Satheesh Krishna Sabarish Narayanasamy Wael Shabana Adnan Sheikh

Department of Medical Imaging, The Ottawa Hospital.

Nothing to disclose

Common and unusual presentations and manifestations of testicular torsion

Identify common, uncommon and unusual causes of testicular ischemia and differentiate them from torsion of the testis

• 9 year old male with 6

hour history of right

scrotal pain.

• Ultrasound (US) shows

subtle reduction of

vascularity to right testis

compared to left.

• Intraoperatively, torsion

was confirmed, testis was

viable and orchidopexy

was done.

Right

Left

• Presence of vascularity does not always exclude torsion

• Vascularity in both testes should always be compared for subtle differences

• US demonstrates

complete absence of

flow and

heterogeneous

testicular echo texture.

Features are

suggestive of testicular

necrosis secondary to

torsion.

• Swirl sign (arrow)

reflects twisting of the

spermatic cord

Early diagnosis is crucial as likelihood of testicular salvage depends on time interval between onset and surgery

22 year old male with 4 hour history of left scrotal pain. Pain

completely relieved en route to hospital. Ultrasound shows subtle

increased vascularity to left testis compared to right. Epididymis

was normal (inset). Findings were confirmed intraoperatively.

Left Right

Classical history with subtle hyperemia should raise concern of possible torsion followed by spontaneous detorsion.

• Ultrasound shows absent flow to the left testis. Figure on the

right shows an inguinal hernia with dilated, thickened small

bowel loops with poor vascularity.

• Intraoperatively, strangulated hernia was seen. The testicular

perfusion normalised after surgical release of the hernial sac.

Strangulated hernia

Right Left

• Ultrasound demonstrates a tense hydrocele on the right with

no demonstrable internal vascularity in right testes.

• Testicular flow normalised after drainage of hydrocele.

Tense hydrocele

Right Post surgery Absent vascularity

• Increased intrascrotal pressure can cause secondary testicular ischemia.

• Urgent correction of the primary cause is necessary to preserve testicular viability.

• Decreased flow

with high

resistance in a

chronically

atrophic testis

from prior

orchitis.

• Contralateral

testis showing

normal flow.

• Testicular

hypoperfusion

may be chronic.

Right

Left

Right

Left Left

• 45 year old male with left scrotal discomfort/pain.

• History of vasectomy 4 months prior. Ultrasound shows diffuse

hypoechogenicity and segmental absence of flow in the upper

two-thirds of the testicular parenchyma.

• Testicular ischemia was secondary to gonadal artery injury

from the prior vasectomy surgery.

• 65 year old male with a 4-day history of testicular pain.

• Ultrasound shows complete absence of flow within the testis.

However, the epididymis was bulky and hyperemic (orange arrow).

Surrounding septated hydrocele was also noted (yellow arrow).

• Intraoperatively, there was no evidence of torsion!!

• Inflamed, red epididymis was seen with infected hydrocele fluid.

• Testicular ischemia was sequel to epididymitis. Postulated

mechanism is venous thrombosis.

• Testicular torsion usually results in absent flow in both the testes and epididymis.

• Absent testicular flow with preserved or increased flow in epididymis should suggest other etiologies.

• 23 year old male with history

of trauma with severe pain.

• Absence of flow in lower

portion of testis with

geographic well demarcated

hypoechogenicity (arrow).

Geographic hypoechogenicity reaching the capsule with absence of flow is diagnostic of testicular rupture in the setting of trauma.

• 18 year old was kicked in testicle.

• US shows no fracture or hematoma.

• Diffusely heterogenous echotexture of

the testes with absent color flow.

• Swirling of cord was noted (not shown)

and a diagnosis of torsion was made.

Torsion of spermatic cord can be secondary to testicular trauma.

There is apparent reduced

flow in the left testis

compared to the right. This

can potentially mimic

ischemia/torsion of the left.

However, apparent reduced

flow in left testes is due to

increased vascularity on the

right. Patient had right sided

epididymo-orchitis with pain

and swelling on the right side.

Hence it is important to know

which testis is symptomatic.

Right Left

Right

Hyperperfusion in the contralateral testis can potentially mimic torsion due to apparent appearance of reduced flow in the other testis. Clinical history is of paramount importance.

A variety of causes (acute, subacute and chronic) may result in testicular ischemia manifesting as decreased colour flow on Doppler ultrasound.

Depending on the cause of ischemia, they may be potentially emergent conditions requiring urgent management or chronic incidental findings managed conservatively.

Familiarity with various causes and features of testicular ischemia is essential to help guide management.

Satheesh Krishna Jeyaraj

Fellow in Abdominal Imaging,

The Ottawa Hospital,

501, Smyth Road,

Ottawa,

K1H 8L6

Email: dr.satheeshkrishna@gmail.com