Diagnostic ultrasound ( PDFDrive )

1894 PART V Pediatric Sonography
SAG
RT
SAG
RT
NO FLOW
SAG
A
B
LT
TESTIS
SAG
TRV LT TESTIS
POST DETORSION
C
D
FIG. 54.37 Acute Testicular Torsion. This 13-year-old boy had acute, excruciating right-sided scrotal pain. (A) Transverse gray-scale image of
both testes demonstrates enlargement of the avascular right testis. (B) Absence of both color and pulsed Doppler low is noted on this sagittal
image of the right testis. (C) Normal pulsed and color Doppler low conirmed in asymptomatic, normal-appearing left testis. (D) Teenage boy with
acute left-sided testicular torsion. Closed manual detorsion of the left testis was done at diagnosis in the ultrasound suite. Color Doppler sonogram
of the left testis obtained immediately after detorsion shows dramatic hyperemia throughout the left testis.
is oten a history of similar previous self-limited episodes, suggesting
prior torsion and detorsion. Nausea and vomiting are
more frequently seen in testicular torsion than in other causes
of acute scrotum, with a positive predictive value of more than
96%. he boys may also have anorexia and low-grade fever.
Physical examination is diicult because of severe tenderness.
he afected hemiscrotum is swollen and erythematous with the
afected testis oten oriented transversely. he cremasteric relex
may be absent. 114 Most important, patients with suspected
intravaginal torsion require emergency surgery to optimize
testicular salvage. If it is clinically obvious that a patient has an
acute torsion, emergency surgery should be done, even without
imaging, because any delay in surgical treatment reduces the
likelihood of testicular salvage. Some believe that closed manual
detorsion may improve salvage rates and convert an emergent
situation to an elective surgical procedure for future orchiopexy
(Fig. 54.37); however, this is controversial. 124,125 he best results
are obtained in those who have immediate detorsion and ixation
to the scrotal wall and orchiopexy of the contralateral testis. 97
he salvage rate is greater than 80% when surgery is performed
within 6 hours of the onset of symptoms; approximately 70%
when performed within 6 to 12 hours of symptoms; and less
than 20% if surgery is delayed for 12 to 24 hours ater the onset
of pain. 89,115,126 Ater 24 hours, the testis is virtually never salvageable.
he sonographic features in testicular torsion depend on
the duration and severity of the vascular compromise.
Sonographic Signs of Testicular Torsion
TESTES
Normal early
Hypoechoic after 4-6 hours from edema
Heterogeneous after 24 hours from hemorrhage and
infarction (“missed” torsion)
PERITESTICULAR
Hypoechoic epididymis
Reactive hydrocele
Skin thickening
Enlarged, twisted spermatic cord