Figure 5: Transverse scan of both testicles showing normal left testicle and

right testicular torsion. Note the hypoechogenicity of the right testicle. (Courtesy
of Michael Blaivas, M.D (TORSIO TESTIS)

Figure 6: Transverse plane through both testes. The power Doppler image of
the scrotum demonstrates right testicular perfusion. The swollen left testicle is
not perfused. (Courtesy of Michael Blaivas, M.D.) TORSIO TESTIS

Figure 7: A slightly oblique view of a testicle with an enlarged hypoechoic

epididymis. (Courtesy of Michael Blaivas, M.D.) EPIDIDIMIS

Figure 8: Orchitis. Marked increase in blood flow is seen along with a reactive
hydrocele. (Courtesy of Michael Blaivas, M.D.)

Figure 9: Testicular Fracture. Note the inhomgenicity of the testicular

echotexture and fracture line. (Courtesy of Michael Blaivas, M.D.)

Figure 4: Longitudinal view of testicle with enlarged pampiniform plexus. Also

note the thickening of the surrounding connective tissue secondary to scrotal
inflammation after a failed penile implant. (Courtesy of Beatrice Hoffmann, M.D.)
VARIKOKEL

Figure 3: Image of right and left testicles with hydrocele on right.

Scrotal hernia anak

Fluid surrounding the right testicle and normal left scrotum transverse

Varicocele with dilatated venous plexus and reflux during straining

Torsion of the epididymal appendix and a normal vascularized testis and

epididymis

Swollen hydatide (left arrow) and epididymis transverse (right arrow)

Torsion of the epididymal appendage (Morgagnis hydatide) with a hypoechoic
mass between the right testis and the epididymis in a 12 year old boy

Focal orchitis with a focal hypoechoic area with increased flow

Longitudinal
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Longitudinal
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Transverse

ID: /44126-Afbeelding3.jpg
Longitudinal
ID: /44127-Afbeelding4.jpg

Focal hypoechoic area with increased flow transverse

ID: /44128-Afbeelding5.jpg

Focal hypoechoic area with increased flow transverse

ID: /44129-Afbeelding6.jpg

Focal hypoechoic area with increased flow longitudinal

ID: /44130-Afbeelding7.jpg

Normal flow in the other testis

ID: /44131-Afbeelding8.jpg

LONGITUDINAL

Normal testis

Srikar R. Adhikari, M.D., RDMS

I. Introduction and Indications

Acute scrotal pain accounts for approximately 0.5 % of all complaints presenting to the
emergency department. Differential diagnosis of acute scrotal pain includes epididymitis,
orchitis, testicular torsion, torsion of the testicular appendage, testicular trauma, and
herniation of abdominal contents into the scrotum. The history and physical examination
findings of various etiologies of acute scrotal pain have a significant overlap, therefore
making it difficult to differentiate these entities clinically. However, distinction between the
underlying pathology is critical as prompt intervention is required in cases of testicular
torsion, trauma, and incarcerated hernias. Misdiagnosing testicular torsion can lead to organ
loss and infertility. Patient distress and the possibility of fertility-threatening disease place
significant pressure on the emergency physician to make an accurate diagnosis. Bedside
ultrasonography of the acute scrotum is a relatively new application to emergency medicine
ultrasound and has high utility for emergency physicians managing patients with acute scrotal
complaints.
Indications:
1. Testicular pain
2. Testicular swelling/mass
3. Trauma
II. Anatomy
The scrotum is a saccular structure divided into two compartments by the median raphe. Each
compartment contains a testicle, epididymis, vas deferens, and spermatic cord. The testes are
surrounded by a fibrous capsule, called the tunica albuginea, which is covered by the tunica
vaginalis. The tunica vaginalis has two layers, an outer parietal layer and an inner visceral
layer which are separated by a small amount of fluid. The normal adult testis is ovoid in
shape and measures approximately 2 to 3 cm in width and 3 to 5 cm in length. The size of the
testicle varies with age, increasing in size from birth to puberty and then decreasing later in
life. Structurally, the testes are divided into lobules by septa radiating from the tunica
albuginea. Within the testicular parenchyma, seminiferous tubules converge at the
mediastinum testis, an incomplete septum formed through invagination of the tunica
albuginea. It is located in the posterior aspect of the testis.
The epididymis is found along the posterolateral aspect of each testis. The epididymis
measures approximately 6 to 7 mm in length and consists of a head, body and tail. The head
of the epididymis is located adjacent to the superior pole of the testis, the body runs
posteriorly, with the tail at the inferior pole. The largest portion of the epididymis is the head
and is usually round or triangular in shape. The tail of the epididymis becomes the vas
deferens as it ascends superiorly out of the scrotum. The spermatic cord suspends the testis in
the scrotum and consists of arteries, veins, nerves, lymphatics, and the vas deferens. The
appendix testis and the appendix epididymis are both embryological remnants that are found
toward the superior pole of the testis. Blood supply to the testis primarily originates from the
testicular artery, which arises from the aorta. Other sources of blood supply include the
deferential artery, which supplies the epididymis and the vas deferens and the cremasteric
artery supplies the peritesticular tissues. Venous outflow from the scrotum is via the
pampiniform plexus, which empties into the testicular veins. (1,5,6,7)

