the acute scrotum - lieberman's...
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The Acute ScrotumThe Acute Scrotum
Alex Lam, Harvard Medical School Alex Lam, Harvard Medical School Year IIIYear III
Gillian Lieberman, MDGillian Lieberman, MD
Alex Lam, HMS IIIGillian Lieberman, MD
September 2002
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Alex Lam, HMS IIIGillian Lieberman, MD
DDxDDx: Acute Scrotal Pain & Enlargement: Acute Scrotal Pain & Enlargement
PAIN PAIN
Inflammatory disorderInflammatory disorderTesticular torsionTesticular torsionTesticular infarctionTesticular infarctionTesticular abscessTesticular abscessTraumaTrauma
ENLARGMENTENLARGMENT
HydrocelesHydrocelesHerniasHerniasHematomasHematomasTesticular torsionTesticular torsionEpididymitisEpididymitisAbscessAbscessTraumaTrauma
*In 20% of cases, testicular tumors may present with a painful mass.
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Alex Lam, HMS IIIGillian Lieberman, MD
Modes of Scrotal ImagingModes of Scrotal Imaging
UltrasoundUltrasoundRadioisotope ScanningRadioisotope ScanningComputed TomographyComputed TomographyMagnetic Resonance ImagingMagnetic Resonance ImagingAngiographyAngiography
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Alex Lam, HMS IIIGillian Lieberman, MD
Primary Modality: UltrasoundPrimary Modality: Ultrasound
AccuracyAccuracyConvenienceConvenienceComfortComfortAbsence of Ionizing RadiationAbsence of Ionizing Radiation
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Alex Lam, HMS IIIGillian Lieberman, MD
Best ResultsBest Results
ShortShort--focused, highfocused, high--resolution, real time resolution, real time 7.57.5--10 MHz transducer w/ direct contact 10 MHz transducer w/ direct contact scanningscanningImages taken in Images taken in saggitalsaggital and transverse and transverse planesplanes
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Alex Lam, HMS IIIGillian Lieberman, MD
Body ImagingBody Imaging
Ultrasound, Color Doppler, Power DopplerUltrasound, Color Doppler, Power Doppler
From http://www.ob-ultrasound.net/aloka_880.html
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Alex Lam, HMS IIIGillian Lieberman, MD
Acute ScrotumAcute Scrotum
TraumaTraumaTorsionTorsionInfarctionInfarctionInflammatoryInflammatoryAbscessAbscess
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Alex Lam, HMS IIIGillian Lieberman, MD
ANATOMYANATOMY
From: http://matweb.hcuge.ch/Selected_images/Testis_images/Testis_%20normal_diagrams.htm AND http://www.aafp.org/afp/980215ap/junnila.html
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Alex Lam, HMS IIIGillian Lieberman, MD
Power Doppler Power Doppler --Normal TestisNormal Testis
From http://matweb.hcuge.ch/Selected_images/Testis_images/testis_normal_imaging.htm.
Normal Vasculature of Testis
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Alex Lam, HMS IIIGillian Lieberman, MD
Blunt TraumaBlunt Trauma
Testis Testis Mobility in scrotumMobility in scrotumElasticity of scrotumElasticity of scrotum
Injury occurs w/:Injury occurs w/:Compression against Compression against solid object such as solid object such as pubic bonespubic bonesBurst tunica Burst tunica albugineaalbuginea
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Alex Lam, HMS IIIGillian Lieberman, MD
Why Important to DiagnoseWhy Important to Diagnose
Rapid surgical intervention within 72 Rapid surgical intervention within 72 hrs = 90% savedhrs = 90% savedDelayed = 55% salvage rateDelayed = 55% salvage rate
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Alex Lam, HMS IIIGillian Lieberman, MD
Normal TesticleNormal Testicle
Tunica Albuginea
Intact
From BIDMC ED Sept. 8, 2002: s/p
MCC vs car, now p/w
scrotal eccymosis
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Alex Lam, HMS IIIGillian Lieberman, MD
Testicular RuptureTesticular Rupture
BIDMC ED Sept. 8, 2002: s/p
MCC vs car, now p/w
scrotal eccymosis
hematoma
Epididymitis
w/ hematoma
Tunica Albuginea
Rupture
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Alex Lam, HMS IIIGillian Lieberman, MD
Testicular TorsionTesticular Torsion
Ischemia & InfarctionIschemia & InfarctionAbnormality in fusion Abnormality in fusion of tunica of tunica vaginalisvaginalis & & scrotal wallscrotal wallBell Clapper AnomalyBell Clapper Anomaly
From: http://health.discovery.com/diseasesandcond/encyclopedia/2485.html
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Alex Lam, HMS IIIGillian Lieberman, MD
Testicular TorsionTesticular Torsion
Children & AdolescentsChildren & AdolescentsAdults: 20% of acute trauma incidenceAdults: 20% of acute trauma incidencePreceded by trauma, sexual Preceded by trauma, sexual intercourse, intercourse, strenousstrenous activity: forceful activity: forceful contraction of contraction of cremastercremaster
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Alex Lam, HMS IIIGillian Lieberman, MD
Signs & SymptomsSigns & Symptoms
