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Hello, and welcome to Noon Conferences hosted by MRI

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Online. In response to changes happening around the world

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right now, in the shutting down of in-person

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events, we've decided to provide free daily

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noon conferences to all radiologists worldwide.

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Today we're joined by Dr. Laura L. Avery.

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Dr. Avery is an emergency radiologist.

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She's a radiology clerkship director for

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Harvard Medical Students at MGH, and Dr.

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Avi has received numerous teaching awards.

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She's also been recognized as

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an honored educator by the RSNA.

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Quick reminder, there'll be a Q&A session

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at the end of the lecture, so please use the Q&A

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feature to ask your questions, and we'll

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get to as many as we can before time's up.

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That being said, thank you all so

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much for joining us today, Dr. Avery.

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I'll let you take things from here.

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All right.

0:42

Hi.

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Thank you so much for having me today.

0:44

I am very excited to bring you a lecture on the

0:47

ups and downs of penile and scrotal emergencies.

0:51

Let me see if I can get myself all in there.

0:53

All right, um, okay, let's go.

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I have no financial disclosures, sadly.

1:01

Um, learning objectives today will be going

1:04

through, um, some penile and scrotal emergencies.

1:06

We're going to start with testicular emergencies,

1:08

including torsion, infection, and trauma.

1:11

Then go on to penile emergencies, including

1:15

priapism and, um, uh, penile, uh, injuries.

1:20

Okay, so let's start with normal scrotal anatomy.

1:23

I have to say the scrotum is, uh, one of the

1:25

last bastions of, um, ultrasound, or one of the

1:28

finest points of ultrasound, so easily accessible.

1:30

So we're going to go through the ultrasound anatomy of the

1:33

testicle, um, as our first, uh, portion of this lecture.

1:37

Okay.

1:37

So the testicle is made up of numerous little

1:41

seminiferous tubules that all are nicely fluid-filled.

1:43

Hence, ultrasound loves it, um, that

1:46

converge into the rete testis centrally.

1:49

46 00:01:50,445 --> 00:01:50,684 Okay.

1:50

These little seminiferous tubules and lobules

1:52

of seminiferous tubules are, um, confined

1:56

by a thick fibrous sheath of the tunica albuginea.

1:59

On ultrasound, that's an echogenic thick fibrous sheath,

2:03

keeping that nice ovoid configuration of the testicle.

2:08

Now that, um,

2:11

thick fibrous sheath comes to the midline

2:13

here and reflects back into the testicle

2:16

itself, causing the, um, mediastinum testis.

2:19

Additionally, the seminiferous tubules converge

2:21

into the rete testis at this mediastinum level.

2:24

At times, you may see dilatation, as in this case,

2:28

these nice fluid-filled structures here, that's

2:29

dilatation, cystic formation of the rete testis.

2:33

That is a normal, benign variant.

2:35

You may even see it be more dramatic, as in this sweep,

2:38

where you see a number of little, um, cystic dilatations

2:42

of that rete testis at the mediastinum of the testicle.

2:45

Be warned, if your, if your ultrasound sonographer

2:48

measures this, don't think of it as a lesion.

2:50

That's a normal, benign finding at that level.

2:54

Now we're gonna go outside of the testicle.

2:56

We're gonna come up to the superior pole of the

2:58

testicle to the epididymis, the epididymal head.

3:00

A nice triangular, either, um, isoechoic or hypoechoic.

3:05

Uh, nice epididymal head here.

3:08

Then going down the epididymal body.

3:11

It should be nice and small, homogeneous body.

3:14

And then into the tail, then the ductus

3:17

deferens go up into the urinary tract.

3:21

The entire testicle is surrounded with the tunica vaginalis.

3:24

That is a reflection of the peritoneum,

3:27

and that is a normal structure as well.

3:29

So normal testicular blood flow,

3:31

normal testicular blood flow.

3:33

Um, you can see her with the color.

3:34

Doppler is, uh, avid flow, which is low,

3:37

um, resistance, similar to your brain.

3:39

I mean, testicle, brain, I'm not sure, anyway, so it

3:41

should have this normal, low-resistant blood flow

3:44

and should be symmetric between the two sides.

3:47

Unlike the ovary, which can have variable, um, low

3:51

resistant waveform, depending on the functional ovary

3:54

that month, the testicles should be more symmetric.

3:58

Let's start with our first case.

3:59

Here's a 16-year-old with, um, right scrotal pain.

