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Torsion of the spermatic cord: the main gray-scale and doppler sonographic signs

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Abstract

Scrotal ultrasonography (US) is usually the initial imaging modality for evaluating patients who present with acute pathologic conditions of the scrotum. Acute epididymitis, acute epididymo-orchitis, torsion of the spermatic cord (TSC), and other acute scrotal abnormalities may have similar findings at clinical examination. Pain and swelling make the clinical examination difficult, sometimes practically impossible, potentially resulting in management delays. The objective of this review is to summarize the main clinical signs of the TSC and to illustrate and briefly discuss the US features of this entity, including gray-scale imaging, color Doppler with spectral analysis, and power Doppler sonography. Although TSC can occur at any age, it is most common in adolescent boys. The intensity of the symptoms and the US findings vary with the duration of the torsion, number of twists in the spermatic cord (degree of rotation), and how tightly the vessels of the cord are compressed. An enlarged, more spherical, and diffusely hypoechogenic testis without detectable arterial and venous testicular flow at color and power Doppler US is considered diagnostic of acute testicular ischemia. The presence of a color or power Doppler signal in one part of the testis does not exclude TSC. Positive blood flow but significantly diminished, usually near or inside the mediastinum, may be found, mainly in the partial or incomplete TSC. Identification of a large echogenic extratesticular mass distal to the site of the torsion, frequently misinterpreted as a chronic epididymitis, can be the key to the diagnosis of TSC. When a small arterial sign is found a low amplitude waveform is present with an increased resistive index on the affected side due to a diminished, absent, or reversed diastolic flow. Gray-scale imaging, color Doppler, power Doppler and pulsed Doppler with spectral analysis are very effective to make or exclude the diagnosis of TSC.

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References

  1. Süzer O, Özcan H, Küpeli S, et al. Color Doppler imaging in the diagnosis of the acute scrotum. Eur Urol 1997;32: 457–461

    PubMed  Google Scholar 

  2. Dubinsky TJ, Chen P, Maklad N Color-flow and power Doppler imaging of the testes. World J Urol 1998;16:35–40

    Article  PubMed  CAS  Google Scholar 

  3. Kadish HA, Bolfe RG A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics 1998;102:73–76

    Article  PubMed  CAS  Google Scholar 

  4. Kass EJ, Lundak B The acute scrotum. Pediatr Clin North Am 1997;44: 1251–1266

    Article  PubMed  CAS  Google Scholar 

  5. Lin EP, Bhatt S, Rubens DJ, et al. Testicular torsion: twists and turns. Semin Ultrasound CT MRI 2007;28:317–328

    Article  CAS  Google Scholar 

  6. Dogra VS, Gottlieb RH, Oka M, et al. Sonography of the scrotum. Radiology 2003; 227:18–36

    Article  PubMed  Google Scholar 

  7. Siegel MJ The acute scrotum. Radiol Clin North Am 1997;35: 959–976

    PubMed  CAS  Google Scholar 

  8. Hörmann M, Balassy C, Philipp MO, et al. Imaging of the scrotum in children. Eur Radiol 2004;14:974–983

    Article  PubMed  Google Scholar 

  9. Oyen RH Scrotal ultrasound. Eur Radiol 2002;12:19–34

    Article  PubMed  Google Scholar 

  10. Favorito LA, Cavalcante AG, Costa WS Anatomic aspects of epididymis and tunica vaginalis in patients with testicular torsion. Int Braz J Urol 2004;30:420–424

    PubMed  Google Scholar 

  11. Ringdhal E, Teague L Testicular torsion. Am Fam Physician 2006;74:1739–1743

    Google Scholar 

  12. Pavlica P, Barozzi L Imaging of the acute scrotum. Eur Radiol 2001;11:220–228

    Article  PubMed  CAS  Google Scholar 

  13. Frush DP, Sheldon CA Diagnostic Imaging for pediatric scrotal disorders. Radiographics 1998;18:969–985

    PubMed  CAS  Google Scholar 

  14. Prando D Torsion of the spermatic cord: sonographic diagnosis. Ultrasound Quart 2002;18:41–57

    Article  Google Scholar 

  15. Noske HD, Kraus SW, Altinkilic BM et al. Historical milestones regarding torsion of the scrotal organs. J Urol 1998;159:13–16

    Article  PubMed  CAS  Google Scholar 

  16. Schulsinger D, Glassberg K, Strashun A Intermittent torsion: association with horizontal lie of the testicle. J Urol 1991;145:1053

    PubMed  CAS  Google Scholar 

  17. Albrecht T, Lotzof K, Hussain HK et al. Power Doppler US of the normal prepubertal testis: does it live up to its promises? Radiology 1997;203:227–231

    PubMed  CAS  Google Scholar 

  18. Dogra VS, Sessions A, Mevorach RA, et al. Reversal of diastolic plateau in partial testicular torsion. J Clin Ultrasound 2001;29:105–108

    Article  PubMed  CAS  Google Scholar 

  19. Hernanz-Shulman M, Yenicesu F, Heller RM, et al. Sonographic identification of perinatal testicular torsion. J Ultrasound Med 1997;16:65–67

    Google Scholar 

  20. Zinn HL, Cohen HL, Horowitz M Testicular torsion in neonates: importance of power Doppler imaging. J Ultrasound Med 1998;17:385–388

    PubMed  CAS  Google Scholar 

  21. Paltiel HJ, Connolly LP, Atala A et al. Acute scrotal symptoms in boys with an indeterminate clinical presentation: comparison of color Doppler sonography and scintigraphy. Radiology 1998;207:223–231

