Imaging, 22 (2013), 20120025

RENAL TRACT IMAGING

Ultrasound imaging of the on call acute scrotum

G MILES, MBBS, BSC and S J FREEMAN, MRCP, FRCR

Imaging Directorate, Level 6, Derriford Hospital, Plymouth, UK

Summary
Causes of the acute scrotum
1. Vascular
Spermatic cord torsion
Torsion of the appendix testis
2. Trauma
Testicular rupture/fracture
Haematoma/haematocele
Penetrating injury
3. Infective/Inflammatory
Epididymitis/epididymo-orchitis
Testicular abscess
Fourniers gangrene
4. Miscellaneous
Acute idiopathic scrotal oedema
Inguinoscrotal hernia
Testicular tumours
HenochSchonlein purpura
Torsion of the spermatic cord
Is a surgical emergencyirreversible ischaemia occurs after 6 h
Represents 17% of all acute scrotal presentations, the incidence is 1 in 4000 males
Intravaginal torsion is associated with the bell-clapper deformity. Presentation is
most commonly between the ages of 1218 years
Extravaginal torsion is rare and occurs in utero or the perinatal period, the testis
is usually unsalvageable
Greyscale ultrasound may be normal in immediate post-torsion period. Following
this, sonographic changes frequently mimic acute epididymo-orchitis.
Lack of flow or diminished flow on colour/power Doppler implies torsion.
Incomplete torsion will demonstrate a high resistance arterial waveform on
spectral Doppler imaging
Testicular trauma
The peak age range is 1540 years
Blunt trauma secondary to sporting injury is the commonest cause
The main purpose of ultrasound examination in blunt trauma is to assess the
integrity of the tunica albuginea and perfusion of the testicular parenchyma
Testicular rupture requires urgent surgical exploration to preserve normal
endocrine function; surgery may also be required for large haematomas that are
compressing the testis

Address correspondence to: Dr Simon J Freeman, Department of

Radiology, Derriford Hospital, Plymouth PL6 8DH, UK. E-mail:
simonfreeman@nhs.net

imaging.birjournals.org 1 of 16
 G Miles and S J Freeman

Ultrasound is not usually indicated in cases of penetrating scrotal trauma that

requires immediate surgical exploration
Epididymitis/epididymo-orchitis
Is the commonest cause of the acute scrotum with prevalence 40 per 10 000 men
in UK
In young men sexually transmitted infection is the most common cause; in elderly
men and children urinary pathogens predominate
Rarely may have a non-infective cause (sarcoidosis/Behets syndrome/amiodarone
treatment)
May be clinically indistinguishable from acute spermatic cord torsion
Hyperaemia on colour Doppler examination is the sonographic hallmark of this
condition; the epididymis may be enlarged and hypoechoic on greyscale
examination with involvement of the testis in cases of orchitis. There is
frequently an associated hydrocele and scrotal skin thickening
Complicated by abscess formation in 35% of cases
Chronic epididymitis normally due to Mycobacterium tuberculosis
Fourniers gangrene
Is an infective, necrotising fasciitis of the perineal, genital and perianal regions
Represents a surgical emergency with high morbidity and mortality rates where
diagnosis is delayed
Risk factors include diabetes mellitus, alcoholism, immunocompromise and recent
perineal/pelvic surgery
Scrotal subcutaneous emphysema is the pathognomonic sonographic feature and
may track to thighs, ischiorectal fossae and anterior abdominal wall
The testes are usually spared and sonographically normal
Acute idiopathic scrotal oedema
Peak incidence is at 67 years; this condition is very rare in adults
Scrotal swelling may be gross but severe pain is an unusual feature
Self-limiting condition that does not require surgical intervention
No definite causative agent identified; aetiology may be infective or allergic
Marked scrotal wall thickening, oedema and hyperaemia are the sonographic doi: 10.1259/imaging.
features 20120025
The testis and epididymis will be normal in appearance with normal intra-testicular
blood flow allowing easy differentiation from spermatic cord torsion 2013 The British Institute of
Radiology

Cite this article as: Miles G, Freeman SJ. Ultrasound imaging of the on call acute scrotum. Imaging 2013;22:
20120025.

Ultrasound evaluation of acute scrotal pathology is an
increasingly common request for the on-call radiologist.
Ultrasound is the imaging investigation of choice for
evaluation of the scrotum; in experienced hands, scrotal
ultrasonography allows rapid and accurate assessment of
most potential scrotal surgical emergencies. The superfi-
cial location of the scrotal contents permits the use of
high-frequency linear array transducers resulting in
images of extremely high resolution; this is combined
with assessment of scrotal blood flow using colour and
spectral Doppler techniques. The ultrasound practitioner
on call should have a good grasp of the normal anatomy,
scan technique and imaging appearances of the acute
pathologies which can present with scrotal pain and
swelling.
Although epididymitis is the commonest cause of acute
scrotal pain, imaging is frequently requested due to the
consequences of failing to diagnose torsion of the spermatic
cord, particularly in adolescent and young men. Despite
some studies quoting the specificity of clinical exami-
nation alone for the detection of acute spermatic cord
torsion to be as high as 90% [1], there is still diagnostic
uncertainty in a significant number of cases. Ultrasound
can also diagnose a number of other causes of scrotal
pain and swelling and provide valuable information in
cases of blunt scrotal trauma.
The aim of this article is to familiarise the reader with
the sonographic appearances of conditions that may
present with acute scrotal symptoms.
Imaging technique
Ultrasound examination should be performed in
a quiet and private setting ensuring that access to the
examination room is restricted to essential staff; as with
all intimate ultrasound examinations, the ultrasound
practitioner is advised to include the presence of a chap-
erone during the examination. The patient should be
positioned supine with scrotum elevated, supported and
immobilised by a rolled-up towel placed between the
patients thighs. The penis should be placed on the an-
terior abdominal wall with a further towel placed over it
and held in position by the patient.

