it is painful condition for boys , coming in emergency, ultrasound is basic imaging .it is to see testes and accordingly guide the surgeon whether testes could be saved

1. Paediatric scrotum--Imaging
Dr Rekha khare
MD Radiology
Prof & HOD HIMS Barabanki

2. Acute scrotum
• Acute scrotum is defined as acute scrotal swelling and pain
and is a common presentation in the emergency department
among boys
• The common causes----
testicular torsion, testicular appendageal torsion,
epididymitis, infarction or rupture , inguinal hernia
• History, clinical, and sonographic findings should all be used in
making the diagnosis.

3. Acute scrotum---testicular torsion
• Testicular torsion accounts for up to 26% of cases of acute
scrotum and is the most important diagnosis to rule out
because it is a surgical emergency
• Because of the disruption of testicular blood supply in
torsion, time is a crucial factor in salvaging the affected testis.
The salvage rate can be up to 80–100% with surgery within 6
hours, and less than 20% with surgery after 12 hours
• Patients usually present with acute onset of diffuse scrotal
pain, nausea, and vomiting
• Physical findings can include high-riding testicle and absent
cremasteric reflex.

4. Why ultrasound as an imaging?
• Although torsion of the testicular appendix and
epididymitis are more common, our goal is mainly to
detect or exclude a testicular torsion
•
We want to be able to tell the surgeon whether or
not it is a surgical emergency

5. How to do U/S?
• Use at least a 10 MHz linear transducer.
Always start with the examination of the normal side
and optimize the settings for low flow, low resistance
and low velocity.
The background 'noise' should just be visible in the
asymptomatic testis.
• Once you have a good image of the normal
side, don't touch any of the settings' and go to the
symptomatic side

6. Testes on U/S

7. Gross anatomy
• At birth, testes measure approximately 1.5 cm
(length) x 1 cm (width), reaching ~4 mL
volume at puberty .
• Normal adult testes are ovoid and measure
approximately 3 cm (AP) x 2-4 cm (TR) x 3-5
cm (length), with a volume of 12.5-19 mL .
• However, the size of the testes decreases
with age

8. TESTICULAR VOLUME
• The pre pubertal testis has a volume of about
1-2 cc,
• while the post pubertal testis has about 30cc.

9. Testicular torsion
Torsion occurs when an abnormally mobile testis
twists on the spermatic cord, obstructing its blood
supply.
Patients present with acute onset of severe testicular
pain
The ischemia can lead to testicular necrosis if not
corrected within 5-6 hours of the onset of pain.

10. On examination---Testicular
torsion
• The testis is usually elevated as a result of the
torsion and the shortening of the cord itself
and may be in a transverse lie.
• The affected side can be larger from the
swollen testis itself, a hydrocele or skin
thickening.

11. Testicular torsion
• There is no flow on
the affected side
so difference in
echogenicity.

12. Testicular torsion on U/S

13. How U/S predict outcome in a
case of Torsion
For the first 4-6 hours: normal architecture
good outcome
For next 4-24 hours:
Testis becomes heterogeneous and enlarged
Epididymis and scrotal wall may swell and
become hypoechoic
A worsening appearance of the testis on gray scale US
correlates with decreased viability

14. Testicular appendageal torsion
• It is a common cause of acute scrotum in pre-pubertal boys
• The appendages are normal remnants of embryonic tissue
and are usually located at the superior testicle or epididymal
head
• Patients typically present with focal scrotal pain of variable
onset.
• Physical findings can include a para-testicular nodule and
bluish skin discoloration on the scrotum
• the “blue dot” sign

15. Appendageal torsion on ultrasound
• Sonography may show an oval avascular mass
(torsed appendage) with variable echogenicity
located between the testicle and epididymis
• Additional findings may include scrotal edema and
reactive hydroceles.
• Color Doppler may show hyperemia surrounding the
torsed appendage
• Treatment involves conservative management

16. TORSION OF TESTICULAR
APPENDAGE
Imaging scrotum is simply
to exclude the possibility
of testicular torsion in
case of acute scrotum
Testicular appendage
torsion appears as a lesion
of low echogenecity with a
central hypoechogenic
area adjacent to the
epididmis

17. Colour doppler
• Complete absence of intra testicular blood
flow and normal extra testicular blood flow on
color Doppler
• Image is diagnostic,
• Flow is normal in the contra lateral testis

18. Epididymitis
• Epididymitis is an inflammation of the
epididymis.
• The epididymis is a tube located at the back of
the testicles that stores and carries sperm
• When this tube becomes swollen, it can cause
pain and swelling in the testicles

19. Epididymitis
• Epididymitis is the most common inflammatory process
involving the scrotum and more common in adults
• Epididymitis also occurs in children, but is then due to
infection with Streptococcus or Staphylococcus.
In urinary tract abnormalities also infection with E.Coli is
seen
• A sterile chemical epididymitis can result from reflux of sterile
urine through the ejaculatory ducts, for instance if the ureter
inserts in the prostatic urethra, this may lead to increased
pressure in the vas deferens.

