Diagnosing testicular torsion using ultrasound

Using ultrasound to evaluate an acute scrotum can help you to diagnose a variety of scrotal pathologies. In this video, from our POCUS Masterclass, you'll learn how to recognize the ultrasound findings that are consistent with testicular torsion.

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[00:00:00] Acute scrotal conditions can present with a variety of symptoms. These can include pain, swelling, vomiting or abdominal pain. The most time-sensitive and critical, of the diagnosis considered in acute scrotal pain, is testicular torsion. Torsion is ultimately a clinical diagnosis. If you think that's the diagnosis, then the patient needs urologic consultation. You need to get that resource activated. However,

[00:00:30] imaging reinforces the clinical diagnosis and can help motivate a consultant to act faster and if needed, supports the decision to rapidly transfer the patient for evaluation. There are a range of findings that can be seen on ultrasound in testicular torsion. In this lesson, we'll learn how to recognize them. Perhaps the most important is the absence of blood flow. Seeing no blood flow on color Doppler strongly supports the diagnosis of testicular torsion. There are other supporting findings that may be seen as well

[00:01:00] including enlargement of the affected testicle, edema surrounding the testicle or an abnormal lie or positioning. It's helpful to obtain a spectacle view, to be able to compare both testicles. In this clip, we see that the testicle at left appears enlarged compared to the one on the right. There is also a small rim of hypoechoic fluid seen here, consistent with edema. This would be suspicious for torsion and we'd certainly want to proceed to Doppler evaluation next.

[00:01:30] Here we are again, in spectacle view, now applying color Doppler to the affected testicle. Notice how there is no flow seen in the color Doppler box. That little twinkle you see, as we watch the clip, is just artifact introduced by the operator's hand, otherwise, there is no flow present. This ultrasound data is consistent with testicular torsion. Here's another example of color Doppler used to evaluate torsion. This is a still image. At right, we see that there's flow through the testicle.

[00:02:00] At left, there's a complete absence of color flow. This is the sort of thing we're looking for, to be able to comment that flow is absent. Here's another example of color Doppler in spectacle view. It's nice to be able to compare both testicles in the same color Doppler box. We can clearly see that we have flow to the right testicle but no color flow through the left. As well, the left testicle appears enlarged. This is absolutely consistent with testicular torsion. The sensitivity

[00:02:30] of Doppler to detect flow increases if you change your setting from color Doppler to color power Doppler. The difference between these two settings is that color power Doppler will no longer show any information about the directionality of flow but it is more sensitive to be able to detect any flow at all. Here, the operator has applied color power Doppler and still there's an absent color power Doppler signal, indicating that no flow is present. The testicle again appears enlarged and overall these findings

[00:03:00] are consistent with testicular torsion. Here, we have a patient who presented after five days of testicular pain. This is a long-axis view of the testicle. This is an example of a late presentation with advanced findings of testicular torsion. The testicle appears enlarged and we can see that there's an irregular echotexture, that is, we have a mix of both hyperechoic and anechoic areas within the testicle. Typically, the testicle appears uniform in its echotexture. We can also see that there's an edema

[00:03:30] surrounding the testicle. In fact, this testicle has infarcted from a prolonged loss of blood flow. This is the same patient now with color power Doppler applied. We can see that there is no flow inside the affected testicle. At right, we can see that there is some color power Doppler signal but none on the affected side of the left. So, now you have an approach to what to look for when you're evaluating the acute scrotum, for the ultrasound findings of testicular torsion. Remember that sensitivity

[00:04:00] is not perfect and don't hesitate to obtain consultation or get follow-up imaging if you need it. This skill will make you better equipped to care for the next case of scrotal pain. You may not save a life with this technique, but you can definitely save a testicle.