Background:

The acute scrotum is a clinical feature that is characterized by symptoms such as pain, swelling, and redness in the scrotum and requires urgent diagnosis and intervention. The aim of this study is to reveal the typical imaging findings detected in ultrasonography (US), which is the imaging method frequently and primarily used in the differential diagnosis of clinical conditions causing acute scrotum.

Findings and procedure details:

We will present cases of testicular torsion, torsion of the appendix testis,epi-didymo orchitis, and testicular abscess, which may be confused with a mass lesion. Testicular torsion often results from the rotation of the spermatic cord. Anatomically there are two types of testicular torsion; extra-vaginal (supravaginal) torsion occurs at the level of the outer inguinal ring seen in newborns. İntra-vaginal torsion is more common and typically occurs in adolescents and young adults (1) (Figures 1,2,3).

Torsion of the appendix testis is the most common cause of an acute painful hemiscrotum in a child (1). Unlike testicular torsion, medical treatment is often sufficient (Figure 4).

We will present cases of testicular torsion, torsion of the appendix testis,epi-didymo orchitis, and testicular abscess, which may be confused with a mass lesion. Testicular torsion often results from the rotation of the spermatic cord. Anatomically there are two types of testicular torsion; extra-vaginal (supravaginal) torsion occurs at the level of the outer inguinal ring seen in newborns. İntra-vaginal torsion is more common and typically occurs in adolescents and young adults (1). Testicular torsion, testis, and spermatic cord twists within the scrotum cause vascular occlusion and subsequent infarction if not corrected immediately (Figure 1,2,3).

Torsion of the appendix testis is the most common cause of an acute painful hemiscrotum in a child (1). Testicular appendages are vestigial remnants of the mesonephric and

Paramesonephric ducts are composed of vascularized connective tissue along the testis and epididymis. Unlike testicular torsion, medical treatment is often sufficient (1)(Figure 4).

Epididymoorchitis is also a common cause of acute scrotal pain in adults. The infection usually originates from the bladder or prostate gland spreading to the epididymis through the spermatic cord, eventually reaching the testis, leading to epididymo-orchitis (2). Epididymitis with orchitis occurs in approximately 20% to 40% of cases  (2) (Figure 5). Testicular abscess formation is a rare complication of epididymo-orchitis (3) (Figure 6). Clinical history and Doppler findings are critical in the differential diagnosis, as malignant processes are also included in the differential diagnosis of focal testicular lesions(3) (Figure 7)

Conclusion:

Differential diagnosis of scrotal pain is vital in determining the treatment plan.  Ultrasound is the modality of choice. Early imaging is essential in patients presenting with scrotal pain, following a detailed history and physical examination. Especially in cases of testicular torsion, detorsion within the first six hours is vital to preserving the testis's vitality. Therefore, early diagnosis and rapid action are required. It is also emphasized in the literature that scrotal exploration should not have hesitated in cases where torsion cannot be ruled out with imaging methods.

References:

1-David E. Sweet,  Myra K. Feldman, Erick M. Remer; Imaging of the acute scrotum: keys to a rapid diagnosis of acute scrotal disorders; 2020 DOI: 10.1007/s00261-019-02333-4

2-Dogra V, Bhatt S (2004) Acute painful scrotum. Radiol Clin North Am 42:349-363.

3-Wang CL, Aryal B, Oto A, et al (2019) ACR Appropriateness Criteria: Acute Onset of Scrotal Pain-Without Trauma, Without Antecedent Mass. J Am Coll Radiol, 16:5:S38-S43