20. Epididymitis---another common cause of
acute scrotum 21%
Post pubertal
• In postpubertal male
patients, it is usually related
to retrograde extension of
infection.
• Treatment commonly
involves antibiotic
Pre pubertal
• In pre pubertal boys, it is
mostly idiopathic but can be
related to underlying
urogenital anomalies

21. Epididymitis ON U/S
• The epididymis is swollen and heterogeneous.
There is reactive hydrocele and scrotal wall
thickening
•
With color doppler there is increased flow.
A normal epididymis has only limited colorflow
• Patients typically present with gradual onset of
scrotal pain with fever.

22. Epididymitis

23. Orchitis
• Orchitis (or-KIE-tis) is an inflammation of one or both
testicles.
• Bacterial or viral infections can cause orchitis, or
the cause can be unknown.
• Orchitis is most often the result of a bacterial
infection, such as a sexually transmitted infection
(STI).
• In some cases, the mumps virus can cause orchitis.
• Rarely isolated

24. Orchitis

25. Orchitis on ultrasound

26. Orchitis

27. Epididymo- orchitis on Doppler
• Orchitis also exhibits testicular hyperemia on
color Doppler sonography images and is
usually accompanied by epididymal
hyperemia due to concomitant epididymitis.
•
A reactive hydrocele is also frequently
associated with epididymo orchitis.

28. Epididymo orchitis

29. Infarction—complication of
epididymitis
Scrotal ultrasound
showed an avascular,
heterogeneous,
hypoechoic lesion in
the testis
suggestive
of infarction or
neoplasm

30. Testicular abscess

31. Testicular trauma
• In trauma there is either a hematocele or testicular
hematoma.
In the acute phase the hemorrhage is echogenic and in
the chronic phase it is hypoechoic.
• A hematocele results from scrotal or intra-abdominal
hemorrhage.
It represents bleeding between the leaves of the tunica
vaginalis and appears as a complex fluid collection.
With time, this collection can develop loculations,
which appear as thick septations

32. Testicular rupture
• Testicular rupture is seen as focal alterations
of testicular echogenicity
correlating with areas of intra testicular
hemorrhage or infarction in a patient with a
hematocele.

33. Trauma on U/S
• The normal tunica
albuginea is a thin
echogenic line
surrounding thetestis
• Ultrasound detection
of disruption of this
structure in a patient
with blunt
scrotal trauma support
the diagnosis
of testicular rupture

34. Hernia
• Hernias in children are common especially in
premature infants.
• Inguinal hernia occurs when tissue, such as
part of the intestine, protrudes through a
weak spot in the abdominal muscles.
• The resulting bulge can be painful, especially
on coughing or bending over or lifting a heavy
object

35. What happens in hernia?

36. How to do U/S in hernia
• The ultrasound examination starts with the child lying
down and is then continued in the standing position.
The bowel or omentum is visible separate from the
testis
The intestinal loop descends through the unclosed
processus vaginalis.
An incarcerated hernia is a cause of acute scrotal pain
•
Peristalsis suggests viability and absence of peristalsis
is worrisome for incarceration

37. Hernia on U/S

38. • In general, the presence of scrotal swelling in
boys should also raise the possibility of
cellulitis or skin reaction from insect bites
• In this setting, the major causes of scrotal
swelling should initially be ruled out
• Careful history and physical examination may
guide the clinician into the appropriate
diagnosis.
Scrotal swelling

40. Idiopathic scrotal swelling
• Idiopathic scrotal edema is seen in school-aged boys.
They present with scrotal skin swelling.
So the clinical question is??
• if there is torsion or infection
•
At examination the testes and epididymes are normal and
all that we see on US is skin edema.
•
If this is all we see and the
child does not have fever or elevated white count, which is
seen in cellulitis then we can make the diagnosis of
Idiopathic scrotal edema

41. U/S Idiopathic scrotal swelling

42. Paediatric scrotum in Henoch-
schonlein purpura
• Henoch-Schönlein purpura is a systemic vasculitis more
commonly seen in children that usually affects the skin,
kidneys, gastrointestinal tract, and joints
• Scrotal involvement is rare but can occur in up to 15% of cases
• Sonographic findings typically include thickening of the scrotal
skin, enlargement of the epididymis, and presence of a
hydrocele.
• In Henoch-Schönlein purpura, the testes are usually
unaffected, and normal testicular blood flow is maintained.

43. Paediatric testicular tumours
• Testicular tumors in boys are rare, accounting for only 1–2%
• Most (> 95%) intratesticular lesions are malignant and
typically present as a painless mass, with treatment usually
involving orchiectomy.
• Testicular tumors are classified as germ cell tumors or non–
germ cell tumors.
• Germ cell tumors are further classified as seminomas and
nonseminomatous tumors.
• Seminomas are the most common testicular tumors among
men, whereas nonseminomatous germ cell tumors are the
most common testicular tumors among boys

44. What is undescended testes in
children?
• Undescended testes is when one
or both of the testes have not
passed down (descended) into the
scrotal sac mostly in preterm or
premature baby boy
• Ultrasound is the first line
investigation,
• About 80% undescended
testicles are within the inguinal
canal and therefore can be
identified

45. Conclusion
• Many scrotal and testicular diseases can affect the
pediatric population, ranging from acute disorders
such as testicular torsion and traumatic injuries to
other less common disorders such as malignancies.
• The initial imaging modality of choice is sonography.
• Thorough knowledge of the typical clinical and
sonographic findings of these disorders is necessary
in making accurate diagnoses to guide appropriate
therapy.

46. Thank you
Have a nice day