THE JOURNAL OF UROLOGY
Vol. 113, January
Copyright © 1975 by The Williams & Wilkins Co.
Printed in U.S.A.
TORSION OF THE TESTIS DIAGNOSED BY ULTRASOUND JAN FOG PEDERSEN, HANS HENRIK HOLM
From the Ultrasonic Laboratory, Department of Surgery H, Gentofte Hospital, Copenhagen, Denmark
ceives its arterial supply from the testicular artery which reaches the posterior border of the gland through the spermatic cord (fig. 1). The artery branches and enters the testis perpendicular to its long axis via the mediastinum testis. In addition to the testicular artery the spermatic cord contains small arteries to the cremaster from the inferior epigastric artery and to the vas deferens from the internal iliac artery. These artery systems also supply the testis via collaterals. In case of torsion of the spermatic cord all 3 artery systems are obstructed. The arteries supplying the scrotum are branches from the femoral artery, from the internal pudenda! artery and from the inferior epigastric artery. Procedure. The testis is fixed by one hand and isolated as much as possible from the opposite gland. An aqueous gel is applied to ensure a good acoustic coupling. The transducer is placed on the anterior aspect of the testis perpendicular to its longitudinal axis, pointing towards the tiny branches of the arteries inside the testis (fig. 2). The transducer is gently pressed against the testis to compress the vessels in the scrotal wall and, thereby, to avoid flow artifacts from these vessels. By means of the earphones the examiner tries to identify a pulse synchronous soughing, indicating pulsatile flow in the testis. When pulsatile testis flow has been detected the spermatic cord is compressed to assure that the pulse disappears. It may be necessary to change position and direction of the transducer but in any case it is mandatory that the ultrasonic beam does not aim at the spermatic cord proximal to the site of a possible torsion or at the opposite testis. If a reasonably distinct frequency shift is detected it may be recorded graphically (fig. 3).
Immediate diagnosis of testicular torsion is important since an incorrect diagnosis usually will result in necrosis within a few hours. In some cases the clinical diagnosis is rather obvious because of the age of the abent the acute onset of ain and t e tenderness together with the abnormally high positioned gland. Often, however, especially the ~ d i a g n o s i s of epididymitis is difficult and undoubtedly many cases of torsion of the testis are misjudged. When diagnosis is uncertain an operation is recommended 1 but help in establishing a definite indication for operation should be welcomed by the clinician. The Doppler ultrasound has been used to determine the presence or absence of intratesticular arterial pulsations. The principle of this study has been described briefly by Milleret and Liaras and applied to the diagnosis of 2 cases of testicular torsion and 1 case of orchitis. 2 METHOD
The Doppler principle. This term denotes the apparent change in sound frequency when a sound source (for example the signal horn of an ambulance) moves relative to the observer. An ultrasound transducer with a separate transmitter and receiver crystal is used. 3 A continuous ultrasonic beam is emitted from the transmitter. If the beam is directed at a moving target (for example blood corpuscles in a vessel which is not perpendicular to the sound beam) there will be a frequency shift of the reflected ultrasound. This frequency shift is detected by the receiving part of the transducer and may be presented as a visible or an audible signal which gives information about flow velocity. Instrument. A directional Doppler model 806* operating with a 10 MHz transducer was used. A frequency shift can be read on a rate meter or detected as a soughing in an earphone headset. When a permanent documentation is desired a curve can be obtained by means of a recorder. We have used a Hewlett Packard 7700 recorder. Arterial supply of the testis. The testis reAccepted for publication October 11, 1974. Supported by the Danish Hospital Foundation for Medical Research, Region of Copenhagen, Foroe Islands and Greenland. 1 Kaplan, ( G. W. and King, L. R.: Acute scrotal Lswelling in children. J. Urol., 104: 219, 1970. 2 Milleret, R. and Liaras, H.: Ultrasonic diagnosis and therapy of torsion of the testis. J. Chir., 107: 35, 1974. 3 Strandness, D. E., Jr., McCutcheon, E. P. and Rushmer, R. F.: Application of a transcutaneous Doppler flowmeter in evaluation of occlusive arterial disease. Surg., Gynec. & Obst., 122: 1039, 1966. * Park Electronics Laboratory, Beaverton, Oregon.
MATERIAL AND RESULTS
Four young adult patients with suspected testicular torsion were examined by ultrasound in the acute phase, that is within 24 hours after onset of pain (see table). No Doppler sounds were registered from the affected testis in contrast to the distinct Doppler sounds from the opposite testis. Diagnosis was confirmed at the operation. After detorsion and fixation equal Doppler sounds were noted. In 1 newborn an ultrasound diagnosis of testicular torsion was made, which proved to be correct at operation. Postoperatively no testicular pulsations could be detected. The control series consists of 10 patients with unilateral epididymitis and 30 patients without known intrascrotal disease. Of the latter 30 patients 10 were between 10 years old and puberty, 10 66
TORSION OF TESTIS DIAGNOSED BY ULTRASOUND
FIG. 1. Schematic representation of arterial supply of testis and correct position of ultrasound transducer when searching for intratesticular pulse.
