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    Ultrasound of Srotal Emergency in Pediatric

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    Isti Iryan Prianti
    Ultrasound is the primary imaging modality for evaluating pediatric scrotal emergencies. Common causes include infection, torsion, and trauma. On ultrasound, infection appears as an enlarged, heterogeneous testis or epididymis with increased vascularity. Torsion causes testicular enlargement, transverse lie, and absent or decreased blood flow. Appendage torsion presents as an avascular nodule between the testis and epididymis. Prompt diagnosis and treatment are important to preserve testicular viability in cases of torsion.

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    Ultrasound of Srotal Emergency in Pediatric

    Uploaded by

    Isti Iryan Prianti
    107 views53 pages
    Ultrasound is the primary imaging modality for evaluating pediatric scrotal emergencies. Common causes include infection, torsion, and trauma. On ultrasound, infection appears as an enlarged, heterogeneous testis or epididymis with increased vascularity. Torsion causes testicular enlargement, transverse lie, and absent or decreased blood flow. Appendage torsion presents as an avascular nodule between the testis and epididymis. Prompt diagnosis and treatment are important to preserve testicular viability in cases of torsion.

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    Ultrasound is the primary imaging modality for evaluating pediatric scrotal emergencies. Common causes include infection, torsion, and trauma. On ultrasound, infection appears as an enlarged, heterogeneous testis or epididymis with increased vascularity. Torsion causes testicular enlargement, transverse lie, and absent or decreased blood flow. Appendage torsion presents as an avascular nodule between the testis and epididymis. Prompt diagnosis and treatment are important to preserve testicular viability in cases of torsion.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    107 views53 pages

    Ultrasound of Srotal Emergency in Pediatric

    Uploaded by

    Isti Iryan Prianti
    Ultrasound is the primary imaging modality for evaluating pediatric scrotal emergencies. Common causes include infection, torsion, and trauma. On ultrasound, infection appears as an enlarged, heterogeneous testis or epididymis with increased vascularity. Torsion causes testicular enlargement, transverse lie, and absent or decreased blood flow. Appendage torsion presents as an avascular nodule between the testis and epididymis. Prompt diagnosis and treatment are important to preserve testicular viability in cases of torsion.

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    of 53

    Ultrasound of Pediatric Scrotal Emergency

    Everything You Should Know


    Dr. Lenny Violetta,Sp.Rad,Subsp.RA (K)
    • Introduction
    • Anatomy
    • Technique
    • Patology
    • Take home message
    Introduction

    • Ultrasonography (US)
    • Primary imaging modality in the evaluation of scrotal emergency
    • It provides excellent anatomical detail and assessment of testicular
    perfusion by CD
    • Symptom :
    • Scrotal pain with/without swealling and redness of acute onset
    • Clinical evaluation of pediatric scrotal emergency can be challenging
    • Different pathologies have similar presentations,
    • Scrotal swelling may limit physical examination
    ANATOMY
    Anatomy

    • Scrotal wall
    • Normal scrotal wall thickness 2-8 mm
    • > 10 mm → abnormal
    Testicular
    • Testicular size
    • At birth : 1,5x1x1 cm
    • 6 M – 6 Y : 2x1,5x1,5 cm
    • Adult 4,5x3x3 cm
    • Oval-shape , homoeneous pattern
    • The tunica albuginea is a thick fibrous capsule
    surrounding the testis.
    • The tunica folds into the testicular
    parenchyma parallel to the epididymis to form
    the linear echogenic mediastinum testis.
    Epididymis
    • Consist of head,body and tail
    • Epididymis head 5-12 mm
    • Isoechoic to slightly hypoechoic relative to the
    adjacent testis.
    Spermatic cord

    • Contain the vas


    deferens,lymphatics,nerves,arteri
    es and the venous vessels ( the
    pampinniforms plexus of vein)
    • US : a non peristalsing tight
    bundle of tubular elements
    coursing from the scrotum to the
    internal inguinal ring, with some
    tubular elements having
    demonstrable Doppler blood flow.
    Vascularisasi • Testicular artery
    – Branch off aorta
    – Major intra-
    testicular blood
    supply

    • Cremaster and
    deferential artery –
    Extra-testicular
    Testicular artery

    Testicular blood Capsular arteries


    flow
    Centripetal branches
    Developmental
    anatomy
    • Testicles descend into the
    scrotum betwen the 7th-9th
    month of fetal life
    • Proscessus vaginalis appears
    at about 13 weeks
    • Processus vaginalis :
    • Upper portion → closed
    • Lower portion → remain
    open ( tunica vaginalis)
    Developmental anatomy

