Clinical History
A 64 years-old male patient referred to the hospital for recent scrotal pain. He had been operated from right sided scrotal hernia 20 days ago. After 4 days of the operation fever and scrotal pain has begun and continued one week, during this time the patient has not referred to the hospital and had used analgesics and antibiotics. He has no symptoms now.
Imaging Findings
A 64 years-old male patient referred to the hospital for recent scrotal pain. He had been operated from right sided scrotal hernia 20 days ago. After 4 days of the operation fever and scrotal pain has begun and continued one week, during this time the patient has not referred to the hospital and had used analgesics and antibiotics. He has no symptoms now. A scrotal ultrasonography and color Doppler sonography of the scrotum was performed. The dimensions of the both testes were normal. However right sided diffuse hypoechogenity and tiny hyperechogen focuses were evident, there was a little collection around the right testis which included internal septations. The epididymis was slightly enlarged and echogenic. Right spermatic cord seemed thickened and hypoechoic. Then color and power(PDUS) Doppler sonography of the testes were performed. There was no blood flow neither in right testis nor the spermatic cord while the left side was normal.
Discussion
Testicular torsion is the twisting of a testis on its spermatic cord, that results in obstruction of the blood vessels supplying the testis and epididymis. It is usually the result of anomalous suspension of the testes within the scrotum. Torsion is more common in children, but accounts for 20% of acute scrotal pathology in post-pubertal males. Severe pain and swelling in the scrotum along with nausea and vomiting occur immediately. Urine anlysis is mostly normal. Testicular torsion and acute epididymitis or epididymo-orchitis are the most common causes of an acute scrotal pain. Differentiating between these entities is often difficult on physical examination and testicular sonography with pulsed and color Doppler examination is helpful in this regard. Prompt diagnosis is necessary since torsion requires immediate surgery to preserve the testis.the testicular salvage rate is 80% to 100% if surgery is performed within 5 to 6 hours and only 20% if surgery is delayed for more then 12 hours. Sonographic findings of the acute testicular torsion(first 6 hours within onset of symptoms) includes; enlarging the testis, decreasing of the echogenity. Enlarged epididymis,thickened spermatic cord,hydrocele and loss of Doppler signal of the testis and spermatic cord also exists. During the subacute phase of the torsion(1 to 10 days) sonography shows hypoechogenity of the testis, enlargement of epididymis,increased peritesticular flow without parenchymal blood flow. After the tenth day chronic phase of torsion begins with slowly diminishing size of the testis with dystrophic calcifications. Radionuclide imaging with Tc-99m pertechnetate can complement ultrasound in differentiating torsion from epididymo-orchitis. There is diminished or absent blood flow to the torsed testicle compared to increased blood flow in epididymitis or orchitis. Delayed images in torsion show increased peripheral activity around a cold testicle.The twisted cord cuts off the blood supply to the testis. Thus, the only hope of saving the testis is surgery to untwist the cord within 24 hours and preferably 6 hours of the onset of symptoms.
Differential Diagnosis List
Chronic spermatic cord torsion
Final Diagnosis
Chronic spermatic cord torsion
