Pe d i a t r i c I m a g i n g C l i n i c a l Pe r s p e c t i ve

Sung et al.
Ultrasound of Pediatric Scrotum

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Pediatric Imaging
Clinical Perspective

Edward K. Sung1
Bindu N. Setty
Ilse Castro-Aragon
Sung EK, Setty BN, Castro-Aragon I

Sonography of the Pediatric

Scrotum: Emphasis on the Ts
Torsion, Trauma, and Tumors
OBJECTIVE. The purpose of this article is to review the different scrotal disease entities in
the pediatric population, focusing on acute scrotum, traumatic injuries, and testicular tumors.
CONCLUSION. Many pediatric scrotal disorders can be well characterized on sonography. An understanding of the various disease entities, their clinical presentations, and the
typical sonographic features should all be combined to make an accurate diagnosis.

onography is the imaging modality of choice for the evaluation of

scrotal disorders in children.
When combined with color Doppler, many scrotal diseases can be well characterized, guiding the clinician toward appropriate therapy. Common categories of scrotal
diseases in the pediatric population include
acute scrotum, traumatic injury, and tumors.

Keywords: pediatrics, scrotum, trauma, tumor,

ultrasound
DOI:10.2214/AJR.11.8034
Received September 30, 2011; accepted after revision
December 10, 2011.
1

All authors: Department of Radiology, Boston Medical

Center, 820 Harrison Ave, FGH Bldg, Third Fl, Boston, MA
02118. Address correspondence to E. K. Sung
(Edward.Sung@bmc.org).

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American Roentgen Ray Society

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Acute Scrotum
Acute scrotum is defined as acute scrotal
swelling and pain and is a common cause of
presentation to the emergency department
among boys. The common causes include
testicular appendageal torsion, epididymitis,
and testicular torsion [1]. Historical, clinical,
and sonographic findings should all be used
in making the diagnosis.

hours. Other findings may include visualization of a torsed spermatic cord, scrotal edema, and reactive hydroceles. Color Doppler
usually shows reduced or absent blood flow
to the testicle, a highly specific finding [24].
False-negative Doppler evaluations can occur in the setting of partial torsion, spontaneous detorsion, or incorrect measurement of arterial waveforms along the periphery of the
testicle. In these settings, repeat ultrasound
should be considered, and attention should
be made to the centripetal testicular arteries.
False-positive Doppler evaluation can be seen
in infants and young boys who often have normally reduced intratesticular blood flow [3],
but this is currently less problematic with the
availability of modern more-sensitive equipment. Moreover, comparison should always
be made to the unaffected side for symmetry.

Testicular Torsion
Testicular torsion accounts for up to 26%
of cases of acute scrotum [2] and is the most
important diagnosis to rule out because it is
a surgical emergency. Because of the disruption of testicular blood supply in torsion,
time is a crucial factor in salvaging the affected testis. The salvage rate can be up to
80100% with surgery within 6 hours, and
less than 20% with surgery after 12 hours
[3]. Patients usually present with acute onset of diffuse scrotal pain, nausea, and vomiting. Physical findings can include high-riding testicle and absent cremasteric reflex.
On sonography (Fig. 1), the torsed testicle
may be enlarged and appear hypoechoic, but
it can appear relatively normal in the first few

Testicular Appendageal Torsion

Testicular appendageal torsion is a common cause of acute scrotum in prepubertal
boys [2, 5]. The appendages are normal remnants of embryonic tissue and are usually located at the superior testicle or epididymal
head. Testicular appendages are more prevalent than epididymal appendages [5]; however, the distinction is often difficult to make
and is not important clinically.
Patients typically present with focal scrotal pain of variable onset. Physical findings
can include a paratesticular nodule and bluish
skin discoloration on the scrotum (i.e., the blue
dot sign) [5, 6]. Sonography may show an oval
avascular mass (torsed appendage) with variable
echogenicity located between the testicle and

