Radiographic and Other Studies

1. Scrotal ultrasound. Instrumental in differentiating tense hydroceles from testicular tumors. Doppler flow analysis is also essential to distinguish testicular torsion (diminished or absent flow) from torsion of appendix or epididymitis (increased flow). Combination of parenchymal visualization and testicular blood flow makes ultrasound the ideal radiologic study for evaluation of scrotal swelling.

2. Nuclear testicular scans (technetium). Useful in cases of possible testicular torsion, although seldom used if Doppler flow sonography is available.

3. CT scan. Of minimal use in evaluating scrotal swelling, but necessary in evaluating retroperitoneum and chest of patients with testicular tumors.

V. Plan. Most important determination is to exclude spermatic cord torsion, which is a surgical emergency; delay in diagnosis and management may lead to loss of testis. Most testes can be salvaged if detorsed within 6 hours of onset. Management of torsed appendages is primarily supportive. Hernias must be repaired surgically if they cannot be reduced. Epididymitis is treated with antibiotics in addition to supportive therapy if there is evidence to support bacterial infection.

VI. Problem Case Diagnosis. The 3-year-old patient had communicating hydrocele associated with viral illness. The viral illness caused an increased volume of peritoneal fluid and cough, which lead to increased intra-abdominal pressure, with fluid directed into the hydrocele.

VII. Teaching Pearl: Question. To what does the term bell-clapper deformity refer?

VIII. Teaching Pearl: Answer. The bell-clapper deformity refers to an anatomic anomaly in which the spermatic cord twists inside the tunica vaginalis due to its high insertion on the cord. This is the usual etiology of adolescent testicular torsion. Deformity is bilateral; therefore, bilateral testicular fixation is recommended at the time of surgical detorsion.

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