    - Normal : The tunica vaginalis does


    Anatomy review Anatomy
    not completely surround the
    testis and epididymis, which are review
    attached to the posterior scrotal
    • Bell-clapper
    wall anomaly. Normal anatomy
    Create vaginalis
    The- tunica completely
    to the vertical The
    lie of•the surrounds
    tunica vaginalis does not
    testis epididymis,
    the testis, and sacs
    within the scrotal of the
    partcompletely surround the testis and
    spermatic cord, predisposing to torsion. which are attached to the
    epididymis,
    posterior scrotal wall.
    - Bell-clapper deformity : The
    tunica vaginalis completely
    surrounds the testis, epididymis,
    and distal part of the spermatic
    cord→ testicle swing freely
    Technique
    • High frequency
    • Probe 7,5-15 Mh
    • Linear probes and curve transducer
    • Supine position
    • Testis examined in two plane : tranverse and longitudinal
    • Evaluation of skin thickness ,testes,epididymis
    size,echogenicity and vascularisasi
    • Compared of both testes
    Doppler Ultrasound of Scrotum
    • Color,power and spectral doppler
    • Low flow setting
    • Decrease PRF
    • Low wall filter
    • Small collor box
    • Optimize your colour gain
    • Doppler setting to evaluate symertic of flow →Flow in symptomatic side vs
    asymptomatic side
    • If CD cannot detect flow → use of power doppler to increase flow sensitivity
    • PD more sensitive than CD for detection of intratesticular blood flow in children
    Technique
    • Normal Doppler Finding
    • Flow at periphery of testicle capsular artery
    • Scattered flow within testicle
    • Minimal flow in epididymis
    • PUBERTAL : RI = 0,48-0,75 ,mean 0,62,PRE PUBERTAL
    0,39-1,0
    CAUSES

    Infection

    Torsion

    Trauma
    Infection

    Epididymitis

    Orchitis

    Epididymo-
    Orchitis
    Epididymitis,Orchitis and Epididymo-orchitis
    • Most common in postpubertal men, rare in prepubertal boys
    • Result from infection via the ascending route (urinary tract infection, congenital
    anomalies) or by hematogenous spread.
    • Clinical finding
    • Pain ,gradual onset
    • Fever
    • Increased size
    • Reddish skin
    • US : differentiate from torsion with infection
    Epididymitis,Orchitis and Epididymo-orchitis

    US :
    • Enlarged epididymis or testes, and decreased
    echogenicity or heterogeneous (focal/diffus)
    • Thickened scrotal wall ,reactive hydroceles
    • Color Doppler : increased vascularity
    • RI: < 0,5
    • Concurrent orchitis can occur in 20–40% of cases
    Eleven-year-old boy with
    testicular pain lasting for 3
    days. → right epididymitis
    4-month-old boy with scrotal pain .
    • Right scrotal pain 11-year-old boy
    Complication

    Scrotal and testicular abscess

    Testicular ischemia and infarction

    Secondary testicular atrophy


    A complex intratesticular fluid collection with
    peripheral hypervascularity and no internal
    Testicular absces vessels
    Testicular ischemia
    The testes and spermatic cord twis, compromising blood flow , causes
    of venous occlusion and arterial due to ischemia and infarction

    Has to be diagnosed urgently, emergency surgery

    Early diagnosis and treatment are vital to saving the testicle

    Testicular
    Torsion The degree and duration of torsion the testicle endures may play a role
    in the viability of the testicle

    The salvage rate can be up to 80–100% with surgery within 6 hours

    > 24 jam → necrosis


    Testicular torsion
    • Symptom
    • Sudden pain
    • Nausea
    • Vomitus
    • Physical examination
    • Pain cannot be relieved by elevating the scrotum
    • Swelling
    • High riding testicle
    • Tranverese location of testes
    • Absent cremasteric reflex.
    Intravaginal torsion • Most commonly occurs
    when the tunica
    vaginalis completely
    surrounds the testis and
    inserts high on the
    spermatic cord → Bell
    clapper deformity
    • Can occur in any age
    group, most common in
    adolescents and young
    adults
    • Rare
    Extravaginal torsion • Very young children
    (including fetuses and
    neonates)
    • Due to a tunica vaginalis
    has not adhered to the
    gubernaculum → the
    testicle and processus
    vaginalis to twist
    together.
    • Most often occurs intra
    uterine or soon after
    birth.
    US Finding
    • Related to the duration of the torsion.
    • Early phase : Normal
    • After 4 to 6 hours, the testis is enlarged and hypoechoic due to edema
    • After 24 hours (late torsion → heterogeneous because of vascular congestion,
    hemorrhage, and ischemia
    • A twisted spermatic cord → Enlarged twisted spermatic cord superior to the
    symptomatic testis—“whirlpool sign.”
    • Transverse lie of the affected testis due to shortening of the vascular pedicle
    • Reactive hydrocele
    • Scrotal wall thickening, and epididymal enlargement
    US Finding
    • Doppler :
    • Sensitivities of 95–100% and specificities of 85–95%
    • Complete : abssence of flow
    • Partial : Decreased flow and elevated RI
    Testicular torsion
    • Normal CD US does not exlude
    • Early torsion
    • Partial torsion
    • Torsion /detorsion syndrom