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epididymis (Fig. 2). Additional findings may

include scrotal edema and reactive hydroceles.
Color Doppler may show hyperemia surrounding the torsed appendage [5, 6]. Treatment involves conservative management.
Epididymitis
Epididymitis is another common cause of
acute scrotum, accounting for up to 21% of
cases [2]. In postpubertal male patients, it is
usually related to retrograde extension of infection. In prepubertal boys, it is mostly idiopathic but can be related to underlying urogenital anomalies [7].
Patients typically present with gradual onset of scrotal pain with fevers. Sonography
may show an enlarged hypoechoic epididymis, scrotal edema, and reactive hydroceles
(Fig. 3). Color Doppler will show hyperemia
around the epididymis [2, 7, 8]. Concurrent
orchitis can occur in 2040% of cases [8].
Treatment commonly involves antibiotics.
Other Causes of Scrotal Swelling
Acute idiopathic scrotal edema is a rare disease that can cause acute scrotal swelling and
erythema in boys [9] and is usually painless.
Its exact cause is unclear, but it may have an
allergic origin. Sonography and color Doppler
show diffuse scrotal edema and hyperemia
[9] (Fig. 4). Acute idiopathic scrotal edema is
self-limited, and treatment is conservative.
Another cause of acute scrotal pain and
swelling in the pediatric population is Henoch-Schnlein purpura. Henoch-Schnlein
purpura is a systemic vasculitis more commonly seen in children that usually affects the
skin, kidneys, gastrointestinal tract, and joints.
Scrotal involvement is rare but can occur in
up to 15% of cases, and the sonographic findings typically include thickening of the scrotal
skin, enlargement of the epididymis, and presence of a hydrocele [10]. In Henoch-Schnlein
purpura, the testes are usually unaffected, and
normal testicular blood flow is maintained.
In general, the presence of scrotal swelling in boys should also raise the possibility of
cellulitis or skin reaction from insect bites. In
this setting, the major causes of scrotal swelling should initially be ruled out, and careful
history and physical examination may guide
the clinician into the appropriate diagnosis.
Trauma
Traumatic testicular injuries are relatively uncommon because the testes are protected by mobility within the scrotum, laxity of the overlying
skin, and coverage by the tunica albuginea [11,

12]. Scrotal trauma in boys is most commonly

due to sports-related activity (> 50%) followed
by motor vehicle accidents (17%) [11].
Testicular Rupture
Testicular rupture involves disruption of
the tunica albuginea, with extrusion of testicular contents. This can lead to loss of the
normal oval shape of the testicle. Sonography shows a heterogeneous testicle with irregular contours and a disrupted tunica albuginea [11, 12] (Figs. 5 and 6). Treatment
involves urgent surgical repair [11].
Testicular Fracture
Testicular fracture involves a break or discontinuity within the normal testicular parenchyma. However, the tunica albuginea remains intact, and thus the testicle maintains its
normal shape. Sonography shows a linear hypoechoic fracture line within the normally
shaped testicle [11, 12] (Fig. 7A). Treatment
is usually conservative management.
Testicular Hematoma
Testicular hematomas may be intratesticular or extratesticular. Sonography usually shows an avascular heterogeneous region
within or outside the testicle, corresponding to the hematoma [11, 12] (Figs. 5 and
7B). Treatment of small hematomas is usually conservative; however, large hematomas
may require surgical evacuation to prevent
pressure necrosis and testicular atrophy [11].
Tumors
Testicular tumors in boys are rare, accounting for only 12% of all pediatric solid
neoplasms, with an incidence of only 0.52
per 100,000 boys [2, 13]. Most (> 95%) intratesticular lesions are malignant and typically present as a painless mass, with treatment
usually involving orchiectomy.
Testicular tumors are classified as germ cell
tumors or nongerm cell tumors. Germ cell tumors are further classified as seminomas and
nonseminomatous tumors. Seminomas are the
most common testicular tumors among men,
whereas nonseminomatous germ cell tumors
are the most common testicular tumors among
boys and include yolk sac tumors, teratomas,
embryonal carcinomas, and choriocarcinomas.
Nongerm cell tumors include Sertoli and
Leydig cell tumors and are rare in boys [2, 13].
Yolk Sac Tumors
Yolk sac tumors are the most common testicular tumors in boys, accounting for up to

