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IMAGING FOR RESIDENTS – ANSWER |
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| Ahead of print
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| Acute Scrotum – When ultrasound is enough for the diagnosis |
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Carolina Cairrao Padilha, Lara Delgado
Department of Radiology, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
Click here for correspondence address and email
| Date of Submission | 11-Feb-2022 |
| Date of Decision | 07-Feb-2022 |
| Date of Acceptance | 01-Mar-2022 |
| Date of Web Publication | 27-May-2022 |
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| Section 2 – Answer | |  |
Case
A 45-year-old male presented to the emergency department with a progressive 5 days of pain in the right testicle. The examination showed a fever (38°C), an increase of the right testicle volume, and pain through palpation. Ultrasound (US) was performed, and what is your diagnosis?
| Interpretation | | |
The US showed an enlarged and hypoechoic right epididymis, with a heterogeneous echotexture [Figure 1]a, and hyperemia in color Doppler US [Figure 1]b. Further, the spermatic cord has a hyperechoic fat, reactive to inflammation [Figure 1]b. | Figure 1: Gray-scale ultrasound of the right epididymis (a), and color Doppler (b) of the right epididymal head and spermatic cord, in the longitudinal plane
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There was a marked asymmetry in the volume of the testis, with an increase of volume and hyperemia of the right testicle [Figure 2]. | Figure 2: Color Doppler ultrasound in the longitudinal plane of both testicles
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These alterations in the right testicle were consistent with acute epididymal orchitis.
Beyond that, the US of the right epididymal tail showed a lack of blood flow in the central region of the tail, consistent with abscess [Figure 3]. | Figure 3: Color Doppler ultrasound in the longitudinal plane of the right epididymal tail
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| Discussion | | |
Acute epididymitis is one of the two most common causes of acute scrotal pain. In 20%–40% of these patients, there is also an involvement of the ipsilateral testicle (orchitis), as the infection progresses through the testicular parenchymal. Orchitis is rarely isolated.[1],[2],[3]
These conditions are caused by a retrograde bacterial infection from a lower urinary tract infection. Therefore, it is logical that the epididymal tail is involved before the body and head.
In the US, an inflamed epididymis appears enlarged, heterogeneous, and often hypoechoic due to edema. The color Doppler shows hyperemia, and it may be the only finding of acute epididymitis. Testicular involvement is confirmed by the presence of an increased volume and heterogeneous echotexture. Sometimes, a reactive hydrocele/pyocele and scrotal wall thickening may be present.[1],[2],[3],[4],[5]
As a complication, such as in our case, abscesses may occur. They are represented in the US as a more hypoechoic focus with a lack of flow centrally in color Doppler.[1],[2],[3],[4],[5]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Avery LL, Scheinfeld MH. Imaging of penile and scrotal emergencies. Radiographics 2013;33:721-40.  |
| 2. | Deurdulian C, Mittelstaedt CA, Chong WK, Fielding JR. US of acute scrotal trauma: Optimal technique, imaging findings, and management. Radiographics 2007;27:357-69. |
| 3. | Parker RA 3 rd, Menias CO, Quazi R, Hara AK, Verma S, Shaaban A, et al. MR imaging of the penis and scrotum. Radiographics 2015;35:1033-50. |
| 4. | Bhatt S, Dogra VS. Role of US in testicular and scrotal trauma. Radiographics 2008;28:1617-29. |
| 5. | D'Andrea A, Coppolino F, Cesarano E, Russo A, Cappabianca S, Genovese EA, et al. US in the assessment of acute scrotum. Crit Ultrasound J 2013;5 Suppl 1:S8. |
Correspondence Address:
Carolina Cairrao Padilha,
Department of Radiology, Centro Hospitalar de Lisboa Ocidental, Hospital São Francisco Xavier, Estrada Forte Do Alto Duque, 1449-005, Lisbon
Portugal
 Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3] |
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