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Imaging the acute scrotum
Using a high-frequency (8-15 MHz) linear array
transducer and commencing with the asymptomatic side,
each testis should be scanned in both longitudinal and
transverse planes, comparing size and echotexture. It is
good practice to obtain an additional transverse or split-
screen image of both testes, accentuating any differences
between the two sides.
Colour Doppler images should be obtained to dem-
onstrate arterial blood flow to each testis and epididymis,
with parameters optimised to demonstrate low flow
velocities [2]. In the pre-pubertal testis power Doppler
may be useful in detecting low velocity flow where
colour Doppler alone may fail; in one study flow was
seen in 92% of pre-pubertal testes using power Doppler
but only 83% of cases using conventional colour
Doppler [3].
Spectral Doppler imaging allows quantitative interro-
gation of arterial flow. The normal intratesticular and
capsular arteries demonstrate a low resistance spectral
flow pattern with resistive indices (RIs) ranging from 0.46
to 0.78 [4, 5], depending on the size of the testis (Figure 1);
RI often being higher in pre-pubescent boys with smaller
testicular volumes [6]. Obtaining a spectral trace from
a small intratesticular artery can be a technical challenge
requiring a co-operative patient and steady hand by the
ultrasound practitioner.
The examination should then evaluate the epididymis,
extratesticular soft tissues and scrotal skin in longitudinal
and transverse planes. The patient should be asked to in-
dicate any specific sites of pain or mass and these should
be examined with particular care.
Although only limited studies have been performed
to date, the use of contrast-enhanced ultrasonography
(CEUS) is yet to show a significant benefit over conven-
tional Doppler assessment of the acute scrotum. A recent
study by Moschouris et al [7] of 19 patients presenting
with an acutely painful scrotum showed that CEUS failed
to increase diagnostic accuracy over conventional grey-
scale and colour Doppler ultrasound. In our institution,
CEUS is not routinely used in this setting but can be
valuable as a problem-solving tool (Figure 2).
imaging.birjournals.org
Relevant imaging anatomy
The scrotal wall is approximately 36 mm thick and
is made up of (listed from superficial to deep) rugated
skin, superficial fascia, dartos muscle, external spermatic
fascia, cremasteric fascia and internal spermatic fascia.
The scrotum is architecturally divided by the midline
septum that separates the two testes and their associated
structures.
Each testis is covered by the fibrous capsule of the
tunica albuginea. As the testis descends into the scrotal
sac during foetal development, it takes with it the cov-
ering of a reflected fold of peritoneumthe processus
vaginalis. As it passes over the pubic bone, the reflected
processus vaginalis becomes the tunica vaginalis, with
parietal and visceral layers, the latter attached to the tu-
nica albuginea of the testis. In the normal patient, there is
12 ml of fluid lying between the two layers of the tunica
vaginalis. The connection with the peritoneal cavity is
usually obliterated shortly after birth but may remain
patent allowing formation of a congenital hydrocoele.
The testes lie in a longitudinal plane, tilted slightly
forwards, the left usually slightly lower than the right.
Before puberty, average testicular volume is approxi-
mately 12 cm3. At puberty, the volume is approxi-
mately 4 cm3. In adulthood, the average testis measures
53332 cm [8], with a volume of up to 30 cm3 [9]. In each
testis, there are multiple fibrous septa extending from the
tunica albuginea separating approximately 250 lobules.
Each of these lobules contains 14 seminiferous tubules,
which join to form the tubuli recti that are larger ducts.
The tubuli recti join the mediastinum testis (a fibrous
band that provides support for both the ducts and the
vessels) to form the rete testis, which drains into 1015
efferent ductules that in turn drain into the epididymis
[10]. The normal rete testis can be seen in 18% of patients
adjacent to the echogenic mediastinum testis as a hypo-
echoic striated area (Figure 3).
The four testicular appendages are thought to repre-
sent embryological duct remnants. The two most radio-
logically significant are the appendix testis and the
Figure 1. Normal spectral Dopp-
ler trace from an intratesticular
artery in an adult patient. There is
a low resistance flow pattern with
a large component of forward
diastolic flow. The resistance in-
dex is 0.62.
3 of 16

