Scrotal emergencies Subramaniyan Ramanathan

Transcription

1 Scrotal emergencies Subramaniyan Ramanathan Weill Cornell Medicine, New York (Qatar campus) Hamad medical corporation, Doha, Qatar

2 Disclosure Statement I have no relationships with commercial interests to disclose

3 Learning objectives To review the common and uncommon causes of acute scrotum To understand role of various imaging in scrotal emergencies. To illustrate the imaging features of torsion, epididymitis and scrotal trauma Target audience Radiology residents, practicing radiologists, Urologists and Emergency physicians

4 Acute scrotum Common in children, adolescents and young adults Sudden onset of pain, swelling or combination 0.5% of total ED visits. 1/20th the frequency of acute abdomen Role of imaging decide surgical or conservative management Time factor Testicular viability Sensitive issue - Fertility and erectile function

5 Acute scrotum- Differential diagnosis Structures: Testis, epididymis, scrotal cavity, cord, inguinal canal Ischemia Testicular torsion, appendiceal torsion Inflammation- Epididymitis, orchitis, Fournier s gangrene, cellulitis, abscess Injury Testicular rupture, hematoma, hematocele Inguinal hernia Others - testicular tumours, idiopathic scrotal edema, Henoch-Schonlein purpura, scrotal fat necrosis, thrombosed varicocele

6 Acute scrotum - Incidence European multicenter study 2007 Age <18 yrs Torsion testicular appendage 33% Epididymitis 31% Torsion of spermatic cord 22% Testicular trauma 7% Torsion/detorsion 15% Acute Scrotal edema 1% Others 2% Kalfa N etal. J Urol Jan;177:

7 Ultrasound High-resolution gray-scale and color Doppler ultrasound Superficial location, rapid, radiation free, wide availability, repeatable Color doppler (CDUS) Essential component Spectral/pulsed doppler - Useful in equivocal cases Power doppler- Independent of angle correction - useful in low flow states, pediatric patients Power Doppler- identified flow in 97% testes, whereas color Doppler in 88% testes. Combined techniques depicted blood flow in 100% testes Radiology. 1997;204:389-93

8 Ultrasound- Scanning technique Supine position, scrotal support Asymptomatic side should be scanned first - to appropriately set the flow/gain parameters Transverse image including both testicles on same image - to allow side-to-side comparison of echostructure and vascularity Parameter settings Linear high frequency transducer low flow rates (4 to 5 cm per second) low wall filter (100 KHz) low pulse repetition frequency (1 to 2 Hz) 70% to 90% color gain small color-sampling box Radiology 1997;204:389 93

9 3 Vessel Supply to scrotum Testicular artery Testis High flow, low resistance RI Vas deferens artery Epididymis High flow, low resistance RI Cremasteric artery Scrotal wall Low flow, high resistance RI 0.7-1

10 Contrast enhanced ultrasound CEUS CEUS - Evaluates perfusion instead of vascular flow More direct approach CEUS > CDUS - Technical factors, vasculitis, external compression by large fluid collection, venous thrombosis, and scrotal edema INDICATIONS Incomplete torsion, torsion-detorsion Epididymitis Abscess characterization Secondary testicular ischemia from epididymitis Trauma Better delineation of fracture line, hematoma, tunica defect Testicular viability Valentino M et al. Eur Radiol (2011) 21:

11 MRI Inconclusive US findings Incomplete testicular torsion Referred with delayed torsion Appropriate treatment planning - Viability Segmental testicular infarct (STI)

12 Nuclear scan Despite its equal/high sensitivity and specificity, lost its battle to CDUS Limitations less availability, radiation, poor anatomical detail, long, false positive Tc-99m Pertechnetate Sensitivity: 90-98%, Specificity: % Epididymitis- Hot spot Torsion Early: Nubbin sign (Abrupt cut-off of iliac a) with cold spot Late: Halo/Rim/Dough-nut sign Am J Emerg Med. 2011;29(1): International medical journal Malaysia. 11. June 2012

13 ACR appropriateness criteria

14 Testicular Torsion Misnomer. Actually torsion of spermatic cord (TSC) Clinical dx not reliable -50% false positive Peri-pubertal, 1 in 4,000 <25 yrs L>R, 2% bilateral, 5-8% traumatic torsion Testicular torsion Symptoms pain <24 h, Severe nausea/vomiting Acute epididymitis Few days insidious pain Mild to moderate Dysuria, fever Age Peri-pubertal Post pubertal Signs Absent cremasteric reflex Present cremasteric reflex No pain relief on elevation- Prehn -ve Pain relief on elevation- Prehn +ve high position of the testis painful epididymis on palpation Dogra et al. Radiology 2003 Labs Normal CRP, WBC, Pyuria

