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

The role of multimodal ultrasound in diagnosis of fetal bowel dilatation and prediction of adverse neonatal outcomes: A study of 86 cases in a series of 43,562 births

Objective

To investigate the diagnostic utility of multimodal ultrasound for fetal bowel dilatation (FBD) in different parts of the bowel and to examine its prognostic potential in FBD.

Methods

This retrospective study analyzed 86 fetuses with a dilated bowel identified via ultrasound in a 10-month postnatal follow-up. Both two- and three dimensional (2D and 3D, respectively) ultrasound volume imaging were used to characterize dilation across different bowel sections. The optimal intestinal diameter cut-off values for pathological bowel dilatation were determined and a predictive model for neonatal surgery was developed.

Results

The 86 cases of dilatation were distributed as follows: duodenal (n = 36); jejunum/ileum (n = 35); and colonic (n = 15). Duodenal dilatations presented the earliest during pregnancy compared to the other 2 groups (24.4 versus [vs.] 29 vs. 33.7 weeks respectively; p < 0.05). Cases with small intestinal dilatation were delivered earlier than those with colonic dilatation (p < 0.05). Infants with duodenal dilatation had the lowest birth weight and the highest rate of multi-system abnormalities (30.6% vs. 5.7% vs. 20%; p < 0.001). More than one-half of the multi-system abnormalities had chromosomal abnormalities (multiple, 54% vs. single, 12.5%; p = 0.015). There were 2 stillbirths, 24 induced labors, 44 postnatal surgeries, and 18 normal cases after birth. In predicting adverse neonatal outcomes of jejunum/ileum dilatation using a cut-off value of 15.5 mm small intestine diameter, sensitivity was 81.5%, specificity was 62.5%, and the area under the receiver operating characteristic curve (AUC) was 0.762 (p < 0.05). For colonic dilatation, using a cut-off value of 21.5 mm colon diameter: sensitivity was 83.3%, specificity was 77.8%, and AUC was 0.861 (p < 0.05). In detecting jejunum/ileum and colonic obstruction, 3D ultrasound demonstrated significantly better diagnostic efficiency than 2D ultrasound (p < 0.05). Using the backward stepwise selection method, a predictive model for neonatal surgery in patients with jejunum/ileum and colonic dilatation was established: logit (P) = -1.58 + (2.32 × polyhydramnios) +(2.0 × ascites) +(1.14 × hyperechogenic bowel). The AUC for the prediction model was 0.874 (p < 0.05), with 76% sensitivity and 94.1% specificity.

Conclusions

Duodenal dilatation occurred earlier, with a higher incidence of chromosomal abnormalities and multi-system abnormalities than dilatation of other parts of the bowel. 3D ultrasound played an important role in the detection of jejunum/ileum and colon obstructions. Clinical signs, including polyhydramnios, ascites, and strong echoes in the intestine, can be used to predict neonatal surgery.

Point-of-care ultrasonography for the diagnosis and manual detorsion of testicular torsion

Testicular torsion is a urological emergency caused by the loss of testicular tissue due to ischemic damage. Rapid diagnosis and urgent treatment play a crucial role in the management of testicular torsion. Manual detorsion can be performed at the bedside, thereby reducing the duration of ischemia. Recent studies have reported the use of point-of-care ultrasonography for diagnosing testicular torsion; however, no review article has focused on the ultrasonographic findings pertaining to manual detorsion. This review describes the diagnosis of testicular torsion and the ultrasonographic indications for manual detorsion. Spermatic cord twisting or the whirlpool sign, absence of or decreased blood flow within the affected testis, abnormal testicular axis, abnormal echogenicity, and enlargement of the affected testis and epididymis due to ischemia are the sonographic findings associated with testicular torsion. The following findings are considered indications for manual detorsion: direction of testicular torsion, i.e., inner or outer direction (ultrasonographic accuracy of 70%), and the degree of spermatic cord twist. The following sonographic findings are used to determine whether the treatment was successful: presence of the whirlpool sign and the degree and extent of perfusion of the affected testis. Misdiagnosis of the direction of manual detorsion, a high degree of spermatic cord twisting and insufficient detorsion, testicular compartment syndrome, and testicular necrosis were found to result in treatment failure. The success of manual detorsion is determined based on the symptoms and sonographic findings. Subsequent surgical exploration is recommended in all cases, regardless of the success of manual detorsion.

[Ultrasound imaging of the testes in children and adolescents]

BACKGROUND

Ultrasound, the imaging method of choice to evaluate abnormalities of the testes and the scrotum, provides accurate anatomic details and allows the assessment of perfusion using color Doppler and power Doppler. Ultrasound represents a rapid and reliable procedure which in most cases leads to a conclusive diagnosis.

DIFFERENTIAL DIAGNOSIS

The three most common conditions in the clinical picture of acute scrotum are testicular torsion, torsion of the testicular appendages and inflammatory changes of the testis and the epididymis (epididymo-orchitis). Especially in the case of testicular torsion, rapid diagnosis is essential since time is an important factor to initiate organ-preserving therapy.

EQUIPMENT TECHNOLOGY

High-frequency linear array transducer (at least 10 MHz), which allows detection of slow flow rates, is recommended.

