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ACUTE SCROTUM

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ACUTE SCROTUM Torsion of testis and appendage Infection: epididymitis, epididymo-orchitis, orchitis Trauma Hernia Idiopathic scrotal edema Testicular torsion Torsion ... – PowerPoint PPT presentation

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Title: ACUTE SCROTUM


1
ACUTE SCROTUM
  • Torsion of testis and appendage
  • Infection epididymitis, epididymo-orchitis,
    orchitis
  • Trauma
  • Hernia
  • Idiopathic scrotal edema

2
Testicular torsion
  • Torsion occurs when an abnormally mobile testis
    twists on the spermatic cord, obstructing its
    blood supply.
  • Patients present with acute onset of severe
    testicular pain.
  • The ischemia can lead to testicular necrosis if
    not corrected within 5-6 hours of the onset of
    pain.
  • Torsion can be intermittent and can undergo
    spontaneous detorsion.
  • Types Intravaginal most common, peak incidence
    b/w 13-16 years of life.
  • Extravaginal- less common and
    confined to perinatal period.

3
TESTICULAR TORSION
4
  • In a child with an acute scrotum, testicular
    torsion is not the most common condition Torsion
    of testicular appendices represents the more
    common cause of scrotal pain with the peak
    incidence at 11 years of age.
  • Typically, it has a more gradual onset than
    testicular torsion and patients may endure pain
    for several days before seeking medical
    attention.
  • Epididymitis occurs in children with spina bi
    fida or infants with imperforate anus with recto
    urethral fistula.

5
CLINICAL PRESENTATION IN TORSION TESTES
6
NOT TO MISS TESTICULAR TORSION
  • So although torsion of the testicular appendix
    and epididymitis are more common, our goal is
    mainly to detect or exclude a testicular torsion.
  • Color Doppler
  • Complete absence of intratesticular blood flow
    and normal extratesticular blood flow on color
    Doppler images is diagnostic, if the flow is
    normal in the contra lateral testis. Yet, the
    presence of flow within the testis does not
    exclude the presence of torsion, because
    incomplete vascular obstruction can sometimes
    occur or intermittent torsion.
  • This case is very obvious because there is no
    flow on the affected side, but also a difference
    in echogenicity. With prolonged torsion, the
    testis is typically hypoechoic and inhomogeneous
    and is often accompanied by a surrounding
    hydrocele. By the time these sonographic findings
    occur, surgical salvage of the testicle is
    unlikely.

7
TESTICULAR TORSION IN YOUNG CHILDREN
  • In the very young child it can be difficult to
    examine the testes because they are very small
    and mobile.
  • The prepubertal testis has a volume of about 1-2
    cc, while the postpubertal testis has about 30cc.
  • With age the testis increases in echogenicity, so
    in a very young child the small testis can be
    difficult to differentiate from the surrounding
    fat, especially if it is retracted into the
    inguinal canal
  • Color Doppler imaging has limited sensitivity for
    detecting blood flow in pediatric patients with a
    testicular volume of less than 1cc.

8
Testicular appendage torsion
  • Testicular appendage torsion appears as a lesion
    of low echogenicity with a central
    hypoechogenic area adjacent to the epididymis.
  • Peak incidence at 11 years of age.
  • Presents with scrotal pain of less severe
    intensity , upper scrotal tenderness and some
    times with blue dot sign.
  • Most of the time however, we don't see it and we
    do the US just to exclude a testicular torsion.
  • We should see torsion of testicular appendices
    more as a diagnosis of exclusion.

9
Epididymitis
  • Epididymitis is the most common inflammatory
    process involving the scrotum and more common in
    adults.
  • Epididymitis also occurs in children, but is then
    rare and due to infection with Streptococcus or
    Staphylococcus.
  • In urinary tract abnormalities also infection
    with E.Coli is seen.
  • A sterile chemical epididymitis can result from
    reflux of sterile urine through the ejaculatory
    ducts, for instance if the ureter inserts in the
    prostatic urethra, this may lead to increased
    pressure in the vas deferens. .

10
Epididymitis

  • The case on the left shows
    the
  • typical features of epididymitis. The epididymis
    is swollen and
  • heterogeneous. There is a hydrocele
  • and scrotal wall thickening. With
  • color Doppler there is increased flow. A normal
    epididymis has only limited color flow.

11
ORCHITIS
  • Orchitis is characterized by focal, peripheral,
    hypoechoic testicular lesions that are poorly
    defined, amorphous, or crescent-shaped.
  • Orchitis also exhibits testicular hyperemia on
    color Doppler sonography images and is usually
    accompanied by epididymal hyperemia due to
    concomitant epididymitis.
  • A reactive hydrocele is also frequently
    associated with epididymoorchitis.
  • Focal testicular infarction can occur as a
    complication of epididymitis when swelling of the
    epididymis is severe enough to constrict the
    testicular blood supply.
  • This appears as a hypoechoic intratesticular mass
    devoid of blood flow.
  • The complications of orchitis are abscess
    formation and ischemia.

12
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13
ORCHITISCOMPLICATIONS
14
Trauma
  • Hematocele
  • In trauma there is either a hematocele or
    testicular hematoma. In the acute phase the
    hemorrhage is echogenic and in the chronic phase
    it is hypoechoic.
  • A hematocele results from scrotal or
    intra-abdominal hemorrhage. It represents
    bleeding between the leaves of the tunica
    vaginalis and appears as a complex fluid
    collection. With time, this collection can
    develop loculations, which appear as thick
    septations. It is important to be able to tell
    sonologically if the testis is intact, because if
    there is a rupture, this can sometimes be treated
    surgically.

15
HEMATOCELE
16
Testicular rupture
  • Testicular rupture is seen as focal alterations
    of testicular echogenicity correlating with areas
    of intratesticular hemorrhage or infarction in a
    patient with a hematocele.A discrete fracture
    plane is identified in fewer than 20 of cases,
    although visible alterations in the testicular
    contour are a common finding sonologically.

17
STRANGULATED HERNIA
  • .
  • Strangulated Hernias in children are common
    especially in infancy.
  • Children may present with acute irreducible
    scrotal swelling, irritability and symptoms and
    signs of intestinal obstruction.
  • Sometimes we can see them on plain films .
  • If they are filled with bowel, they are easy to
    detect on ultrasound, but sometimes these hernias
    are only filled with soft tissue .

18
  • Idiopathic scrotal edema is seen in school-aged
    boys.
  • They present with scrotal skin swelling which
    spread to or from the inguinal region, penis or
    perineum so redness is not confined to
    hemiscrotum but spreads to both halves of
    scrotum.
  • Cause is not always apparent but may be
    bacterial cellulitis or a topical allergy. So
    the clinical question is, if there is torsion or
    infection.
  • At examination the testes and epididymis are
    normal and all that we see on US is skin edema.
  • If the child does not have fever or elevated
    white count, which can be seen in cellulitis,
    than we can make the diagnosis of Idiopathic
    scrotal edema.
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