Case Study - May 2008

This is a scrotal ultrasound scan in a 12-year-old boy who presented with a painful right testis. The testis was enlarged, reddened and acutely tender to touch but the spermatic cord was normal. There were no urinary symptoms but there was a past history of bilateral dartos pouch orchidopexies, 6 years earlier, for ectopic testes.

  1. What does the ultrasound show?
  2. What is the differential diagnosis?
  3. What further investigations might be helpful?
  4. What treatment is needed?

Case presented by Mr Nigel Bullock

Reveal Answer

Open answer There is no fixed answer to this question, however your response should be similar to the one below:

  1. The testis and epididymis appear normal. There is a discrete mass attached to the upper pole of the right testis which is contained within a fluid-filled space
  2. Torsion of the testis, torsion of a testicular or epididymal appendage, epididymitis, idiopathic scrotal oedema, orchitis. Torsion of the testis is unlikely following previous orchidopexy. Epididymitis is unlikely in the absence of significant urinary symptoms. Orchitis is probably excluded by the finding of a normal testis on ultrasound. Idiopathic scrotal oedema does not usually affect the underlying scrotal contents.
  3. Doppler ultrasound or radionuclide scrotal scintigraphy might be useful to assess blood flow to the scrotal contents. Doppler studies (see below) confirmed increased blood flow to the right testis, normal flow to the epididymis and no flow in the lesion at the top of the testis. Routine urine testing was normal, excluding significant infection.
  4. Urgent scrotal exploration is required. An infarcted testicular appendage was found and excised with complete resolution of symptoms.

Further comments
During dartos-pouch orchidopexy, any testicular or epididymal appendages would normally be excised. This, therefore, is a very unusual presentation which was only resolved by exploration and excision; such surgery can be technically difficult when the testis lies in a dartos pouch.

Most torsed appendages will, in fact, resolve spontaneously by falling off (when infarcted) but surgical excision shortens the course of the condition and is probably the optimum treatment.

illustrative image for answer to question $n

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