appendix epididymis. Torsion of either of these structures
may present acutely and can mimic torsion of the sper-
matic cord. The appendix testis (hydatid of Morgagni)
lies at the upper testicular pole between the testis and
epididymis (Figure 4). It is a remnant of the Mullerian
duct. The appendix epididymis is attached to the epi-
didymal head and represents a remnant of the meso-
nephron. The vas aberrans and the paradidymis are not
usually identified sonographically.
The epididymis can be considered as three parts: head,
body and tail. The epididymal head is found at the cra-
nial pole of the testis, the body lies longitudinally along
the posterolateral aspect and the tail is found at the
caudal pole. The echotexture of the head may be coarser
than that of the testis but is usually isoechoic to the pa-
renchyma of the testis [11]; the epididymal body and tail
are usually hypoechoic relative to normal testicular pa-
renchyma. The head contains the convergence of the ef-
ferent ductules that form a single tube, which follows
Figure 3. Normal rete testis. A linear hypoechoic collection
of tubules (arrows) is seen lying adjacent to the (echogenic)
mediastinum testis.
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G Miles and S J Freeman
Figure 2. Contrast-enhanced ul-
trasonography image of the testis
in a patient with scrotal pain
showing extensive testicular in-
farction. The contrast-specific im-
age (split screen image to the
readers left) shows poor and
patchy perfusion of the testis
1 min 15 s after i.v. injection of
ultrasound contrast microbubbles
(SonoVue 4.8 ml).
a convoluted course along the epididymal body and tail
and back to eventually become the vas deferens as it joins
the spermatic cord above the testis. Mean epididymal sizes
(6SD) are 7.6 6 1.6 mm for the head, 3.2 6 0.8 mm for
the body and 7.7 6 1.3 mm for the tail [12].
The spermatic cord contains seven structures: namely
the vas deferens, the venous pampiniform plexus, lym-
phatics, the genital branch of the genitofemoral nerve
(L1/2) and three arteries (testicular, cremasteric and
deferential). The main blood supply of the testis is via the
testicular artery, arising directly from the infrarenal ab-
dominal aorta. This travels in the spermatic cord through
the inguinal canal to reach the tunica albuginea where it
divides into capsular arteries that run beneath the tunica.
These capsular arteries give off centripetal arteries which
pass towards the central mediastinum testis and which
Figure 4. Normal appendix testis (arrow). The testicular
appendages are more easily seen when hydrocele fluid is
present (as in this case).
Imaging 2013, 22, 20120025
Imaging the acute scrotum

can be easily identified on colour Doppler examination

(Figure 5). Approximately half of all normal testes have
a transtesticular branch of the testicular artery [13] seen
on ultrasound as a hypoechoic band running through the
testis with an accompanying vein (Figure 6). Spectral
Doppler assessment of the testicular artery and its
branches shows a low resistance waveform with a broad
systolic peak and large component of forward diastolic
flow [14]. The other scrotal tissues are supplied by the
cremasteric artery (a branch of the inferior epigastric
artery) and the deferential artery (a branch of the ve-
sicular artery). The scrotal skin takes its supply from the
pudendal artery. These differences in arterial supply
play an important role in differentiating various disease
processes. The pampiniform plexus is the venous drainage Figure 6. Transtesticular vessels (arrows). Colour Doppler
network of the testes. It drains into the testicular vein, image showing the straight course of the transtesticular
which on the right drains directly into the inferior vena vessels crossing the testicular parenchyma towards the
cava and on the left, into the left renal vein. echogenic mediastinum testis.

Acute scrotal pathology occurs after 6 h [17], therefore, it is vital to make an ac-
curate prompt diagnosis. Further studies have reported
Vascular conditions 100% testicular salvage rates in patients operated on within
6 h of the onset of pain; a 70% salvage rate in patients
operated on within 612 h and 20% salvage rate in those
Torsion of the spermatic cord
operated on .12 h after the onset of pain [18].
Torsion of the spermatic cord (frequently referred to as
Two types of torsion are described: namely intravaginal
testicular torsion) is one of the most important surgical
and extravaginal. These descriptions relate to the ana-
emergencies relating to the testes and is usually the prime
tomical relationship of the testis to the tunica vaginalis.
diagnostic consideration in any young man presenting
Intravaginal torsion accounts for 6580% of cases of
with acute scrotal pain; 17% of all acute scrotal pre-
spermatic cord torsion [16]. In most of these patients, the
sentations are due to testicular torsion [15], the incidence
testis is prone to twisting due to an underlying bell-
is 1 in 4000 [16]. This condition is uncommon in children
clapper deformity that allows abnormal testicular mo-
prior to the rapid increase in testicular volumes that occurs
bility (Figure 7). The testis is able to fall forward and rotate
at puberty.
within the tunica vaginalis due to deficient attachment of
Symptoms of torsion are seen when the spermatic cord
the testis posteriorly. This deformity has been found in as
twists by ,180, initially resulting in obstructed venous
many as 12% of adolescent males [19]. The peak ages for
drainage causing oedema and possibly haemorrhage and
intravaginal torsion are between 12 and 18 years of age
ultimately increased intratesticular pressures which im-
[20]. The patient commonly presents with an acute onset of
pair arterial supply to the testis. If left untreated, unless
severe scrotal or lower abdominal pain with accompanying
spontaneous untwisting occurs, the testis will become
scrotal swelling and associated nausea and vomiting.
necrotic and non-viable. The opportunity for successful
The patient may also have low-grade pyrexia. On
surgical treatment of torsion decreases rapidly with time;
experimental studies show that irreversible ischaemia

Figure 7. Bell-clapper testis. In this patient, with a hydrocele

the spermatic cord and testis are surrounded by fluid
Figure 5. Normal testicular flow shown with power Doppler. demonstrating the deficiency of posterior attachment to
Straight vessels are seen passing along the intratesticular the scrotal wall. This patient will be at increased risk of
septa towards the mediastinum testis. spermatic cord torsion.