15 Testicular Torsion types 1. Intravaginal: 90%- most common (Bell Clapper deformity - 12% asymptomatic men, 80% bilateral) 2. Extravaginal: Neonatal 3. Long mesorchium: with cryptorchidism Pediatric Radiology (2018) 48: RadioGraphics 2013; 33:

16 Testicular Torsion Gray scale Early acute Acute Late Acute Subacute Chronic

17 Testicular Torsion - CDUS CDUS - 82 % sensitivity and 100 % specificity for torsion Absent or diminished colour flow Decreased flow velocity on pulsed doppler Diminished or reversed diastolic flow Increased RI >0.7

18 Testicular Torsion - Direct signs Testicular flow Indirect effects of torsion 10% of early/partial torsions - Normal US Whirlpool sign - abrupt change in course of the spermatic cord with a spiral twist of the cord at the external inguinal ring Pseudo mass sign - oval-shaped heterogeneous mass below the point of torsion Sensitivity 97.3% and specificity 99% Strictly linear cord 100% sensitive in ruling out torsion AJR. 2013;201:

19 Testicular Torsion- CEUS More confident diagnosis of testicular infarction - complete absence of perfusion on CEUS when doppler shows diminished flow due to flow artifacts and arterial pulses of contralateral testis Viability Eur Radiol (2011) 21:

20 Testicular Torsion- MRI Dynamic contrast-enhanced MRI in the evaluation of testicular torsion in 39 patients sensitivity 100%, specificity 93% and NPV 96%. T2W T1 PRE T1 POST T1 POST JMRI. 2007;26:100-8 Urology. 2006;67:

21 Testicular salvage Degree of torsion and duration of ischemia <180 rotation decreased flow >720 rotation complete occlusion 100% within 6 h, 70% 6-12h, 20% 12-24h

22 Testicular torsion - Management Surgical exploration and bilateral orchidopexy Manual detorsion Open book technique

23 Diagnosis please? 16-year-old patient who had severe left testicular pain, nausea, and vomiting for 10 hrs RIGHT TESTIS LEFT TESTIS -UPPER LEFT TESTIS -LOWER Early/partial/incomplete torsion J Ultrasound Med 2004; 23:

24 Early/partial/incomplete torsion Short duration or partial twist (<360) Diminished colour flow Asymmetrically reduced perfusion on the symptomatic side Pulsed doppler - Increased RI, reduced diastolic flow, reversed diastolic (to and fro) Tip Look for whirlpool sign in spermatic cord RIGHT LEFT Pediatric Radiology (2018) 48:

25 Intermittent torsion Altered flow RIGHT LEFT Classical history with subtle hyperemia should raise the concern of possible torsion followed by spontaneous detorsion 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. Findings were confirmed intraoperatively

26 Intermittent torsion - Ultrasound 1. Horizontal lie 2. Altered testicular flow Absent to normal flow 31% Increased flow 31% Normal flow 26% Decreased flow 10% 3. Direct signs Whirlpool or pseudomass-80% Boggy/redundant cord -10% Normal cord 10% Pediatric Radiology (2018) 48: AJR. 2013;201:

27 Extravaginal torsion Rare, exclusively Neonates Prenatal Vanishing testis Immature Scrotal ligament and tunica vaginalis Swelling, discoloration of scrotum and firm painless mass Often infarcted necrotic testis at birth Enlarged, heterogeneous testis, ipsilateral hydrocele, skin thickening, and no color flow Right testis Left testis Left testis Right testis

28 Torsion testicular appendage Remnant of mesonephric and paramesonephric ducts MC - Appendix testis (95%) groove b/w testis and epididymis MC cause acute scrotum in 7-14 yrs?? (Most cases misdiagnosed as epididymitis in head. But tail epididymitis is much more common) Clinical presentation similar to testicular torsion Blue dot sign - only 23% Baldisserotto et al AJR 2005 Sheldon CA. Surg Clin North Am 1985;65:1303