4:02

We see the right testicle here, um, with color

4:04

flow, demonstrates no color flow, and a very

4:07

heterogeneous echotexture, as opposed to the

4:09

normal left testicle, which demonstrates flow

4:12

in that normal flow-resistant waveform as well.

4:15

This is a typical, everyday example

4:18

of testicular torsion.

4:22

Testicular torsion is a very common presentation for,

4:25

uh, of the acute scrotum in the emergency department.

4:28

It's prevalent in neonates and postpubertal boys, um,

4:31

usually has rapid onset of pain, nausea, and vomiting.

4:34

Something called a Prehn's test, where you

4:36

can, where that, um, testicle is painful as well.

4:38

The key here is that it's very important to move quickly.

4:42

The viability of the testicle really degrades

4:45

quickly with time, so we want to bring that patient.

4:49

Right back to ultrasound.

4:50

Um, do the evaluation and make that phone call straight

4:53

to the ER so that that patient can, um, be activated.

4:58

Let's go into some of the findings

4:59

you're going to see with testicular torsion.

5:01

Such a classic.

5:02

We might as well go deep into that.

5:03

Here's a spermatic cord.

5:04

It's going to twist 360 to 540 degrees.

5:08

Um, it's going to result in.

5:09

Venous outflow problems and

5:11

arterial inflow problems as well.

5:13

Now, the baseline to know about the, uh,

5:16

torsed testicles, not everyone can get it.

5:18

So this is the normal configuration of

5:21

the testicle with the tunica vaginalis.

5:23

Here's surrounding the testicle just anteriorly,

5:25

where the testicle is nicely adhered posteriorly.

5:28

Now, in some individuals, there is a high attachment of

5:32

the posterior aspect of the tunica vaginalis that allows.

5:35

The full testicle to have no attachment and

5:39

results in what is called the bell clapper deformity.

5:42

Now, I didn't really know what a bell clapper was,

5:44

so I bring this to you as a little bit of knowledge.

5:46

This here is the bell clapper, and that's

5:48

a free-form thing, I guess, in the bell.

5:50

So typical to that, the testicle is now mobile

5:54

in the scrotum and can result in torsion.

5:58

Its prevalence is about 12% of boys.

6:00

And the key here is that it, um, second.

6:05

Remind me later.

6:07

Uh, something.

6:08

Shoot,

6:15

I need to upgrade my Citrix Viewer.

6:17

Sorry.

6:18

Um.

6:19

So the key here is that it's also bilateral in most cases.

6:23

So if you have testicular torsion, you really have to go

6:26

to surgery regardless because the likelihood of both testicles

6:29

having this abnormal configuration is very high, and you

6:32

would need to pexy or attach the other testicle to

6:36

the scrotum so that it doesn't tors as well, especially

6:39

in a patient who would have testicular infarction.

6:41

Okay, so let's go into some of the findings you may see

6:44

on ultrasound, um, in the setting of testicular torsion.

6:49

Okay.

6:49

So number one, here we have the, um, spiral

6:52

twist of the testicle, uh, of the spermatic cord.

6:56

Um, and here you're going to see

6:57

a whirlpool, uh, configuration.

7:00

Let's have this play again.

7:01

Um.

7:03

There we go.

7:04

You can see that whirling of the structures.

7:07

That is a very, uh, sensitive

7:09

finding for testicular torsion.

7:14

In the early phase of testicular torsion, you

7:16

can see the right testicle here and the left

7:17

testicle here have very similar echotexture.

7:20

That's very typical of early-phase

7:22

torsion, where you have normal architecture.

7:24

But notice here we have a slight hydrocele that

7:27

can indicate that there's a little bit of a problem.

7:30

And when we put on vascular flow, we like

7:32

to refer to this as the buddy view, where

7:34

you have both testicles in the same image.

7:36

That really can give you knowledge that, um,

7:39

the same parameters are in each testicle,

7:41

which is very helpful for ultrasound.

7:43

You can see that there's blood flow to the left testicle,

7:46

but no blood flow to the right testicle.

7:48

So that would be a really, um, nice view of an early torsion.

7:52

Again, the color flow here demonstrates

7:54

no significant flow.

7:57

No spectral Doppler is obtained either, unlike the normal

8:00

side, where with that normal low-

8:03

resistant waveform, this is likely a salvageable testicle.

8:06

It's very early in, um, torsion.

8:09

Here's another image of, um, early torsion.

8:12

Look at the epididymis.

8:13

Okay.

8:13

The right epididymis enlarged.