Illustration 1: Overview of testicular anatomy.

Normal Variants
In 50 % of men the transmediastinal artery, a large branch of the testicular artery, courses
through the mediastinum testis to supply the capsular arteries and is usually accompanied by
a large vein.
III. Scanning Technique and Normal Findings
Prior to performing a scrotal ultrasound examination adequate analgesia and reassurance
should be provided. The patient is placed in a supine position with the legs slightly spread
apart. The scrotum is placed in a sling designed from a towel to improve exposure and should
be supported and immobilized on a rolled towel placed between the patients thighs. The
penis is covered with a towel and the towel is taped to the abdominal wall. Alternatively, one
can request the patient to support the penis with his hand in a cephalad direction and a drape
can be placed on top. Of note, utilizing cold gel may cause the skin on the scrotum to contract
and become thick or may cause the testicles to ascend in the scrotal sac making imaging more
difficult.
A high frequency broadband linear transducer (7.5-10 MHz) that can perform both power and
spectral Doppler ultrasonography is used. The scrotum and its contents are scanned in at least
two planes, along the longitudinal and transverse axis. The unaffected hemiscrotum is
scanned initially to familiarize the patient with the process, and also to provide a comparison
of anatomy and blood flow as well. The scan is performed initially in a long axis to the
testicle, with the indicator directed cephalad showing a longitudinal cut through the testis
with the epididymis on the left side of the screen (Figure 1).

Figure 1: A properly exposed and draped patient with the scrotum supported in a sling of
towels. (Courtesy of Michael Blaivas, M.D.)
The entire testis is scanned from one extreme to another, noting the echotexture and
abnormalities. The epididymis is visualized as well. The transducer is moved smoothly and
slowly, examining all aspects of the anatomy. The scan is then repeated with the probe turned
90 toward the patients right to obtain a transverse image of the testicle. A coronal scan

