SONOWORLD : Bilateral Extravaginal Testicular Torsion
 
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Pelvis » Scrotum And Testicles
Bilateral Extravaginal Testicular Torsion
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Presentation
Clinical examination of the neonate revealed a swollen, red and firm scrotum bilaterally.  Neither testicle could be individually palpated. No cremasteric reflex observed. No trauma to scrotum during cesarean birth of the neonate. Uncomplicated delivery.
Neonates mother has cystic fibrosis and was recently diagnosed with Invasive Ductal Breast Cancer.
The neonate was sent for a tertiary assessment to confirm the clinical diagnosis.

 
 
 
Caption: Transverse both testicles
Description: Both testicles are located within the scrotum
 
 
 
Caption: Rt testicle transverse
Description: Inhomogenous testicular echotexture with mild peripheral echogenic foci
 
 
 
Caption: Rt testicle longitudinal
Description: Same as image 2
 
 
 
Caption: Rt testicle transverse colour Doppler
Description: No Doppler flow demonstrated, low flow scale 4cm/s, light probe pressure with hockeystick transducer.
 
 
 
Caption: Lt testicle transverse
Description: Inhomogenous testicular echotexture with moderate peripheral echogenic foci
 
 
 
Caption: Lt testicle longitudinal
Description: Inhomogenous testicular echotexture with moderate peripheral echogenic foci
 
 
 
Caption: Lt testicle transverse colour Doppler
Description: No Doppler flow demonstrated, low flow scale 2.6cm/s, light probe pressure with hockeystick transducer.
 
 
 
Caption: Transverse scrotum both testicles
Description: Annotation of being bilaterally firm to palpate, useful clinical information for other doctors when reviewing the case.
 
 
 
Caption: Rt kidney longitudinal
Description: No pathology demonstrated.
 
 
 
Caption: Lt kidney longitudinal
Description: No pathology. Equal size and appearance compared to the Rt kidney.
 
Differential Diagnosis
Testicular Torsion, Teratoma, Yolk sac tumour, Gonadal stromal tumour, Juvenile Granulosa tumour, Hydrocele, hernia, meconium periorchitis, intraperitoneal bleeding tracking through the patent processus vaginalis.
 
Final Diagnosis Extravaginal testicular torsion – bilateral
 
Discussion
Extravaginal torsion is generally found in neonates at the level of the spermatic cord, because the cord is poorly fixed in the inguinal canal.    Because of this all the scrotal contents are strangulated.  While extravaginal torsion most commonly occurs unilaterally, it does occur bilaterally however is an extremely rare event.  Clinically the scrotum presents swollen and red with a firm, painless enlarged testicle, or testicles which is generally unilateral (Rumack 2011, p1948).

The ultrasound findings vary according to the duration of the torsion. In more recent torsion, the testis is heterogeneously enlarged with hypoechoic and hyperechoic areas (Rumack 2011, p 1948).  When the torsion is more chronic, the testis may be normal or slightly enlarged in size, with peripheral echogenicity corresponding to calcifications in the tunica albuginea (Rumack p1948).
This ultrasound finding was of particular note at the time of the examination.

Scrotal skin thickening and hydroceles with debris and/or septations are common associated findings (Siegel Paediatric Sonography p 577). 

Doppler signals are often absent in the testis and in the spermatic cord, although some flow may be seen with power Doppler imaging (Siegel Paediatrics Sonography p 577).

 
Case References
Siegel, M.J Paediatric Sonography, 4th edn. 2011.
Rumack, C.M Diagnostic Ultrasound, 4th edn, Vol 2. 2011

 
Technical Details
Philips IU22. 
Linear  L15-7 MHz. Paediatric Testis preset.
** Colour Doppler with low Doppler scale, power Doppler. **
 
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