent to the epididymis alone, and none were adjacent to the testis alone. Owing to the close proximity of the upper pole of the testis, the epididymis, and the appendage, differentiation between testicular and epididymal appendages was not possible.

CONCLUSIONS

Torsion of the intrascrotal appendages has a typical appearance on color Doppler US; thus, we believe that it is the method of choice for diagnosing torsion of the scrotal appendages and safely ruling out other disorders as well as avoiding unwarranted surgical intervention or antibiotic treatment.

Ovary and testicle and everything in between: lesions and imaging in the newborn

Assessment of the neonatal reproductive tract requires an understanding of embryology, awareness of common clinical presentations, and familiarity with normal newborn variation. This review of the neonatal reproductive tract emphasizes the use of sonography in the evaluation of developmental, acquired, and neoplastic conditions in male and female newborns. Anchored in embryologic origins, the discussion also includes descriptions of findings that may be encountered in prenatal imaging. Comments on clinical correlation are included to guide appropriate triaging of these complex cases. Imaging pearls and pitfalls are incorporated into this review, including the recognized effects of maternal hormones in female infants.

Sonography of the scrotum: from appendages to scrotolithiasis

In this pictorial essay, we review and discuss the varying morphologic characteristics of scrotal appendages and calculi. Characteristic sonograms obtained from patients with coexisting hydrocele are presented, and recent literature is included. Hydrocele greatly facilitates the imaging of these intrascrotal structures, as it acts as a "water path". On the one hand, torsion of a scrotal appendage should always be included in the differential diagnosis of acute scrotum, especially in children. On the other hand, scrotolithiasis may occasionally cause mild discomfort. As a consequence, and given the widespread use of sonography for the evaluation of both acute and chronic conditions of the scrotum, radiologists should be familiar with these entities.

Sonography of intrascrotal appendage torsion: varying echogenicity of the torsed appendage according to the time from onset

OBJECTIVES

The purpose of this study was to evaluate sonographic findings in torsed intrascrotal appendages and to assess the effect of the time from symptom onset on echogenicity and the relationship between the time from symptom onset and manual reduction success.

METHODS

Thirty-five boys (6-13 years old; mean, 9.9 years) with torsion of an intrascrotal appendage were evaluated. All had painful unilateral scrotal swelling and palpable tender nodules on physical examination and underwent sonography. Thirty-two underwent subsequent manual reduction. Before manual reduction, we assessed the size, echogenicity, appendage blood flow, periappendiceal blood flow, and scrotal swelling. Data were analyzed according to time from symptom onset. After manual reduction, the number of reduction trials, pain relief, size, and blood flow of the appendix testis were assessed.

RESULTS

The torsed appendage was hypoechoic in all 17 boys assessed within 24 hours of symptom onset. In boys assessed more than 24 hours after onset, the torsed appendage was hypoechoic in 6, isoechoic in 4, and hyperechoic in 8. Twenty-two of 23 hypoechoic appendages showed a salt-and-pepper pattern. The echogenicity differed significantly between boys assessed within and more than 24 hours after symptom onset (P < .001). The success rates of manual reduction were 90.9% (20 of 22) for hypoechoic appendages, 75.0% (3 of 4) for isoechoic appendages, and 50.0% (3 of 6) for hyperechoic appendages. Sonography revealed increased blood flow and decreased appendage sizes in all boys with successful reduction.

CONCLUSIONS

The echogenicity of a torsed appendage changes according to the time from onset. A hyperechoic intrascrotal appendage is associated with later sonography and is a poor predictor of manual reduction success.

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.

The testis: the unusual, the rare and the bizarre

Ultrasound is the preferred technique when imaging the scrotal contents. Although appearances of many of the more common abnormalities present the examiner with no diagnostic difficulty, the more unusual conditions may present a considerable challenge. Many normal variants, unusual and rare abnormalities may be instantly recognized once seen. The current review highlights the more unusual and rare conditions affecting the scrotal contents in order to allow the reader the opportunity to gain knowledge of their existence and to aid future interpretation of the difficult examination.

Manual reduction of torsion of an intrascrotal appendage under ultrasonographic monitoring

OBJECTIVE

The purpose of this study was to evaluate the feasibility and safety of manual reduction of torsion of an intrascrotal appendage under ultrasonographic monitoring.

METHODS

Fifteen boys with torsion of an intrascrotal appendage, confirmed by scrotal ultrasonography and clinical status, were included in the study. The boys were 6 to 13 years old (mean age, 9 years). They all had painful, unilateral swelling of the scrotum and a palpable, tender nodule on physical examination. Scrotal ultrasonography indicated a single, variably echoic mass corresponding to the intrascrotal appendage. The mass was avascular according to Doppler ultrasonography. Thirteen boys underwent manual reduction under ultrasonographic monitoring. We tried to pull and release the swollen appendage in 8 patients and gently squeezed the appendage in 5. The procedure was considered successful when ultrasonography showed reperfusion in the appendage and the patients stated complete relief of scrotal pain. In 14 boys, follow-up scrotal ultrasonography was performed after the manual reduction.

RESULTS

Successful reduction was obtained in 12 (80.0%) of 15 boys. Only 1 boy was regarded as having reduction failure; this patient had intractable pain after the trial reduction, and ultrasonography showed transient vascular flow that promptly disappeared in the appendage. On follow-up ultrasonography, the maximal diameter +/- SD of the intrascrotal appendages significantly decreased from 6.1 +/- 1.2 to 4.0 +/- 1.3 (P=.005) in 11 patients with successful reduction.

CONCLUSIONS

Manual reduction under ultrasonographic monitoring seems to be a feasible and effective method for the treatment of torsion of an intrascrotal appendage to immediately relieve pain.