showing both testicles side by side should be performed to identify differences in size and
echogenicity, and vascularity.
The visceral and parietal layers of the tunica are visualized as one echogenic stripe. The
normal testis has midgray or medium-level echoes and is homogenous in appearance. The
echogenicity of the testis is similar to that of the liver or the thyroid gland. The epididymis
has similar or slightly increased echogenicity as compared to the normal testis. The
mediastinum testis is seen as a linear echogenic band running craniocaudally or parallel to the
epididymis. The appendix testis and appendix epididymis are small ovoid hyperechoic
protuberances found at the superior pole of the testis, normally hidden by the epididymal
head. Unless outlined by fluid from a hydrocele, they are difficult to find on ultrasound. The
spermatic cord appears as multiple hypoechoic linear structures in the longitudinal plane and
circular hypoechoic structures in the transverse plane. (1,5,6,7)
Power Doppler examination is performed after gray-scale imaging is complete. The
unaffected side is scanned initially to obtain accurate Doppler settings. To adequately
evaluate blood flow, Doppler parameters should be adjusted to their most sensitive settings
without introducing significant artifact. Power Doppler and pulsed Doppler should be
optimized to display low-flow velocities to demonstrate blood flow in the testes and adjacent
structures. The wall filter, scale and gain may need to be adjusted to pick up maximal blood
flow without significant artifact. The wall filter should be set at the lowest selection possible
and the PRF (Pulse Repetition Frequency) is minimized as well. The color gain should be
adjusted carefully, as the artifactual appearance of flow may be created in a torsed testicle.
Intratesticular and epididymal flow should be confirmed using both power Doppler and
spectral Doppler waveform analysis. Power Doppler helps to detect blood flow within the
testicle and spectral Doppler allows identification of the flow whether it is venous or arterial.
Spectral Doppler waveforms should be obtained in several areas of blood flow detected by
power Doppler to document both arterial and venous flow patterns. Typically, power and
spectral Doppler scan can be performed on the same ultrasound window.

Figure 2: Image of the normal testicle with the epididymal head on the left and body of
testicle on the right. (Courtesy of Michael Blaivas, M.D.)

VI. Pathology

Illustration 2: Schematic overview of testicular pathology.

Hydrocele
A hydrocele is the most common cause of scrotal swelling. The normal scrotum contains
small amounts of serous fluid between the layers of the tunica vaginalis. Abnormal collection
of fluid in the space between the visceral and parietal layers of the tunica vaginalis results in
a hydrocele. The fluid collections are usually confined to the anterolateral portions of the
scrotum because of the posterior location of attachments of the tunica to the testis and
scrotum. Hydroceles may be unilateral or bilateral and can be seen as an isolated finding or in
conjunction with acute or chronic pathology. Many of these fluid collections are congenital.
Acquired hydroceles are associated with infection, tumors, trauma, torsion and radiation
therapy. Hematoceles and pyoceles are complex hydroceles. Sonographically, a simple
hydrocele is seen as an anechoic dark fluid collection surrounding the testicle (Figure 3),
whereas a complex hydrocele may contain internal echoes with septations and loculations. A
chronic hydrocele may also demonstrate internal echoes from cholesterol crystal formation.
(1,2,3,6)

Figure 3: Image of right and left testicles with hydrocele on right. (Courtesy of Michael
Blaivas, M.D.)
Varicocele
A varicocele is a collection of tortuous and dilated veins within the pampiniform plexus of
the spermatic cord. They are found in approximately 15 % of adult males and can result in
infertility secondary to decreased sperm motility and count. They are due to incompetent
valves in the testicular vein. The vast majority of varicoceles are located on the left side and
only 1 % are bilateral. The left sided predominance of varicoceles is thought to be due to the
long course and angle of entry of the left testicular vein as it empties into the left renal vein.
The right testicular vein is shorter and empties directly into the inferior vena cava.
Varicoceles are much more apparent when the patient performs a Valsalva maneuver or is
standing. Hence, ultrasound should be performed in both supine and standing positions.
Sonographically, they appear as multiple anechoic serpiginous tubular or curvilinear

structures of varying sizes (larger than 2 mm in diameter) in the region of the epididymis
(Figure 4). Power Doppler should be used to confirm flow in the varicocele. (5,6,7)