High risk and low prevalence diseases: Testicular torsion

INTRODUCTION

Testicular torsion is a serious condition that carries with it a high rate of morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of testicular torsion, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Testicular torsion is a urological emergency that occurs with rotation of the testicle along its supporting ligaments leading to obstruction of vascular flow. A key risk factor is the presence of a bell-clapper deformity. The most common population affected includes children in a bimodal distribution with the most cases occurring in the first year of life and between 12 and 18 years, although cases do occur in adults. Acute, severe, unilateral scrotal pain is the most common presenting symptom. Nausea and vomiting are common, but the presence or absence of a cremasteric reflex is not a reliable indicator of disease. The TWIST score may assist with clinical decision making in patients presenting with acute testicular pain but should not be used in isolation. If torsion is suspected or confirmed, consultation with the urology specialist should not be delayed, as outcomes are time sensitive. Ultrasound can be used for diagnosis, but a normal ultrasound examination cannot exclude the diagnosis. Treatment includes emergent urology consultation for surgical exploration and detorsion, as well as symptomatic therapy in the ED. Manual detorsion can be attempted in the ED while awaiting transfer or consultation.

CONCLUSIONS

An understanding of testicular torsion can assist emergency clinicians in diagnosing and managing this disease.

Prediction of testicular atrophy based on sonographic findings immediately after successful manual detorsion

Purpose

To investigate and determine the sonographic findings obtained from manually distorted testes to predict testicular atrophy following manual detorsion.

Materials and methods

Twenty-two patients who had been diagnosed with testicular torsion and undergone manual detorsion were included. These patients were classified according to the presence or absence of testicular atrophy. The duration of symptoms, presence or absence of hyperperfusion within the entire affected testis, and echogenicity (homogeneous or heterogeneous) within the affected testis were compared using the Mann-Whitney U-test or Fisher's exact test, as appropriate.

Results

Testicular atrophy was detected in seven patients. There was a significant difference in the frequency of hyperperfusion within the entire affected testis (with atrophy [present/absent] vs. without atrophy [present/absent] = 0/7 vs. 8/7, P = 0.023) between patients with and without testicular atrophy. No significant differences in the duration of symptoms (with atrophy vs. without atrophy = 7 ± 3.3 h vs. 4.7 ± 3.6 h, P = 0.075) or frequency of echogenicity within the testis (with atrophy [heterogeneous/homogeneous] vs. without atrophy [heterogeneous/homogeneous] = 2/5 vs. 2/13, P = 0.565) were observed between the groups.

Conclusions

This small cohort study suggests that the presence of hyperperfusion within the entire affected testis immediately after successful manual detorsion is useful in predicting the avoidance of testicular atrophy.

Diagnostic accuracy of point-of-care ultrasound for paediatric testicular torsion: a systematic review and meta-analysis

BACKGROUND

Previous studies have examined the utility of ultrasonography performed by radiologists for diagnosing paediatric testicular torsion. While point-of-care ultrasound (POCUS) is used in paediatric emergency medicine, its diagnostic accuracy is still unknown.

OBJECTIVES

The present systematic review and meta-analysis aimed to clarify the accuracy of POCUS in diagnosing testicular torsion in children.

METHODS

Following the Preferred Reporting Items for Systematic Review and Meta-analysis of Diagnostic Test Accuracy guidelines, a systematic review was performed using the indices of MEDLINE, EMBASE plus EMBASE classics, PubMed and the Cochrane database from inception to November 2020. Any study investigating the diagnostic accuracy of POCUS for paediatric testicular torsion was extracted. The primary outcome was the assessment of the diagnostic accuracy of POCUS for paediatric testicular torsion. The pooled sensitivity and specificity were calculated. Quality analysis was conducted using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2).

RESULTS

Four studies enrolling 784 patients in total were included. The pooled sensitivity, specificity, and positive and negative likelihood ratios of POCUS were 98.4% (95% CI: 88.5% to 99.8%), 97.2% (95% CI: 87.2% to 99.4%), 34.7 (95% CI: 7.4 to 164.4) and 0.017 (95% CI: 0.002 to 0.12), respectively. Risk-of-bias assessment using QUADAS-2 revealed that two of the studies had a high risk of bias in patient selection.

CONCLUSION

The present systematic review and meta-analysis showed that POCUS had high sensitivity and specificity for identifying testicular torsion in paediatric patients although the risk of bias was high in the studies analysed.

The Role of Demographic and Clinical Characteristics in Distinguishing Testicular Torsion from Torsion of the Appendix Testis: A Single-center Retrospective Study

The acute scrotum (AS) in the pediatric population is a medical emergency. AS is usually caused by testicular torsion (TT) and torsion of the appendix testis (TAT). The current study explored which demographic and clinical characteristics can help distinguish between TT and TAT. We analyzed all children ≤16 years who underwent surgical exploration for AS. The patients were divided into Group 1/TT and Group 2/TAT. Ninety patients were included in the study (24 with TT and 66 with TAT). The peak incidence of TT was significantly higher than in the TAT group (p<0.001). Scrotal pain was more prevalent in the TAT group (p=0.02), whereas systemic signs (nausea/vomiting and abdominal pain) affected more frequently the TT patients (p=0.003 and p<0.001, respectively). The duration of symptoms was significantly longer in the TAT group (p<0.001). The duration of symptoms in the TT cohort significantly impacted the testicular salvage (p=0.008). Color Doppler ultrasound (CDUS) findings of absent/decreased testicular blood flow in the affected testis strongly favored the diagnosis of TT (p<0.001). The older age, shorter duration of symptoms, systemic signs, and CDUS findings can help distinguish between the two most common acute scrotum causes.

Sonographic findings of COVID-19 related acute scrotal infection and associations with clinical-laboratory data

BACKGROUND

During the Coronavirus Disease 2019 (COVID-19) pandemic, patients present to hospitals with a wide range of symptoms. Some of these symptoms include acute orchitis and epididymitis. The goal of this research is to see if COVID-19 infection and scrotal infection are associated.