imaging.birjournals.org 5 of 16
 G Miles and S J Freeman

clinical examination, the scrotum will be swollen and

acutely tender. The torted testis may be lying in an ab-
normal transverse plane in a high-riding location within
the scrotum. A hydrocele may or may not be present. If
there is a typical presentation, definitive operative man-
agement should not be delayed with an unnecessary ul-
trasound scan.
Ultrasound may be useful when the diagnosis is in
doubt. It should however be noted that the greyscale
appearances of a torted testis may be normal in the im-
mediate post-torsion period. In the following 46 h, the
testis becomes increasingly swollen and hypoechoic with
the onset of oedema. At 24 h, the testis is unsalvageable
and will appear more heterogeneous in echotexture
(Figure 8). This appearance is caused by vascular conges-
tion, haemorrhage and infarction that invariably ensues
[21]. If there is involvement of the deferential artery, the
epididymis will be enlarged and may be heterogeneous Figure 9. Spermatic cord torsion, transverse image of both
and echogenic (if haemorrhagic) [22]. Other possible as- testes. There is a complex right hydrocoele containing low-
sociated findings include a hydrocele and thickening of level echoes and septation. The right testicular parenchyma is
the scrotal wall secondary to congestion (Figure 9). It can mildly hypo-echoic in comparison with the normal left testis.
be seen therefore that the greyscale appearances of sper-
matic cord torsion may be normal or indistinguishable clinician should be aware of the falsely re-assuring ap-
from epididymo-orchitis and therefore are of limited value pearance of normal or increased colour flow that may be
in the diagnosis of this condition. demonstrated following de-torsion of an intermittently
In suspected spermatic cord torsion ultrasound di- torting testis (Figure 12).
agnosis is predominantly based on assessment of vascular In the pre-pubescent small volume testis, power
flow with colour Doppler interrogation of the testicular Doppler may be more sensitive at demonstrating testic-
parenchyma (with the Doppler scale and gain suitably ular flow [23]. Occasionally, it is not possible to demon-
adjusted for low flow). Comparison should be made with strate intratesticular flow on either side in a child, even
the colour Doppler appearances of the normal testis. with a modern high-end ultrasound system, this repre-
Absent flow in the symptomatic testis should be inter- sents a non-diagnostic study and ultrasound cannot assist
preted as confirmation of the clinical suspicion of torsion with the confirmation or exclusion of spermatic cord
(Figures 10 and 11). In cases of incomplete torsion, de- torsion in this situation.
creased flow signal may be demonstrated within the Some authors believe that spectral Doppler is the only
testicular parenchyma in comparison with the normal accurate sonographic tool for assessing intratesticular
side and this should also be regarded as a positive blood flow [24], especially in incomplete torsion. In cases
study. The ultrasound practitioner and referring where some intratesticular blood flow is still present,
there will be a high resistance arterial waveform, with
decreased or reversed diastolic flow and an increased RI
[25], these findings will be asymmetric when compared
with the normal side.

Figure 8. Spermatic cord torsion. This 15-year-old patient

presented .24 h following the onset of pain. Greyscale Figure 10. Spermatic cord torsion. Colour Doppler image
ultrasound shows a heterogeneous testicular parenchyma shows that there is no detectible flow within the right
with ill-defined hypoechogenicity indicating testicular oe- testicular parenchyma. Note that there is relative hyperaemia
dema, ischeamia and necrosis. of the adjacent scrotal soft tissue.

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Imaging the acute scrotum
Figure 11. Spermatic cord torsion. (a) On the symptomatic
left side, no intratesticular flow can be demonstrated
confirming the clinical diagnosis of torsion. (b) On the
asymptomatic right side, intratesticular flow is easily appre-
ciated with power Doppler examination. (c) Colour Doppler
image of the left spermatic cord shows a leash of colour flow
signal representing the twisted vessels; this appearance is
known as the torsion knot.
Extravaginal torsion usually occurs in utero and in the
peri-natal period, when the testis and its covering tunica
are not firmly attached to the scrotum during testicular
descent and can rotate freely. This normally occurs at the
level of the external inguinal ring [26]. The neonate usu-
ally presents with an unsalvageable testis in the form of
imaging.birjournals.org
a painless, enlarged globular, heterogeneous testis with
associated bilateral hydroceles and skin thickening, with
absent Doppler signals [27].
Torsion of the appendix testis
Torsion of the appendix testis or appendix epididymis
can present in an identical manner to acute spermatic
cord torsion, with scrotal pain and swelling but is more
frequently seen in younger patients. It is important to
differentiate this condition from acute spermatic cord
torsion, as it can be successfully treated conservatively
without surgical exploration. Clinically, it may be possi-
ble to find the classic blue dot sign [26], a tender, firm
small nodule attached to the upper pole of the testis
which exhibits a blue colour through the overlying skin;
however, this is not an invariable appearance, with some
studies reporting that it is only present in 7% of cases [28].
Variable sonographic greyscale appearances have also
been reported; with studies in 1993 by Hesser [29] and in
2005 by Baldisserotto [30] describing the torted appendix
testis with variable echogenicities and sizes, some finding
an oval-shaped hyperechoic nodule of a size .5.6 mm
being suggestive of torsion (Figure 13). While colour
Doppler may be useful in differentiating a normal from
an avascular appendix testis [31], increased peritesticular
blood flow (as well as the presence of a hydrocele) may
be useful adjuncts in the diagnosis of torted appendices
testis [28].
Demonstration of normal flow within the testicular
parenchyma provides reassurance that spermatic cord
torsion is not present.
Trauma
Trauma represents the third most common presen-
tation of acute scrotal pain [32]; it occurs most commonly
in men between the ages of 1540 years [33]. Performing
an accurate clinical examination in trauma is frequently
difficult and findings may not truly represent the un-
derlying pathology. Careful ultrasonongraphic assess-
ment may identify the nature and extent of injury and
those patients with conditions that require emergency
surgical exploration; particularly, testicular rupture
where timely intervention can result in testicular salvage
rates of 83% [34]. Mechanisms of injury can be considered
as either blunt or penetrating trauma. Thermal or iatro-
genic trauma will not be considered in this paper. Blunt
trauma accounts for the majority of cases.
The commonest cause of blunt scrotal trauma is
sporting activity, accounting for approximately half of all
cases, with road traffic accidents causing 917%, the re-
mainder is predominantly caused by assault [35]. The
testis often becomes crushed between the pubic bone and
a solid object. Due to its more cranial anatomical location,
the right testis is more commonly injured than the left
[36].
Testicular rupture can be defined as disruption of the
inelastic tunica albuginea with protrusion of the semi-
niferous tubules into the scrotal sac [33]. This can be
identified on ultrasound as disruption of the normal
echogenic contour of the tunica albuginea and poorly
defined testicular margins (Figure 14, [37]). The echo-
texture of the testis may appear heterogeneous secondary
to haemorrhage, infarction and distortion of the normal
7 of 16
 G Miles and S J Freeman