Figure 4: Longitudinal view of testicle with enlarged pampiniform plexus. Also note the
thickening of the surrounding connective tissue secondary to scrotal inflammation after a
failed penile implant. (Courtesy of Beatrice Hoffmann, M.D.)
Testicular Torsion
Testicular torsion is a urologic emergency. Prompt diagnosis and early treatment is essential
as time is critical for testicular salvage. Torsion is more common in children but can occur in
post pubertal males. The majority of testicular torsions result from anatomic defects that lead
to redundant spermatic cord and anomalous suspension of the testes in the scrotum. An
undescended testicle also increases the likelihood of torsion. A redundant spermatic cord is
mobile and during torsion it begins to twist upon itself. As the twisting progresses, venous
flow is interrupted initially due to easily collapsible vessel walls and the low intravascular
pressure. Venous obstruction is followed by a decrease in arterial inflow, which eventually
progresses to complete obstruction. Once the spermatic cord is fully torsed and no blood flow
is present, infarction and loss of the testicle can occur quickly. Rapid diagnosis of testicular
torsion is critical to preserve fertility. The salvage rates are approximately 100 % at 3 hours,
83-90 % at 5 hours, 75 % at 8 hours, and 50-70 % at 10 hours. The salvage rates decrease to
10 to 20 % when the testicle remains torsed for more than 10 hours. After 24 hours, salvage
of a testicle is rare unless there has been intermittent detorsion. Sonographic findings can be
variable depending on the duration of torsion and extent of vascular compromise. The testicle
can appear enlarged and hypoechoic and the parenchyma of the testicle will become less
homogenous when compared with the unaffected testicle (Figure 5). Unfortunately
ultrasound may not always be helpful, as sonographic findings may be subtle early in the
course. Color Doppler or power Doppler may be helpful to identify flow patterns in the
acutely tender testicle (Figure 6). When blood flow is absent in the affected testicle, the
diagnosis of testicular torsion is clear. Occasionally decreased blood flow seen in early
torsion can be erroneously diagnosed as normal. Thus, comparison to the contralateral side is
crucial. Color Doppler alone will not assure both venous and arterial flow in the testicle.
Spectral Doppler tracings should also be obtained to confirm both arterial and venous flow.
The absence of a venous pattern by spectral Doppler on the affected side suggests early
torsion. If the diagnosis is in doubt due to torsion-detorsion, repeat color Doppler imaging
along with spectral examination in one hour is recommended. (2,3,4)

Figure 5: Transverse scan of both testicles showing normal left testicle and right testicular
torsion. Note the hypoechogenicity of the right testicle. (Courtesy of Michael Blaivas, M.D.)

Figure 6: Transverse plane through both testes. The power Doppler image of the scrotum
demonstrates right testicular perfusion. The swollen left testicle is not perfused. (Courtesy of
Michael Blaivas, M.D.)
Epididymitis
Epididymitis is the most common cause of acute scrotal pain in postpubertal males.
Classically, patients present with a painful tender scrotum, dysuria, and fever. Retrograde
spread of infection from the bladder or prostate is usually the underlying etiology with the
head of the epididymis most commonly involved. Gray-scale findings of acute epididymits
include an enlarged epididymis with decreased echogenicity. Often, a reactive hydrocele is
noted as well (Figure 7). A chronically inflamed epididymis becomes thickened and has focal
echogenicity with areas of calcification. With Doppler sonography increased blood flow
secondary to epididymal inflammation is noted. The presence of normal or increased blood
flow in the affected testicle when compared to the contralateral side differentiates
epididymitis from testicular torsion. (2,3,4)

Figure 7: A slightly oblique view of a testicle with an enlarged hypoechoic epididymis.

