SONOWORLD : Uncomplicated acute epididymo-orchitis

Username

Password

174,427 Registered Members as of 06/18/2019.

JavaScript must be enabled in order for you to use Sonoworld.com in standard view. However, it seems JavaScript is either disabled or not supported by your browser. To use standard view, enable JavaScript by changing your browser options, then try again.

Pelvis » Scrotum And Testicles

Uncomplicated acute epididymo-orchitis

« Back to Listing

Author(s) :

Chaitali Shah, FRCR

Pamela T. Johnson, MD

Presentation A 25-year-old male, presents with a 1-day history of acute left-sided scrotal pain. He has no history of trauma.

Caption: Transverse view comparing right and left testes.

Description: Transverse sonogram of scrotum, demonstrating an enlarged, and slightly less echogenic left testis as compared to the contralateral side.

Caption: Sagittal view of the left testis.

Description: Sagittal sonogram, depicting an enlarged [5.2x3.0x3.2 cms], and slightly heterogeneous left testis.

Caption: Transverse sonogram of left scrotum.

Description: Transverse sonogram revealing an enlarged [1.4x1.1x2.2 cms] and heterogeneous epididymis.

Caption: Color Doppler study of left scrotum.

Description: Color Doppler study, showing markedly increased flow throughout the left testis and epididymis.

Caption: Power Doppler study of left scrotum.

Description: Power Doppler study revealing markedly increased flow throughout the testis and epididymis on the affected side.

Caption: Transverse color Doppler study.

Description: Transverse view, comparing the color flow through both testes. The affected side shows obvious increase in flow, compared to the normal right testis.

Differential Diagnosis Acute uncomplicated epididymo-orchitis

Final Diagnosis Acute uncomplicated epididymo-orchitis

Discussion Although the scrotum is a superficial structure, clinical examination is frequently not enough for making a specific diagnosis. The differential diagnosis in a patient presenting with acute scrotal pain may pose a diagnostic dilemma, and ultrasound can play a key role in effectively narrowing down the differentials and distinguishing acute epididymitis, acute epididymo-orchitis and testicular torsion.

Epididymo-orchitis can occur with Neisseria and Chlamydial infections, which are sexually transmitted and can also occur with E.coli or Pseudomonas. The epididymis is the organ initially more severely affected in epididymo-orchitis, with testicular involvement occurring in about half the cases due to contiguous spread. Systemic infections and trauma are uncommon causes of acute epididymo-orchitis. Primary orchitis occurs very rarely and may be due to viral infections such as mumps, where it can present with bilateral testicular swelling.

Gray scale imaging depicts an enlarged epididymis and testis. Secondary findings such as scrotal wall thickening or pyocele may be seen. With epididymitis, the epididymis may be significantly enlarged and shows altered echotexture, usually hypoechoic, but may sometimes be hyperechoic. With testicular involvement, change in the echogenicity is also noted, with the testis usually becoming hypoechoic. Testicular edema in a rigid tunica albuginea is responsible for a heterogeneous appearance. The testicular involvement may be diffuse or focal; if the latter it may present as patchy hypoechoic lesions in the testis. This appearance of testicular involvement is non- specific, and if the acute clinical scenario is not present, it needs to be differentiated from neoplastic conditions involving the testis such as leukemia and lymphoma.

Increased blood flow throughout the affected testis and epididymis is an established criterion for the diagnosis of epididymo-orchitis. The sensitivity of color Doppler in diagnosing inflammation is almost 100%. In acute epididymitis, the epididymis demonstrates an increased number of vessels, which show low resistance and high velocity flow. Studies have shown that in 20% of cases of epididymitis and 40% of cases of orchitis, only the color Doppler findings are abnormal with normal gray-scale ultrasound findings. Therefore, in all cases of suspected epididymo-orchitis, it is important to image the scrotum in both gray scale and color Doppler mode.

The aim of ultrasonography in a patient presenting with an acute painful scrotum is to rule out testicular torsion from acute epidiymo-orchitis, as the former needs emergent surgery to prevent permanent damage. Gray scale findings may be completely normal in the early stages of torsion; however, the absence of color flow on Doppler favors the diagnosis of testicular torsion. Findings of hyperemia in the epididymis and testis are diagnostic for inflammatory pathology. Ultrasound also helps in detecting the complications of acute epididymo-orchitis which includes:
1. Progression to chronic stage
2. Abscess formation [click here to view]
3. Infarction [click here to view]
4. Pyocele
5. Infertility and
6. Atrophy

Case References 1. Hawtrey CE. Assessment of acute scrotal symptoms and findings. A clinician`s dilemma. Urol Clin North Am 1998 Nov; 25(4): 715-23.
2. Dogra VS, Gottlieb RH, Oka M, Rubens DJ. Sonography of the scrotum. Radiology. 2003 Apr; 227(1): 18-36. Epub 2003 Feb 28.
3. WG Horstman, WD Middleton, GL Melson and BA Siegel. Color Doppler US of the scrotum. RadioGraphics.1991 Vol 11, 941-957.
4. Pavlica P, Barozzi L. Imaging of the acute scrotum. Eur Radiol. 2001; 11(2): 220-8.
5. Ralls PW, Jensen MC, Lee KP, Mayekawa DS, et al. Color Doppler sonography in acute epididymitis and orchitis. J Clin Ultrasound. 1990 Jun; 18(5): 383-6.

