1. Ultrasound Diagnosis of Testicular Torsion
Turandot Saul, M.D.
February 20, 2008
Ultrasound Diagnosis of Testicular Torsion

2. Xoắn tinh hoàn True urologic emergency
Delayed diagnosis and testicular loss
Infertility
Cosmesis
Medico-legal

3. Testicular Anatomy - Tunica
Tunica vaginalis
Posterolateral surface of testicle
Limits mobility
Bell clapper deformity
Congenital
12% of males
40% bilateral
Posteriorlateral surfact of testicle to scrotum
Congenitally high attachment of tunica
Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice

4. Testicular Anatomy - Vascular
Cremaster a.
Testicular artery
Branch off aorta
Major intra-testicular blood supply
Cremaster and deferential artery
Extra-testicular
Testicular artery off abdominal aorta
Cremaster: off inferior epigastric, supplies tunica
Deferential, off superior vesicle, supplies vas deferens, variable anastamosis between them
Left testicle drains to left renal vein, right to IVC

5. Testicular Torsion Testicle rotates on spermatic cord
Venous occlusion, edema
Arterial ischemia
Infarction
720º necessary to
compromise testicular a.
Males, peak 14 years
Image: Behrman: Nelson Textbook of Pediatrics

6. History Severe unilateral scrotal pain
Previous episodes, spontaneous resolution
Related to activity, trauma, during sleep
Nausea, vomiting, abdominal pain, fever
5-10% of torsed testes spontaneously detorse

7. Physical Elevated testicle, tender Loss of cremaster reflex
Thick, tender spermatic cord
Brunzel sign – horizontal lie
Ger sign - skin pitting at the scrotal base
Prehn sign – persistent pain despite elevation
Loss of cremaster most sensitive
Image: American Family Physician

8. Diagnosis Clinical suspicion Nuclear scintigraphy Ultrasound
Radiation, limited availability
Ultrasound
Altered echotexture (B-mode)
Vascular flow (Color / Spectral / Power Doppler)
Alternative diagnosis
Operator dependent
Nuclear: no additional information, inject technesium 99 and see if flow to testicle.
Image: Ferri's Clinical Advisor 2008, 10th ed.

9. Ultrasound for Testicular Torsion
Sensitivity 86%, specificity 100% experienced provider using color / power doppler1
EPs capable of diagnosing with bedside ultrasound2
Burks: 32 patients , surgical correlation in 15, scintigraphic correlation in had torsion, doppler caught 6.
Small case series but can decrease time to OR
1Burks et al. Suspected testicular torsion & ischemia: Eval w color doppler. Radiology 1990;175:815-21
2Blaivas et al. Ultrasonographic diagnosis of testicular torsion by EM physicians. AM J Emerg Med 2000;18:

10. Logistics Linear Array (7-10 MHz) Scan asymptomatic side first
Positioning
Frog leg position
Drape for support and elevation
Generous amount of warm gel
Straddle allows for bilateral comparison

11. Ultrasound – B-Mode Compare echotexture (straddle view)
Visualize each testicle in two planes

12. Ultrasound – B-Mode Normal: homogenous symmetric
Early ischemia: enlargement, no Δ echogenicity
Hemorrhage: hyperechoic areas in an
infarcted testis, heterogenous
Late ischemia/infarct:
hypoechoic
Looking at echotexture
Straddle view to see portions of each in same image.
Enlarged to engorged blood

13. Ultrasound: Color Doppler
Normal
Intratesticular artery
Torsion
Arterial flow absent
Normal / increased
in detorsion

14. Ultrasound: Color Doppler
Early Torsion
No flow, echogenicity similar
Late Torsion
Heterogenous echotexture
Increased extra testicular
blood flow

15. Ultrasound: Spectral Doppler
Arterial waveform
Venous waveform
Early loss of venous

16. Ultrasound: Spectral Doppler
Intratesticular blood flow-
Low resistance, high flow
Extratesticular blood flow-
High resistance, low flow
Intrastesticular supply- TESTICULAR a off aorta, low resistance with high flow
Extratesticular supply- DEFERENTIAL and CREMASTERIC a, high resistance with low flow
Flow during diastole

17. Ultrasound – Power Doppler
Increased sensitivity in low flow states
Measures power of doppler signal
Prepubertal patient
Power, not doppler frequency shift therefore independent of angle to measure blood flow therefore more sensitive.
Debate over whether catch more torsion because of this.
Prepubertal pt has smaller testicular volumes.

18. Ultrasound: other diagnosis
Epididymitis
Scrotal abscess
Torsion of epididymal appendage
Intratesticular hematoma
Epidid: enlarge hyperemic epydidymis
Abscess: comples fluid collection
Appendix: mass next to epididymal head with absence of flow
Hematoma has surrounding blood flow.

19. Pitfalls
False negatives: post-torsion hyperemia, capsular blood flow, power doppler motion artifact
False positives: small testicular volumes
Either: inappropriate gain settings
Atypical presentations mimic epididymitis, appendicitis, renal colic
False negative if background noise if gain too high.

20. Treatment Definitive treatment: surgical detorsion and orchioplexy
Manual detorsion: medial to lateral; “opening a book”
May need to rotate 2-3 times for complete detorsion
Roberts: Clinical Procedures in Emergency Medicine

21. Testicular Viability Salvage rate 100% detorsed at 3 hours
1Pratter JM et al. Testicular torsion: a surgical emergency. Am Fam Physician 1991;44:

22. Summary Use saddle view to compare bilaterally
B-mode to compare echogenicity
Color / Spectral / Power Doppler for flow
Image normal side first to set gain settings
Consider clinical picture
May have detorsed

23. References
Burks et al. Suspected testicular torsion & ischemia: Eval w color doppler. Radiology 1990;175:815-21
Pratter JM et al. Testicular torsion: a surgical emergency. Am Fam Physician 1991;44:
Ferri: Ferri's Clinical Advisor 2008, 10th ed.
Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed.
Roberts: Clinical Procedures in Emergency Medicine, 4th ed.Dogra, VS etal. Sonographic Evaluation of Testicular Torsion. Ultrasound Clinics; 2006.
Blaivas et al. Ultrasonographic diagnosis of testicular torsion by EM physicians. AM J Emerg Med 2000;18:198-20
Ringdahl, E et al. Testicular Torsion. American Family Physician 2006;74(10)