Purpose or Case Report: 1. Highlight recent literature on ultrasound (US) imaging of the spermatic cord for testicular torsion.
2. Present illustrative cases of testicular torsion from our institution that demonstrate the spectrum of US findings, highlighting the importance of evaluating the spermatic cord and how relying solely on grayscale US and doppler of the testicle itself can be misleading in the setting of torsion.
3. Encourage real-time US evaluation of the spermatic cord in all suspected cases of testicular torsion.
Methods & Materials: Draw on over 611 pediatric scrotal ultrasound examinations performed at our instution between 09/01/2014 and 08/31/2015 to highlight the variety of grayscale and Doppler imaging findings in the setting of surgically confirmed testicular torsion.
Results: Select cases of testicular torsion will demonstrate the wide variety in the imaging presentaton of torsion. For example:
1. Classic testicular torsion with stromal edema, lack of vascular flow, and "whirlpool" sign of the twisted spermatic cord.
2. Normal grayscale and Doppler in the setting of torsion. Only findings are a small hydrocele and subtle twisting of the spermatic cord.
3. Normal grayscale and Doppler in the setting of torsion, but edematrous, hypervascular epididymis. Clear twisting of the spermatic cord.
4. Initial edematous, avascular testicle with twisted spermatic cord. During real-time exam there is sudden testicular hyperemia, despite persistent twisting of cord, proving that a hyperemic testicle can still be torsed. This must be distinguished from epididymo-orchitis.
5. Single patient with 5 scrotal US exams over 2 months, with varying interpretations suggesting either torsion-detorsion with reactive hyperemia or epidydimitis/orchitis. Initially treated infection. After several weeks of improved symptoms, the patient returned with recurrent pain, and US showed normal grayscale and Dopple evaluation of the testicle, but tight spermatic cord twisting throughout the lower inguinal canal. Found to be 900 degrees torsed in operation room.
Conclusions: While historically the US diagnosis of testicular torsion has focused on grayscale and Doppler evaluation of testicular parenchyma, direct imaging of the spermatic cord itself is critical for assessing torsion, and should be the standard of care.