22 yo male in obvious distress presents to the ED with acute onset of left testicular pain one hour prior to arrival. Physical exam demonstrated an exquisitely tender left testicle in a horizontal position. Bedside ultrasound is shown below. What is the diagnosis and the most appropriate treatment plan?
Answer: Testicular Torsion (lack of both venous & arterial flow)
Some tips for the exam - elevate the scrotum with a towel or sheet and place the patient in a frog-leg supine position. Use the linear (vascular) probe. Ultrasound each testicle separately and then examine both testicles in the same view (as shown above). Use color doppler flow on both testicles - classically there will be limited or no flow to the torsed testicle. Lack of blood flow on color doppler is 100% specific for torsion. The testicle may be enlarged and edematous (in early torsion) as well or have an abnormal echogenicity (later finding). Utilize bedside ultrasound immediately when testicular torsion is high on your differential.
The patient was taken immediately to the OR by urology and had an uncomplicated outcome.
Great catch by Dr Alexei Adan, a future EUS fellow in the making!
Pearls: Venous flow with be absent initially, therefore the presence of arterial flow does not rule out torsion. Torsion is a clinical diagnosis. Do not delay ultrasound evaluation or surgical consultation. Attempt manual detorsion. Lower your gain to limit movement artifact while using Color Doppler.
- Jessica Patterson, MD, Emergency Medicine Ultrasound Fellow
1. Blaivas M, et al. Ultrasonographic diagnosis of testicular torsion by emergency physicians. Am J Emerg Med 2000; 18(2):198-200.
2. Blaivas M, et al. Emergency evaluation of patients presenting with acute scrotum using bedside ultrasonography. Acad Emerg Med 2001; 8(1):90-93.
3. Blaivas M, et al. A Two-Year experience with bedside emergency ultrasonography for acute scrotal pain in the emergency department. Ann Emerg Med 2004; 44(4):S82.
4. Wu S, et al. Sonographic Patterns of Testicular Torsion. J Diag Med Sonography 2011; 27(6):273-278.