MATERIALS AND METHODS

Patients with a COVID-19 (+) who agreed to a scrotal ultrasound (US) examination were studied prospectively in a tertiary care center between October 2021 and February 2022. The severity of the disease was used to divide patients into groups. Patients diagnosed with acute scrotal infection based on scrotal ultrasonography findings were compared in these groups, as were their age, comorbidities, and laboratory data.

RESULTS

The median age of the 213 participants was 61.7 ± 8.3. During the ultrasonographic examination of the patients, 15 (7%), 8 (3.7%), 17 (7.9%), and 40 (18.7%) were diagnosed with acute orchitis, acute epididymitis, acute epididymo-orchitis, and scrotal infection, respectively. Acute scrotal infection was far more common in patients with a higher clinical severity of the disease. The patients' comorbidities were also assessed, and it was discovered that they were statistically more common in the same group.

CONCLUSIONS

Even if there are no clinical symptoms, ultrasonography can help detect acute scrotal infection in COVID-19 patients. Furthermore, in groups with higher clinical severity, this association is more likely to be seen. It is critical to understand this in order to avoid complications.

Real-time Ultrasound-Guided Manual Testicular Detorsion: A Case Report

Introduction: Acute testicular torsion is a surgical emergency due to acute testicular ischemia. Manual testicular detorsion is a testis-saving, bedside therapeutic when performed correctly and in a timely fashion. This procedure is most commonly performed blindly with pain relief as the endpoint for detorsion. However, up to one-third of patients continued to show signs of residual torsion in the operating room even using pain relief as the stopping point for the procedure. Case Report: We present a case demonstrating the utility of color Doppler ultrasound to confirm complete manual detorsion in a 14-year-old male with acute testicular torsion. The patient underwent 360-degree detorsion and had relief of pain; however, color Doppler demonstrated incomplete return of flow to the testis. After an additional 180-degree turn was made, color Doppler demonstrated complete return of normal vascular flow to the torsed testis. Conclusion: When it comes to testicular viability, timely restoration of blood flow to the testicle is of utmost importance. Manual detorsion is a non-invasive intervention that can be quickly and effectively performed at the bedside. Moreover, using color Doppler ultrasound guidance can ensure that physicians detorse in the proper direction and to completion, by providing instant visualization of restorative flow and ensuring reperfusion of the testis while awaiting definitive surgical management.

Shear wave elastography for the evaluation of testicular salvage after testicular torsion

The aim of this study was to assess the utility of shear wave elastography in the follow-up of testicular detorsion, evaluate long-term outcomes, and explore its relationship with parameters such as tissue stiffness values, pain duration, and torsion type. Elastography examinations were independently performed by two radiologists to evaluate patients who presented to our hospital for follow-up after being diagnosed with testicular torsion and age-matched controls. Inter-observer variability of the mean testicular tissue elasticity was excellent (Intraclass correlation coefficient: 0.939, p < 0.001). Median time between testicular detorsion and follow-up ultrasound examination was 18 months (range, 11-36 months). Torsion side, torsion degree, and pain duration were recorded, and testicular volumes were calculated. The study population comprised 24 patients (48 testes) with a mean age of 21.1 ± 7.8 years. The mean testicular volume was measured as 12.3 ± 5.4 ml for the testicular salvage group, 13.9 ± 3.8 ml for the contralateral testes, and 13.7 ± 2.7 ml for the control group (p = 0.553). The mean testicular speed mode values were higher in the testicular salvage group (1.34 ± 1.21 m/s) compared with the contralateral testes group (1.00 ± 0.08 m/s), and the control group (1.01 ± 0.06 m/s), however there was no statistically significant difference between the three groups (p = 0.861). While testicular atrophy was detected in three patients, an intraparenchymal wedge-shaped focal hypoechoic area developed after torsion in a further three patients. The elastography examination for focal hypoechoic areas revealed an increase or decrease in tissue stiffness compared to the normal parenchyma. The tissue stiffness values of the testicular salvage group were higher in complete torsion compared to incomplete torsion. The elastography method contributes to other imaging methods in distinguishing focal lesion areas that can be seen after testicular torsion from malignant conditions. Elastography presents as a feasible and practical complementary modality for the follow-up of testicular salvage after torsion.

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.

Do Not Get It Twisted: Common and Uncommon Manifestations of Testicular Torsion

Color flow and spectral Doppler ultrasound are the backbone of scrotal imaging when evaluating acute scrotal pain. Testicular Torsion is one of the most common causes of acute scrotal pain but can be a challenging diagnosis both clinically and sonographically. This article will review the pertinent Doppler ultrasound findings that can help make the diagnosis of both complete and partial torsion. A review of other causes of testicular ischemia will also be included as these pathologies can mimic Testicular Torsion.

The diagnostic value of ultrasound in pediatric testicular torsion with preserved flow

BACKGROUND

Testicular torsion is the reduction of blood flow to the testis after spermatic cord torsion. For patients, the diagnosis of testicular torsion is controversial and complicated by the fact that ultrasound blood flow signals are not significantly reduced in comparison to the unaffected, healthy, testis, despite persistent symptoms on the affected side. Our study aims to investigate the diagnostic characteristics of high-resolution ultrasonography (US) in pediatric testicular torsion with the preserved flow to increase diagnostic accuracy.

METHODS

Seven pediatric patients aged 49 days to 15 years old, with the preserved blood flow, but surgically diagnosed as testicular torsion, from October 2017 to August 2019, were retrospectively included in the study. The imaging manifestations of high-frequency ultrasonography were evaluated.

RESULTS

All cases had preserved testicular blood flow, but the surgical findings showed various degrees of twist, from 90 to 540 degrees. Preoperative ultrasound showed spermatic cord distortion in all cases, and testicular long axis tilting in four cases (4/7 = 57.1%).