80% of cases, with a peak incidence at age 2

years [2, 13, 14]. Serum -fetoprotein levels
are usually elevated. Sonography may reveal
a heterogeneous solid mass replacing the entire testis (Fig. 8). Treatment involves radical
orchiectomy, followed by routine monitoring
of serum -fetoprotein levels [13].
Teratoma
Teratomas are the second most common
testicular tumors among boys. Sonography
will reveal a heterogeneous mass, usually
with solid and cystic components (Fig. 9).
Echogenic fat or calcifications may also be
seen [2, 13, 14]. In prepubertal testes, teratomas are considered benign and can be
treated with testis-sparing surgery. However,
postpubertal teratomas are malignant and require orchiectomy [13].
Lymphoma and Leukemia
Lymphoma and leukemia are the most
common metastases to the testes. Lymphoma accounts for only 5% of all testicular tumors [14] but is the most common cause of
bilateral testicular tumors. Among boys, the
testes are also common sites of posttreatment leukemia recurrence [14]. Sonography
may show a diffusely enlarged hypoechoic
testicle or multifocal hypoechoic nodules [2,
14] (Fig. 10).
Tumor Mimickers
Benign conditions can mimic the appearance
of tumors. Accurate diagnoses of these disorders can prevent unnecessary orchiectomy. In
some cases, history and physical examination
findings are often equivocal, and the diagnosis
may be dependent on the sonographic findings.
These benign conditions may appear cystic or
heterogeneous on sonography.
Benign cystic lesions include epidermoid,
tunica albuginea, and intratesticular cysts.
Epidermoid cysts have characteristic sonographic appearances, either as a rounded hypoechoic lesion with a hyperechoic rim, or
the more classic lamellated onion ring appearance [15]. Tunica albuginea and intratesticular cysts appear as simple cystic lesions
on sonography. Although it can be difficult
to distinguish the two, tunica albuginea cysts
are usually located more peripherally along
the tunica albuginea [15].
Heterogeneous-appearing benign lesions
include adrenal rests and segmental testicular infarcts. Adrenal rests are caused by aberrant adrenal tissue trapped in the gonads
during embryonic development. They can be

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Sung et al.
associated with congenital adrenal hyperplasia. Sonography may show a hypoechoic heterogeneous lesion that is eccentrically
located and is frequently bilateral [14] (Fig.
11). Segmental testicular infarcts can be iatrogenic or related to predisposing conditions,
such as polycythemia vera or sickle cell disease. Sonography typically shows an avascular wedge-shaped hypoechoic lesion, which
can resolve over time [15] (Fig. 12).
Testicular Microlithiasis
Testicular microlithiasis is due to calcium deposition within seminiferous tubules.
It can be associated with conditions such as
cryptorchidism and Klinefelter syndrome.
Ultrasonographic criteria include visualization of at least five microliths on a single image [2, 8, 14, 16] and may be unilateral or
bilateral and focal or diffuse (Figs. 13 and
14). The predisposition of testicular microlithiasis for malignancy is still unclear, and
follow-up in asymptomatic patients may involve self-examinations; however, ultrasound should be considered in symptomatic
patients, patients with a history of malignancy, or on patient request [16].
Conclusion
Many scrotal and testicular diseases can
affect the pediatric population, ranging from
acute disorders such as testicular torsion and

