This document discusses acute scrotum imaging and provides information on various etiologies of acute scrotal pain including ischemia, infection, trauma, inflammation, hernia, and acute on chronic events. It describes ultrasound findings for conditions like testicular torsion, epididymitis, orchitis, hydrocele, hematocele, and Fournier's gangrene. Key points are made about Doppler ultrasound findings in torsion and the importance of prompt evaluation and treatment of acute scrotum to preserve testicular viability. Anatomy of the scrotum and imaging appearances of various acute pathologies are depicted through multiple ultrasound images.

1. ACUTE SCROTUM
DR. AMITHA VIKRAMA KS
CONSULTANT VASCULAR AND INTERVENTIONAL RADIOLOGY
SAKRA WORLD HOSPITAL, BANGALORE

2. ACUTE SCROTUM IMAGING
• ACUTE SCROTAL PAIN REQUIRES PROMPT CLINICAL EVALUATION.
• "ACUTE SCROTUM" - UROLOGIST'S EQUIVALENT TO THE GENERAL SURGEON'S
"ACUTE ABDOMEN."
• BOTH CONDITIONS ARE GUIDED BY SIMILAR MANAGEMENT PRINCIPLES
• WHEN THE ETIOLOGY IS UNCLEAR, ULTRASOUND IS THE IMAGING MODALITY OF
CHOICE FOR FURTHER EVALUATION

3. ETIOLOGY
ISCHEMIA
TRAUMA
INFECTION
INFLAMMATION
HERNIA
ACUTE ON CHRONIC EVENTS

4. ISCHEMIA
TORSION OF THE TESTIS
INTRAVAGINAL / EXTRAVAGINAL (PRENATAL OR NEONATAL)
 APPENDICEAL TORSION - TESTIS / EPIDIDYMIS
TESTICULAR INFARCTION - DUE TO OTHER VASCULAR INSULT (CORD
INJURY,THROMBOSIS)

5. INFECTIOUS CONDITIONS
ACUTE EPIDIDYMITIS
ACUTE EPIDIDYMO ORCHITIS
ACUTE ORCHITIS
ABSCESS (INTRATESTICULAR, INTRAVAGINAL, SCROTAL CUTANEOUSCYSTS)
GANGRENOUS INFECTIONS (FOURNIER’S GANGRENE)

6. TRAUMA
TESTICULAR RUPTURE
INTRATESTICULAR HEMATOMA,
TESTICULAR CONTUSION
HEMATOCELE

7. INFLAMMATORY CONDITIONS:
HENOCH-SCHONLEIN PURPURA VASCULITIS OF SCROTAL WALL
FAT NECROSIS OF SCROTAL WALL

8. HERNIA
INCARCERATED, STRANGULATED INGUINAL HERNIA WITH OR WITHOUT
ASSOCIATED TESTICULAR ISCHEMIA

9. ACUTE ON CHRONIC EVENTS
SPERMATOCELE RUPTURE OR HAEMORRHAGE
HYDROCELE RUPTURE, HEMORRHAGE OR INFECTION
TESTICULAR TUMOR WITH RUPTURE, HEMORRHAGE, INFARCTION OR INFECTION
VARICOCELE

10. ANATOMY

11. ANATOMY OF THE SCROTUM
LAYERS INCLUDE
• TESTIS
• TUNICA ALBUGINEA
• VISCERAL LAYER OF TUNICA VAGINALIS
• PARIETAL LAYER OF TUNICA VAGINALIS
• INTERNAL SPERMATIC FASCIA
• CREMASTER MUSCLE AND FASCIA
• EXTERNAL SPERMATIC FASCIA
• DARTOS MUSCLE AND FASCIA
• SKIN

12. ISCHEMIA
TORSION OF THE TESTIS
INTRAVAGINAL / EXTRAVAGINAL (PRENATAL OR NEONATAL)
 APPENDICEAL TORSION - TESTIS / EPIDIDYMIS
TESTICULAR INFARCTION - DUE TO OTHER VASCULAR INSULT (CORD
INJURY,THROMBOSIS)

13. BELL CLAPPER DEFORMITY
• FAILURE OF NORMAL POSTERIOR
ANCHORING OF THE GUBERNACULUM,
EPIDIDYMIS AND TESTIS
• TESTIS FREE TO SWING AND ROTATE
WITHIN THE TUNICA VAGINALIS
• MUCH LIKE THE GONG (CLAPPER)
INSIDE OF A BELL.

14. TORSION
10 MHZ LINEAR TRANSDUCER.
ALWAYS START WITH NORMAL SIDE AND OPTIMIZE THE SETTINGS
BACKGROUND 'NOISE' SHOULD JUST BE VISIBLE IN THE ASYMPTOMATIC TESTIS.
ONCE YOU HAVE A GOOD IMAGE OF THE NORMAL SIDE, DON'T TOUCH ANY OF
THE SETTINGS' AND GO TO THE SYMPTOMATIC SIDE

15. TORSION
• DOPPLER SENSITIVITY – 86-100%
• SPECIFICITY – 100%
• TESTICULAR SALVAGE RATE IN SURGERY:
• < 5 HRS - 80-100%
• 7-12 HRS – 70%
• >12 HRS – 20%

16. TESTICULAR TORSION
• ABNORMALLY MOBILE TESTIS TWISTS ON THE SPERMATIC CORD, OBSTRUCTING
ITS BLOOD SUPPLY.
• ACUTE PAIN
• NECROSIS IF NOT CORRECTED WITHIN 5-6 HRS.
• CAN BE INTERMITTENT.
• BEWARE OF DETORSION !!!

