February 2014 Case of the Month- Courtesy of Dr. Van de Leuv

A 30yo male presented to the ED with right testicular pain and swelling for one week.  He denied any history of trauma or cycling.  He denied any abnormal discharge, dysuria, fevers or chills.  Bedside ultrasound revealed the following:

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The ultrasound images reveal an enlarged, heterogeneous epididymis with hypervascularity (demonstrated by increased blood flow throughout the testis and epididymis) and a reactive hydrocele, consistent with epididymo-orchitis. Epididymo-orchitis is often caused by infections- STI’s such as Gonorrhea/Chlamydia, or E.Coli, Pseudomonas. This patient was treated with antibiotics.

The heterogeneity of the testis is caused from testicular edema. Color Doppler is useful to identify inflammation as increased flow to the affected side- which is often secondary to vasodilation with low resistance/high velocity flow. When there is concern for testicular torsion, it is important to utilize color doppler, as you will often see decreased flow. One step further, apply spectral doppler to document both venous and arterial waveforms, as early in torsion venous flow decreases first. Early incomplete testicular torsion can be easily missed- so maintain a high level of suspicion and make sure to image both sides!