Figure 12. Spontaneous spermatic cord detorsion with rebound hyperaemia. This pre-pubertal boy presented with acute onset
of left testicular pain that had almost resolved by the time of the ultrasound study several hours later. The left testis (a) increased
low resistance flow on spectral Doppler imaging in comparison with the low velocity high resistance flow in the asymptomatic
right testiswhich is a normal finding in a child (b). Note the abnormally heterogeneous appearance of the left testicular
parenchyma interpreted as ischaemic/oedematous change.

parenchymal architecture (Figure 15). There may be an
associated haematocele or scrotal haematoma. Vascular
compromise may result in ischaemia identifiable as a loss
of normal colour Doppler flow to part or all the testicular
parenchyma. Testicular rupture requires urgent surgical
exploration with excision of necrotic testicular tissue and
closure of the tunical defect; this results in high rates of
testicular preservation and maintenance of normal en-
docrine function [38].
Testicular fracture can be considered as a separate
entity to rupture and comprises disruption of the testic-
ular parenchyma with an intact tunica albuginea. It is
uncommon with studies reporting this finding in only
17% of cases [37]. Sonographically, testicular fracture will
appear as an echo-poor, avascular line running through
the substance of the testis. Unlike rupture of the testes,
it may be successfully treated conservatively if normal
testicular blood flow is demonstrated on colour Doppler
examination [39].
Haematomata and haematoceles are common associ-
ated findings with both testicular rupture and fracture
but may also present as single post-traumatic entities
(Figure 16). A haematocele is a collection of blood within
the two layers of the tunica vaginalis as opposed to
a haematoma, which may be present within the scrotal
wall, epididymis or within the testis itself. As is common
to all collections of blood, their sonographic appearances
vary with their age at presentation. In the acute setting,
both are seen as echogenic collections without flow. As
time progresses, they become increasingly hypoechoic.
They may contain internal septations and fluidfluid
levels as the blood products degenerate and are resorbed
[40]. The presence of both haematoceles and scrotal hae-
matomata may exert pressure on the testis causing a
tamponade effect on testicular blood flow; this may result
in tissue ischaemia and ultimately necrosis [41]. The
presence of a large haematocele or haematoma on ultra-
sound, particularly when the testicular parenchyma is

Figure 13. Torsion of a left tes-

ticular appendage. Split screen
images of longitudinal and trans-
verse views of an enlarged and
avascular testicular appendage
(note the shallow hydrocele). Nor-
mal flow was demonstrated within
the left testis and the patient was
treated conservatively.

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Imaging the acute scrotum
Figure 14. Testicular rupture. In this 24-year-old man a de-
fect of the tunica is demonstrated at the lower pole of the
testis (arrows) with protrusion of a nodule of testicular
parenchyma through the defect (*). Note the associated
adjacent echopoor haematoma. This injury required surgical
exploration.
compressed and hypovascular, should prompt surgical
review as it may not be possible to confidently identify an
intact tunica albuginea in the presence of a large complex
fluid collection [36]. Some guidelines recommend con-
servative management for scrotal haematomas less than
three times the size of the contralateral testis and early
surgical intervention for larger haematomas [38].
Penetrating scrotal injury has a range of causes from
gun and knife wounds to bites of animal or human nature
and as a result has a range of ultrasonographic findings.
Penetrating injuries are more likely to involve both testes
than blunt trauma [42]. As well as the previously de-
scribed appearances of testicular rupture, one may expect
to find air within the scrotum as well as foreign material.
An intratesticular bullet track may exhibit similar features
to a testicular fracture, with a hypoechoic line through
Figure 15. Testicular rupture. The testis has an abnormal
anterior margin indicating rupture of the tunica albugenea.
There are focal areas of hypoechogenicity within the testis
adjacent to the site of rupture indicating intraparenchymal
haematoma. Note the associated hydrocoele/haematocoele.
imaging.birjournals.org
Figure 16. Post-traumatic scrotal haematoma. There is a
large haematoma indenting and compressing the adjacent
left testis.
the parenchyma [36]. Ultimately, these injuries require
prompt urgent surgical exploration to debride non-viable
tissue and to prevent subsequent infection; ultrasound
imaging is not routinely indicated.
Infective/inflammatory conditions
Epididymitis and epididymo-orchitis
Epididymitis and epididymo-orchitis represent the
commonest cause of the acute scrotum [21] with a prev-
alence of 40 per 10 000 men in the UK [43]. It can affect
a wide age range and different pathogens are identified
within different age groups. Infections such as Chlamydia
trachomatis and Neisseria gonorrhoeae are the commonest
causative agents in sexually active young men, while
urinary pathogens such as Escherichia coli and Proteus
mirabilis are found predominantly in older men, particu-
larly when there is bladder outflow obstruction [17, 44].
Epididymo-orchitis can also be seen in the paediatric
population where structural genitourinary anomalies
should be considered in those with repeated infections.
As with older men, the cause in the pre-pubertal age
group is often E. coli [10].
Infection most commonly tracks to the epididymis via
the vas deferens secondary to urinary or urethral infec-
tion. Rarely infection may be due to haematogenous and
lymphatic spread with pathogens such as Mycobacterium
tuberculosis and Brucella abortus. Non-infective causes
have also been described including sarcoidosis, Behets
disease, trauma, drugs and amiodarone drug treatment
[44].
Clinically, a patient with epididymitis may present
with identical features to a patient with acute spermatic
cord torsion, namely an inflamed, swollen, exquisitely
tender scrotum. There may or may not be signs of systemic
infection and lower urinary tract symptoms such as dys-
uria and frequency. Prehn described a clinical sign to help
differentiate scrotal pain caused by epididymo-orchitis
9 of 16