17. TESTICULAR TORSION
• COMPLETE ABSENCE OF INTRATESTICULAR FLOW AND NORMAL
EXTRATESTICULAR FLOW
• FLOW IS NORMAL IN THE CONTRALATERAL TESTIS.
• PRESENCE OF FLOW DOES NOT EXCLUDE TORSION !!!

18. TORSION
• ACUTE HEMI SCROTAL PAIN
• NAUSEA VOMITING, FEVER
• ELEVATED TESTIS
• TRANSVERSE LIE
• LARGER SIZE OF THE TESTICLE

19. SIGNS OF INFLAMMATION
• TUMOR / SWELLING
• RUBOR / REDNESS
• CALOR / HEAT
• DOLOR / PAIN

20. TORSION USG FINDINGS
• 4-6 HRS – NORMAL ARCHITECTURE – SALVAGABLE
• 4- 24 HRS – HETEROGENOUS AND ENLARGED
• THICKENED EPIDIDYMIS, SCROTAL WALL, HYPOECHOIC
• HYPO / HYPER ECHOIC – POOR OUTCOME

21. HYPER ACUTE < 4 HRS

22. ACUTE > 5HRS

23. INFARCT

24. INFARCT 24 HRS

25. TORSION IN YOUNG

26. TORSION

27. PRESERVED PERIPHERAL VASCULARITY

28. INFARCT, PERIPHERAL VASCULARITY

29. INFARCT

30. INITIAL (H’HAGIC) & CHRONIC LATE PHASE

31. INCOMPLETE TORSION
• REAL-TIME WHIRLPOOL SIGN- A KEY SIGN OF TORSION
• TWISTED PEDICLE WITH PRESERVED VASCULARITY
• ABSENT VASCULARITY DISTAL TO THE TORSED PEDICLE

32. VARIOUS APPEARANCES OF WHIRL POOL
SIGN.
DOUGH NUT SIGN
J Ultrasound Med 2006; 25:563–574

33. TARGET WITH CONCENTRIC RINGS
J Ultrasound Med 2006; 25:563–574

34. SNAIL SHELL SIGN
J Ultrasound Med 2006; 25:563–574

35. STORM ON A WEATHER MAP
J Ultrasound Med 2006; 25:563–574

36. FLOW PROXIMAL TO WHIRL POOL MASS,
ABSENT DISTALLY

37. WHIRL POOL MASS- VESSELS IN CONCENTRIC
RINGS

38. SEGMENTAL INFARCTION

39. NORMAL FLOW ON RT. AND INCREASED FLOW
ON LT.
INTERMITTENT TORSION

40. APPENDIX
• SMALL POLYPOID APPENDAGES - ATTACHED TO
THE TESTIS OR EPIDIDYMIS
• MULLERIAN OR WOLFFIAN DUCT REMNANTS
• IF THE TORSED APPENDAGE IS ECCHYMOTIC -
CAN BE SEEN THROUGH THE SKIN - "BLUE-DOT
SIGN."

41. TESTICULAR APPENDAGE TORSION
MORE COMMON THAN TESTICULAR TORSION
MORE GRADUAL ONSET OF PAIN THAN TESTICULAR TORSION
PTS. ENDURE PAIN FOR FEW DAYS BEFORE PRESENTING
LESION OF LOW ECHOGENICITY WITH A CENTRAL HYPOECHOGENIC AREA.
• ADJACENT TO THE EPIDIDYMIS.
• MOST OFTEN – DIAGNOSIS OF EXCLUSION.

42. APPENDICULAR TORSION
• DOPPLER - NORMALLY PERFUSED TESTIS, OFTEN WITH HYPERVASCULARITY IN
THE AREA OF THE APPENDAGE.
• SELF-LIMITED - INFARCTED APPENDAGE UNDERGOING ATROPHY WITH TIME.
• IF EXPLORATION IS PURSUED, THE APPENDAGE IS SIMPLY EXCISED AND NO
ORCHIDOPEXY IS NEEDED.

