World J Urol (2011) 29:639–643
DOI 10.1007/s00345-011-0698-8
TOPIC PAPER
Role of US in acute scrotal pain
G. Liguori • S. Bucci • A. Zordani • S. Benvenuto •
G. Ollandini • G. Mazzon • M. Bertolotto •
F. Cacciato • S. Siracusano • C. Trombetta
Received: 4 March 2011 / Accepted: 5 May 2011 / Published online: 24 May 2011
Ó Springer-Verlag 2011
Abstract
Background The acute scrotum is a common emergency
department (ED) presentation and can be defined as any
condition of the scrotum or intrascrotal contents requiring
emergent medical or surgical intervention. Although rarely
fatal, acute scrotal pathology can result in testicle infarc-
tion and necrosis, testicular atrophy, infertility, and sig-
nificant morbidity.
Methods Scrotal US is best performed with a linear 7.5- to
12-MHz transducer. In addition to imaging in the longitudinal
and transverse planes, it is helpful to obtain simultaneous
images of both testes for comparison. Color Doppler is used to
evaluate for abnormalities of flow and to differentiate vascular
from nonvascular lesions. Attention to appropriate color
Doppler settings to optimize detection of slow flow is critical.
Results The evaluation of acute scrotal pain can be chal-
lenging for the clinician initially examining and triaging the
patient. Acute scrotal conditions due to traumatic, infec-
tious, vascular, or neoplastic etiologies can all present with
pain as the initial complaint. Additionally, the laboratory
and physical examination findings in such conditions may
overlap; this, coupled with potential patient guarding and
lack of collaboration, may result in a limited, non-specific
physical examination. Therefore, scrotal ultrasound has
emerged to play a central role in the evaluation of the
patient presenting with acute scrotal pain.
G. Liguori
S. Bucci
A. Zordani (&)
S. Benvenuto

G. Ollandini
G. Mazzon
S. Siracusano
C. Trombetta
Department of Urology, University of Trieste, Cattinara
Hospital, Strada di Fiume 447, 34124 Trieste, Italy
e-mail: alessio_zordani@hotmail.it
M. Bertolotto
F. Cacciato
Department of Radiology, University of Trieste, Cattinara
Hospital, Strada di Fiume 447, 34124 Trieste, Italy
Conclusions In conclusion, we are firmly convinced that
a scrotal ultrasound should always be performed in the
presence of acute scrotal pain. Moreover, urologist should
be able to perform a scrotal ultrasound but, if imaging does
not supply a clear diagnosis, surgical exploration is still
mandatory.
Keywords Acute scrotum
Color Doppler ultrasound

