Presentation
Left scrotal pain and swelling for 10 days
Patient Data
Left testis is normal in size (14.5 cc) of the left testis diffuse decreased echogenicity and no flow detected on color Doppler in very low Doppler settings consistent with absent arterial and venous flow, in keeping with testicular infarction.
Twisted distal spermatic cord with no blood flow at the twisted point, in keeping with spermatic cord/teticular torsion. Preserved vascularity of the spermatic cord proximal to the point of twist.
Enlarged left epididymis with decreased echogenicity and no flow detected, reflecting epididymal ischemia. Multiple epididymal cysts are noted at the head around the twist point, largest averages 1.5 x 1.4 cm.
Septated epididymal body and tail cysts with turbid fluid, suggestive of spermatoceles due to obstruction. Mild left scrotal hydrocele.
The right testis is of average size (18.5 cc) with normal echogenicity and no hydrocele.
Case Discussion
Imaging features mostly represent the late features of testicular torsion, leading to testicular infarction and obstructed distal epididymis forming septated spermatocele with turbid echogenic fluid. Epididymal cysts may acted as lead point for the spermatic cord twist.
Doppler ultrasound not necessarily be affected proximal to the obstruction due to collaterals. So, spermatic cord Doppler may be normal as in this case.
At twist point, there may be no vascularity detected in complete obstruction as in this case. Incomplete obstruction shows twisted spermatic cord with visible twisted vessels on color Doppler, which is called whirlpool sign (absent in this case).
Comparing the echogenicity of both testes in side to side view is important to suspect testicular ischemia, as color Doppler may not be visible in normal testes especially in children.
This case has a poor diagnosis after such delay. No imaging done from the onset of symptoms and was treated as epididymo-orchitis based on clinical suspicion, which is the more common main differential diagnosis for testicular torsion.
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