Figure 17. Acute epididymitis. The left epididymal tail is
enlarged and hypoechoic, indenting the lower pole of the
testis.
from that of acute testicular torsion, involving elevating
the scrotum above the level of the symphysis pubis [45].
The elevation brings about relief of scrotal pain in the case
of epididymo-orchitis but the reliability of this sign is
unproven.
The greyscale sonographic appearances of epididymo-
orchitis can also mimic those of acute spermatic cord
torsion with features such a reactive hydrocele, changes
in testicular and epididymal echogenicity and size and
scrotal skin thickening/oedema common to both. Grey-
scale assessment may be more useful in ruling out abscess
or tumour as a cause rather than establishing the primary
diagnosis, with sensitivity reported at only 80% for de-
tection of epididymo-orchitis [46]. Typically, ultrasound
initially shows enlargement of the epididymis that usu-
ally appears hypoechoic when compared with the un-
affected side (Figure 17). If haemorrhage is present the
epididymis may appear more heterogeneous and hyper-
echoic [47]. Orchitis subsequently develops in 2040% of
10 of 16
G Miles and S J Freeman
patients as a consequence of direct spread of infection
[21]. The testis may be enlarged and globally or focally
hypoechoic, particularly in the area of the testis adjacent
to the inflamed epididymis (Figure 18, [10, 48]. Colour
Doppler can facilitate the diagnosis with detection of
hyperaemia of the epididymis and testis which is found
to be a reliable sign of epididymo-orchitis (Figure 19, [46])
and in some cases may be florid [49]. In some patients,
hyperaemia may be the only sonographic finding. Spec-
tral Doppler interrogation usually demonstrates a high
flow and low resistance waveform [46, 49] in distinction
to the high resistance waveform of spermatic cord tor-
sion. In severe epididymo-orchitis, however, venous in-
farction may occur, in this situation, the affected area of
testis may show a high intratesticular arterial resistance
spectral pattern with little or no colour flow and may
mimic spermatic cord torsion (Figure 20).
Rarely orchitis may occur in the absence of epididy-
mitis, usually in the setting of mumps (Figure 21). The
diagnosis of mumps orchitis is usually straightforward if
the patient has a history of parotid gland inflammation
(orchitis usually occurring 12 weeks later) but is more
difficult when parotitis is absent. It is uncommon in chil-
dren under the age of 10 years and bilateral in 10-30% of
cases. 3050% of patients will subsequently develop a de-
gree of testicular atrophy [50].
Chronic epididymitis most commonly results from
M. tuberculosis (via genitourinary tract spread) but can be
caused by other pathogens eliciting a granulomatous re-
action including syphilis, brucellosis and various para-
sitic infections. Acute pain is uncommon in this condition
and patients usually present with scrotal swelling and
discomfort. Ultrasound appearances are non-specific with
an enlarged variable echogenicity epididymis and other
common inflammatory findings including hydroceles
and scrotal wall thickening [51] Calcification may also be
seen. The testis itself is less commonly affected but can
mimic the appearances of a primary testicular malig-
nancy, with a solitary hypoechoic mass or show a more
heterogeneous mixed echogenicity pattern [52]. In the
later stages of the disease, abscess formation and fistu-
lation may also be present (Figure 22).
Figure 18. Acute epididymo-
orchitis. This 82-year-old man pre-
sented with acute right scrotal
pain. The split screen image shows
and enlarged and heterogeneous
right epididymal head and a het-
erogeneous appearance of the
adjacent testicular parenchyma.
The left testis is normal.
Imaging 2013, 22, 20120025
Imaging the acute scrotum
Figure 19. Acute epididymo-orchitis. Power Doppler image
of the lower pole of the left testis and epididymal tail. The
epididymis is enlarged and hyperaemic with associated
hyperaemia of the adjacent testis.
Testicular abscess or suppurative necrosis is a recog-
nised complication of epididymo-orchitis and occurs in
35% of cases in some reported series [53]. An abscess
will appear as a complex intratesticular fluid collection
with peripheral hypervascularity but no internal vessels
(Figure 23, [4]). A study by Mevorach [54] suggested a
more distinguishing sonographic pattern of an abscess;
namely disrupted testicular architecture containing ra-
diating striations of increased reflectivity separating
hypoechoic areas.
Fourniers gangrene
Since its initial anatomical description in 1883 by Jean
Fournier, a French Venerologist [55], Fourniers gangrene
has continued to have devastating consequences, despite
Figure 20. Severe epididymo-orchitis with testicular ischae-
mia. In this adult patient, there are very few colour Doppler
signals within the testicular parenchyma indicating ischeamia
of the testis. Note the marked thickening of the extratesticular
soft tissues and hypoechogenic appearance of the testis.
imaging.birjournals.org
Figure 21. Mumps orchitis. The right testis shows a mild
diffuse echopoor echogenicity. The epididymis and left testis
were normal. This adult patient (who had not suffered from
mumps as a child) presented with right testicular pain. There
was a history of bilateral parotid gland swelling in the
preceding week making the diagnosis of mumps orchitis
straightforward in this case.
considerable improvements in diagnosis and treatment
with mortality rates in the past decade ranging from
15% to 50% [56, 57]. It can be defined as an infective
necrotising fasciitis of the perineal, genital and perianal
regions [58]. Initially thought to have an idiopathic aeti-
ology, more recently, infection with pathogens origi-
nating from the urinary tract, colorectal region and the
skin of the perineum have been implicated as likely
causative agents [57], with an increased incidence seen
in many debilitating conditions including alcoholism,
diabetes, in immunocompromised patients and follow-
ing pelvic surgery.
Although often a clinically based diagnosis, the iden-
tifiable features on ultrasound should not be missed in
a patient presenting with an acutely swollen and painful
scrotum. Clinical findings frequently underestimate the
Figure 22. Tuberculous epididymo-orchitis. This elderly
patient had a long history of left-sided scrotal swelling and
discomfort. The ultrasound image shows and epididymal
abscess posterior to the testis. The testis itself has a micro-
nodular echopoor parenchyma indicating tuberculous orchitis.
11 of 16
 G Miles and S J Freeman