Orchi-epididymitis
Testicular trauma
Testicular torsion

Testicular infarction
Introduction
The acute scrotum is a common emergency department
(ED) presentation and can be defined as any condition of
the scrotum or intrascrotal contents requiring emergent
medical or surgical intervention. Moreover, it can result in
testicle infarction and necrosis, testicular atrophy, infertil-
ity, and significant morbidity.
The evaluation of acute scrotal pain can be challenging
for the clinician initially examining the patient, and scrotal
ultrasound has emerged to play an essential role in the
evaluation of patients presenting with acute scrotal pain.
US technique
Scrotal ultrasound is performed with the patient in the
supine position with the scrotum supported by thighs or a
rolled towel placed between the thighs. The Valsalva
maneuver while scanning in the upright position should be
always performed when evaluating for varicoceles.
Scrotal US is best performed with a linear 7.5- to
12-MHz transducer. In addition to imaging in the
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longitudinal and transverse planes, it is helpful to obtain
simultaneous images of both testes for comparison.
Color Doppler ultrasound (CDU) is used to assess flow
abnormalities and to differentiate vascular from nonvas-
cular lesions [1]. A correct CDU setting in order to opti-
mize detection of slow flow is critical. Power Doppler
increases the sensitivity for slow flow detection [2].
Epididymo-orchitis
Epididymitis and epididymo-orchitis are the most frequent
cause of acute scrotum in adults [3].
Clinically, epididymo-orchitis presents as acute scrotal
pain and swelling of sudden onset. Symptoms of lower
urinary tract infection associated with fever and leukocy-
tosis are distinctive features in the differential diagnosis
with testicular torsion.
Typical gray scale US findings of epididymitis consist of
an enlarged hypoechoic epididymis with parenchymal
heterogeneity due to edema and hemorrhage [4]. Associ-
ated orchitis develops in 20% of epididymitis due to con-
tiguous spread of infection [5]. Isolated orchitis is rare.
Orchitis is characterized by an enlarged and heterogeneous
testis, although findings may be focal or diffuse. When
focal, orchitis is most often located adjacent to an inflamed
epididymis. Focal orchitis can progress into abscess for-
mation and a clear distinction between the two conditions
is not simple. Associated findings of epididymo-orchitis
may include skin thickening and reactive hydrocele.
In case of tuberculous epididymo-orchitis, a more heter-
ogeneous sonographic appearance can be demonstrated [6].
CDU has a sensitivity of quite 100% in detecting scrotal
inflammation [7]. Color and power Doppler readily show a
diffuse or focal areas of increased color signal of the epi-
didymis (Fig. 1) and/or testis. While echogenicity may be
variable, Doppler flow is invariably increased. Spectral
Doppler patterns normally show increased peak systolic
velocity with variable degree of diastolic flow. On pulsed
Doppler, peak systolic velocity in intratesticular arteries
increase 1.7–2.0 fold on symptomatic side in epididymo-
orchitis [8]. A reversed diastolic flow suggests ischemia, a
rare complication that may occur secondary to venous out
flow obstruction. Demonstration of a normal spermatic
cord and lack of avascular areas in the testis are important
findings to exclude torsion [9].
Testicular trauma
Blunt trauma is the most common mechanism of injury
while penetrating scrotal injuries are less common. Direct
blow or straddle injuries can result in contusion,
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World J Urol (2011) 29:639–643
Fig. 1 Acute epididymitis in a 31-year-old man. Longitudinal color
Doppler US demonstrates normal testis and diffuse swelling of the
right epididymis and increased blood flow
hematoma, fracture, or rupture. Untreated testicular injuries
may result in ischemic atrophy, chronic pain, or secondary
infection.
Physical examination is may be limited due to pain and
often reveals varying degrees of edema; therefore CDU is
essential for confirmation or exclusion of testicular rupture,
differentiation of soft-tissue hematomas from hematocele
and follow up of patients undergoing conservative therapy
[3].
Testicular rupture
Ultrasound shows heterogeneous echogenicity within the
testis due to areas of hemorrhage or infarction. An irregular
or indistinct testicular contour is suggestive of testicular
rupture and a break in the continuity of the tunica albu-
ginea confirms the diagnosis (Fig. 2). Guichard et al. [10]
reported a sensitivity of 100% and specificity of 65% for
US in the detection of testicular rupture when comparing
with surgical findings. In addition, absence of normal
vascularity within the testis may help characterize a
rupture.
Testicular fracture refers to a break in the normal tes-
ticular parenchyma. In testicular fracture without rupture of
the albuginea, the capsule is intact (Fig. 3): a discrete
fracture plane is visible in only 17% of cases. A testicular
fracture line is identified at US as a linear hypoechoic and
avascular area within the testis.
Hematoma
Scrotal trauma often results in hematomas which may be
intratesticular or extratesticular [11]. They can involve the
testis, epididymis, or scrotal wall. US appearance varies
World J Urol (2011) 29:639–643
Fig. 2 Testicular Rupture in a 34-year-old man. Longitudinal US
image shows an abnormally shaped testis of the lower border,
intratesticular hematoma, and scrotal hematoma
with time because they can subsequently become complex
with cystic components. Acute hematomas initially appear
hyperechoic and avascular on color Doppler US scans [12],
but subsequently become hypoechoic.
Hematocele
Extratesticular hematoceles, or collections of blood within
the tunica vaginalis, are the most common finding in the
scrotum after blunt injury [13, 14]. The appearance of
hematoceles typically changes with time. In the early
stages, they appear hypoechoic and markedly heteroge-
neous, and then become more echogenic. Large hemato-
celes can take several months to reabsorb and may results
in testicular atrophy. Chronic hematoceles may become
calcified. Moreover, a large hematocele may displace and
obscure the underlying testis, leading to a false-positive
Fig. 3 Testicular Fracture. CDU of the testis of 21-year-old man
shows a wedge-shaped hypoechoic avascular area. A discrete fracture
plane is visible into the testis, with out rupture of tunica albuginea
641
diagnosis of testicular rupture or that may obscure a site of
tunica disruption leading to an exclusion of a testicular
rupture [8].
Testicular torsion
Testicular torsion is the rotation of the testis along its
longitudinal axis. This results in torsion of the spermatic
cord with an initial blockage of venous drainage and sub-
sequent reduction in arterial supply to the testis if complete
rotation persist [3]. Patients with acute torsion present after
a sudden onset of pain. Physical examination reveals a
swollen, tender, and inflamed hemiscrotum [15].
The degree of venous engorgement, edema, hemorrhage,
and arterial distress depends on the degree of torsion; basic
literature has shown that there must be at least 720° tor-
sions for occlusion of the testicular artery [16]. Venous
obstruction occurs first, followed by obstruction of arterial
flow and ultimately by testicular ischemia and infarction.
The severity of torsion of the testis depends on the
degree and length of torsion. If diagnosed in the first 6 h,
torsion can be successfully treated surgically in nearly
100% of cases; the salvage rate drops to approximately
20% between 12 and 24 h after diagnosis [17]. Transient or
intermittent torsion with spontaneous resolution sometimes
occurs. Ultrasound is helpful to differentiate testicular
torsion from other causes of acute scrotal pain and to
identify testicular torsion promptly, ensuring the highest
salvage rate (Fig. 4). One potential limitation with CDU is
in the detection of an episode of torsion after spontaneous
detortion has occurred: blood flow may be normal because
of post-ischemic hyperemia.
Real-time whirlpool sign is a key sign of testicular
torsion that has been recently described as a snail shell, a
doughnut shape, a target with concentric rings, and a storm
on a weather map [18]. The presence of vascular flow in
the testis can be readily detected by CDU with a sensitivity,
specificity, and accuracy that has been reported to be 86,
100, and 97%, respectively [19]. Unilateral diminished or
absent flow is the most accurate sign of testicular torsion,
but the presence of blood flow does not exclude torsion. In
these cases, spectral examination can show a decrease or
inverted diastolic flow secondary to initial venous out flow
obstruction. With time the testis becomes hypoechoic and
swollen on gray scale images, and peritesticular hyperemia
develops.
Torsion of the testicular appendages
Torsion of the testicular appendages is a frequent issue in
childhood [20, 21]. They occurs less frequently than
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Fig. 4 Testicular torsion. 18-year-old man who presented with left scrotal pain for 10 h. Longitudinal US shows an unevenly hypoechoic left
testis (a) compared to the normal right testis (b). CDU shows normal vascular flow in right testis and absent vascular flow in the left testis

