Testicular torsion

Case contributed by Dr Silvia Moguillansky

Presentation

Swelling and pain of left scrotum for two days

Patient Data

Age: 12 years
Gender: Male

Ultrasound

Ultrasound

Testicular blood flow is visualized on the normal side but is absent on the affected side (left) and the spermatic cord displays the whirlpool sign. The diagnosis of testicular torsion was confirmed with surgery.

 (a) normal right longitudinal US scan (left image) obtained at the level of the external inguinal ring

(b) left longitudinal US scan (middle image) obtained at the level of the external inguinal ring shows an abrupt change in the configuration of the spermatic cord (arrow), with whirlpool sign

(c) color Doppler of both testes in transverse view (right image) shows normal vascularization on the right. The left testis is increased in size, mildly heterogeneous in echotexture and without central vascularization.

Case Discussion

Testicular torsion, i.e. torsion of the spermatic cord, is relatively common and its end-result is the obstruction of the arterial blood supply to the testis. A prompt diagnosis is important for saving the testis. However, atypical presentations of testicular torsion may delay recognition of the condition. We must also differentiate between this and other causes of an acute scrotum. Diagnostic imaging, particularly Doppler ultrasonography, plays an important role in the assessment of the patient with acute scrotal pain.

The differential diagnosis includes:

The ability to rapidly distinguish between these possibilities is important because the morbidity of testicular ischemia is high and there is a need to institute appropriate treatment.

Twisting of the spermatic cord usually first causes venous, then later arterial flow obstruction. The amount of testicular necrosis depends on the duration and degree of torsion. Torsion of greater than 6 hours usually results in a non-viable testis.

Whirlpool sign is highly reliable for the direct diagnostic confirmation of testicular torsion, especially with the presence of vascular flow in the testis with torsion-detorsion twisting.

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