29 Torsion testicular appendage -USG Extra testicular mass with variable echogenicity adjacent to the testis or epididymis measuring >5.6 mm with absent flow Increased peripheral flow can be seen mimic epididymitis Reactive hydrocele and skin thickening is common Conservative management Pain resolves in 2-3 d with atrophy and calcification later 9-year-old boy with left-side pain Am J Roentgenol 184:

30 Torsion mimics Poor technique Pediatric testis Large hydrocele/hematoma Scrotal wall edema Vasculitis PAN, SLE

31 Epididymitis-Orchitis MC cause of acute scrotum, 1 in 1000 men Adults - Retrograde infection - STD or UTI Children viral infections or refluxed urine Scrotal pain relieved on elevation (Prehn sign) Tail before body and head Attention to tail necessary to diagnose an early infection Orchitis complicates epididymitis in 20-40% of cases- Unilateral Isolated (primary) orchitis- rare and 1/3rd bilateral Viral RadioGraphics 2013; 33:

32 Epididymo-orchitis - USG Right Right

33 Epididymo-orchitis Complications Epididymal/testicular abscess Testicular abscess - in 3 5 %, complex intra-testicular fluid collection without internal vascularity, but peripheral hyper-vascularity

34 Diagnosis please? VENOUS INFARCTION 35.M. 7 days right testicular pain and fever Testicular torsion usually results in absent flow in both testis and epididymis Absent testicular flow with preserved or increased flow in epididymis should suggest alternate etiologies

35 Fournier gangrene Rapidly progressing necrotizing fasciitis involving the perineal, perianal, genital regions Surgical emergency % mortality rate Polymicrobial, middle aged male (10:1/M:F), 50% diabetes Fascial necrosis cm per hour Sudden onset of scrotal pain, swelling, hyperemia, pruritus, crepitus, and fever Treatment - Aggressive surgical debridement, broad-spectrum antibiotics, intensive supportive care and hyperbaric oxygen (HBO) RadioGraphics 2008; 28:

36 Fournier gangrene US/CT hyperechoic foci with "dirty" shadowing - 18% to 62% of cases Reactive hydrocele Normal testicles USG - to r/o testicular cause and in unstable patients as bedside examination Modality of choice- From diaphragm to upper thigh 90% subcutaneous emphysema fluid collections or abscesses pneumoperitoneum RadioGraphics 2008; 28:

37 Testicular trauma 3 rd MC acute scrotum Surgical Emergency >80% salvage rate if OR <72h Physical examination can be misleading Blunt (85%), penetrating (15%) Rare: Iatrogenic, electrical, scrotal bites RadioGraphics 2008; 28:

38 Testicular rupture Interruption of tunica albuginea, testicular contour deformity, heterogeneous echotexture 100% sensitivity and 93% specificity Urgent surgical treatment is needed to preserve fertility, and prevent ischemic necrosis and infection J Urol 2006;175:

39 Testicular fracture Break in testicular parenchyma with maintained contour May or may not be associated with tunica albuginea defect USG - Linear avascular hypoechoic area only 17% CEUS- better demonstration of fracture and viability Conservative or with minimal debridement J Ultrasound (2013) 16:

40 Testicular hematoma

41 Testicular trauma Indications for surgery Testicular rupture Testicular fracture (depends on retained vascularity) Large testicular hematoma (to avoid infection/necrosis) Large hematocele/hematoma (3 times size) Torsion Clinical-US mismatch

42 Diagnosis please? 40/M 5 days right groin pain Strangulated omental hernia

43 Inguino-scrotal hernia Painless swelling or dull aching pain Acute pain and swelling due to strangulation or bowel obstruction Fluid, omentum and bowel loops Akinetic dilated bowel - high sensitivity (90%) and specificity (93%) for strangulation Hyperemia of the scrotal soft tissue and bowel wall suggests strangulation J Ultrasound (2013) 16:

44 42/M 2 months left scrotal pain aggravated in the past 3 days Other causes 35/M 1 month post hernia surgery Right groin pain Testicular tumour Thrombosed Varicocoele

45 Take home messages Testicular Torsion Go with the flow! Presence of vascularity does not always exclude torsion. Compare both testis for subtle differences. Repeat US Epididymitis Absent testicular flow with normal or increased flow in epididymis Look for other etiologies Unresolving/recurrent epididymitis- Suspect complication Testicular Trauma Tunica albuginea- Key in testicular trauma Testicular torsion, testicular rupture and strangulated hernia Surgical emergency

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