traumatic injuries to other less common disorders such as malignancies. The initial imaging modality of choice is sonography.
Thorough knowledge of the typical clinical
and sonographic findings of these disorders
is necessary in making accurate diagnoses to
guide appropriate therapy.
References
1. Baldisserotto M. Scrotal emergencies. Pediatr
Radiol 2009; 39:516521
2. Aso C, Enriquez G, Fite M, et al. Gray-scale and color
Doppler sonography of scrotal disorders in children:
an update. RadioGraphics 2005; 25: 11971214
3. Prando D. Torsion of the spermatic cord: the main
gray-scale and Doppler sonographic signs. Abdom
Imaging 2009; 34:648661
4. Chmelnik M, Schenk JP, Hinz U, Holland-Cunz
S, Gunther P. Testicular torsion: sonomorphological appearance as a predictor for testicular viability and outcome in neonates and children. Pediatr
Surg Int 2010; 26:281286
5. Baldisserotto M, Ketzer de Souza JC, Pertence
AP, Dora MD. Color Doppler sonography of normal and torsed testicular appendages in children.
AJR 2005; 184:12871292
6. Singh AK, Kao SC. Torsion of testicular appendage. Pediatr Radiol 2010; 40:373
7. Karmazyn B, Kaefer M, Kauffman S, Jennings
SG. Ultrasonography and clinical findings in children with epididymitis, with and without associated lower urinary tract abnormalities. Pediatr

Radiol 2009; 39:10541058

8. Kim W, Rosen MA, Langer JE, Banner MP, Siegelman ES, Ramchandani P. US-MR imaging
correlation in pathologic conditions of the scrotum. RadioGraphics 2007; 27:12391253
9. Lee A, Park SJ, Lee HK, Hong HS, Lee BH, Kim
DH. Acute idiopathic scrotal edema: ultrasonographic findings at an emergency unit. Eur Radiol
2009; 19:20752080
10. Ben-Sira L, Laor T. Severe scrotal pain in boys
with Henoch-Schnlein purpura: incidence and
sonography. Pediatr Radiol 2000; 30:125128
11. Bhatt S, Dogra VS. Role of US in testicular and scrotal trauma. RadioGraphics 2008; 28:16171629
12. Deurdulian C, Mittelstaedt CA, Chong WK,

Fielding JR. US of acute scrotal trauma: optimal
technique, imaging findings, and management.
RadioGraphics 2007; 27:357369
13. Agarwal PK, Palmer JS. Testicular and paratesticular neoplasms in prepubertal males. J Urol
2006; 176:875881
14. Woodward PJ, Sohaey R, ODonoghue MJ, Green
DE. Tumors and tumorlike lesions of the testis:
radiologic-pathologic correlation. RadioGraphics
2002; 22:189216
15. Dogra VS, Gottlieb RH, Rubens DJ, Liao L. Benign intratesticular cystic lesions: US features.
RadioGraphics 2001; 21:S273S281
16. Chiang LW, Yap TL, Asiri MM, Ong CCP, Low
Y, Jacobsen AS. Implications of incidental finding
of testicular microlithiasis in paediatric patients. J
Pediatr Urol 2011 [Epub ahead of print]

Fig. 112-year-old boy with left-sided testicular torsion.

A, Color Doppler ultrasound image shows severely diminished blood flow to left testicle (asterisk). Note soft-tissue mass (arrow) next to left testicle, corresponding to
torsed spermatic cord.
B, Color Doppler ultrasound image adjacent to torsed testicle shows twisted appearance of spermatic cord (arrows), consistent with torsion of spermatic cord. Minimal
color flow is seen centrally within spermatic cord, uncommon finding. Also note associated reactive hydrocele (asterisk).
(Fig. 1 continues on next page)

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Fig. 1 (continued)12-year-old boy with left-sided testicular torsion.

C, Color Doppler ultrasound image obtained after surgical detorsion shows
reperfusion (asterisk) of previously torsed left testicle.

Fig. 23-year-old boy with appendageal torsion.

A, Gray-scale ultrasound image shows well-defined oval-shaped mass (asterisk) next to epididymis (arrow) and testicle (T), consistent with torsed appendage. It is often difficult
to distinguish between testicular and epididymal appendages; however, testicular appendages are more common.
B, Color Doppler ultrasound image shows hyperemia (asterisk) around torsed appendage. Note central salt-and-pepper pattern from edema of torsed appendage, common
finding.

Fig. 34-month-old boy with epididymoorchitis.