testicular torsion does, but it can be as painful. Patients

typically present with gradual pain and may manifest with
a firm bluish nodule at the superior aspect of the testis
referred to as the ‘‘blue dot’’ sign [19]. Ultrasound shows a
circular hyperechoic mass with central hypoechoic area
adjacent to the testis or epididymis which may show
peripheral increased flow on color Doppler examination;
scrotal wall edema, epididymal enlargement, and reactive
hydrocele may also been shown. These cases are managed
conservatively, with attention to pain management. The
role of US examination in torsion of testicular appendages
is to exclude testicular torsion and acute epididymo-
orchitis [22].

Fig. 5 Testicular Infarct. CDU shows an ill-defined hypoechoic mass

with increased peritesticular vascularity but absence of intravascu-
Testicular infarction larity flow, indicating testicular infarction

Acute infarction usually presents as acute scrotum, but

sometimes sequelae of partial infarction of the testis may
atypically present as a testicular mass that may mimic a
testicular neoplasm [23]. The pathophysiology of this
clinical picture is congestion and thrombosis of the venous
and arterial blood supply to the testis.
US findings of testicular infarction are similar to torsion,
including lack of Doppler flow; and at gray scale, it appears
like an ill-defined hypoechoic mass, usually peripheral in
location, septal in distribution, and without mass effect
(Fig. 5). At times, a wedge-shaped area may be seen [24].
Infarction may also be segmental if due to an embolic
phenomenon, manifesting as a well-demarcated region of
hypoechogenicity with lack of flow.
Conclusion
In conclusion, we are firmly convinced that a scrotal
ultrasound should always be performed in the presence of
acute scrotal pain. Moreover, urologist should be able to
perform a scrotal ultrasound but, if imaging does not sup-
ply a clear diagnosis, surgical exploration is still
mandatory.
Conflict of interest The authors declare that they have no conflict
of interest.
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