Case 28 - Oh Balls...
Author: Dr Julia Burkert-Milone Reviewer: Dr Nick Mani
A gentleman in his 20s presents to the ED in middle of the night complaining of sudden onset severe worsening right testicular pain, over ~2hrs duration.
He has no urinary symptoms, previous testicular problems or surgery. The right testicle is tender and firm, with absent cremasteric reflex.
After urgently calling the urology team on-call, you elect to perform POCUS of testicles as an extension of the standard clinical assessment: -
Clip Collection (Press right/Left to change the clips)
Clip 1- Transverse View with colour flow doppler (left of the image is the right testicle)
Clip 2- Longitudinal view left testicle with flow colour doppler
Clip 3- Longitudinal view right testicle with colour flow doppler
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Linear Probe (high frequency
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Linear Transducer, on small organ/equivalent present such as MSK/soft tissue/breast
Depth, gain, focus and TGC (time gain compensation)
Size of the colour box (smaller=better)
Angle of the transducer when scanning (an artefactual blood flow absent at insonation 90°to the vessel)
Reducing PRF (pulse repetition frequency)/velocity scale
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Right testicle- No colour flow doppler signal, in both transverse and longitudinal views, compared to the other side
Note- Colour flow doppler signal present (sometimes increased) in the periphery of the right testicle, most likely from the capsule/cremasteric muscle vessels as this is intact in torsion. Could lead to false negative result.
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Direct:-
Increased testis and epididymis size.
Heterogeneous echotexture of the testis (?infarction)
Horizontal or abnormal lie of the testis (?bell-clapper deformity)
Epididymal thickening due to ischaemic (not inflammation)
Whirlpool Sign (a spiral-like pattern of the spermatic cord twisting)
Decreased rather than absent colour flow/power doppler to the testicle
Change in the pattern of pulsed-wave/spectral doppler (advanced competency)-
Note- Partial/incomplete testicle torsion may exhibit arterial flow but no venous flow, or it may show an abnormal high-resistance pattern of arterial flow on pulse-wave/spectral doppler.
Indirect:-
Hydrocele (reactive)
Thickened scrotal soft tissue with hyperaemia and increased colour flow/power doppler (Reactive)
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Acute complete right testicular torsion/ischaemia (unlikely infarcted) is highly likely/ruled-in
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Children: -
100% Sensitivity
99.1% specificity
100% NPV
Adults: -
95% sensitivity
94% specificity
References: -
Friedman N, Pancer Z, Savic R, Tseng F, Lee MS, Mclean L, et al. Accuracy of point-of-care ultrasound by pediatric emergency physicians for testicular torsion. J Pediatr Urol. 2019 Dec;15(6):608.e1-608.e6
Blaivas M, Sierzenski P & Lambert M. Emergency Evaluation of Patients Presenting with Acute Scrotum Using Bedside Ultrasonography. Academic Emergency Medicine. 2008 8(1).
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TWIST (Testicular Workup for Ischemia and Suspected Torsion) score.
100% PPV when all clinical findings present, but inadequate NPV requiring the need for additional assessment
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Surgical exploration of the testicle
CASE RESOLUTION
The patient was taken for an emergency exploration of the right testicle without any delays as torsion was ruled-in/highly likely based on addition of POCUS to standard clinical assessment. Right testicular torsion was confirmed and managed surgically with good outcome.
Take Home messge
POCUS colour (power>flow) doppler is an extension of standard clinical assessment could help with assessment of suspected testicular torsion (rule-in or low/high/equivocal), particularly out of hours and/or in some settings without access to sonography support.
Presence of flow in the peripheries could lead to false negative, as could be the case with incomplete testicular torsion (advance competencies with pulse power/spectral doppler is required). The gold standard still remains surgical exploration until more primary research studies are performed to show otherwise.
