Download 36 year old gentleman with unilateral pain/swelling of scrotum for 4

Department of Radiology
Henry Ford Health System
Detroit, Michigan
36 year old gentleman with unilateral
pain/swelling of scrotum for 4 days.
Pinky Sharma
Wayne State School of Medicine
02/26/2010
Resident: Dr. Brent Griffith, R1
History
36 year old gentleman with history of trauma
to left testicle,
 Now presents with left-sided pain/swelling for
4 days.
 Patient denies fever, chills, abdominal pain,
dysuria, frequency or urgency.
 PMH: Unremarkable
 Multiple high-resolution grayscale and high
sensitivity Doppler images of the testicles
obtained

Color doppler images of the
testicles
Ultrasound Images cont.
Increased vascular flow in Left
Kidney
FINDINGS
Both testicles symmetric
 Both testes demonstrate normal
homogenous echotexture
 Right testicle measures 4.7 x 2.9 x 2.3 cm

 small
anechoic structure in the right
epididymis may relate to an epididymal head
cyst or spermatocele.
 A small right-sided hydrocele with low level
echoes present.
Ultrasound Findings cont.

Left testicle measures 4.2 x 3.6 x 2.0 cm
 left
epididymis enlarged and heterogeneous
in appearance with increased vascular flow
compared to the right
 A small left-sided hydrocele present.
 The skin of the left hemi- scrotum thickened,
measuring 8.4 mm

Normal color as well as arterial and
venous flow within both testes.
Differential Diagnosis
Testicular Torsion
 Appendiceal torsion
 Epididymitis
 Testicular tumor
 Fournier's gangrene
 Orchitis
 Epididymal cyst
 Hydrocele/Varicocele/Spermatocele

Final Diagnosis
Epididymitis
Epididymitis
an inflammatory reaction of the epididymis
 caused by either an infectious agent or
local trauma
 a significant cause of morbidity
 5th most common urologic diagnosis in
men aged 18-50 years.
 important to differentiate from testicular
torsion, which is a true urologic
emergency.

Epididymitis
Although thought to be an infectious
process, cultures commonly fail to
demonstrate any identifiable infection
 Severe infection that extends to the
adjacent testicle called acute epididymoorchitis
 Orchitis is an acute inflammatory reaction
that involves only the testes, exclusive of
epididymitis, and is much less common.

Epididymitis
The exact pathophysiology of acute
epididymitis is unclear
 Believed to be caused by the retrograde
passage of infected urine from the
prostatic urethra to the epididymis via the
ejaculatory ducts and vas deferens

Epididymitis
56% of men > 60 years with epididymitis
exhibit concurrent bladder outlet
obstruction such as urethral stricture or
benign prostatic hyperplasia
 Orchitis is found in association with acute
epididymitis in 20%-40% of cases

Diagnostic Imaging
Ultrasonography is the first-line imaging
modality for evaluating a patient with
suspected acute epididymo-orchitis
 Sensitivity of color Doppler
ultrasonography in detecting scrotal
inflammation is almost 100%.

Ultrasound and Color doppler
Findings





Usually shows enlargement of the epididymal
head with decreased echogenicity secondary to
edema.
A reactive hydrocele may be present
Chronic Epididymitis - hyperechoic
Acute Epididymitis - hypoechoic, increased
blood flow
Color Doppler findings include


an increased amount of flow in and around the
epididymis.
If abscess formed, complex cystic areas may be
identified in the epididymis
Physical Findings and Clinical
Presentation
1. Tender swelling of the scrotum with
erythema, usually unilateral testicular pain
and tenderness
2. Dysuria and/or urethral discharge
3. Fever (less common)
5. Hydrocele or even epididymo-orchitis,
especially late
6. Chronic draining scrotal sinuses with a
“beadlike” enlargement of the vas deferens in
tuberculous disease
ETIOLOGY
In young, sexually active men - N.
gonorrhoeae and C. trachomatis infections
 In men >35 yr or with underlying urologic
disease: Gram-negative aerobic rods
predominant.
 Mycobacteria also a cause of epididymitis.
 Young, prepubertal boys may present with
epididymitis caused by coliform bacteria
almost always a complication of reflux.

Complications

Complications of epididymitis and/or
epididymo-orchitis include the following:
Chronic epididymitis
 Infarction
 Infertility
 Abscess
 Atrophy
 Pyocele

Current Therapy
Appropriate antibiotics if infectious agent
isolated
 Antiinflammatories
 Decreased activity
 Scrotal elevation
 Pain control

Follow-up
Failure to improve within 3 days:
Reevaluate initial diagnosis and therapy
 For persistent swelling and tenderness
after therapy, consider:

1. Testicular tumor
2. Abscess
3. Testicular infarction
4. Tuberculosis
5. Fungal epididymitis
References




Lewis, AG, Bukowski, TP, Jarvis, PD, et al. Evaluation of
acute scrotum in the emergency department. J Pediatr
Surg 1995; 30:277.
Al Mufti, RA, Ogedegbe, AK, Lafferty, K. The use of
Doppler ultrasound in the clinical management of acute
testicular pain [see comments]. Br J Urol 1995; 76:625.
Wilbert, DM, Schaerfe, CW, Stern, WD, et al. Evaluation
of the acute scrotum by color-coded Doppler
ultrasonography. J Urol 1993; 149:1475.
Edmund S Sabanegh Jr, MD, Director, Center for Male
Fertility, Glickman Urological and Kidney Institute,
Cleveland Clinic Foundation
References cont.

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
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Uptodate: Robert C Eyre, MD Evaluation of
acute scrotum in adult men
MD Consult: Epididymitis
Vikram S Dogra, MD, Professor of Diagnostic
Radiology, Urology, and Biomedical
Engineering, University of Rochester School of
Medicine; Director
Sandra L. Hagen-Ansert, M.S., RDMS, RDCS
(F)SDMS ;Ultrasound Education Specialist and
Clinical ConsultantCharleston, South Carolina