Ultrasound Assessment of Scrotal Emergencies
Summarized by: Akshay Wadera, M.D.
Reviewed by: Zonia Ghumman, M.D.
Original publication details
Authors: Christopher R. McAdams & Andrew J. Del Gaizo
DOI: https://doi.org/10.1007/s10140-018-1606-y
Reference: McAdams, C. R., & Del Gaizo, A. J. (2018). The utility of scrotal ultrasonography in the emergent setting: beyond epididymitis versus torsion. Emergency Radiology, 25(4), 341-348.
Background
Physical examination and sonography are cost-effective ways of assessing scrotal and periscrotal emergencies
Testicular torsion and epididymo-orchitis are two of the most common diagnoses
Technique
Position
Supine position with penis positioned superiorly/superolaterally and proper draping technique
Transducer
Linear high frequency (7.5 - 15 MHz). Curvilinear lower frequency in cases with significant scrotal edema.
Views:
Saddle view, sagittal and transverse planes
Quick Navigate
Testicular Torsion
Typical presentation
Acute scrotal pain
Imaging:
Can be relatively hypoechoic, homogenous (early) and heterogeneous (late after 24 hours) suggesting necrosis
Decreased or absent blood flow
Epididymitis-Orchitis
Typical presentation
Acute scrotal pain
Imaging:
Relatively hypoechoic in orchitis
Variable echogenicity in epididymitis
Increased blood flow/hyperemia
Torsed Testicular/Epididymal Appendage
Typical presentation
Unilateral focal acute scrotal pain in prepubertal males. No clinical significance between torsed testicular appendage or torsed epididymal appendage
Imaging:
Ovoid extratesticular/extra-epididymal mass
Variable echogenicity
Peripheral vascularity with no internal blood flow
Associated findings: ipsilateral scrotal skin thickening and reactive hydrocele
Intratesticular or Epididymal Abscess
Typical presentation
Untreated epididymitis-orchitis or retrograde spread lower urinary tract bacterial infections. May progress to pressure necrosis if left untreated
Imaging:
Round intratesticular/intraepidydmal collection
Variable echogenicity
Peripheral vascularity with no internal blood flow
Hematoma
Typical presentation
Acute scrotal pain, usually traumatic.
Imaging:
Hyperechoic ovoid collection of varying size
Variable echogenicity
No internal blood flow or peripheral vascularity
Sonographic follow-up to resolution recommended due to high risk of infection/necrosis and exclusion of incidental tumor
Testicular Fracture/Rupture
Typical presentation
Acute scrotal pain after blunt trauma. Delayed surgical management can lead to increased risk of infection and necrosis
Imaging:
Linear hypoechoic abnormality extending across parenchyma
Rupture defined by visible discontinuity/irregularity of tunica albuginea
Associated findings: Can have extrusion of testicular parenchyma through defect
Penetrating Trauma
Typical presentation
Most common source is gunshot wounds
Imaging:
Hypoechoic tracts
Associated findings: may have secondary testicular parenchymal injury, vascular compromise, and spermatic cord transection
Intratesticular or Extratesticular Varicocele
Typical presentation
Vague discomfort or palpable mass, more common on the left
Imaging:
Hypoechoic/anechoic tubular structures inside testicular parenchyma close to mediastinum testes or extratesticular tubular structures measuring over than 2mm.
Internal blood flow with venous spectral waveforms that enlarge with Valsalva or standing maneuvers
Simple Hydrocele
Typical presentation
Idiopathic or reactive to infection, trauma, torsion, or neoplasm
Imaging:
Uniform anechoic extratesticular collection with no blood flow
Complex Hydrocele
Typical presentation
Traumatic or infectious presentations are most common. Large collections can exert mass effect which predispose patent to vascular compromise/infarct
Imaging:
Extratesticular collection with mobile internal echoes.
Foci of dirty shadowing may represent gas in cases of pyocele
Variable echogenicity
No internal blood flow. Peripheral vascularity in cases of abscess
Inguinal Hernia
Typical presentation
Acute pain/swelling in cases of incarceration that may enlarge with Valsalva
Imaging:
Hyperechoic fat or bowel signature with foci of dirty shadowing that may represent gas in bowel
Variable blood flow pattern on Doppler depending on contents
Fat demonstrates no blood flow in normal circumstances Decreased/absent blood flow in cases of incarceration
Funiculitis
Typical presentation
Painful unilateral scrotal pain
Imaging:
Edematous enlargement of ipsilateral spermatic cord
Heterogeneous echotexture
Increased blood flow
Associated Findings: engorged para-funicular vessels that enlarge with Valsalva maneuver
Funicular Collections
Pathology
Encysted hydroceles result from irregular closure of processus vaginalis and does not communicate with the peritoneum or scrotum
Imaging:
Beaded/loculated fluid collections accumulate along spermatic cord
Penile Trauma/Fracture
Typical presentation
Blunt trauma when the penis is erect because of physiologic stretching/thinning of tunica albuginea
Imaging:
Discontinuity of thin echogenic tunica albuginea band
Associated Findings: possible hematoma and herniation of corpora
Fournier Gangrene
Typical presentation
Pain and swelling is an often common first presentation making sonography often the initial imaging study. CT is preferred for potential perineal infection.
Imaging:
Multiple echogenic foci with dirty shadowing representing gas within the scrotal wall
Increased blood flow
Cellulitis
Typical presentation
Erythema swelling and warmth of the scrotal skin surface
Imaging:
Subcutaneous reticulation with heterogeneous/hypoechoic scrotal wall thickening
Increased blood flow
Associated Findings: Possible localized superficial fluid collections
3rd Spacing
Typical presentation
Generalized ascites or volume overload states due to systemic process such as congestive heart failure or sepsis
Imaging:
Diffuse symmetric scrotal heterogeneous/hypoechoic skin thickening due to edema
Variable blood flow
Referred Pain
Typical presentation
Colicky pain in a patient with history of urolithiasis and no periscrotal cause
Imaging:
Echogenic focus with shadowing most commonly in the lower urinary tract
Citation
McAdams, C. R., & Del Gaizo, A. J. (2018). The utility of scrotal ultrasonography in the emergent setting: beyond epididymitis versus torsion. Emergency Radiology, 25(4), 341-348.