The Acute ScrotumThe Acute Scrotum

Alex Lam, Harvard Medical School Alex Lam, Harvard Medical School Year IIIYear III

Gillian Lieberman, MDGillian Lieberman, MD

Alex Lam, HMS IIIGillian Lieberman, MD

September 2002

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Alex Lam, HMS IIIGillian Lieberman, MD

DDxDDx: Acute Scrotal Pain & Enlargement: Acute Scrotal Pain & Enlargement

PAIN PAIN

Inflammatory disorderInflammatory disorderTesticular torsionTesticular torsionTesticular infarctionTesticular infarctionTesticular abscessTesticular abscessTraumaTrauma

ENLARGMENTENLARGMENT

HydrocelesHydrocelesHerniasHerniasHematomasHematomasTesticular torsionTesticular torsionEpididymitisEpididymitisAbscessAbscessTraumaTrauma

*In 20% of cases, testicular tumors may present with a painful mass.

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Alex Lam, HMS IIIGillian Lieberman, MD

Modes of Scrotal ImagingModes of Scrotal Imaging

UltrasoundUltrasoundRadioisotope ScanningRadioisotope ScanningComputed TomographyComputed TomographyMagnetic Resonance ImagingMagnetic Resonance ImagingAngiographyAngiography

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Alex Lam, HMS IIIGillian Lieberman, MD

Primary Modality: UltrasoundPrimary Modality: Ultrasound

AccuracyAccuracyConvenienceConvenienceComfortComfortAbsence of Ionizing RadiationAbsence of Ionizing Radiation

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Alex Lam, HMS IIIGillian Lieberman, MD

Best ResultsBest Results

ShortShort--focused, highfocused, high--resolution, real time resolution, real time 7.57.5--10 MHz transducer w/ direct contact 10 MHz transducer w/ direct contact scanningscanningImages taken in Images taken in saggitalsaggital and transverse and transverse planesplanes

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Alex Lam, HMS IIIGillian Lieberman, MD

Body ImagingBody Imaging

Ultrasound, Color Doppler, Power DopplerUltrasound, Color Doppler, Power Doppler

From http://www.ob-ultrasound.net/aloka_880.html

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Alex Lam, HMS IIIGillian Lieberman, MD

Acute ScrotumAcute Scrotum

TraumaTraumaTorsionTorsionInfarctionInfarctionInflammatoryInflammatoryAbscessAbscess

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Alex Lam, HMS IIIGillian Lieberman, MD

ANATOMYANATOMY

From: http://matweb.hcuge.ch/Selected_images/Testis_images/Testis­­_%20normal_diagrams.htm AND http://www.aafp.org/afp/980215ap/junnila.html

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Alex Lam, HMS IIIGillian Lieberman, MD

Power Doppler Power Doppler --Normal TestisNormal Testis

From http://matweb.hcuge.ch/Selected_images/Testis_images/testis_normal_imaging.htm.

Normal Vasculature of Testis

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Alex Lam, HMS IIIGillian Lieberman, MD

Blunt TraumaBlunt Trauma

Testis Testis Mobility in scrotumMobility in scrotumElasticity of scrotumElasticity of scrotum

Injury occurs w/:Injury occurs w/:Compression against Compression against solid object such as solid object such as pubic bonespubic bonesBurst tunica Burst tunica albugineaalbuginea

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Alex Lam, HMS IIIGillian Lieberman, MD

Why Important to DiagnoseWhy Important to Diagnose

Rapid surgical intervention within 72 Rapid surgical intervention within 72 hrs = 90% savedhrs = 90% savedDelayed = 55% salvage rateDelayed = 55% salvage rate

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Alex Lam, HMS IIIGillian Lieberman, MD

Normal TesticleNormal Testicle

Tunica Albuginea

Intact

From BIDMC ED Sept. 8, 2002: s/p

MCC vs car, now p/w

scrotal eccymosis

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Alex Lam, HMS IIIGillian Lieberman, MD

Testicular RuptureTesticular Rupture

BIDMC ED Sept. 8, 2002: s/p

MCC vs car, now p/w

scrotal eccymosis

hematoma

Epididymitis

w/ hematoma

Tunica Albuginea

Rupture

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Alex Lam, HMS IIIGillian Lieberman, MD

Testicular TorsionTesticular Torsion

Ischemia & InfarctionIschemia & InfarctionAbnormality in fusion Abnormality in fusion of tunica of tunica vaginalisvaginalis & & scrotal wallscrotal wallBell Clapper AnomalyBell Clapper Anomaly

From: http://health.discovery.com/diseasesandcond/encyclopedia/2485.html

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Alex Lam, HMS IIIGillian Lieberman, MD

Testicular TorsionTesticular Torsion

Children & AdolescentsChildren & AdolescentsAdults: 20% of acute trauma incidenceAdults: 20% of acute trauma incidencePreceded by trauma, sexual Preceded by trauma, sexual intercourse, intercourse, strenousstrenous activity: forceful activity: forceful contraction of contraction of cremastercremaster

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Alex Lam, HMS IIIGillian Lieberman, MD

Signs & SymptomsSigns & Symptoms

Pain @ rest (due to ischemia)Pain @ rest (due to ischemia)EnlargmentEnlargment hemiscrotumhemiscrotumNausea & vomitingNausea & vomitingTense & tender testisTense & tender testisFeverFeverErythemaErythema & Edema of scrotal skin& Edema of scrotal skin