CONCLUSION

In some testicular torsion cases, Color Doppler may show normal or increased blood flow signals in the testis. We should further observe the morphology and position of the testes and epididymides, the echo of the testicular parenchyma, and, especially evaluate the "whirlpool sign" in the spermatic cord, to avoid missing testicular torsion with blood flow signals.

Role of ultrasound in manual detorsion for testicular torsion

PURPOSE

Manual detorsion can be performed for testicular torsion before scrotal exploration. Using sonographic findings, this study investigated the need for additional treatments after manual detorsion for testicular torsion.

METHODS

This study evaluated 13 retrospective cases of testicular torsion subjected to manual detorsion. Manual detorsion was classified as failure or success based on residual spermatic cord twist. The following sonographic findings of the affected testis were compared using the Fisher exact test: whirlpool sign, horizontal or altered lie, and hypoperfusion.

RESULTS

Manual detorsion failed in five patients. There was a significant difference in the incidence of the whirlpool sign between the two groups (present/absent sign in the failure vs. success groups: 4/1 vs. 0/8, p = 0.007). Horizontal or altered lie and hypoperfusion in the affected testis were not significantly different between groups (5/0 vs. 3/4, p = 0.07, one case excluded, and 5/0 vs. 4/4, p = 0.10, respectively).

CONCLUSIONS

Ultrasound findings after manual detorsion, particularly, the whirlpool sign, were useful for planning subsequent treatment such as additional manual detorsion or surgical intervention. The testicular axis and the perfusion of the twisted testis may not recover to normal after successful manual detorsion, but if they recover, this procedure could be judged a success.

Microvascular imaging ultrasound (MicroV) and power Doppler vascularization analysis in a pediatric population with early scrotal pain onset

INTRODUCTION

The power Doppler is a useful tool in the evaluation of pediatric acute scrotal pain. Nonetheless, it may have some inherent limitations in scrotal vascularization analysis, potentially causing unnecessary surgery. The microvascular imaging ultrasound (MicroV) is an innovative Doppler technique able to improve the detection of very low flow. This retrospective study aims to compare both power Doppler and MicroV in the evaluation of a pediatric population with early-stage scrotal pain onset, first in testis vascularization analysis, and second in their diagnostic performances.

MATERIALS AND METHODS

69 patients met the following inclusion criteria, age < 18-year-old, a clinical diagnosis of acute scrotal disease, pain onset ≤ 6 h, ultrasound examination (including B-mode, power Doppler, and MicroV), 3-months follow-up. For both power Doppler and MicroV, through a defined vascularization scale, it was evaluated the agreement in vascularization detection, and the sensitivity and specificity in US diagnostic abilities.

RESULTS

Retrospective diagnoses were of 8 testicular torsion, 15 orchi-epididymitis, and 46 children with other scrotal conditions. Power Doppler provided inconclusive US evaluation in 37.68% of the cases, while MicroV only in the 1.45% (p < 0.0001). Testicular torsion and orchi-epididymitis were identified, respectively, with MicroV in 100% (sensitivity, specificity, PPV, NPV, and accuracy of 100%) and 80% of patients (80% sensitivity, 100% specificity and PPV, 94.73% NPV, 95.65% accuracy); with power Doppler the identification was, respectively, of 87.5% (87.5% sensitivity, 100% specificity and PPV, 98.38% NPV and accuracy) and of 73.3% (73.33% sensitivity, 98.14% specificity, 91.66% PPV, 92.98% NPV, 92.75% accuracy).

CONCLUSIONS

Our findings indicate that MicroV is a reliable technique in vascularization detection of pediatric testes, being able also to detect vascularization in healthy testicles with no-flow at power Doppler examination. Moreover, MicroV could be a valuable ally in the US diagnostic of children with early-stage scrotal pain onset.

Ultrasound Imaging Findings of Acute Testicular Infection in Patients With Coronavirus Disease 2019: A Single-Center-Based Study in Wuhan, China

OBJECTIVES

Coronavirus disease 2019 (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become a global pandemic, raising widespread public health concerns. Our team treated hospitalized patients with COVID-19 in Wuhan, where the outbreak first began, and we suspected that SARS-CoV-2 may cause testicular infection in male patients. We conducted this study to explore that observation.

METHODS

We enrolled male patients with a confirmed diagnosis of COVID-19 and performed a bedside ultrasound (US) examination of the scrotum, focused on findings of acute inflammation such as tunica albuginea thickening, enlargement and heterogeneous echogenicity of the testis, epididymis, or both, an abscess, scrotal wall edema, and hydrocele. Then we compared the proportions of observed epididymo-orchitis in patients from different age groups and COVID-19 severity groups.

RESULTS

A total of 142 patients with COVID-19 were enrolled in our study, and 32 (22.5%) patients had acute orchitis, epididymitis, or epididymo-orchitis on scrotal US imaging, according to the diagnosis criteria. The observed risk of acute scrotal infection increased with age, with the incidence reaching 53.3% in men older than 80 years. We also observed that men with severe COVID-19 had a significantly higher possibility of epididymo-orchitis compared to the nonsevere COVID-19 group (P = .037).

CONCLUSIONS

This study shows US imaging evidence that SARS-CoV-2 may cause infection of the testis or epididymis, and the risk is worthy of the attention of clinicians.

Role of color flow Doppler ultrasound in the evaluation of acute scrotal pain

Color flow Doppler ultrasound is a critical tool in the assessment of the scrotum. Ultrasound is the first-line imaging modality and can rapidly differentiate between surgical and nonsurgical conditions, allowing for appropriate and prompt patient management. We review the role of color flow Doppler in the evaluation of acute scrotal pain, highlighting some of the most commonly seen pathologies such as epididymo-orchitis and testicular torsion.