8:16

Big, heterogeneous.

8:17

The left epi is nice and small and normal.

8:19

Normal.

8:20

Um, this can also be an early sign of torsion.

8:23

Uh, once we make this bigger, you're going to see.

8:25

Because when we see these big epididymides, we

8:26

wonder, you know, is the patient infected?

8:28

But this one will have no blood flow.

8:30

It's hypovascular, avascular.

8:32

Um, epididymis, so that could be

8:35

an early, uh, sign of torsion.

8:37

In a late torsion, you frequently have a

8:39

very dramatic heterogeneous

8:42

echotexture to the testicle.

8:45

Here on the left, you can see that that's very different

8:47

than the normal right testicle when you bring them together.

8:50

In our buddy view, you can see that there's

8:52

normal blood flow on the right and no blood flow

8:54

in our infarcted, late-stage testicular torsion.

8:57

Um, very unlikely to be salvageable at that point.

9:01

This is just a neat image because this

9:03

is, uh, the image of, um, the buddy view.

9:06

Here you can see that the normal right test

9:08

testicle is in the transverse plane as opposed to

9:11

the left testicle, which is in the sagittal plane.

9:13

This is actually just an illustration of the

9:15

physical exam finding patients may have, um,

9:18

in that they may have, uh, a very palpable,

9:21

uh, transverse lie of the torsed testicle.

9:25

Um, so there are some times where testicular

9:29

torsion will have maintained blood flow.

9:31

All right, so here we have blood flow

9:33

to the, on the buddy view, bilaterally.

9:35

You know which one's going to be bad?

9:36

I don't know, but maybe the bigger one, potentially,

9:39

because it would have a little edema, but it's not dramatic.

9:42

Um, there is still blood flow, but on the spectral

9:44

Doppler, you're going to notice that the normal low

9:47

resistance waveform, um, is, uh, visualized on the

9:51

right, whereas there's significantly increased resistance.

9:53

About 0.7 of the left testicle, and that would

9:56

indicate an early partial, um, testicular,

10:00

uh, torsion and/or a torsion-detorsion situation.

10:04

So up to 30% of cases can still have

10:07

some blood flow, which is concerning.

10:10

And again, with our, um, with our maintained blood flow,

10:14

if we looked back, we would see that that epididymis, which

10:17

is going to kind of clue us in that there's something wrong,

10:20

once we saw the blood flow being wrong, that epididymis again,

10:23

enlarged, looks kind of angry, but without blood flow,

10:27

like in cases of infection.

10:29

Do not forget the newborns.

10:31

Newborns do present with swollen scrotums.

10:34

They do present with, um,

10:37

with testicular torsion.

10:39

I know that, you know, the night residents always,

10:41

we don't love to have to do newborn ultrasounds,

10:43

but this is definitely an emergency here.

10:46

And we have the, um, left testicle with normal blood flow,

10:48

but notice that there's no blood flow, even on the power

10:51

Doppler, that very sensitive power Doppler in the testicle.

10:55

And there's enlargement again of the, um, epididymis.

10:59

So this is a surgical emergency in this newborn.

11:03

All right, let's keep on moving now.

11:05

This patient has bilateral normal-looking

11:07

blood flow to the, um, to the testicles.

11:11

No evidence of torsion, but let's see this play.

11:14

Good.

11:15

This is going to play, so the testicle looks okay, but

11:17

there's this funny little lobular thing right here,

11:22

without significant blood flow next to the epididymal head.

11:26

Now we'll bring up the still images, and you'll see this

11:29

nice little, uh, lobulated thing without blood flow.

11:33

This is a torsed, um, testicular appendage.

11:36

The testicular appendage is a little thingy here that

11:40

comes off of the, um, the epididymis, uh, usually

11:44

near the epididymal head, but can be variable, um,

11:47

and it can tors and cause a significant amount of

11:49

pain similar to that of, um, uh, testicular torsion.

11:54

Now, over time.

11:55

These may fall off and calcify once

11:57

they kind of tors themselves to death.

11:59

Um, and you'll see a little tiny echogenic focus within

12:03

the scrotum that causes that posterior shadowing,

12:06

um, sometimes referred to as the scrotal pearl.

12:10

Um, so that's just an old torsed appendage of

12:14

the testis, um, which, uh, has fallen into the

12:17

scrotum, can sometimes even be palpable on exam.

12:22

Now let's go away from your typical testicular torsions

12:25

into some other vascular insults of the testicle.