Figure 23. Testicular abscess. In this patient with epididymo-

orchitis, there is a focal complex fluid collection with
surrounding hyperaemia representing a testicular abscess.
This abnormality resolved completely following antibiotic
treatment on a follow-up examination.

extent of infection within the fascial tissue planes. Some

studies have quoted rates of fascial necrosis, up to
23 cm per hour [59]. Early diagnosis and prompt
treatment with aggressive surgical debridement and in-
travenous antibiotic therapy have been found to confer
significantly higher survival rates; one study reported
a mortality rate of 76% when diagnosis was delayed by 6
days compared with 12% mortality when the diagnosis
was made within 24 h [60, 61].
Although other radiological modalities such as CT and
MRI have a role to play in defining the extent of spread of
infection, ultrasound often represents the first investi-
gation requested in the patient with Fourniers gangrene
presenting with acute scrotal swelling and pain. The
presence of scrotal subcutaneous emphysema is the
hallmark sonographic finding [62] and may precede
the clinical finding of soft-tissue crepitus. Gas appears as
numerous hyperechoic foci within the scrotal wall, casting
posterior acoustic shadows [60] with reverberation arte-
fact [56] (Figure 24). This finding may also be present
within the anterior abdominal wall as the infection tracks
along Colles and Scarpas fascia as well as to the ischior-
ectal fossae and thighs. A normal sonographic appear-
ance of the testes and epididymides is an expected
finding, as their separate blood supply (testicular and
deferential arteries) from that of the scrotal skin (puden-
dal artery) confers a partial protection from the oblitera-
tive endarteritis [63] and ensuing spread of infection.
Miscellaneous conditions
Acute idiopathic scrotal oedema
This condition was initially described by Qvist in 1956
[64] and predominantly affects pre-pubertal boys with an
average age at presentation of 67 years [65]. It accounts
for between 20% and 69% of boys younger than 10 years
of age presenting with acute scrotal discomfort and
swelling [64, 65]; it is very rarely described in adult males
[66]. The condition is self-limiting but accurate diagnosis
is required to prevent unnecessary surgical intervention.
Its presenting features of a 12 day history of a swollen,
Figure 24. Fourniers gangrene. (a): In this 67-year-old
diabetic patient there are areas of linear high echogenicity
with posterior acoustic shadowing and reverberation arte-
fact consistent with gas (arrows) in the right hemi-scrotum
above the testis. (b): In this more severe case a transverse
view of the scrotum demonstrates extensive gas within the
left hemi-scrotum obscuring the underlying testis.
hot and tender scrotum may be identical to those of
a patient with Fourniers gangrene, epididymo-orchitis or
acute spermatic cord torsion although swelling rather
than intense pain is more usual. Although no causative
agent has been identified, infection is a mechanism fav-
oured by some authorities [67]; a full blood count may
demonstrate eosinophilia more in keeping with an aller-
gic reaction akin to angioneurotic oedema, a cause fav-
oured by other authors [64, 68].
Sonographic findings are of marked scrotal wall
thickening and oedema [69], with the greyscale appear-
ances of the testes and epididymides remaining normal
(Figure 25). There is hyperaemia of the scrotal skin seen
on colour Doppler imaging, while testicular blood flow
remains normal [10, 17]. A more recent report suggests
a characteristic fountain appearance of scrotal skin
hyperaemia seen on scanning in a transverse plane [70].
Inguinoscrotal hernias
This cause of scrotal swelling can usually be confi-
dently made on history and clinical examination findings