Pain @ rest (due to ischemia)Pain @ rest (due to ischemia)EnlargmentEnlargment hemiscrotumhemiscrotumNausea & vomitingNausea & vomitingTense & tender testisTense & tender testisFeverFeverErythemaErythema & Edema of scrotal skin& Edema of scrotal skin
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Alex Lam, HMS IIIGillian Lieberman, MD
EpididymitisEpididymitis
and/or and/or OrchitisOrchitis
Most commonMost common7575--80% cases of 80% cases of acute scrotal painacute scrotal painEpididymitisEpididymitis: 64% : 64% 2020--29 29 y.oy.o..OrchitisOrchitis: viral : viral originorigin
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Alex Lam, HMS IIIGillian Lieberman, MD
ColorColor--flow Doppler Examinationflow Doppler Examination
Visualize Testicular ArteriesVisualize Testicular ArteriesTorsion: lack of flowTorsion: lack of flowEpididymitisEpididymitis: increased flow in : increased flow in epididymisepididymisOrchitisOrchitis: increased flow in testes: increased flow in testes
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Alex Lam, HMS IIIGillian Lieberman, MD
Torsion Torsion ––
Power Doppler USPower Doppler US
From http://radiology.rsnajnls.org/cgi/content/full/215/2/313
absence of perfusion in testicle w/ rim of peripheral hyperemia
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Alex Lam, HMS IIIGillian Lieberman, MD
EpididimytisEpididimytis: Color flow : Color flow dopplerdoppler
USUS
From http://www.med.wayne.edu/diagRadiology/TF/GU/GU03.html
enlarged epididymal
head with increased blood flow
Increased size of epididymis
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Alex Lam, HMS IIIGillian Lieberman, MD
OrchitisOrchitis: Power Doppler US: Power Doppler US
From http://www.gemedicalsystems.com/rad/us/products/log_700pro/msul7or1l.html
Increased test. flow
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Alex Lam, HMS IIIGillian Lieberman, MD
Testicular InfarctionTesticular Infarction
US US hypoechoichypoechoic mass or diffusely mass or diffusely heterogenousheterogenous and smaller and smaller hypoechoichypoechoictestistestisDecrease in size w/ ageDecrease in size w/ ageTumor will increase in size w/ ageTumor will increase in size w/ age
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Alex Lam, HMS IIIGillian Lieberman, MD
Testicular Infarction Testicular Infarction --
USUS
From http://www.uhrad.com/ctarc/ct222c2.jpg
Anechoic areas of necrosis
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Alex Lam, HMS IIIGillian Lieberman, MD
Testicular AbscessTesticular Abscess
Accompany Accompany epididymoepididymo--orchitisorchitisComplication of Complication of missed torsionmissed torsionNecrotic tumorNecrotic tumorInfectious Agents: Infectious Agents: Mumps, Smallpox, Mumps, Smallpox, TB, InfluenzaTB, Influenza
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Alex Lam, HMS IIIGillian Lieberman, MD
Testicular Abscess USTesticular Abscess US
From http://www.sma.org.sg/smj/4001/articles/4001me1.html
Normal Hyperechoic
abscess
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Alex Lam, HMS IIIGillian Lieberman, MD
Infarct vs. AbscessInfarct vs. Abscess
How could you differentiate between an infarct and an abscess if you are
not sure on US?
Power Doppler!!!!
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Alex Lam, HMS IIIGillian Lieberman, MD
What’s the Diagnosis?What’s the Diagnosis?
Tunica Albuginea
Rupture w/ flow to testis
BIDMC PACS BIDMC PACS
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Alex Lam, HMS IIIGillian Lieberman, MD
We can never take back yesterday, or prevent those moments in time we wished
had never happened; however we can rest assured in that the things we do
today will make our tomorrow. And in that, we are the keepers of own destiny.
Sept 12, 01
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Alex Lam, HMS IIIGillian Lieberman, MD
What do you see?What do you see?
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Alex Lam, HMS IIIGillian Lieberman, MD
Harris, John H., Harris, John H., The Radiology of Emergency MedicineThe Radiology of Emergency Medicine, Williams & Wilkins, 3, Williams & Wilkins, 3rdrd edition, 1993, pgs. 896edition, 1993, pgs. 896--909.909.KrekauKrekau, , Doppler Ultrasound: Principles & InstrumentsDoppler Ultrasound: Principles & Instruments, WB Saunders Comp., Philadelphia, 1990.http://www.ob-ultrasound.net/aloka_880.htmlhttp://matweb.hcuge.ch/Selected_images/Testis_images/testis_normal_imaging.htmFrom: http://health.discovery.com/diseasesandcond/encyclopedia/2485.htmlhttp://radiology.rsnajnls.org/cgi/content/full/215/2/313http://www.med.wayne.edu/diagRadiology/TF/GU/GU03.htmlhttp://www.uhrad.com/ctarc/ct222c2.jpghttp://www.sma.org.sg/smj/4001/articles/4001me1.htmlhttp://www.gemedicalsystems.com/rad/us/products/log_700pro/msul7or1l.html
ReferencesReferences
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Alex Lam, HMS IIIGillian Lieberman, MD
AcknowledgmentsAcknowledgments
Many thanks!!!!!•Robert A. Kane, MD•Don “Buddy” Wiese, MD•Larry Barbaras and Cara Lyn D’amour
our Webmasters•Gillian Lieberman, MD•Pamela Lepkowski
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