Case 41

24 yo M w no sig PMH presenting with testicular pain that began after a physical altercation involving a knee to his scrotum injury 4 days ago.  The pain was exacerbated by a basketball hitting his testicles yesterday.  Pt denies hematuria, dysuria, inability to achieve or maintain erection, and N/V.  Pain improved with advil.

ROS
Denies recent fevers or chills, no n/v/d, + for left scrotal pain. No abdominal pain.

PE
T: 97.2 Oral, P: 68, RR: 20, BP: 119/85 O2: 99% RA
CONSTITUTIONAL: The patient is alert and in no apparent distress. Appears WDWN.
CARDIOVASCULAR: RRR
RESPIRATORY: Breath sounds clear, no distress present, no wheezing rales, rhonchi or tachypnea. Normal rate and effort.
GI/ABDOMEN: Palpation: Soft, non-tender, no guarding or rebound tenderness.
GENITOURINARY: Penis: External inspection normal. No tenderness or swelling. L testicle swollen in normal lie and tender/firm. No cremasteric reflex on either side.
INTEGUMENTARY: Color normal for race, warm and dry, no rash.
NEURO: Oriented x 3. Motor/Sensory: No motor or sensory deficit. normal gait
PSYCH: Normal mood and affect.

FIGURE 1

FIGURE 1

FIGURE 2

FIGURE 2

QUESTIONS:

  1. What is your differential diagnosis?
  2. What are the critical features of a testicular US?
  3. Describe proper technique in performing a testicular US.
  4. Based on the images above what is your diagnosis and what is the definitive management in this case?

ANSWERS:

  1. The differential diagnosis for testicular pain should include: testicular torsion, hydrocele, varicocele, traumatic injury, hernia, (epididymo)orchitis, scrotal abscess, Fournier’s gangrene, as well as referred pain from other abdominopelvic pathology including cystitis or appendicitis.
  2. Views of each testicle in transverse and sagittal planes, venous and arterial blood flow to bilateral testes using spectral power Doppler. Color flow should be utilized to compare both testes for hyperemia, ideally with both testes in the same image to allow for direct comparison. Additionally, each epididymis should be visualized similarly. The inguinal canals should also be assessed for presence of hernia.
  3. The exam is performed ideally with the patient in the supine position. For patient comfort and ease of sonographic exam, a rolled towel may be used to elevate the scrotum. The high frequency linear transducer should be used. The exam should begin with the unaffected testicle and proceed to the affected or painful side. Valsalva maneuver may be employed to enhance visualization of hernias or hydroceles.
  4. The images demonstrate testicular rupture with disruption of the hyperechoic margins of the left testis and surrounding complex fluid collection representing likely hematoma. Emergent urologic consultation is warranted, as definitive management must include emergent scrotal exploration with repair and/or excision of the affected testis. 90% of testes can be salvaged within 72 hours of injury, with half of these becoming unsalvageable thereafter.