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Paediatric scrotum

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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

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Paediatric scrotum

  1. 1. Paediatric scrotum--Imaging Dr Rekha khare MD Radiology Prof & HOD HIMS Barabanki
  2. 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. 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. 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. 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. 6. Testes on U/S
  7. 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. 8. TESTICULAR VOLUME • The pre pubertal testis has a volume of about 1-2 cc, • while the post pubertal testis has about 30cc.
  9. 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. 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. 11. Testicular torsion • There is no flow on the affected side so difference in echogenicity.
  12. 12. Testicular torsion on U/S
  13. 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. 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. 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. 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. 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. 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. 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. 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. 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. 22. Epididymitis
  23. 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. 24. Orchitis
  25. 25. Orchitis on ultrasound
  26. 26. Orchitis
  27. 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. 28. Epididymo orchitis
  29. 29. Infarction—complication of epididymitis Scrotal ultrasound showed an avascular, heterogeneous, hypoechoic lesion in the testis suggestive of infarction or neoplasm
  30. 30. Testicular abscess
  31. 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. 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. 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. 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. 35. What happens in hernia?
  36. 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. 37. Hernia on U/S
  38. 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
  39. 39. 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
  40. 40. U/S Idiopathic scrotal swelling
  41. 41. 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.
  42. 42. 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
  43. 43. 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
  44. 44. 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.
  45. 45. Thank you Have a nice day

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