12 of 16 Imaging 2013, 22, 20120025

Imaging the acute scrotum
Figure 25. Idiopathic scrotal oedema. (a): Longitudinal image
of the left testis of a child presenting with acute scrotal
swelling and mild discomfort. Note the gross thickening and
oedema of the scrotal soft tissues but normal underlying
testis. (b): Transverse view of the scrotum in a second case
showing marked thickening of the scrotal soft tissues and
shallow bilateral hydrocoeles. Note that a low frequency
curved array transducer was required to achieve adequate
depth penetration to demonstrate the testes
alone however, a proportion of adult patients with ingui-
noscrotal hernias may present with an acutely painful
scrotal swelling. Ultrasound can help to differentiate this
condition from other testicular pathology. Groin hernias
are an uncommon finding in the paediatric population;
a study of 750 boys aged 17 or under with scrotal abnor-
malities found a 5.3% incidental rate of hernias [71]. In
infants, a patent processes vaginalis can potentially allow
the normal intraperitoneal omentum or loops of bowel to
enter the scrotal sac [21]; due to the later closure of the
processes on the right hernias are more commonly found
on this side [10, 71].
Sonographic diagnosis relies on the identification of
gas or fluid-filled bowel loops or omental fat within the
scrotum (Figure 26). These appearances can however
imaging.birjournals.org
Figure 26. Indirect inguinal hernia containing fat. Trans-
verse ultrasound image of the right spermatic cord in the
inguinal canal. There is herniated intra-abdominal fat (*)
medial to the spermatic cord vessels (arrow), this could be
traced down into the scrotum from the inguinal canal.
occasionally be difficult to differentiate from those of a
loculated, complex hydrocele or haematocele [72]. Visu-
alisation of normal bowel peristalsis can be a reassuring
sign; conversely, a prompt surgical opinion should be
sought if an aperistaltic bowel loop is found; this finding
having both a high sensitivity (90%) and specificity (93%)
for bowel strangulation [73]. If the accompanying feature
of hyperaemia is identified within the scrotal soft tissues
on colour Doppler examination, incarceration of the
hernia should be suspected [10].
Testicular tumours
Testicular tumours usually present as a painless scrotal
masses but occasionally will present more acutely as a
result of infiltration or haemorrhage, as many as 10% of
patients present with inflammatory symptoms and signs
[74]. For this reason, any focal testicular abnormality seen
on ultrasound that is assumed to have an inflammatory
cause should be rescanned at a later date to ensure
resolution.
The commonest primary testicular tumour to present
with pain and swelling is seminoma, secondary to tu-
mour infiltration and obstruction of the seminiferous
tubules (Figure 27, [21, 35]). While malignancy and in-
flammation can occasionally appear very similar, there
are sonographic features that may allow them to be dif-
ferentiated. Orchitis tends to occur peripherally with a
crescent shaped morphology in comparison to the more
rounded or oval-shape of most testicular tumours which
may be found in any part of the testis [11]. Scrotal wall
thickening and a large volume hydrocele are more likely
to be secondary to an inflammatory cause [11, 74]. Dis-
tortion of the normal linear intratesticular vessels on
colour Doppler examination also raises the possibility of
a mass lesion within the testis. Given that the sensitivity
of greyscale sonography for detecting testicular tumours
13 of 16

Figure 27. Infiltrating seminoma mimicking acute orchitis.
36-year-old man presenting with left testicular pain. (a)
There is a diffuse infiltrative echopoor abnormality within
the testis. (b) The abnormal area is seen to be hypervascular
on colour Doppler imaging. Appearances of the testis are
consistent with orchitis however the epididymis was normal
and the ultrasound appearances were unchanged following
antibiotic treatment; the patient proceeded to orchidectomy.
approaches 100% [35], the presence of a testicular tumour
should always be actively ruled out when assessing the
painful scrotum.
HenochSchonlein purpura
This small vessel vasculitis, which normally affects the
skin and gastrointestinal tract, has scrotal involvement in
1538% of cases [75, 76] and can present as an acutely
painful, swollen scrotum. Sonographically epididymal
enlargement can be seen with the epididymis often
appearing heterogeneously echogenic secondary to
haemorrhage and showing hyperaemia on colour Doppler
imaging. The testes however remain normal in their
greyscale and colour Doppler appearances.
14 of 16
G Miles and S J Freeman
Conclusion
In this article, we have attempted to describe the
common and important scrotal pathologies that can
present as acute scrotal pain and swelling to the on-call
ultrasound practitioner. Excluding a diagnosis of torsion
of the spermatic cord is one of the most frequent reasons
for an urgent ultrasound study to be requested. Ultra-
sound should not delay surgical exploration in cases with
typical clinical findings but a careful Doppler ultrasound
study can be helpful in equivocal cases provided that
both the referring clinician and ultrasound practitioner
are aware of the limitations of this examination, partic-
ularly with regard to the greyscale features (which may
be normal or indistinguishable from epididymo-orchitis)
and the difficulty in diagnosing incomplete or intermit-
tent torsion.
Epididymitis is the commonest cause of acute testicular
pain and swelling; ultrasound has a limited role in con-
firming the diagnosis but is useful to identify complica-
tions such as testicular abscess formation or ischaemia.
Fourniers gangrene has a characteristic ultrasound ap-
pearance and may prompt the diagnosis allowing early
treatment with an improved clinical outcome.
Ultrasound examination can be very helpful in the
setting of blunt scrotal trauma, particularly to diagnose
testicular rupture and testicular ischaemia secondary to
compression by haematoma, both of which require ur-
gent surgical intervention.
It is important to remember that a small proportion of
patients with testicular tumours will present with acute
scrotal symptoms and this should always be in the mind
of the ultrasound practitioner when undertaking an ul-
trasound study in this setting.
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