IOTW 10/13/2020

36 y/o M p/w R scrotal pain

  1. What is the hyperechoic linear structure labeled “A”?
    • Mediastinum testis of the right testicle. It is a network of fibrous connective tissue formed by invagination of the tunica and not a pathologic finding.
  2. What is the hyperechoic structure labeled “B” in the images above?
    • Epididymal head. It is normally isoechoic or mildly hyperechoic compared to the testicle echotexture. It is located near the superior pole of the testicle. The epididymal body (not visualized) extends down the posterior aspect of the testicle leading to the epididymal tail (not visualized) near the inferior pole of the testicle which becomes the proximal ductus deferens.
  3. What is the layer labeled “C”?
    • Tunica albuginea. It is a fibrous covering of the testis and is best visualized in the presence of fluid.
  4. What is the layer labeled “D”?
    • Visceral layer of the tunica vaginalis. It is a serous membrane covering the testis.
  5. What is the layer labeled “E”?
    • Parietal layer of the tunica vaginalis. This layer is normally held tightly against the visceral layer however becomes separated in the presence of hydrocele.
  6. How would you describe the fluid collection indicated by “F”?
    • Complex hydrocele. Note the subtle layering of debris. Hydroceles form between the layers of the tunica vaginalis and may be congenital or acquired. They are normally anechoic and simple unless complicated by infection or hemorrhage.
  7. Does the presence of normal vascular flow rule out testicular torsion? In females, does the presence of normal vascular flow rule out ovarian torsion?
    • The presence of normal flow rules out testicular torsion in males at the time of the ultrasound examination. The presence of flow, however, DOES NOT rule out ovarian torsion in females. The sole blood supply to the testicle is the testicular artery, whereas the ovaries have dual blood supply from primarily the ovarian arteries with collateral flow from the uterine arteries. Be aware that in the case of intermittent testicular torsion and detorsion, testicular flow may be increased and appear hyperemic, making it difficult to distinguish from orchitis. Thus, a proper history and physical exam are extremely important.
  8. What is the most likely diagnosis in this case?
    • Right-sided epididymo-orchitis. Notice the more hyperechoic appearance and hypervascularity of the right epididymis and testicle when compared to the left. Management is targeted at treating sexually transmitted infections and/or enteric organisms depending on age and risk factors. Patients should follow-up with urology in 1 week if they do not meet admission criteria.

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