GU – Scrotum

“Our own recommendation for a possible dictation template is as follows: Testicular microlithiasis is present without intratesticular mass or other worrisome findings. In the absence of any other risk factors for testicular cancer (e.g., personal history of testicular cancer, a father or brother with testicular cancer, history of cryptorchidism or maldescent, testicular atrophy, or other risk factors), no further imaging or biochemical follow-up is necessary; all that is recommended is routine monthly testicular self-examination. However, if the patient has risk factors for testicular cancer, referral to a urologist for evaluation and determination of an optimal follow-up strategy is recommended.”

“In a study in which all children with symptoms of acute scrotum underwent surgical revision, torsion of the appendix testis was the most common pathology (57%), followed by torsion of the spermatic cord (27%) and much less commonly epididymitis.”

“Complete torsion occurs when the testis twists 360° or greater, usually leading to absence of intratesticular flow on color Doppler exam; however sometimes the flow is preserved or decreased. Intermittent torsion is defined as sudden onset of unilateral testicular pain of short duration with spontaneous resolution. In partial or incomplete torsion, the degree of spermatic cord twist is less than 360°, allowing for some residual perfusion to the testis. However there is no spontaneous resolution of pain.”

“Sonographic features most reliable for diagnosing testicular torsion: Spermatic cord whirlpool sign, redundant spermatic cord, and horizontal or altered testicular lie.”

“The “whirlpool sign” is defined as an abrupt change in the course of the spermatic cord with a spiral twist at the external inguinal ring or in the scrotal sac. It is a reliable and direct sonographic sign that implies torsion of the spermatic cord and testis. The classic whirlpool sign is observed less frequently compared to a tortuous redundant cord but is considered to be of great diagnostic significance.”

“Redundant spermatic cord can be described as the presence of excess and tortuous spermatic cord in the scrotal sac and is a very helpful sign of anomalous attachment of the tunica vaginalis. Normally, there should be no free piece of cord in the scrotal sac. The bunched up cord often looks like an extratesticular, ovoid heterogeneous-echotexture mass that has been described as “boggy pseudomass,” typically seen below the point of torsion. The exact point of twisting of the cord is frequently indiscernible and hence the term “torsion knot” might be used interchangeably with boggy pseudomass, both implying a tangle of varying proportions of convolutions of the swollen spermatic cord with or without the epididymis.”

“Normally the testes lie in a vertical orientation. A horizontal lie is thought to result from abnormal attachments of the tunica vaginalis, namely the bell clapper anomaly. Horizontal or altered/oblique lie has been known to be associated with intermittent torsion.”

“Swollen epididymis and testis with testicular flow that is only minimally decreased, normal, or increased in boys with incomplete or intermittent testicular torsion can mimic epididymo-orchitis. The most common cause of acute scrotal pain in children is torsion of appendix testis, which can also mimic epididymo-orchitis. Therefore it is important to evaluate for the presence of avascular nodule that might represent the torsed appendage.”

“Likelihood of salvage of the testis is directly related to the time between symptom onset and detorsion. However in our experience salvage is unpredictable depending on how tightly or loosely the cord was twisted, and hence surgery should not be delayed after the diagnosis of torsion is established, even if the time to presentation exceeds the 6- to 10-h window. A testis might become nonviable as early as 4 h after a 720° twist, or it might remain viable for several days if the torsion is incomplete. In one of our cases, salvage was achieved after 3 weeks from initial diagnosis of epididymitis to final diagnosis of incomplete torsion.”

“The presence of redundant spermatic cord within the scrotum is highly suspicious for testicular torsion. An enlarged epididymal-cord complex representing the torsion knot/pseudomass is more frequently identified at the sonographic examination compared to the more classic whirlpool sign of twisted spermatic cord. Residual flow might be preserved in parts of the cord when the twist is not tight enough to completely obliterate the flow. An astute analysis of the cord and lie of the testis can prevent the overdiagnosis of epididymitis.”