    PubMed  CAS  Google Scholar 

  22. Sanelli PC, Burke BJ, Lee L Color and spectral Doppler sonography of partial torsion of the spermatic cord. AJR 1999;172:45–51

    Google Scholar 

  23. Aso C, Enríquez G, Fité M, et al. Gray-scale and color Doppler sonography of scrotal disorders in children: an update. Radiographics 2005;25:1197–1214

    Article  PubMed  Google Scholar 

  24. Prando D. Diagnostico por imagem. Ultra-sonografia escrotal. In: Hering FLO, Srougi M, eds. Urologia. Diagnóstico e tratamento. São Paulo, Roca, 1998; 35–66

    Google Scholar 

  25. Prando D. Escroto. In: Prando A, Prando D, Caserta NMG, Bauab Jr. T, eds. Urologia. Diagnóstico por Imagem. São Paulo: Sarvier, 1997:349–381

    Google Scholar 

  26. Dijk van R, Karthaus HFM Ultrasonography of the spermatic cord in testicular torsion. Eur J Radiol 1994;18:220–223

    Article  PubMed  Google Scholar 

  27. Baud C, Veyrac C, Couture A, et al. Spiral twists of the spermatic cord: a reliable sign of testicular torsion. Pediatr Radiol 1998;28:950–954

    Article  PubMed  CAS  Google Scholar 

  28. Vijayaraghavan SB Sonographic differential diagnosis of acute scrotum: real time whirlpool sign, a key sign of torsion. J Ultrasound Med 2006;25:563–574

    PubMed  Google Scholar 

  29. Kalfa N, Veyrac C, Baud C, et al. Ultrasonography of the spermatic cord in children with testicular torsion: impact on the surgical strategy. J Urol 2004;172:1692–1695

    Article  PubMed  CAS  Google Scholar 

  30. Middleton WD, Middleton MA, Dierks M, et al. Sonographic prediction of viability in testicular torsion. J Ultrasound Med 1997;16:23–27

    PubMed  CAS  Google Scholar 

  31. Dogra VS, Bhatt S, Rubens DJ Sonographic evaluation of testicular torsion. Ultrasound Clin 2006;1:55–66

    Article  Google Scholar 

  32. Dogra VS, Bhatt S Acute painful scrotum. Radiol Clin North Am 2004;42 (9):349–363

    Article  PubMed  Google Scholar 

  33. Galejs LE, Kass EJ Color Doppler ultrasound of the acute scrotum. Tech Urol 1998;4:182–184

    PubMed  CAS  Google Scholar 

  34. Arce JD, Cortes M, Vargas JC Sonographic diagnosis of acute spermatic cord torsion. Rotation of the cord: a key to diagnosis. Pediatr Radiol 2002;32:485–491

    Article  PubMed  Google Scholar 

  35. Jee WH, Choe BY, Byun JY et al. Resistive index of the intrascrotal artery in scrotal inflammatory disease. Acta Radiol 1997;38:1026–1029

    PubMed  CAS  Google Scholar 

  36. Lucker GD, Siegel MJ Scrotal US in pediatric patients: comparison of power and standard color Doppler US. Radiology 1996;198:381–385

    Google Scholar 

  37. Barth RA, Shortliffe LD Normal pediatric testis: comparison of power Doppler and color Doppler US in the detection of blood flow. Radiology 1997;204:389–393

    PubMed  CAS  Google Scholar 

  38. Bader TR, Kammerhuber F, Herneth AM Testicular blood flow in boys as assessed at color Doppler and power Doppler sonography. Radiology 1997;202:559–564

    PubMed  CAS  Google Scholar 

  39. Babcock DS, Patriquin H, LaFortune M et al. Power Doppler sonography: basic principles and clinical applications in children. Pediatric Radiol 1996;26:109–115

    Article  CAS  Google Scholar 

  40. Liao L, Dogra VS, Oka M, et al. (2000) Torsion and beyond: new twists in spectral Doppler evaluation of the scrotum (abstr.). RSNA Scientific program

  41. Sanders LM, Haber S, Dembner A, et al. Significance of reversal of diastolic flow in the acute scrotum. J Ultrasound Med 1994;13:137–139

    PubMed  CAS  Google Scholar 

  42. Dogra VS, Rubens DJ, Gottlieb RH, et al. Torsion and beyond: new twists in spectral Doppler evaluation of the scrotum. J Ultrasound Med 2004;23:1077–1085

    PubMed  Google Scholar 

  43. Williamson RCN (1976) Torsion of the testis and allied conditions. Br J Sur 63:465–476

    Article  CAS  Google Scholar 

  44. Skoglund RW, McRoberts JW, Radge H (1970) Torsion of the spermatic cord: A review of the literature and an analysis of 70 new cases. J Urol 104:604–607

    PubMed  CAS  Google Scholar 

  45. Dogra VS, Bhatt S (2006) Acute scrotal pain: imaging evaluation for a more specific diagnosis. RSNA Categorical course in Diagnostic radiology, pp 255–269

Download references

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  1. Av. República do Libano 990, Sao Paulo, SP, 04502-001, Brazil

    Décio Prando

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Prando, D. Torsion of the spermatic cord: the main gray-scale and doppler sonographic signs. Abdom Imaging 34, 648–661 (2009). https://doi.org/10.1007/s00261-008-9449-8

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