12:29

Here is a 38-year-old who presents to the ED with, uh, left

12:33

scrotal tenderness two days after undergoing vasectomy.

12:35

So just had a recent.

12:37

Intervention.

12:38

Now you can see in this testicle that

12:40

there is blood flow, but peripherally.

12:42

There is a wedge-shaped appearance of this

12:45

hypoechoic abnormality, um, without blood flow.

12:48

This is a very typical appearance

12:51

of a segmental testicular infarct.

12:54

Um.

12:55

Usually we would require a recent history

12:57

of surgery here, um, to go with that.

12:59

Or even a vasculitis can cause this.

13:01

It can be seen in patients with vasculitis.

13:03

It has a very typical wedge-shaped, kind

13:05

of like any infarct anywhere would, um.

13:09

But we still would probably follow this to

13:11

make sure that it resolved, uh, as we do any

13:13

abnormality of the testicle such as this.

13:15

And sometimes they do scar and can be a

13:17

palpable abnormality on the outset of it.

13:19

But this is, um, a testicular infarct.

13:21

I had one last week that was, um, actually a very,

13:24

very low-flow testicle in a patient who had a recent

13:27

vasectomy, and there was a hematoma in the spermatic cord.

13:31

Um.

13:32

Here we have a more dramatic case.

13:33

This guy is young.

13:34

25, three-day status post inguinal hernia

13:37

repair with significant scrotal swelling.

13:39

Here we have those wedge-shaped peripheral

13:42

infarcts, again, in this very large and

13:45

edematous testicle, along with no blood flow.

13:47

Unlike this torsion, this patient actually

13:50

had very tight plugs of his hernia repair, and

13:53

they had to go and release the hernia repair

13:55

plugs in order to revascularize the testicle.

13:58

I think it was still swollen, um, shrunken on, uh,

14:02

in the future, but it seemed to have some viability.

14:05

Or that was the hope.

14:06

So, you know, testicular infarct

14:09

after hernia repairs are a risk.

14:11

Anytime you are evaluating the postoperative patient,

14:14

um, make sure again that that blood flow is symmetric,

14:18

um, and that you don't have any, uh, problems because

14:22

it can be, um, a pretty big surgical emergency for,

14:26

uh, either post-vasectomy or hernias to be released.

14:31

Okay.

14:32

We're going to move on now.

14:33

Now.

14:33

Here's our 42-year-old with scrotal pain.

14:36

All right, look at that.

14:37

Epididymis, nice and triangular in appearance.

14:40

Very small, homogeneous.

14:41

Looks nice coming down here.

14:44

The technologist has graciously, um,

14:47

labeled the, uh, image here with the

14:49

head on into that, the epididymal body.

14:52

The body looks good.

14:53

Okay, homogeneous, uh, hypoechoic, looking good.

14:58

But then when you get down to the tail,

14:59

you see this big enlargement of the

15:02

epididymal tail with significant hyperemia.

15:06

This brings up the point that,

15:08

um, epididymitis starts in the tail.

15:10

All right?

15:10

Like we always say, death starts with the feet.

15:12

Um.

15:13

Epididymitis starts in the tail.

15:15

That's because it's usually from a urinary source.

15:17

Coming down the vas deferens into

15:20

the tail of the epididymis first.

15:22

Uh, so that's where you would have your

15:24

various, um, epididymitis. Young people,

15:26

you think about gonorrhea, um, uh, chlamydia, gonorrhea.

15:30

Older people, it's usually urinary tract infections.

15:33

Um, don't forget the possibility of chemical epididymitis.

15:36

That's actually something where you get a

15:38

bit of epididymitis as a result of reflux

15:40

of urine after heavy lifting, you know?

15:43

Maybe you had too much time at the gym. Warning.

15:45

Um, so that's another option.

15:47

Uh, usually the patient isn't,

15:49

um, febrile in any way for those.

15:51

Okay, so here's another case.

15:53

This guy, his epididymis is a bit big, okay?

15:57

He has a little epididymal cyst here.

15:59

That's anechoic.

16:01

Um, finding, kind of a regular finding that

16:03

we see at times. It can be palpable again.

16:06

With him, you have a lot of blood flow.

16:07

So you're already playing in the

16:09

epididymitis world, um, very typical.

16:12

But as you come down to the tail, you're going to notice

16:14

a little area that doesn't, uh, have any blood flow,

16:17

and that is a small abscess in the epididymal tail.

