Testicular Torsion Ultrasound Protocol

So, we've had a couple of cases presented here, but how exactly do you do a testicular exam you ask?  Well, lets discuss it...

Testicular ultrasound was not included in the 2008 revision of the ACEP Emergency Ultrasound Policy Statement, but it may make it into the next revision.  Testicular ultrasound is pretty easy to perform and can rule out testicular torsion rapidly which can expedite a trip to the OR in these patients.  Time is Testicle, remember?

Perform your normal history and physical exam, attempt to manually detorse the testicle if needed.  Consult the Urologist (order a ultrasound, if they request it), then perform your bedside ultrasound.  This way, the Urologist is already on their way down to the ED and, hopefully, you can provide some useful info when they get down there.

Positioning:
Have your patient lying supine in bed, lay a towel down on thier legs at the groin level and have them place thier scrotum on the towel.  Then place another towel over their penis pointed toward thier umbilicus.  Now the scrotum is isolated between the two towels.

Scan Protocol:
Using a linear high frequency probe, scan through the affected testicle in the longitudinal position.  The testicle should appear as a oval or egg-shaped structure that is medium grey speckled with black.  You may see a hyperechoic or white linear structure in the midline which is the mediastinum teste.

Scan through the testicle in a longitudinal plane from medial to lateral.  Then turn your probe 90 degrees to the patient's right to view the testicle in a transverse plane.  In this plane, the testicle should appear as a circular medium grey speckled tissue.

Scan through the testicle in the transverse plan, cranial to caudal.  Using color flow doppler, identify the small vessels in the testicle.

Now place the spectral doppler gates over one of the vessels you seen on color flow.  This will create a spectral doppler tracing which will either illustrate an artial waveform or a venous waveform.

 arterial waveform

venous waveform

 You need to document both to rule out torsion.  If you are unable to document flow, then torsion is highly likely.

Seems pretty simple doesn't it?  Try it out the next time you are ruling out torsion and see how it can expedite patient care!

May Case #2: Testicular Pain- Discussion

This patient does not have testicular torsion, but has epididymitis, likely secondary to a sexually transmitted disease (GC, chlamydia, etc).

Epididymitis

Epididymitis is the number one cause of acute scrotal pain and is due to the inflammation of the epididymis, usually due to  bacterial invasion.   Most commonly this infection stems from Chlamydia and Neisseria gonorrhea.  Symptoms include acute scrotal pain, discharge and may include fever or dysuria.

On ultrasound, acute epididymitis is diagnosed by a hypoechoic epididymis or an epididymis that appears darker grey than the testicle itself.  Color doppler shows increased blood flow in the epididymis.

For more images of epididymitis: ultrasound cases of epididymitis

May Case #2: Testicular Pain

22 y/o WM presents to the ED with acute onset of testicular pain X 2 h.  He denies F/C, N/V/D.  He is currently sexually active with 1 partner.  He denies dysuria, hematuria, penile discharge, lesions or pain.

PMHx:  none
PSHx:  none
Meds:  none
All: NKDA
SocHx:  +tob (ippd), +ETOH (6 pk/d), no drug use

PE:  BP 123/85, P 68, R 12, T 98.4 (o), Pox 99% (RA)
GEN:  WNW, WM, NAD
CHEST:  CTA B, nonlabored
CV:  RRR, no M/R/G
ABD: soft, NTND, +BS, DRE norm tone, heme -
GU:  no inguinal LAD, penis without lesions or discharge, testicles with normal lie, +TTP R testicle

Bedside US is performed:

 

 

What is the diagnosis?

Procedure: Paracentesis

A patient presents to the ED with complaints of gradually worsening shortness of breath and abdominal pain.  He admits to daily alcohol use and abdominal fullness.  You note that his abdomen is distended with a fluid wave and diffuse tenderness to palpation.  You are concerned about new onset ascites and spontaneous bacterial peritonitis.  So how do you tap his belly?

Paracentesis

If the patient has been tapped previously, then using the previous site is preferable.  Now in this instance, there is no previous site, so there are 2 preferred sites.  The first is the infraumbilical approach, which is located about 2 cm below the umbilicus.  The other choice is the lateral approach, 4-5 cm cranial and medial to the anterior superior iliac spine in the lower quadrants.  If using the infraumbilical approach, be sure to make sure the bladder is empty.

Now, ultrasound certainly makes positioning much easier.  Using a low frequency 3-5 MHz transducer, scan through the abdomen to find the largest pocket of fluid.  Now, without moving the patient, prep the area and sheath the probe with a sterile cover.  Now place the probe in a longitudinal plane (probe indicator to the pt's head) and find the largest pocket of fluid.  Insert the needle in alignment with the midline seam on the probe.  The needle is then advanced in real time through the abdominal wall, watching the needle (hyperechoic structure) enter the peritoneum on ultrasound.  By using this technique, you are able to stay away from bowel or when using the infraumbilical approach, bladder.


Ultrasound Guided Paracentesis from Jax Emergency Medicine on Vimeo.

May Case #1: Abdominal Pain- Discussion

This patient has splenomegaly due to hyperviscosity syndrome.  She had a relapse of her leukemia and developed tumor lysis syndrome due to her overwhelming tumor burden while in the hospital.  She was noted initially to be anemic and thrombocytopenic and later required transfusions of both PRBCs and platelets. 

Splenomegaly

On ultrasound, splenomegaly is defined as a longitudinated measurement of the spleen greater than 13 cm (in adults). 

Although it is not a disease state itself, it is usually a response to underlying pathology.  Causes of splenomegaly include:

• neoplasm or myeloproliferative disorders (lymphomas, leukemias, metastatic disease)
• infectious processes (TB, EBV, CMV, HIV, Lyme disease, RMSF)
• portal hypertension or systemic congestion (CHF, cirrhosis)
• chronic transfusion

Hypersplenism is indiscriminate destruction of the formed elements of the blood by an enlarged spleen.  Any blood line can be affected (erythrocytes, neutrophiles or platelets) alone or in combination.  Splenic hypertrophy leads to premature destruction of cells by splenic macrophages, an exaggeration of the spleen's normal function of removing senescent cells.  Splenectomy may correct cytopenia.