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This is Pediatrics week 4 case number three and

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our diagnosis under consideration is epididymitis. This

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is a teenage patient with scrotal pain

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and of course the first consideration and

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the Urgent diagnosis to exclude

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would be testicular torsion, which is a surgical emergency

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and ultrasound is the ideal Imaging modality

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for this diagnosis because it's

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portable it can be taken to the emergency department or

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the clinic or wherever it needs to go. It's non-invasive and

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it has the capability to identify Doppler

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vascular flow which can really help

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with the diagnosis.

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That we're looking at so here we've got grayscale sonographic

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Imaging of the testicle. This is the echo

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texture of the testicle itself, which appears grossly

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normal. It doesn't look swollen or indemnus and

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then centrally within the testicle. We've got this mediastinum testis

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and a little epididymis over

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here. Here's a measurement of the testicle again.

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We're not seeing a swollen or in large testicle and we

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are seeing normal Doppler signal within the testicle. So

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we've essentially excluded torsion of

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this right testicle. No edema. No a vascular

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appearance.

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But we do see some signs of reactivity. So anytime

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that we've got inflammation in

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the testicles fluid is drawn down into the testicle. And

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this space here is a hydrocele. You

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can see a little bit of hydrocele fluid there and all

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in here so we know that there's some inflammation

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of the scrotum and testicle and if

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we go over to the other side of the scrotum we

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can see the same type of appearance now here we've

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gotten Doppler signal of the epididymis and

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note just how much more prominent this is

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than the testicle. I'm going to take you back a couple of images to

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look at the Doppler signal of the testicle a very

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moderate appropriate amount of flow. Now, we're going to come forward

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and look at the epididymis. Wow, that is a lot

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of signal. There's a lot of blood flow in this epididymis.

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So we're concerned right now that the inflammatory process

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is not centered in the testicle. But rather the epididymis we're

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going to look in the inguinal Canal. We don't see any

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problems there. We see normal blood flow in the

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inguinal Canal. We're going to come over and look at the other side as well.

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But right away we're concerned about a focal

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inflammation of the epidemis. Here's spectral Doppler

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signal normal and appropriate. I'm going

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to scroll through this exam so we can look over at the left side. Here's

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our left testicle normal Echo texture. No

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edema. Nice media Steinem testis. I'm not

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concerned. I'd like to see some blood flow in there it is. That's perfect.

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We know this testicle has not been Twisted no

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torsion on the left and you'll notice that when

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we get to look at the epididymis, which we

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haven't seen quite yet. Here's a non-doppler signal

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appearance of the epididymis normal looking.

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Echo texture and then here we can see a little bit of flow

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in this epidemis. We're seeing the sort of tail of

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the epididymis more than the head on this image and it's quite

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prominent as well. Just like that other side here in the

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left. We've got the inguinal Canal

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look at these fluid spaces in the inguinal Canal

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if we put Doppler on those I bet they're gonna light up and they

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do and I bet if we ask this patient to Val Salva or

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bear down those venous spaces are gonna really enlarge look

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at that this is passive and then with valsalva maneuver

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those veins of the paniform plexus are

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really dilating. It is on the left side and we know the gonadal vein

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drains up to the renal before coming over to the

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IVC. So you're more likely to have dilatation of

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the veins like a varica seal on the left. This is

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sort of a red herring. This is an incidental finding the pain

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and the inflammation is coming from that

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hypervascular epidemis. Now

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if this were a younger child,

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I would say maybe they have a tourist testicular

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epididymal appendage. But in a 17

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18 year old the most common causes gynecostal

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infection sexually transmitted disease. This is

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an infectious epididymitis and needs to be treated accordingly.

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That's the end of the case.