A, Gray-scale ultrasound image shows diffusely enlarged heterogeneous epididymis (arrows), consistent with epididymitis. Gray-scale ultrasound appearance of testicle
(asterisk), however, is normal.
B, Color Doppler ultrasound image shows hyperemia around epididymis (arrows) and testicle (asterisk), consistent with inflammation in epididymoorchitis.

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Sung et al.

Fig. 411-year-old boy with acute onset of painless scrotal swelling, consistent with acute idiopathic scrotal edema.
A, Gray-scale ultrasound image shows diffuse scrotal edema (asterisks). Note normal appearance of testes.
B, Color Doppler ultrasound image shows increased vascularity in edematous scrotum (arrows). Note normal vascularity of testes.

Fig. 613-year-old boy with testicular rupture after penetrating trauma from
gunshot injury. Gray-scale ultrasound image shows abnormal contour of testicle,
as well as linear hyperechoic region (arrows), representing air along bullet tract.
This should not be confused with testicular microlithiasis (see Figs. 13 and 14).

Fig. 518-year-old man with testicular rupture after blunt trauma. Gray-scale
ultrasound image shows interruption of echogenic tunica albuginea (arrow).
Adjacent heterogeneously echogenic material (asterisk) likely represents
extruded testicular material as well as associated extratesticular hematoma.

A
1000

Fig. 717-year-old boy with testicular fracture after blunt trauma.

A, Gray-scale ultrasound image shows linear hypoechoic fracture line (arrows).
Also note heterogeneous region (asterisk), consistent with intratesticular
hematoma.
(Fig. 7 continues on next page)

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Ultrasound of Pediatric Scrotum

Fig. 7 (continued)17-year-old boy with testicular fracture after blunt trauma.

B, Another gray-scale ultrasound image of affected testicle shows large heterogeneous mostly hyperechoic region (asterisk), compatible with intratesticular hematoma.
C, Color Doppler ultrasound image shows lack of vascularity within center of abnormal heterogeneous region (asterisk), compatible with intratesticular hematoma.

Fig. 82-year-old boy with yolk sac tumor.

A, Gray-scale ultrasound image shows large slightly hyperechoic mass (margins outlined by arrows) almost replacing entire testis.
B, Color Doppler ultrasound image shows diffusely increased vascularity around tumor. (Courtesy of Chow J, Childrens Hospital, Boston, MA)

Fig. 96-month-old boy who presented with left testicular swelling. Gray-scale
ultrasound image shows heterogeneous mass replacing entire testicle, with solid
and cystic components, most compatible with teratoma, which was confirmed on
pathologic analysis.

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Sung et al.

Fig. 105-year-old boy with testicular lymphoma.

A, Gray-scale ultrasound image shows diffuse heterogeneous echotexture of testicle, which is enlarged. No discrete mass is identified.
B, Color Doppler ultrasound image shows increased vascularity, more compatible with malignant process.

Fig. 1115-year-old boy with congenital adrenal hyperplasia, found to have testicular adrenal rest.
A, Gray-scale ultrasound image shows lobular heterogeneous intratesticular mass (arrow).
B, Color Doppler ultrasound image shows diffusely increased vascularity (arrow) within and around mass.

Fig. 1218-year-old man with sickle cell disease and testicular pain found to have segmental testicular infarct.
A, Color Doppler ultrasound image shows wedge-shaped hypoechoic region (asterisk) without vascularity, consistent with focal infarct.
B, Two-week follow-up color Doppler ultrasound image shows nearly complete resolution of infarct (asterisk) and return of normal vascularity.

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Ultrasound of Pediatric Scrotum

Fig. 1317-year-old boy with diffuse testicular microlithiasis. Gray-scale

ultrasound image shows innumerable echogenic foci (i.e., microliths) spread
diffusely throughout both testicles.

Fig. 1413-year-old boy with focal testicular microlithiasis. Gray-scale ultrasound

image shows several punctate echogenic foci (arrows), consistent with microliths.

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