FIG. 2. Ultrasonic examination
were between puberty and 50 years old and 10 were more than 50 years old. In all patients without intrascrotal disease distinct and equal Doppler signals were registered on each side. All 10 patients with epididymitis had increased Doppler sounds on the affected side as compared to the normal side. Diagnosis of epididymitis is purely clinical in all but 1 patient who was operated upon because of a slight suspicion of testicular torsion. DISCUSSION
Torsion of the testis is a fairly common surgical catastrophe in puberty and young adulthood. During a 3-year period Del Villar and associates explored all cases of acute scrotal swelling in
patients less than 30 years old. In 42 early explorations they found 9 cases of testicular torsion.' Immediate operation is advised to avoid hemorrhagic infarction and subsequent loss of the testis. Contralateral orchiopexy is recommended to avoid a similar threat to the opposite testis.' The fundamental idea of using ultrasonic examination with the Doppler technique is that it might be possible to detect a lack of perfusion in torsion of the testis by monitoring the arterial pulse in the organ. In the acute phase of a torsion venous stasis with preserved arterial pulsation might be the first disturbance of circulation. In this case the Doppler examination would be misleading. However, our experience in early testicular torsion seems to indicate that arterial obstruction is present at least within a few hours, if not from the very beginning. The technique is simple, painless, rapid and should not cause any significant delay in treatment. Negative surgical explorations may be avoided, thereby saving the patient the risk of anesthesia and an unnecessary operation. From a theoretical viewpoint the 2 main causes of acute scrotal swelling in the age group concerned-epididymitis and testicular torsion-should affect the blood perfusion of the testis in opposite directions. In acute epididymitis a reactive hyperemia is present and in testicular torsion the perfusion is diminished or zero. The corresponding changes in the arterial pulse amplitude of the testis should expectedly be characteristic, and this was confirmed in this limited series. However, it should be stressed that the 4 adult patients with testicular torsion had symptoms for a few hours only. We examined 2 patients with scrotal swelling for 8 and 10 days, respectively, clinically diagnosed as suspected epididymitis. Both patients had weak testicular pulsations at the ultrasonic examination but at the operation neglected torsions of the funiculus were revealed. Since these 2 cases were not acute they have not been included in the material. Thus, it appears that after some time the testis may regain some arterial pulsation, possibly caused by collaterals or partial detorsion. A correct ultrasonic diagnosis of a testicular torsion was made in a newborn. This demonstrates the sensitivity of the Doppler technique but is of minor clinical significance since a scrotal swelling in a newborn always should be surgically explored. The lack of pulsation in a testis in torsion may be imitated by examining a normal testis while compressing the spermatic cord. The change in pulse is easily heard in a headphone but is often difficult to record graphically. For clinical purposes it is satisfactory to confirm the lack of arterial noise in torsion or the increased noise in epididymitis by comparing the sound 4 Del Villar, R. G., Ireland, G. W. and Cass, A. S.: Early exploration in acute testicular conditions. J. Urol..
108: 887, 1972.
5 Krarup, T.: Torsion of the testis. Scand. J. Urol. Nephrol., suppl. 15, 6: 165, 1972.
PEDERSEN, HOLM AND HALD
FIG. 3. Characteristic recordings of Doppler sounds. A, arterial pulse in normal testis; pulse disappears while spermatic cord is compressed. B. no detectable pulse in testicular torsion; pulse regained after detorsion. C, increased pulsations at epididymitis as compared to non-diseased side.
Ultrasonic findings in 5 patients with testicular torsion
Initials Age Duration of symptoms (hrs.) Doppler sounds: Rt. testis Lt. testis Testis involved Postop. Doppler sounds: Rt. testis Lt. testis
J.D. 16 yrs.
T.J. 15 yrs.
B.S.P. 21 yrs.
C. 1 day
S.F. 15 yrs.
obtained from identical transducer positions on each side. The technique is simple to learn and may be useful in other types of clinical situations too, for example arterial embolism and thrombosis, and venous thrombosis. The amount of energy transmitted to the tissue at diagnostic ultrasound is far less than the levels used at therapeutic ultrasound, and no harmful effects have been registered. The present series suggests that ultrasonic examination is useful in the differential diagnosis of acute scrotal swellings.
An ultrasonic method to diagnose acute testicular torsion is presented. With the Doppler principle the presence or absence of intratesticular arterial pulsation can be demonstrated. In 5 patients with acute testicular torsion and 10 patients with epididymitis a correct ultrasonic diagnosis was made. In long-standing torsions some arterial pulsation may be present.