    • If high clinical suspicious : repeat doppler US in 1-4 hours


    Extravaginal
    torsion
    Newborn boy with an
    impalpable left testicle.→
    an atrophic left testicle
    related to intrauterine
    extravaginal torsion
    Intravaginal torsion

    • Peripubertal patient with


    acute scrotal pain
    • Enlarged and hypoechoic
    • Hydrocele
    • Scrotal skin thickening
    • There is a small hydrocele
    separating the testis from
    the posterior scrotal→ bell
    clapper deformity
    12-year-old boy with acute left testicular pain and nausea and
    vomiting
    Newborn with a swollen left scrotum
    14-year-old boy, with acute right scrotal pain
    A boy with an acute pain
    scrotum
    Remnants of the embryonic mesonephric and paramesonephric
    ducts, ussually pedunculated ,betwen testes and head epididymis

    Prepubertal boys (aged 7–14 years),

    Testicular
    Appendages Scrotal pain of variable onset.
    Torsion
    Physical examination
    - Paratesticular nodule
    - Blue dot sign on the scrotum
    Normal Appendages Testis
    Oval avascular mass (torsed appendage) , over 5
    mm, with variable echogenicity located between
    the testicle and epididymis
    Epididymis enlargement

    US Finding Reactive hydroceles, scrotal skin thickening

    CD:Absent flow on color Doppler, and hyperemia


    of the surrounding structures.
    Testicular Appendages Torsion

    A boy, 3 years old


    Hematocele

    Hematoma
    • Intratesticular
    • Extratesticular

    Trauma • Scrotal wall


    • Epididymis
    Testicular contusion

    Testicular rupture
    Hematocele
    • Blood colection between the
    visceral and parietal layer of the
    tunica vaginalis
    • Acute : Blood is heterogeneous and
    predominantly echogenic,
    • Septations , thick walls
    • Large hematoceles can displace the
    testis from its normal position
    • Chronic : scrotal wall thickening and
    internal calcification
    Hematoma
    - Collection of blood in soft tissue of scrotal wall, epididymis or testis
    - Intratesticular
    - Extratesticular
    - US Finding
    - Scrotal wall hematoma, may appear as focal thickening of the wall or as fluid
    collections within the wall
    - Enlarged testis or epididymis
    - Focal or multiple
    - Complex hematoma may be heterogen echogenicity , Hyperacute :
    hypoechoic , acute: predominantly hyperechoic
    - Color Doppler : absent vascularity in the area of the hematoma
    • A 17-year-old boy after scrotal trauma
    Intratesticular
    hematoma
    Extratesticular
    Hematoma
    Involve the scrotal wall or epididymis
    Testicular
    Fracture
    • Disruption of testicular parenchym, tunica
    albuginea is intact
    • US Finding
    • A linear hypoechoic in the testicular
    parenchyma.
    • Contour is smooth , well defined and the
    tunica albuginea is intact.
    • Hematocele
    • CD : Normal in the viable testicular tissue
    • The absence of testicular Doppler signals
    indicates ischemia
    Testicular Rupture

    Disruption of the tunica albuginea and leads to


    extrusion of testicular contents into the scrotal sac

    Indication for urgent surgery testicular

    US Findings :

    • Discontinuitas of tunica albuginea


    • A heterogeneous testis with irregular, poorly defined borders
    • Scrotal wall thickening and hematocele
    • Color Doppler : diminished or absent.
    Self-limiting disease

    common in children under 10 years of age (mean, 6 years)


    Acute Etiology : unknown, infection, allergic reaction

    Idiopathic Clinical presentation


    • Scrotal erythema

    Scrotal • Edema
    • Afebrile, but systemic fever can be seen in up to one-third of cases

    Edema US findings
    • Scrotal wall thickening and hypervascularity
    • Inguinal lymphadenopathy
    • Testes , epididymis, and spermatid cord are normal
    Acute idiopathic
    scrotal edema
    11-year-old boy with acute onset of painless
    scrotal swelling
    Take Home Massege
    • Common scrotal emergencies
    • Testicular torsion
    • Testicular trauma
    • Epididymitis, Epididymo -orchitis
    • Testicular appendage torsion
    • Acute idiopathic scrotal edema( AISE)
    • Ultrasound is the imaging modality of choice, combined with color doppler, can improve
    diagnosis accuracy
    • Thorough knowledge of the typical clinical and sonographic findings of these disorders is
    necessary in making accurate diagnoses to guide appropriate therapy.

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