Differential Diagnosis of Acute Scrotum in Childhood and Adolescence with High-Resolution Duplex Sonography

Acute testicular pain in childhood can be caused by testicular torsion, torsion of the appendix testis, or epididymo-orchitis. Quick and reliable diagnosis is essential for determining the further course of action (surgery or conservative approach). The diagnostic tool of choice is high-resolution sonography with a linear transducer (> 10 MHz) combined with color and spectral Doppler sonography. The Doppler device settings should include a low pulse repetition frequency (< 4 cm/s), a low wall filter (< 100 Hz), and adequate gain. Comparison with the unaffected healthy testis is essential. The most important of the three diseases is torsion of the spermatic cord because it requires immediate surgical intervention and detorsion. The affected testis is enlarged and has an inhomogeneous echotexture with hypoechoic and hyperechoic areas as well as an associated hydrocele. In testicular torsion, color Doppler shows reduced or absent intratesticular vessels in comparison with the healthy contralateral testis. Spectral Doppler shows decreased flow velocities especially during diastole in intratesticular arteries and an increased resistance index. The investigation should always include imaging of the spermatic cord from the outer inguinal ring to the upper pole of the testis. In contrast to a normal finding, the vessels and the ductus deferens are not displayed as linear tubular structures but in form of a spiral twist. Ultrasound shows a target-like structure with multiple concentric rings. Color Doppler sonography shows the typical whirlpool sign. In torsion of the appendix testis, the appendix testis is enlarged in the groove between the testis and epididymis. The longitudinal diameter of the appendix testis can be greater than 5 mm. The echogenicity of the torsed appendage can vary between hypoechoic (acute torsion) and hyperechoic (prior torsion). An associated hydrocele of varying size is usually seen. Color Doppler sonography reveals a lack of perfusion of the enlarged appendix testis and increased vascularity of the testis and primarily the epididymis. Epididymo-orchitis is characterized by an enlarged epididymis and/or testis with inhomogeneous echogenicity (hypoechoic - hyperechoic). Color Doppler sonography shows increased vascularity in comparison with the unaffected testis. Spectral Doppler reveals increased diastolic flow velocities and a decreased resistance index. Idiopathic scrotal edema and an incarcerated inguinal hernia must be ruled out in the differential diagnosis.

A systematic review on the utility of ultrasonography in the diagnosis of testicular torsion in acute scrotum patients

INTRODUCTION

Ultrasound is a valuable tool in establishing the cause of acute scrotum pain. However, its role in testicular torsion (TT) detection remains controversial. This review aims integrate pre-existing data to assess the value of B-mode and colour Doppler ultrasound (CDS) features combined in the detection of TT in acute scrotum pain patients of all ages.

METHODS

A search through electronic databases, grey literature and hand searching using specific search terms was conducted to identify relevant literature. Search results were subjected to a three-step selection process to ensure the inclusion criteria of this review were met. Statistical data pertaining to the accuracy, sensitivity, and specificity of the B-mode, CDS and combined B-mode CDS features were extracted. These results subsequently underwent a narrative analysis.

RESULTS

Five studies met the inclusion criteria. A variety of B-mode features were identified. Most studies showed that reliance on CDS alone can be prone to false-negative results. The combination of B-mode and CDS features were found to increase the overall sensitivity of ultrasound towards TT (up to 100% in 3 studies). All studies recommended correlation with clinical examination findings. Several limitations in methodology of the included studies were noted: small sample populations and lack of information on the experience of ultrasound practitioners. This highlighted the need for a primary study with a larger sample population to validate the findings of this review.

CONCLUSION

The combination of B-mode and CDS ultrasound is a useful and reliable triage tool in the detection of TT, particularly in equivocal or low suspicion cases but its findings should always be adjunct with clinical examination. Nevertheless, it is noted that appropriate service level agreements, pathways, and training are key factors in ensuring effectiveness of the process.

IMPLICATIONS FOR PRACTICE

Dedicated training and appropriate departmental protocol are key in ensuring accurate diagnosis across all levels of practice.

Establishment and internal validation of preoperative nomograms for predicting the possibility of testicular salvage in patients with testicular torsion

This study aimed to establish nomograms to preoperatively predict the possibility of testicular salvage (TS) in patients with testicular torsion. The clinical data of 204 patients with testicular torsion diagnosed at Xijing Hospital and Tangdu Hospital (Xi'an, China) between August 2008 and November 2019 were retrospectively analyzed. Univariate and multivariate logistic regression analyses were used to determine the independent predictors of TS. Based on multivariate regression coefficients, nomograms to predict possibility of TS were established. The predictive ability of the nomograms was internally validated by receiver operating characteristic (ROC) curves and calibration plots. The duration of symptoms ranged from 2 h to 1 month, with a median of 3.5 days. Thirty (14.7%) patients underwent surgical reduction and contralateral orchiopexy, while the remaining 174 (85.3%) underwent orchiectomy and contralateral orchiopexy. Finally, long symptom duration was an independent risk predictor for TS, while visible intratesticular blood flow and homogeneous testicular echotexture under color Doppler ultrasound were independent protective predictors. Internal validation showed that the nomograms, which were established by integrating these three predictive factors, had good discrimination ability in predicting the possibility of TS (areas under the ROC curves were 0.851 and 0.828, respectively). The calibration plots showed good agreement between the nomogram-predicted possibility of TS and the actual situation. In conclusion, this brief preoperative prediction tool will help clinicians to quickly determine the urgency of surgical exploration.