Follow Up The patient responded well to antibiotic treatment, and subsequent ultrasound imaging showed complete resolution.

Other contents by this AuthorOther Cases in This Category

Pelvis >> Scrotum And Testicles

Acute right epididymitis
A 25 year old male presents with a 1 day history of acute right-sided scrotal pain. He has no history of trauma.

Left varicocele
A 25 year old man presents with a dull pain in the left scrotum. There is no history of trauma or fever.

Acute left epididymitis
A 25 year old male, presents with a one day history of acute left-sided scrotal pain. He has no history of trauma.

Complicated acute epididymo-orchitis: with an epididymal abscess
A young adult male presents with a one day history of acute right scrotal pain. There is no history of trauma.

Germ cell tumor testis: NSGCT- embryonal carcinoma
A 32 year old male presents with painless left testicular swelling of 2 months duration. There is no history of trauma or fever.

Germ cell tumor testis:Seminoma
A 30 year old man presents with a painless left testicular swelling. A scrotal ultrasound was performed.

Left testicular and epididymal torsion
A 25 year old man presents with severe, acute left scrotal pain of a few hours duration. The onset was sudden and not preceded by trauma. A scrotal ultrasound was performed.

Bilateral spermatoceles
A 60 year old man presents with bilateral palpable scrotal masses. He had a vasectomy performed 25 years ago. A scrotal ultrasound was performed.

Epidermoid cyst of the testicle
A 19 year old male presented with a unilateral non tender testicular mass. The patient gives a history of gradual increase in size of the mass. A scrotal ultrasound was performed.

Complicated acute epididymo-orchitis: with testicular infarct
A 30 year old male presented with severe, acute pain in the left scrotum. A scrotal ultrasound was performed.

Germ cell tumor testis: multifocal NSGCT
A 22 year old male presents with left testicular firmness. He has no history of trauma. A scrotal ultrasound was performed.

Tunica albuginea cyst
A 32 year old male presented for a follow up testicular ultrasound. He had an initial scan performed for a palpable left scrotal swelling.

Zinner syndrome
A 32 year old man presented for infertility. Semen analysis revealed oligo-asthenospermia. A scrotal and pelvic scan was performed.

Traumatic testicular rupture with cord hematoma
A young man fell into a well and sustained severe acute blunt injury to the right inguinal region. Clinically he presented with a grossly edematous penis and scrotum. The swelling extended up to ...

Scrotal calculi
A 50 year old doctor with history of repeated self- limiting attacks of excruciating/shooting pain localized to the left testis. The pain subsides after a minute or two. He has no other symptoms

Benign testicular calcification
A 30 year old man presents for infertility evaluation. A scrotal ultrasound was performed.

Scrotal sac hematoma
These are serial ultrasound scans of a young man with a history of trauma to the scrotum.

Leiomyoma of the epididymis
A 59 year-old man presents with two palpable masses in right hemiscrotum. An ultrasound of the scrotum was performed.

Right undescended testis
This is a scan in a 6-month-old male child with an empty right scrotal sac. An ultrasound was performed to locate the undescended testis.

Testicular microlithiasis
This is an incidental finding in a 35-year-old man with dull pain in the scrotum.

Atrophic right testis
This was a follow-up scan in a 35-year-old man with a previous history of right orchitis.

Granulomatous orchitis
This is a scrotal ultrasound scan in a man with complaints of hematuria.

Cystic dilatation of the Rete Testis
A 51-year-old male presents with left scrotal enlargement.

Leydig Cell tumor
An ultrasound evaluation for varicocele was performed on a 10 year old male, with normal blood sub-beta and alpha fetoproteins markers.

Partial Testicular Torsion
A 20 year old male presented to the emergency room with severe left scrotal pain.

Orchitis with abscess formation and hydrocele
54 year old male with scrotal pain and swelling.

Acute idiopathic scrotal edema
5 year old boy with a red painful swollen scrotum

Neonatal extravaginal testicular torsion
Neonate with a scrotal swelling on the right side

Testicular Microlithiasis
This 26 YO male presented for a scrotal ultrasound as an outpatient with no specific medical history on the referral. On questioning he stated that one side of his abdomen was harder and more ...

Testicular Seminoma
A 37-year-old man presents with a complaint of a painless mass in his left testicle. On examination there is testicular enlargement on the left.

Congenital Adrenal Hyperplasia
42 year old male presented with enlargement of both testicles

Leydig Cell Tumor of the Testicle
This is a 35 year-old male patient who presented for presurgical assessment of left Inguinal hernia. Scrotal and inguinal ultrasound was requested.

Bilateral Extravaginal Testicular Torsion
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 ...