43. APPENDICULAR TORSION

44. INFECTIOUS CONDITIONS
ACUTE EPIDIDYMITIS
ACUTE EPIDIDYMO ORCHITIS
ACUTE ORCHITIS
ABSCESS (INTRATESTICULAR, INTRAVAGINAL, SCROTAL CUTANEOUSCYSTS)
GANGRENOUS INFECTIONS (FOURNIER’S GANGRENE)

45. ACUTE EPIDIDYMITIS
• MOST COMMON INFLAMMATORY PROCESS INVOLVING THE SCROTUM
• MORE COMMON IN ADULTS.
ORIGINATE IN THE LOWER URINARY TRACT
• TYPICALLY CAUSED BY URINARY TRACT PATHOGENS OR SEXUALLY TRANSMITTED
ORGANISMS (CHLAMYDIA OR GONORRRHHEA) .
• IN CHILDREN, - STREPTO OR STAPH.
IN URINARY TRACT ABNORMALITIES -E.COLI
STERILE CHEMICAL EPIDIDYMITIS - REFLUX INTO EJACULATORY DUCTS, ECTOPIC
URETERIC INSERTION

46. EPI- ENLARGED

47. NORMAL TESTIS

48. EPI - HYPEREMIA

49. AC. EPIDIDYMITIS

50. ORCHITIS
• FOCAL, PERIPHERAL, HYPOECHOIC LESIONS - POORLY DEFINED, AMORPHOUS,
OR CRESCENT-SHAPED.
TESTICULAR HYPEREMIA, EPIDIDYMAL HYPEREMIA.
A REACTIVE HYDROCELE
FOCAL INFARCTION - SWELLING SEVERE ENOUGH TO CONSTRICT THE BLOOD
SUPPLY.
HYPOECHOIC INTRATESTICULAR MASS DEVOID OF BLOOD FLOW.

51. ENLARGED TESTIS

52. ACUTE EPIDIDYMO ORCHITIS

53. ORCHITIS

54. EPIDIDYMO ORCHITIS

55. ORCHITIS

56. ACUTE ORCHITIS

57. MICROLITHIASIS IN THE BACKGROUND

58. FUNICULITIS

59. FUNICULITIS

60. FUNICULITIS

61. COMPLICATIONS OF ORCHITIS
• ABSCESS.
• ISCHEMIA.

62. EPIDIDYMAL ABSCESS

63. ACUTE HYDROCELE WITH SEPTATIONS

64. PYOCELE

65. FOURNIER’S GANGRENE
• NECROTIZING INFECTION OF FASCIAL PLANES
• MALE PREDOMINANCE
• A UROLOGIC EMERGENCY - HIGH MORTALITY - 15% TO 50%
• PREDISPOSING - DM, ALCOHOL
• CAUSE OF INFECTION
COMMONLY COLORECTAL (CA, IBD AND PERIRECTAL ABSCESS),
CUTANEOUSUROLOGIC (EPIDIDYMITIS AND UTI)
(PRESSURE ULCERATION).
• SOURCE OF INFECTION OCCULT IN 6–45%

66. THICKENED VASCULAR WALL

67. WALL ABSCESS WITH AIR POCKETS

68. FOURNIER’S GANGRENE

69. PERIANAL INF. SPREADING

70. IDIOPATHIC SCROTAL EDEMA
• SCHOOL-AGED BOYS.
• SCROTAL SKIN SWELLING
• PAIN, EDEMA, ERYTHEMA.
• TESTES AND EPIDIDYMES ARE NORMAL
• NO FEVER OR ELEVATED COUNTS

71. TRAUMA
TESTICULAR CONTUSION
TESTICULAR RUPTURE
INTRATESTICULAR HEMATOMA,
HEMATOCELE

72. CONTUSION

73. CONTUSION

74. CONTUSION INFARCTION

75. CONTUSION INFARCTION

76. CONTUSION

77. TESTICULAR RUPTURE
FOCAL ALTERED ECHOGENICITY CORRELATING WITH AREAS OF
INTRATESTICULAR HEMORRHAGE OR INFARCTION IN A PATIENT WITH A
HEMATOCELE.
DISCRETE FRACTURE PLANE - < 20% OF CASES,
VISIBLE ALTERATIONS IN THE TESTICULAR CONTOUR - COMMON FINDING.
 LARGE HETEROGENEOUS AREA WITH NO IDENTIFIABLE TESTIS

78. TESTICULAR RUPTURE

79. HEMATOCELE
• TRAUMA - HEMATOCELE OR TESTICULAR HEMATOMA.
• ACUTE PHASE - ECHOGENIC
• CHRONIC PHASE - HYPOECHOIC.

80. HEMATOCELE
• BLEEDING BETWEEN LEAVES OF TUNICA VAG.
• COMPLEX FLUID COLLECTION
• WITH TIME - LOCULATIONS / SEPTATIONS.
• IT IS IMPORTANT TO BE ABLE TO TELL IF THE TESTIS IS INTACT, BECAUSE IF
THERE IS A RUPTURE, THIS CAN SOMETIMES BE TREATED SURGICALLY.

81. HEMATOCELE

82. CONTUSION & HEMATOCELE

83. CONTUSION & INFARCTION

84. TESTICULAR RUPTURE HEMATOMA

85. TESTICULAR RUPTURE HEMATOMA

87. TESTICULAR LACERATION HEMATOMA

88. HEMATOMA

89. HEMATOCELE

90. HEMATOCELE

91. HERNIA
INCARCERATED, STRANGULATED INGUINAL HERNIA WITH OR WITHOUT
ASSOCIATED TESTICULAR ISCHEMIA

92. INGUINAL HERNIA- STRANGULATED

93. NON SPECIFIC SCROTAL PAIN.
• 11 YR BOY WITH RIGHT SCROTAL PAIN

97. THANK YOU