[Acute Idiopathic Scrotal Edema - A Relevant Differential Diagnosis of the Acute Scrotum in Childhood and Adolescence]

Hintergrund Das „akute Skrotum“ ist ein häufiger kinderurologischer Notfall, der eine rasche Beurteilung zur Diagnose bzw. zum Ausschluss einer Hodentorsion erfordert. Zu den weniger bekannten Differenzialdiagnosen zählt das idiopathische Skrotalödem (AISE). In dieser Studie beschreiben wir Häufigkeit und klinisches Management des AISE in unserer Klinik.

Patienten 319 Patienten im Alter von 0 bis 17 Jahren, die zwischen 01/2013 bis 12/2017 in der kinderurologischen Klinik der KUNO-Kinderklinik St. Hedwig Regensburg mit der Diagnose „akutes Skrotum“ behandelt wurden.

Methode Retrospektive Analyse der Patientenakten.

Ergebnisse 234/319 Patienten wurden ambulant und 85/319 (27%) stationär behandelt. Bei 23/319 (7,2%) wurde ein AISE diagnostiziert. Alle Patienten mit AISE wurden ambulant behandelt, bei keinem dieser Patienten musste eine operative Exploration erfolgen. Weitere Diagnosen der ambulanten Patienten: Epididymitis (87/234; 37%), Hydatidentorsion (42/234; 18%), Hodentorsion (5/234; 2%) Hodentrauma (10/234; 4%), Hydrozele (9/234; 4%), unspezifische Hodenschmerzen (58/234; 25%). Diagnosen der stationären Patienten: Hodentorsion (58/85; 68%), Hydatidentorsion (17/85; 20%), Epididymitis (8/85; 9%), Hodentrauma (1/85; 1%), Tumor (1/85; 1%).

Diskussion Das AISE ist eine Ausschlussdiagnose mit typischem klinischem Bild. Zusammen mit dem charakteristischen Befund in der (Doppler-) Sonografie ist eine sichere Abgrenzung zu anderen Differenzialdiagnosen des akuten Skrotums möglich. Durch die korrekte Diagnosestellung können unnötige Klinikaufenthalte, Operationen und medikamentöse Behandlungen vermieden werden.

Schlussfolgerung Das AISE ist eine relevante Differentialdiagnose des akuten Skrotums, das Kinder- und Jugendärzten bekannt sein sollte.

Imaging of the acute scrotum: keys to a rapid diagnosis of acute scrotal disorders

Imaging of the scrotum in the setting of acute symptoms such as pain or swelling is commonly performed emergently to differentiate between patients who require immediate surgery and those that do not. Acute scrotal symptoms are generally caused by infectious, traumatic or vascular etiologies. Rapid diagnosis and initiation of treatment is vital for testicular salvage in cases of acute testicular torsion, testicular rupture, and Fournier gangrene. Epididymitis, epididymo-orchitis, torsed testicular appendage, segmental testicular infarction, scrotal hematomas, testicular neoplasms, and acute idiopathic scrotal edema can have similar clinical presentations, but these conditions do not require immediate surgery. Ultrasound is the well-established first-line imaging modality for the acute scrotum. Contrast-enhanced ultrasound and magnetic resonance imaging can be useful as problem-solving tools when ultrasound studies are inconclusive or equivocal. This review describes normal scrotal anatomy and a wide range acute scrotal disorders, with emphasis on the imaging and clinical features that can minimize the risk of misdiagnosis.

Effect of unilateral testicular torsion at different ages on male fertility

Objective

To investigate the effect of early-life unilateral testicular torsion on adult male fertility.

Methods

Clinical information was collected for 122 patients who had experienced unilateral testicular torsion at a median age of 15.5 years. The recent pregnancy rate and time to pregnancy experienced by the patients’ female partners were assessed by structured interviews. Data were analyzed by the chi-squared test and Student’s t-test.

Results

Seventy-two patients with testicular torsion met the criteria for inclusion in our analyses; 49 had undergone orchiectomy, while 23 had undergone surgical repositioning/orchiopexy. The pregnancy rate and median time to pregnancy were 83.67% (41/49) and 1.6 years, respectively, in the orchiectomy group, whereas they were 91.30% (21/23) and 0.75 years, respectively, in the repositioning/orchiopexy group. The recent pregnancy rate was higher in patients with torsion in childhood than in patients with torsion in adolescence; it was lowest in patients with torsion in adulthood. Surgical repositioning/orchiopexy yielded a significantly better recent pregnancy rate among the three groups, based on age at the time of torsion, and a shorter time to pregnancy than orchiectomy in patients with torsion in adolescence.

Conclusion

Onset of unilateral testicular torsion early in life has a negligible effect on adult male fertility.

[Acute idiopathic scrotal edema-an underestimated differential diagnosis of acute scrotum]

Considering that Quist et al. first described the acute idiopathic scrotal edema (AISE) already in 1956, there are not many studies published in literature concerning the etiology, the development, and the progress of the disease since then. According to the literature the incidence of AISE is about 20%. Although it is an important differential diagnosis for acute scrotum, it remains extensively unknown. Therefore, AISE should be kept in mind by urologists, pediatric surgeons and pediatricians to avoid needless surgery or antibiotic therapy.

Diagnostic Accuracy of Ultrasound for the Directionality of Testicular Rotation and the Degree of Spermatic Cord Twist in Pediatric Patients With Testicular Torsion

OBJECTIVES

To evaluate the diagnostic accuracy of ultrasound (US) to diagnose the directionality of testicular rotation and the degree of spermatic cord twist in pediatric patients with testicular torsion.

METHODS

A retrospective review of 14 pediatric patients with testicular torsion was conducted. The directionality of testicular rotation was classified as an inner or outer direction (inner, counterclockwise in the left testis [viewed from below] and clockwise in the right testis; and outer, counterclockwise in the right testis and clockwise in the left testis). The Clopper-Pearson method and the Fisher exact, Mann-Whitney U, and Wilcoxon signed rank sum tests were used for the statistical analyses.