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Alex Lam, HMS IIIGillian Lieberman, MD

EpididymitisEpididymitis

and/or and/or OrchitisOrchitis

Most commonMost common7575--80% cases of 80% cases of acute scrotal painacute scrotal painEpididymitisEpididymitis: 64% : 64% 2020--29 29 y.oy.o..OrchitisOrchitis: viral : viral originorigin

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Alex Lam, HMS IIIGillian Lieberman, MD

ColorColor--flow Doppler Examinationflow Doppler Examination

Visualize Testicular ArteriesVisualize Testicular ArteriesTorsion: lack of flowTorsion: lack of flowEpididymitisEpididymitis: increased flow in : increased flow in epididymisepididymisOrchitisOrchitis: increased flow in testes: increased flow in testes

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Alex Lam, HMS IIIGillian Lieberman, MD

Torsion Torsion ––

Power Doppler USPower Doppler US

From http://radiology.rsnajnls.org/cgi/content/full/215/2/313

absence of perfusion in testicle w/ rim of peripheral hyperemia

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Alex Lam, HMS IIIGillian Lieberman, MD

EpididimytisEpididimytis: Color flow : Color flow dopplerdoppler

USUS

From http://www.med.wayne.edu/diagRadiology/TF/GU/GU03.html

enlarged epididymal

head with increased blood flow

Increased size of epididymis

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Alex Lam, HMS IIIGillian Lieberman, MD

OrchitisOrchitis: Power Doppler US: Power Doppler US

From http://www.gemedicalsystems.com/rad/us/products/log_700pro/msul7or1l.html

Increased test. flow

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Alex Lam, HMS IIIGillian Lieberman, MD

Testicular InfarctionTesticular Infarction

US US hypoechoichypoechoic mass or diffusely mass or diffusely heterogenousheterogenous and smaller and smaller hypoechoichypoechoictestistestisDecrease in size w/ ageDecrease in size w/ ageTumor will increase in size w/ ageTumor will increase in size w/ age

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Alex Lam, HMS IIIGillian Lieberman, MD

Testicular Infarction Testicular Infarction --

USUS

From http://www.uhrad.com/ctarc/ct222c2.jpg

Anechoic areas of necrosis

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Alex Lam, HMS IIIGillian Lieberman, MD

Testicular AbscessTesticular Abscess

Accompany Accompany epididymoepididymo--orchitisorchitisComplication of Complication of missed torsionmissed torsionNecrotic tumorNecrotic tumorInfectious Agents: Infectious Agents: Mumps, Smallpox, Mumps, Smallpox, TB, InfluenzaTB, Influenza

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Alex Lam, HMS IIIGillian Lieberman, MD

Testicular Abscess USTesticular Abscess US

From http://www.sma.org.sg/smj/4001/articles/4001me1.html

Normal Hyperechoic

abscess

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Alex Lam, HMS IIIGillian Lieberman, MD

Infarct vs. AbscessInfarct vs. Abscess

How could you differentiate between an infarct and an abscess if you are

not sure on US?

Power Doppler!!!!

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Alex Lam, HMS IIIGillian Lieberman, MD

What’s the Diagnosis?What’s the Diagnosis?

Tunica Albuginea

Rupture w/ flow to testis

BIDMC PACS BIDMC PACS

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Alex Lam, HMS IIIGillian Lieberman, MD

We can never take back yesterday, or prevent those moments in time we wished

had never happened; however we can rest assured in that the things we do

today will make our tomorrow. And in that, we are the keepers of own destiny.

Sept 12, 01

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Alex Lam, HMS IIIGillian Lieberman, MD

What do you see?What do you see?

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Alex Lam, HMS IIIGillian Lieberman, MD

Harris, John H., Harris, John H., The Radiology of Emergency MedicineThe Radiology of Emergency Medicine, Williams & Wilkins, 3, Williams & Wilkins, 3rdrd edition, 1993, pgs. 896edition, 1993, pgs. 896--909.909.KrekauKrekau, , Doppler Ultrasound: Principles & InstrumentsDoppler Ultrasound: Principles & Instruments, WB Saunders Comp., Philadelphia, 1990.http://www.ob-ultrasound.net/aloka_880.htmlhttp://matweb.hcuge.ch/Selected_images/Testis_images/testis_normal_imaging.htmFrom: http://health.discovery.com/diseasesandcond/encyclopedia/2485.htmlhttp://radiology.rsnajnls.org/cgi/content/full/215/2/313http://www.med.wayne.edu/diagRadiology/TF/GU/GU03.htmlhttp://www.uhrad.com/ctarc/ct222c2.jpghttp://www.sma.org.sg/smj/4001/articles/4001me1.htmlhttp://www.gemedicalsystems.com/rad/us/products/log_700pro/msul7or1l.html

ReferencesReferences

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Alex Lam, HMS IIIGillian Lieberman, MD

AcknowledgmentsAcknowledgments

Many thanks!!!!!•Robert A. Kane, MD•Don “Buddy” Wiese, MD•Larry Barbaras and Cara Lyn D’amour

our Webmasters•Gillian Lieberman, MD•Pamela Lepkowski