Department of Medical Imaging, The Ottawa Hospital. Satheesh Krishna Sabarish Narayanasamy Wael Shabana Adnan Sheikh

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1 Department of Medical Imaging, The Ottawa Hospital. Satheesh Krishna Sabarish Narayanasamy Wael Shabana Adnan Sheikh

2 Nothing to disclose

3 Common and unusual presentations and manifestations of testicular torsion Identify common, uncommon and unusual causes of testicular ischemia and differentiate them from torsion of the testis

4 Right Left 9 year old male with 6 hour history of right scrotal pain. Ultrasound (US) shows subtle reduction of vascularity to right testis compared to left. Intraoperatively, torsion was confirmed, testis was viable and orchidopexy was done.

5 Presence of vascularity does not always exclude torsion Vascularity in both testes should always be compared for subtle differences

6 US demonstrates complete absence of flow and heterogeneous testicular echo texture. Features are suggestive of testicular necrosis secondary to torsion. Swirl sign (arrow) reflects twisting of the spermatic cord

7 Early diagnosis is crucial as likelihood of testicular salvage depends on time interval between onset and surgery

8 Right Left 22 year old male with 4 hour history of left scrotal pain. Pain completely relieved en route to hospital. Ultrasound shows subtle increased vascularity to left testis compared to right. Epididymis was normal (inset). Findings were confirmed intraoperatively.

9 Classical history with subtle hyperemia should raise concern of possible torsion followed by spontaneous detorsion.

10 Right Left Strangulated hernia Ultrasound shows absent flow to the left testis. Figure on the right shows an inguinal hernia with dilated, thickened small bowel loops with poor vascularity. Intraoperatively, strangulated hernia was seen. The testicular perfusion normalised after surgical release of the hernial sac.

11 Tense hydrocele Right Absent vascularity Post surgery Ultrasound demonstrates a tense hydrocele on the right with no demonstrable internal vascularity in right testes. Testicular flow normalised after drainage of hydrocele.

12 Increased intrascrotal pressure can cause secondary testicular ischemia. Urgent correction of the primary cause is necessary to preserve testicular viability.

13 Right Left Right Decreased flow with high resistance in a chronically atrophic testis from prior orchitis. Contralateral testis showing normal flow. Testicular hypoperfusion may be chronic.

14 Left Left 45 year old male with left scrotal discomfort/pain. History of vasectomy 4 months prior. Ultrasound shows diffuse hypoechogenicity and segmental absence of flow in the upper two-thirds of the testicular parenchyma. Testicular ischemia was secondary to gonadal artery injury from the prior vasectomy surgery.

15 65 year old male with a 4-day history of testicular pain. Ultrasound shows complete absence of flow within the testis. However, the epididymis was bulky and hyperemic (orange arrow). Surrounding septated hydrocele was also noted (yellow arrow). Intraoperatively, there was no evidence of torsion!! Inflamed, red epididymis was seen with infected hydrocele fluid. Testicular ischemia was sequel to epididymitis. Postulated mechanism is venous thrombosis.

16 Testicular torsion usually results in absent flow in both the testes and epididymis. Absent testicular flow with preserved or increased flow in epididymis should suggest other etiologies.

17 23 year old male with history of trauma with severe pain. Absence of flow in lower portion of testis with geographic well demarcated hypoechogenicity (arrow).

18 Geographic hypoechogenicity reaching the capsule with absence of flow is diagnostic of testicular rupture in the setting of trauma.

19 18 year old was kicked in testicle. US shows no fracture or hematoma. Diffusely heterogenous echotexture of the testes with absent color flow. Swirling of cord was noted (not shown) and a diagnosis of torsion was made.

20 Torsion of spermatic cord can be secondary to testicular trauma.

21 Right Right Left There is apparent reduced flow in the left testis compared to the right. This can potentially mimic ischemia/torsion of the left. However, apparent reduced flow in left testes is due to increased vascularity on the right. Patient had right sided epididymo-orchitis with pain and swelling on the right side. Hence it is important to know which testis is symptomatic.

22 Hyperperfusion in the contralateral testis can potentially mimic torsion due to apparent appearance of reduced flow in the other testis. Clinical history is of paramount importance.

23 A variety of causes (acute, subacute and chronic) may result in testicular ischemia manifesting as decreased colour flow on Doppler ultrasound. Depending on the cause of ischemia, they may be potentially emergent conditions requiring urgent management or chronic incidental findings managed conservatively. Familiarity with various causes and features of testicular ischemia is essential to help guide management.

24 Satheesh Krishna Jeyaraj Fellow in Abdominal Imaging, The Ottawa Hospital, 501, Smyth Road, Ottawa, K1H 8L6