RESULTS

The diagnostic accuracy of US in the directionality of testicular rotation and the degree of spermatic cord twist were 78.6% (11 of 14; 95% confidence interval, 49.2%-95.3%) and 36.4% (4 of 11; 95% confidence interval, 10.9%-69.2%), respectively. Outer rotation was seen in 50.0% of the cases. The directionality of testicular rotation and the degree of spermatic cord twist as determined by US were not significantly different between the patients with salvaged testis and those with testicular loss (inner/outer direction, 4/2 versus 4/4; P = .627; mean twist ± SD, 330.0° ± 73.5° versus 337.5° ± 115.4°; P > .999). There was no significant difference in the degree of spermatic cord twist determined by US and surgical results (343.0° ± 97.1° versus 458.2° ± 168.2°; P = .063).

CONCLUSIONS

The accuracy of US in determining the directionality of testicular rotation was relatively high in our small cohort. This information may be useful for pediatric surgeons and urologists when performing early manual reduction for testicular torsion.

Lesions Without Borders: Scrotal Lesions That Involve Both the Intratesticular and Extratesticular Regions

OBJECTIVE

Differentiation of scrotal lesions is often dictated by whether they are intraor extratesticular. However, these regions are not entirely isolated, and disease processes can span both spaces. We review a variety of lesions that can involve both regions, describe the relevant anatomy, and illustrate their imaging appearances.

CONCLUSION

Identification of involvement of both intra- and extratesticular regions by a single process can narrow the differential considerations and help arrive at the correct diagnosis.

Frontiers in pediatric testicular torsion: An integrated review of prevailing trends and management outcomes

Testicular torsion remains the most frequent cause of testicular ischemia, especially in adolescents and young adults. Timely diagnosis and intervention are keys to saving the affected testicle. This review presents current trends in the diagnosis and treatment of torsion, potential pitfalls and consequent outcomes. Additionally, other salient issues surrounding testicular torsion are also discussed, including: pathogenesis of injury, legal ramifications, fertility outcomes, novel management techniques, and recent advances in diagnostic technology.

The ultrasonographic "whirlpool sign" in testicular torsion: valuable tool or waste of valuable time? A systematic review and meta-analysis

PURPOSE

A positive whirlpool sign (WS) is defined as the presence of a spiral-like pattern when the spermatic cord is assessed during ultrasonography (US), using standard, high-resolution ultrasonography (HRUS) and/or color Doppler sonography (CDS), in the presence of testicular torsion. The objective of this review was to assess the validity and accuracy of this sign by performing a comprehensive systematic literature review and meta-analysis.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a comprehensive literature search was performed (August, 2017), using the following databases: BMJ Best Practice, Cochrane Library, Embase, PubMed, Scopus, and Web of Science. Selected studies were further assessed for relevance and quality using the Oxford 2010 Critical Appraisal Skills Program (CASP).

RESULTS

Of the studies assessed, a total of 723 participants were included, with a mean of 72.3 (SD 71.9) participants. Of the participants, 226 (31.3%) were diagnosed with testicular torsion (TT). Meta-analysis of the studies that provided sufficient data resulted in a pooled sensitivity and specificity of the WS of 0.73 (95% CI, 0.65-0.79) and 0.99 (95% CI, 0.92-0.99), respectively. Removal of all neonates increased the pooled sensitivity to 0.92 (95% CI, 0.70-0.98) while the pooled specificity remained almost unchanged at 0.99 (95% CI, 0.95-1.00). The estimated summary effect of all studies with sufficient data was 4.34 (95% CI, 1.01-7.67; n = 394; p = 0.001). A large degree of heterogeneity was suggested by an I² statistic of 88.27% (95% CI, 68.60-98.68%). Removal of neonatal subjects increased the estimated summary effect to 5.32 (95% CI, 1.59-9.05; n = 375; p = 0.001).

CONCLUSION

The WS, when correctly diagnosed, may be viewed as a very definitive sign for TT in the pediatric and adult populations. However, its role in neonates is limited.

Testicular torsion with preserved flow: key sonographic features and value-added approach to diagnosis

Testicular sonography has contributed greatly to the preoperative diagnosis of testicular torsion in the pediatric patient and is the mainstay for evaluation of acute scrotal pain. Despite its high sensitivity and specificity, both false-negative and false-positive findings occur. Presence of documented Doppler flow within the testis might be a dissuading factor for surgical exploration with resultant testicular loss in the false-negative cases. Our goal is to illustrate key sonographic features in the spectrum of testicular torsion with preserved testicular flow, and to describe how to differentiate testicular torsion from epididymitis in order to avoid the under-diagnosis of testicular torsion. We simplify the anatomy of the bell clapper testis. We also describe our sonographic protocol for testicular torsion and share valuable tips from our approach to challenging cases.

