Testicular torsion and detorsion – more than just a matter of colour

Author(s)

Maria Ana Serrado¹, Guida Castanha¹

Hospital Nélio Mendonça, SESARAM; Avenida Luís de Camões 9004-514 Funchal, Portugal; Email:m_serrado@hotmail.com

Patient

male, 16 year(s)

Clinical History

A 16-year-old boy presented to the emergency department with sudden onset of right scrotal pain and swelling, 3 hours earlier. He was unable to void. There was no history of previous trauma.

Imaging Findings

Scrotal ultrasound imaging (US) and colour and spectral Doppler were performed to diagnose or exclude testicular torsion.
At B-mode, a mild testicular asymmetry was identified. The right testicle was slightly larger and more hypoechogenic than the left. At the head of the right epididymis two small cysts were identified. Adjacent to the epididymis, the spermatic cord was shown, with spiral pattern – whirlpool sign.
Colour Doppler showed preserved intra-testicular blood flow on the right side, but with lower number of colour signals compared to the left side.
Spectral Doppler analysis were asymmetric too, with "tardus parvus flow" at right and normal rise of waveform peak at left. The spectral Doppler evaluation of the spermatic cord showed a high RI value.
Left testicle, epididymis and spermatic cord were normal.
Manual detortion was performed.
US after detortion showed a linear spermatic cord, without whirlpool sign.
Elective bilateral orchidopexy was done.
No more episodes of scrotal pain were reported after surgery.

Discussion

Acute scrotum may have many causes, such as testicular torsion (complete, incomplete and intermittent), epididymo-orchitis, torsions of testicular or epididymal appendages, acute idiopathic scrotal oedema^{1, 2}.
In 26% of paediatric patients, the underlying cause of acute scrotum is testicular torsion (TT)¹. It has an estimated incidence of 3, 8/100000 and a bi-modal distribution, during the first year of life and early adolescence¹.
TT can be intravaginal (most common form, secondary to the bell-clapper deformity); extravaginal (typically in neonates, involves twisting of the spermatic cord) and mesorchial (least common form, consists of twisting of an elongated mesorchium)¹.

Testicular pain and swelling may prevent physical examination. Clinical differentiation between causes of acute scrotum may be difficult³. Even though there are clinical signs that suggest the aetiology, they are not accurate².

US and colour Doppler US are the methods of choice in the differential diagnosis of acute scrotum. They aim to rule in or rule out TT, which requires emergent surgery.
The whirlpool sign is defined as an abrupt change in course of the spermatic cord with a spiral twist of the cord¹. At US it can have the appearance of a doughnut, a target with concentric rings, a snail shell or a storm on a weather map². It can be located just outside the external inguinal ring, superiorly or posteriorly to the testis^{2, 3}.
Below the point of spermatic cord torsion, a pseudomass can be identified. It is composed of congested epididymis, proximal vas deferens and vascular bundle. At US it appears as an oval-shaped mass with heterogeneous echotexture¹.
In complete torsion, the whirlpool sign is seen only on B-mode US with absent intra-testicular flow on colour Doppler US. In incomplete torsion, the whirlpool sign is seen in B-mode and colour Doppler US and there is flow in the vessels of the whirlpool sign, distal to it and intra-testicular².
The whirlpool sign is the most definitive sign of TT, as it has 100% specificity and sensibility². This is true regardless of colour Doppler US findings^{2, 3}.
To confirm detorsion, a follow-up US should include disappearance of the whirlpool sign and normalization of the vascularization³.

Prompt diagnosis and surgical detorsion are mandatory. Testicular salvage rates are approximately 80-100% within 6 hours, 70% between 6 to 12 hours, 20% after 12 hours and less than 10% after 24 hours^{1, 3}.

Careful evaluation of the course of the spermatic cord should always be included whenever TT is suspected³.

Final Diagnosis

Differential Diagnosis List

References

[1]

Munden MM, Williams JN, Zhang W, Crowe JE, Munden RF, Cisek LJ (2013) Intermittent Testicular Torsion in the Pediatric Patient: Sonographic Indicators of a Difficult Diagnosis. AJR Am J Roentgenol 201:912-9
[2]

Vijayaraghavan SB (2006) Sonographic Differential Diagnosis of Acute Scrotum. J Ultrasound Med 25:563-74
[3]

Esposito F, Di Serafino M, Mercogliano C, Vitale V, Sgambati P, Vallone G (2014) The "whirlpool sign", a US finding in partial torsion of the spermatic cord: 4 cases. J Ultrasound 17:313-5

Citation

Maria Ana Serrado¹, Guida Castanha¹ (2017, Sep 12).

Testicular torsion and detorsion – more than just a matter of colour, {Online}.

URL: http://www.eurorad.org/case.php?id=14968

DOI: 10.1594/EURORAD/CASE.14968

Public License

This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

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Published 12.09.2017
DOI 10.1594/EURORAD/CASE.14968
Section Uroradiology & Genital Male Imaging
Case Type Clinical Cases
Views 102
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Figure 1
Testicular torsion

a

Department of Radiology, Hospital Dr. Nélio Mendonça - SESARAM, E.P.E., Madeira, Portugal

b

Department of Radiology, Hospital Dr. Nélio Mendonça - SESARAM, E.P.E., Madeira, Portugal

c

Department of Radiology, Hospital Dr. Nélio Mendonça - SESARAM, E.P.E., Madeira, Portugal

d

Department of Radiology, Hospital Dr. Nélio Mendonça - SESARAM, E.P.E., Madeira, Portugal

e

Department of Radiology, Hospital Dr. Nélio Mendonça - SESARAM, E.P.E., Madeira, Portugal

f

Department of Radiology, Hospital Dr. Nélio Mendonça - SESARAM, E.P.E., Madeira, Portugal

g

Department of Radiology, Hospital Dr. Nélio Mendonça - SESARAM, E.P.E., Madeira, Portugal

Longitudinal and transverse US shows the right testicle slightly hypoechogenic.

Area of Interest: Genital / Reproductive system male; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Ischaemia / Infarction;

Spectral Doppler of the right testis shows a "pulsus tardus parvus", with a slow rise of the systolic peak, keeping with arterial impairment within the whirled cord.

Area of Interest: Genital / Reproductive system male; Imaging Technique: Ultrasound-Spectral Doppler; Procedure: Diagnostic procedure; Special Focus: Ischaemia / Infarction;

Spectral Doppler of the left testis shows a normal low resistive index flow.

Area of Interest: Genital / Reproductive system male; Imaging Technique: Ultrasound-Spectral Doppler; Procedure: Diagnostic procedure; Special Focus: Ischaemia / Infarction;

Longitudinal US depicts two small cysts in the head of the right epididymis.

Area of Interest: Genital / Reproductive system male; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Ischaemia / Infarction;

Longitudinal US shows the whirlpool sign just outside the right external inguinal ring.

Area of Interest: Genital / Reproductive system male; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Ischaemia / Infarction;

Longitudinal colour and spectral Doppler shows the whirlpool sign.

Area of Interest: Genital / Reproductive system male; Imaging Technique: Ultrasound-Colour Doppler; Procedure: Diagnostic procedure; Special Focus: Ischaemia / Infarction;

Spectral Doppler shows high resistive index value on the right spermatic cord.

Area of Interest: Genital / Reproductive system male; Imaging Technique: Ultrasound-Spectral Doppler; Procedure: Diagnostic procedure; Special Focus: Ischaemia / Infarction;
Figure 2
Testicular detorsion

Longitudinal US shows a lineal spermatic cord, without the whirlpool sign.

Area of Interest: Genital / Reproductive system male; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Ischaemia / Infarction;