36 year old gentleman with unilateral pain/swelling of scrotum for 4 days.

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1 Department of Radiology Henry Ford Health System Detroit, Michigan 36 year old gentleman with unilateral pain/swelling of scrotum for 4 days. Pinky Sharma Wayne State School of Medicine 02/26/2010 Resident: Dr. Brent Griffith, R1

2 History 36 year old gentleman with history of trauma to left testicle, Now presents with left-sided pain/swelling for 4 days. Patient denies fever, chills, abdominal pain, dysuria, frequency or urgency. PMH: Unremarkable Multiple high-resolution grayscale and high sensitivity Doppler images of the testicles obtained

3 Color doppler images of the testicles

4 Ultrasound Images cont.

5 Increased vascular flow in Left Kidney

6 FINDINGS Both testicles symmetric Both testes demonstrate normal homogenous echotexture Right testicle measures 4.7 x 2.9 x 2.3 cm small anechoic structure in the right epididymis may relate to an epididymal head cyst or spermatocele. A small right-sided hydrocele with low level echoes present.

7 Ultrasound Findings cont. Left testicle measures 4.2 x 3.6 x 2.0 cm left epididymis enlarged and heterogeneous in appearance with increased vascular flow compared to the right A small left-sided hydrocele present. The skin of the left hemi- scrotum thickened, measuring 8.4 mm Normal color as well as arterial and venous flow within both testes.

8 Differential Diagnosis Testicular Torsion Appendiceal torsion Epididymitis Testicular tumor Fournier's gangrene Orchitis Epididymal cyst Hydrocele/Varicocele/Spermatocele

9 Final Diagnosis Epididymitis

10 Epididymitis an inflammatory reaction of the epididymis caused by either an infectious agent or local trauma a significant cause of morbidity 5th most common urologic diagnosis in men aged years. important to differentiate from testicular torsion, which is a true urologic emergency.

11 Epididymitis Although thought to be an infectious process, cultures commonly fail to demonstrate any identifiable infection Severe infection that extends to the adjacent testicle called acute epididymo- orchitis Orchitis is an acute inflammatory reaction that involves only the testes, exclusive of epididymitis, and is much less common.

12 Epididymitis The exact pathophysiology of acute epididymitis is unclear Believed to be caused by the retrograde passage of infected urine from the prostatic urethra to the epididymis via the ejaculatory ducts and vas deferens

13 Epididymitis 56% of men > 60 years with epididymitis exhibit concurrent bladder outlet obstruction such as urethral stricture or benign prostatic hyperplasia Orchitis is found in association with acute epididymitis in 20%-40% of cases

14 Diagnostic Imaging Ultrasonography is the first-line imaging modality for evaluating a patient with suspected acute epididymo-orchitis orchitis Sensitivity of color Doppler ultrasonography in detecting scrotal inflammation is almost 100%.

15 Ultrasound and Color doppler Findings Usually shows enlargement of the epididymal head with decreased echogenicity secondary to edema. A reactive hydrocele may be present Chronic Epididymitis - hyperechoic Acute Epididymitis - hypoechoic, increased blood flow Color Doppler findings include an increased amount of flow in and around the epididymis. If abscess formed, complex cystic areas may be identified in the epididymis

16 Physical Findings and Clinical Presentation 1. Tender swelling of the scrotum with erythema, usually unilateral testicular pain and tenderness 2. Dysuria and/or urethral discharge 3. Fever (less common) 5. Hydrocele or even epididymo-orchitis, orchitis, especially late 6. Chronic draining scrotal sinuses with a beadlike enlargement of the vas deferens in tuberculous disease

17 ETIOLOGY In young, sexually active men - N. gonorrhoeae and C. trachomatis infections In men >35 yr or with underlying urologic disease: Gram-negative aerobic rods predominant. Mycobacteria also a cause of epididymitis. Young, prepubertal boys may present with epididymitis caused by coliform bacteria almost always a complication of reflux.

18 Complications Complications of epididymitis and/or epididymo-orchitis include the following: Chronic epididymitis Infarction Infertility Abscess Atrophy Pyocele

19 Current Therapy Appropriate antibiotics if infectious agent isolated Antiinflammatories Decreased activity Scrotal elevation Pain control

20 Follow-up Failure to improve within 3 days: Reevaluate initial diagnosis and therapy For persistent swelling and tenderness after therapy, consider: 1. Testicular tumor 2. Abscess 3. Testicular infarction 4. Tuberculosis 5. Fungal epididymitis

21 References Lewis, AG, Bukowski, TP, Jarvis, PD, et al. Evaluation of acute scrotum in the emergency department. J Pediatr Surg 1995; 30:277. Al Mufti, RA, Ogedegbe, AK, Lafferty, K. The use of Doppler ultrasound in the clinical management of acute testicular pain [see comments]. Br J Urol 1995; 76:625. Wilbert, DM, Schaerfe, CW, Stern, WD, et al. Evaluation of the acute scrotum by color-coded coded Doppler ultrasonography. J Urol 1993; 149:1475. Edmund S Sabanegh Jr, MD, Director, Center for Male Fertility, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation

22 References cont. Uptodate: Robert C Eyre, MD Evaluation of acute scrotum in adult men MD Consult: Epididymitis Vikram S Dogra, MD, Professor of Diagnostic Radiology, Urology, and Biomedical Engineering, University of Rochester School of Medicine; Director Sandra L. Hagen-Ansert, M.S., RDMS, RDCS (F)SDMS ;Ultrasound Education Specialist and Clinical ConsultantCharleston, South Carolina

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