Scrotal Imaging - Torsion and Testicular Carcinoma

by Hetal Verma, MD

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    00:01 So let's take a look at this case.

    00:02 We have 4 ultrasound images of the scrotum here.

    00:05 Let's take a look at each one of these individually.

    00:08 So this is a normal ultrasound image without Doppler.

    00:11 Just take a look at the echo texture of the testicle and compare it with the previous normal ones that we take a look at.

    00:17 This a Doppler evaluation.

    00:18 So a color Doppler evaluation of the left testicle.

    00:22 Again you can see actually very little flow.

    00:24 We have just a little blip of flow over in the corner here but there's really no other flow to that testicle.

    00:28 This a spectral evaluation of the same testicle so you can see here there actually is no spectral wave form identified.

    00:35 So not only is there no color, there's also no spectral wave form identified and then here is the comparison of the two testicles side by side.

    00:41 So this is an example of the normal right testicle and then here we have the abnormal left testicle.

    00:48 So the images demonstrate a slightly heterogeneous hypoechoic testicle which has no color, or spectral flow in Doppler evaluation.

    00:55 And this is an example of testicular torsion.

    00:58 In this patient the testicle looks like it is still salvageable.

    01:01 It doesn't look like it's shrunken in size.

    01:02 And although it's slightly hypoechoic, it's not significantly hypoechoic.

    01:06 So this is a patient that immediately needs surgical detorsion.

    01:10 So when we see testicular torsion on ultrasound, the next step is to call urology immediately for detorsion.

    01:16 This is a surgical emergency.

    01:18 And there is an 80 to a hundred percent chance of salvage if the testicle is detorsed within 6 hours.

    01:24 There's really no chance of salvage unfortunately, if it has already been 24 hours.

    01:28 It's important to remember that normal ultrasound does not exclude early or partial torsion.

    01:33 Early torsion may have no ultrasound findings and partial torsion which is a testicle that torses and detorses may also not have any findings if you're catching it at a phase in which it is in its normal position.

    01:45 So if we do have a clinical suspicion of torsion that we don't see on the ultrasound, it's important to remember to repeat that ultrasound within 4 hours.

    01:52 So let's discuss testicular carcinoma.

    01:55 Any solid mass that's within the testicle should raise a suspicion for carcinoma.

    02:00 The first line of imaging in a patient that presents with the palpable mass is an ultrasound. So let's take a look at these ultrasound images.

    02:08 These are both ultrasound images of the right testicle.

    02:11 You can see here that this is a non-Doppler standard ultrasound image and then image on the right is a Doppler image which does show some color flow to the testicle.

    02:21 Again compare these with some of the normal ones that we saw previously.

    02:32 The testicle appears very heterogeneous.

    02:34 There's a heterogeneous solid mass within it that has increased blood flow.

    02:38 Testicular cancers can often metastasize to the para-aortic lymph nodes.

    02:42 So whenever we see a testicular mass, the next step should always be to do a CT of the abdomen and pelvis to look for staging, to look for abnormal lymph nodes.

    02:50 Lung metastases are also very common so a chest x-ray is usually done in conjunction.

    02:55 This is an example of a patient that actually did have metastatic testicular carcinoma.

    02:59 So this is a coronal CT image of the abdomen and you can see here, this is the normal aorta.

    03:05 And then adjacent to it you see this small soft tissue densities which represent enlarged para-aortic lymph nodes and this is a common location for a testicular cancer to metastasize.

    About the Lecture

    The lecture Scrotal Imaging - Torsion and Testicular Carcinoma by Hetal Verma, MD is from the course Abdominal Radiology. It contains the following chapters:

    • Torsion
    • Testicular Carcinoma

    Included Quiz Questions

    1. Needs to be detorsed within the first 6 hours for salvage.
    2. Once torsion occurs, there is less than 50% chance for salvage.
    3. Normal ultrasound demonstrating flow definitively excludes torsion.
    4. Most often occurs with an associated mass.
    5. Arterial flow is lost first, followed by the venous flow.
    1. Ultrasound
    2. Biopsy
    3. Repeat physical examination after 2 weeks
    4. MRI of the pelvis
    5. Reassurance
    1. It presents as a homogeneous solid mass within the testicle with decreased blood flow.
    2. It often metastases to a para-aortic lymph node.
    3. CT scan is the best imaging modality for staging.
    4. Lung metastases are very common.
    5. It often presents as a painless firm mass.

    Author of lecture Scrotal Imaging - Torsion and Testicular Carcinoma

     Hetal Verma, MD

    Hetal Verma, MD

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