Ultrasonographic assessment of the scrotum

Abstract

G R Dohle and F H Schröder (Nov 11, p 1625)1Dohle GR Schröder FH Ultrasonographic assessment of the scrotum.Lancet. 2000; 356: 1625-1626Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar report that colour doppler ultrasonography is generally recommended to differentiate between testicular torsion and epididymitis and that the presence of intratesticular flow is reason enough to refrain from scrotal exploration.In our current litigious society, no missed diagnosis seems to be gaining as much attention in the courtrooms as causes of missed testicular torsion. Despite all the published work on the diagnosis of torsion and features that distinguish torsion from other diagnoses, no single reliable feature or test can provide 100% diagnostic accuracy, not even colour Doppler ultrasonography.2Sidhu PS Clinical and imaging features of testicular torsion: role of ultrasound.Clin Radiol. 1999; 54: 343-352Summary Full Text PDF PubMed Scopus (61) Google ScholarTesticular torsion leads to a loss of venous drainage and, later, arterial flow. The reduction of blood flow to the testis generally progresses gradually as the oedema increases. Colour doppler assessment in the early phases of torsion can show arterial flow, which is misleading. In normal rabbit testes, a 540° twist consistently produces no colour-flow and testicular infarction, whereas a 360° twist decreases colour flow. In addition, with use of contrast agents,3Lee FT Winter DB Madsen FA et al.Conventional color Doppler velocity sonography versus color Doppler energy sonography for the diagnosis of acute experimental torsion of the spermatic cord.AJR Am J Roentgenol. 1996; 167: 785-790Crossref PubMed Scopus (47) Google Scholar in 20 rabbits (360° twist), intratesticular flow was detected in 85% of affected testes. The same findings were seen on radionuclide imaging.4Coley BC Frush DP Babcock DS et al.Acute testicular torsion: comparison of unenhanced and contrast-enhanced power Doppler US, color Doppler US, and radionuclide imaging.Radiology. 1996; 199: 441-446Crossref PubMed Scopus (50) Google Scholar Colour doppler ultrasonography was reported to show intratesticular flow in six of 23 human cases with proven testicular torsion.5Baud C Veyrac C Couture A Ferran JL Spiral twist of the spermatic cord: a reliable sign of testicular torsion.Pediatr Radiol. 1998; 28: 950-954Crossref PubMed Scopus (80) Google ScholarWe saw a boy aged 12 years with suspected testicular torsion. Colour doppler sonography showed a normal testis with intratesticular blood flow and an enlarged epididymis, which was swollen and tender at physical examination. The findings suggested epididymitis, but we removed a torsed, dead testis 48 h later.Some workers suggest that any boy with acute scrotal pain should undergo a scrotal exploration immediately. However, only 29% of children presenting with acute scrotal pain require immediate surgical exploration.2Sidhu PS Clinical and imaging features of testicular torsion: role of ultrasound.Clin Radiol. 1999; 54: 343-352Summary Full Text PDF PubMed Scopus (61) Google Scholar A blanket policy of scrotal exploration would thus subject many children to unnecessary surgery.Colour doppler ultrasound might best be used to confirm a clinical impression of the presence or absence of torsion, but the presence of intratesticular flow does not absolutely exclude testicular torsion. Partial or intermittent torsion should not be dismissed immediately. The spectral doppler signal should be assessed for loss of diastolic flow, which may be an early sign of torsion. If a negative doppler result is discordant with a strong clinical suspicion, a scrotal exploration should be considered. G R Dohle and F H Schröder (Nov 11, p 1625)1Dohle GR Schröder FH Ultrasonographic assessment of the scrotum.Lancet. 2000; 356: 1625-1626Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar report that colour doppler ultrasonography is generally recommended to differentiate between testicular torsion and epididymitis and that the presence of intratesticular flow is reason enough to refrain from scrotal exploration. In our current litigious society, no missed diagnosis seems to be gaining as much attention in the courtrooms as causes of missed testicular torsion. Despite all the published work on the diagnosis of torsion and features that distinguish torsion from other diagnoses, no single reliable feature or test can provide 100% diagnostic accuracy, not even colour Doppler ultrasonography.2Sidhu PS Clinical and imaging features of testicular torsion: role of ultrasound.Clin Radiol. 1999; 54: 343-352Summary Full Text PDF PubMed Scopus (61) Google Scholar Testicular torsion leads to a loss of venous drainage and, later, arterial flow. The reduction of blood flow to the testis generally progresses gradually as the oedema increases. Colour doppler assessment in the early phases of torsion can show arterial flow, which is misleading. In normal rabbit testes, a 540° twist consistently produces no colour-flow and testicular infarction, whereas a 360° twist decreases colour flow. In addition, with use of contrast agents,3Lee FT Winter DB Madsen FA et al.Conventional color Doppler velocity sonography versus color Doppler energy sonography for the diagnosis of acute experimental torsion of the spermatic cord.AJR Am J Roentgenol. 1996; 167: 785-790Crossref PubMed Scopus (47) Google Scholar in 20 rabbits (360° twist), intratesticular flow was detected in 85% of affected testes. The same findings were seen on radionuclide imaging.4Coley BC Frush DP Babcock DS et al.Acute testicular torsion: comparison of unenhanced and contrast-enhanced power Doppler US, color Doppler US, and radionuclide imaging.Radiology. 1996; 199: 441-446Crossref PubMed Scopus (50) Google Scholar Colour doppler ultrasonography was reported to show intratesticular flow in six of 23 human cases with proven testicular torsion.5Baud C Veyrac C Couture A Ferran JL Spiral twist of the spermatic cord: a reliable sign of testicular torsion.Pediatr Radiol. 1998; 28: 950-954Crossref PubMed Scopus (80) Google Scholar We saw a boy aged 12 years with suspected testicular torsion. Colour doppler sonography showed a normal testis with intratesticular blood flow and an enlarged epididymis, which was swollen and tender at physical examination. The findings suggested epididymitis, but we removed a torsed, dead testis 48 h later. Some workers suggest that any boy with acute scrotal pain should undergo a scrotal exploration immediately. However, only 29% of children presenting with acute scrotal pain require immediate surgical exploration.2Sidhu PS Clinical and imaging features of testicular torsion: role of ultrasound.Clin Radiol. 1999; 54: 343-352Summary Full Text PDF PubMed Scopus (61) Google Scholar A blanket policy of scrotal exploration would thus subject many children to unnecessary surgery. Colour doppler ultrasound might best be used to confirm a clinical impression of the presence or absence of torsion, but the presence of intratesticular flow does not absolutely exclude testicular torsion. Partial or intermittent torsion should not be dismissed immediately. The spectral doppler signal should be assessed for loss of diastolic flow, which may be an early sign of torsion. If a negative doppler result is discordant with a strong clinical suspicion, a scrotal exploration should be considered. Ultrasonographic assessment of the scrotumAuthors' reply Full-Text PDF