Goubaa Mohamed MD Djerba Tunisia

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A 15-year-old male is seen , 12 hours after onset of severe scrotal pain from no apparent cause. On examination in the emergency department, a scrotal ultrasound is ordered. The sonogram (below) reveals slight enlargement of the left testicle when compared with the right testicle and a small hydrocele. On color Doppler examination of the left testicle, no blood flow can be shown. What do these findings suggest? Un patient âgé de 15 ans a consulté 12 heures après le début d'une douleur scrotale aiguë d'aucune cause apparente. Au service d'urgence, une échographie scrotale a été demandée. Les images d'échographie (en bas) montrent un léger agrandissement du testicule gauche en comparaison avec le testicule droit et une petite hydrocèle. Au doppler couleur du testicule gauche, aucun écoulement sanguin n'est visible dans le testicule et l'épididyme gauche. Quelle sont vos suggestion à propos du diagnostic?


Ultrasonography Testicle

Echographie testicule tortion

tortion ultrasound testicle

scrotum doppler vascular

epididymis spermatic torsion

Echography scrotum testicle

Click on the image below
Cliquez sur les images en bas































This presents an acute surgical emergency, because the occlusion of the blood supply to the testis must be restored within 6 hours to prevent necrosis or infarction of the testis, but this male is seen later : 12 hours after onset of severe scrotal pain. Colour Doppler shows no detectable blood within the testis. the testis is more hypoechoic with increased paratesticular hypervascularity. Treatment : surgical ablation of necrosis testicle.

Ceci représente une urgence chirurgicale car l'occlusion vasculaire sanguine du testicule doit être réparée dans un délai de 6 heures pour empêcher la nécrose ou l'infarctus du testicule. Mais notre patient a consulté tard :12 heures après le début des symptômes. La Doppler couleur ne montre aucun flux sanguin dans le testicule et l'épididyme. le testicule est hypoéchogène avec accentuation de la vascularisation scrotale péri-testiculaire. Traitement fait : ablation chirurgicale du testicule nécrosé.


Testicular torsion
Torsion testiculaire


Testicular torsion

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Testicular torsion is a twisting of the spermatic cord. This twisting results in the loss of blood supply to the testis and blocks the venous drainage of blood from the testicle.
Testicular torsion usually presents with acute pain and swelling but may present as a painless scrotal swelling particularly in young children. Surgery must be performed because the occlusion of the blood supply to the testis must be restored within 6 hours to prevent necrosis or infarction of the testis. Patients with testicular torsion have sudden severe testicular pain, nausea and vomiting. The left testicle is more often affected than is the right.

Sonography :
In the early stages the testis appears normal.
In the acute phase, the epididymis and testis enlarge and the testis appears hypoechoic (9) and inhomogeneous (5). Colour Doppler ultrasound may show decreased or absent blood flow to the testis (2, 3, 4). The testis may also appear rather high in the scrotum and may be noted to have a rather horizontal axis.. After 24 hours, the hypoechoic testicle becomes enlarged and a hydrocoele may develop (7). The testis then atrophies making the epididymus appear relatively large and echogenic in comparison.

Differential :
* The main differential diagnosis of testicular torsion in clinical practice is that of epididymo-orchitis.
* Ischaemic orchitis occurs as result of testicular infarction following a testicular torsion or scrotal surgery where extensive dissection of the spermarie cord to mobilise the testis is carried out.
* Testicular trauma or disruption.
* Intrascrotal haematoma
* Scrotal hernia (incarcerated) (1).
* Tumour.
* Abscess.
* Haemorrhage.
* Granuloma - tuberculoses, sarcoid.

Treatment :
Is surgery. The timing of the diagnosis is critical to the prognosis. If surgery occurs within 6 hours of the onset of symptoms, 80% to 100% of torsed testicles are saved. Surgery occurring between 6 and 12 hours of the onset of symptoms almost always results in the loss of the testicle (8).

Reference :
* 1: Derksen RJ, van der Vlist GJ, van Dalen T. [The 'acute scrotum' in children: the clinical presentation as indicated by a rapid operation] Ned Tijdschr Geneeskd. 2005 Jan 15;149(3):113-5.
* 2: Kalfa N, Veyrac C, Baud C, Couture A, Averous M, Galifer RB. Ultrasonography of the spermatic cord in children with testicular torsion: impact on the surgical strategy. J Urol. 2004 Oct;172(4 Pt 2):1692-5; discussion 1695.
* 3: Dogra VS, Rubens DJ, Gottlieb RH, Bhatt S. Torsion and beyond: new twists in spectral Doppler evaluation of the scrotum. J Ultrasound Med. 2004 Aug;23(8):1077-85. Review.
* 4: Prando D. Torsion of the spermatic cord: sonographic diagnosis. Ultrasound Q. 2002 Mar;18(1):41-57.
* 5. Washowich TL: Synchronous bilateral testicular torsion in an adult, / Ultrasound Med 20:933-935, 2001.
* 6. Gill KA: Abdominal ultrasound, Philadelphia, 2001, WB Saunders.
* 8. Kawamura DM: Abdomen and superficial structures, ed 2, Philadelphia and New York, 1997, Lippincott.
* 9. Krebs ÇA, Giyanani VL, Eisenberg RL: Ultrasound atlas of diseuse processes, Norwalk, Conn, 1993, Appleton & Lange.
* 10: Karmazyn B, Steinberg R, Kornreich L, Freud E, Grozovski S, Schwarz M, Ziv N, Livne P. Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys. Pediatr Radiol. 2004 Oct 16.