(Courtesy of Michael Blaivas, M.D.)
Orchitis
Orchitis is an acute infection of the testicle usually following epididymitis. Orchitis often
presents with a tender and inflamed testicle. On gray-scale ultrasound, orchitis is seen as an
enlarged testicle with heterogeneous echogenicity. This appearance is nonspecific and can be
seen in many other conditions such as tumors, metastasis, infarct and torsion. Standard Bmode is not a reliable method to differentiate between orchitis and testicular torsion. For both
orchitis and torsion, inflammation and edema can lead to enlargement and heterogeneous
echogenicity of the testis. Color Doppler is helpful to differentiate between orchitis and

torsion since blood flow in orchitis is increased in comparison with the unaffected side due to
inflammation (Figure 8). (2,3,4)

Figure 8: Orchitis. Marked increase in blood flow is seen along with a reactive hydrocele.
(Courtesy of Michael Blaivas, M.D.)
Scrotal Trauma
Blunt trauma to the scrotum can lead to damage of the testicle and adjacent structures.
Injuries to scrotum include laceration, hemorrhage, or contusion of the testicle. The goal of
scrotal ultrasound in patients with acute trauma to the scrotum is to evaluate injury to the
testicle. Blood flow to the testicle should also be evaluated since trauma could lead to
testicular torsion. Visualization of a normal testicle on ultrasound virtually excludes any
significant injury. Any abnormalities visualized within the testis in the setting of scrotal
trauma should be considered as testicular rupture (Figure 9). Sonographic findings suggestive
of testicular injury include irregular outline and a inhomogeneous echotexture from
hemorrhage or infarction. A discrete fracture line is seen by ultrasound in only 17 % of
ruptures. A significant hematocele is an indirect finding for possible testicular rupture.
Hemorrhage within the testicle changes its appearance depending on the age of the
hemorrhage. Acute hemorrhage will appear inhomogeneously echogenic, but later will
develop large anechoic regions within it. Color Doppler helps to differentiate hematomas
from tumors. Tumors are usually vascular, whereas hematomas will not reveal any blood
flow. (2,3,4,6)

Figure 9: Testicular Fracture. Note the inhomgenicity of the testicular echotexture and
fracture line. (Courtesy of Michael Blaivas, M.D.)

V. Pearls and Pitfalls

Use the mediastinum testis as a point of reference when demonstrating intratesticular

flow. Note, that if mediastinum testis is imaged at an oblique angle, it can be mistaken

for a mass.

Color Doppler cannot differentiate malignant hypervascularity from inflammatory

hypervascularity.

Diagnosing early testicular torsion when it is still incomplete can be challenging with
color Doppler alone. This method relies on subtle differences between the two testicles.
Venous flow initially disappears
followed by arterial flow. Use of spectral Doppler to document both venous and arterial
waveforms is optimal. Some patients may exhibit torsion and detorsion. Shortly after
detorsion, hyperemia may be detected as increased blood flow in the affected testicle.
This will not last longer than 15 minutes usually
and may be missed. Hyperemia must be differentiated from orchitis because these
patients still need
urology follow up for surgical intervention.

VI. References
1. Blaivas M, Brannam L.
Testicular Ultrasound. Emerg Med Clin North Am. 2004;22(3):723-748.
2. Blaivas M, Sierzenski P, Lambert M.
Emergency evaluation of patients presenting with acute scrotum using bedside
ultrasonography.
Acad Emerg Med. 2001;8(1):90-93.
3. Blaivas M, Sierzenski P.
Emergency ultrasonography in the evaluation of the acute scrotum. Acad Emerg Med.
2001;8(1):85-89.
4. Blaivas M, Batts M, Lambert M.
Ultrasonographic diagnosis of testicular torsion by emergency physicians. Am J
Emerg Med.
2000;18(2):198-200.
5. Akin EA, Khati NJ, Hill MC.
Ultrasound of the scrotum. Ultrasound Q. 2004;20(4):181-200.
6. Blaivas M.
Testicular. In: Ma OJ, Mateer J, eds. Emergency Ultrasound. McGraw-Hill: New
York, 2003:221-238.
7. Promes S.
Miscellaneous applications. In: Simon B, Snoey E, eds. Ultrasound in Emergency and
Ambulatory Medicine. Mosby: St. Louis, MO, 1997:250.