Acute Epididymo-orchitis-Related Global Testicular Infarction: Clinical and Ultrasound Findings With an Emphasis on the Juxta-epididymal String-of-Bead Sign

Acute epididymo-orchitis (AEO)-related global testicular infarction (GTI) is rare. We report herein the clinical and ultrasound findings of 6 patients with AEO-related GTI. Seventeen patients with torsion-related GTI were also reviewed and compared. The echotexture of AEO-related GTI ranged from mildly inhomogeneous to diffuse heteroechoic, depending on the severity of testicular necrotic changes. All of the patients showed a juxta-epididymal string-of-bead pattern on color Doppler ultrasound, which was ascribed to patent arteries (5/6, 87%) and collateral vessels (1/6, 13%) in the tunica albuginea. There were no significant differences in age, laterality, leukocyte count, testicular volume ratio (infarcted/normal), frequencies of heteroechoic testicular parenchyma, scrotal skin thickening, and hydrocele between the 2 groups. However, the left testis was predominantly affected in both groups. Compared with torsion-related GTI, patients with AEO-related GTI had significantly longer duration from scrotal pain onset to surgery (13.5 ± 5.2 vs 2.6 ± 2.0 days, P < 0.001), a higher level of serum C-reactive protein (110.0 ± 82.0 vs 41.2 ± 35.9 mg/dL, P = 0.013), a higher frequency of the juxta-epididymal string-of-bead sign (100% vs 12%, P < 0.001), and a lower frequency of the whirlpool/knot sign (0% vs 88%, P = 0.002). Although the testis in AEO-related GTI may appear variable from mildly to extensively heteroechoic on gray-scale ultrasound, this unusual disease can be characterized by an avascular testis with a juxta-epididymal string-of-bead sign on color Doppler ultrasound.

Ultrasonography of pediatric urogenital emergencies: review of classic and new techniques

Urogenital emergencies are fairly common in the pediatric population, and a timely and correct diagnosis is necessary to avoid possible future infertility. In this field, ultrasonography is essential, as it has the advantages of being radiation-free and readily accessible. In particular, a high-frequency transducer allows precise evaluation of the morphology and vascularity of the scrotum, which is on the surface of the body. Beyond conventional techniques, new advanced imaging techniques have been developed, including elastography and contrast-enhanced ultrasonography. However, several pitfalls remain in the diagnosis of urogenital diseases using ultrasonography. Thus, accurate knowledge and sufficient experience with the technique are essential for making a correct diagnosis. This review provides an overview of pediatric urogenital emergency pathologies and recent ultrasonography techniques.

Ultrasound Emergencies of the Male Pelvis

Male pelvic emergencies are uncommon, and symptoms typically include scrotal pain, scrotal enlargement, or a palpable scrotal mass or all of these. Ultrasound is often the first-line modality for evaluation of male pelvic emergencies, which may be stratified into vascular, infectious, or traumatic causes. Entities such as testicular torsion, Fournier gangrene, and testicular dislocation are surgical emergencies and should not be missed or misdiagnosed, as this may cause a significant delay in urgently necessary treatment. Radiologists need to be familiar with the role of imaging as well as the key characteristic imaging findings of these injuries to direct the appropriate management.

Cryptorchid testis with torsion: Inguinoscrotal whirlpool sign

Non contrast helical computed tomography (CT) study of the abdomen is frequently performed in evaluation of suspected ureteric colic. We present CT images of a young adult male patient who had torsion of an undescended, non-neoplastic testis and describe the “Inguinoscrotal whirlpool sign on CT”.

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.

[Scrotal ultrasound examinations in infants and toddlers]

BACKGROUND

Besides physical examination, ultrasonography is the most valuable diagnostic tool to assess the scrotum and testes in the case of an acute scrotum or scrotal pathology.

PROBLEMS

In infants and toddlers the examination can be challenging. Due to the limited patient compliance, the small testicular size (< 0.5 ml), and low blood flow velocity (< 3 cm/s), it can be difficult to achieve a proper flow curve when assessing blood flow.

CONCLUSION

The examiner's skills are as important as adequate equipment (i. e., linear ultrasound probe, 12-14 MHz) and optimal program settings (Doppler scale < 3 cm/s, gate 1 mm). However, if there is doubt, surgical exploration is unavoidable.

Role of ultrasound with color Doppler in acute scrotum management

Background and Objective:

An acute scrotum is defined as acute pain with or without scrotal swelling, may be accompanied by local signs or general symptoms. Acute scrotal pain is a medical emergency. Depending on cause, the management is entirely different. Torsion of testis and strangulated hernia are surgical emergency; whereas, epididymo-orchitis is treated by medicines. Testicular trauma and obstructed hernia can be differentiated by taking history from patient. Physical examination adds only a little information. Color Doppler ultrasound (US) is the modality of choice to differentiate testicular torsion from inflammatory conditions and can thus help in avoiding unnecessary surgical explorations.

Subjects and Methods:

A study on 50 patients was conducted who were referred with history of acute scrotal pain to our department between January 2013 and January 2014. Trauma and scrotal mass were excluded from the study. The clinical presentation, outcome, and US results were analyzed.

Results:

Color Doppler sonography yielded a positive and negative predictive value (PPV and NPV) of 100% each for torsion, whereas, 93.9 and 70.6% for epididymo-orchitis, respectively; a sensitivity and specificity of 100% for torsion, whereas, for epididymo-orchitis it was found to be 86.1 and 85.7%, respectively. In cases of incomplete or early torsion, some residual perfusion may be detected leading to false-negative results.

Conclusion:

We therefore conclude that color Doppler sonography can reliably rule out testicular torsion and can thus help in avoiding unnecessary surgical explorations. Hence, it can significantly improve outcome and decrease morbidity of patient. It is an accurate, rapid, nonexpensive, nonionizing, important adjunct to clinical assessment of scrotum.

Ultrasonography evaluation of scrotal masses

Sonography is the ideal modality for evaluation and characterization of a scrotal mass. Extratesticular masses are usually benign, whereas intratesticular masses are generally malignant until proved otherwise. However, it is important to recognize the benign intratesticular conditions, thus possibly preventing orchiectomy when unwarranted, while appreciating the more significant findings of extratesticular masses that may warrant further intervention. This article reviews the anatomy and sonographic findings of scrotal masses. Normal anatomy, general imaging techniques, and assessment of intratesticular and extratesticular disorders will be discussed.

Core curriculum illustration: testicular torsion

This is the 7th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.aseronline.org/curriculum/toc.htm .