16:21

So this just brings up your need to instruct, and

16:24

most of our technologists are fantastic,

16:26

so I don't need to instruct them on anything.

16:28

But, um, that you want to make sure that they

16:30

interrogate the entire tail of the epididymis.

16:34

All right, here's a 31-year-old complaining of

16:36

left testicular soreness and swelling.

16:41

Notice that enlarged, heterogeneous, I'm

16:44

sorry, this side enlarged, heterogeneous,

16:46

uh, epididymis, comparatively to the right.

16:50

And with blood flow, you can see there's significantly

16:52

increased blood flow on the left and going into

16:55

the testicle itself. I always like the buddy view.

16:58

Okay, so we have normal blood flow here.

17:02

We have extremely avid blood flow.

17:03

This is a case of epididymo-orchitis.

17:06

We know that the infection has hit the testicle

17:08

because of the hyperemia. We like to say the fireball.

17:12

Um, so always look at that buddy view.

17:15

Now these things can go on to problems.

17:18

Here's a 64-year-old, probably a diabetic, status

17:21

post-prostatectomy with urinary tract infection.

17:24

We see an enlarged, heterogeneous, uh, epididymis,

17:28

already concerned about epididymitis into a little

17:32

bit of excess, uh, blood flow into the testicle itself.

17:35

Well, you know, he gets treated.

17:37

Who knows if he takes his antibiotics,

17:39

and this is him two weeks later.

17:42

This is concerning, obviously.

17:45

Um, we have developed a complex hydrocele,

17:48

probably a pyocele. See those echogenic, um, foci

17:52

within the fluid itself and all the septations.

17:54

So it's not just simple fluid; it's not

17:56

even probably just simple sympathetic fluid.

17:59

This is very complex fluid, most

18:01

likely, um, just pus, to be honest.

18:03

And the testicle here is enlarged,

18:06

very heterogeneous, and of concern

18:09

is this echogenic focus with.

18:11

Dirty shadowing. When I'm a blind radiologist someday,

18:14

and y'all are like, you know,

18:15

because Harvard, no one ever retires.

18:17

Um, you know, you can say dirty

18:19

shadowing, and I'm going to say air, right?

18:21

So if you look more at this testicle, you're going to

18:23

see that there was actually full testicular necrosis.

18:26

This is a pyocele with just purulent, um, testicle here,

18:31

with posterior shadowing from the intratesticular air.

18:38

All right.

18:38

Kind of moving away from infections,

18:40

but the things that make you concerned.

18:42

Okay, so here is a patient. He has, um,

18:46

enlargement of that, uh, right epididymis,

18:48

enlargement of the left epididymis.

18:50

So both epididymides are big, much bigger than on that

18:53

kind of normal, thin, um, homogeneous, uh,

18:58

Um, sorry.

18:59

Epididymis, and color flow, you know, it

19:02

looks pretty normal, like not hyperemic,

19:03

so you really wouldn't go with infection.

19:05

Plus it's bilateral, which is a little bit odd

19:07

for infection, but either way, you could even find

19:09

this as a unilateral finding in some patients.

19:11

So it's a normal enlarged epididymis,

19:14

um, with no increased blood flow.

19:16

This can be an appearance of tubular ectasia of

19:21

the epididymis in the setting of a prior vasectomy.

19:23

So when we correlated this with his

19:25

history, he had had, um, a prior vasectomy.

19:28

And this is a good, uh, appearance for a post-vasectomy,

19:32

um, epididymis.

19:32

They don't all have this occur,

19:33

but this can occur at times now.

19:37

I love this case.

19:38

This is from one of my favorite radiologists,

19:40

Mayor Seinfeld, uh, who is at Montefiore.

19:43

And here you can see little, tiny echogenic foci

19:47

within the epididymis kind of dancing around.

19:52

And this is consistent with the

19:54

filarial dance of the, um, in the epididymis.

19:58

This, uh, is oftentimes thought to be secondary

20:01

to, uh, filariasis, um, here causing, uh, elephantiasis.

20:05

It's, uh, a little worm that goes into lymphatics

20:09

and, um, tends to block lymphatic drainage.

20:14

Now, here's a guy.

20:18

From Boston, probably never left Boston a day

20:20

in his life, drinking nothing but Dunkin’ Donuts.

20:22

Right.

20:23

Um, and, uh, pumpkin spice beer.

20:25

Of course.

20:26

Wow.

20:26

Um, anyway, so he's 57 years old, prior vasectomy,

20:31

and we have, again, we have the filarial dance.

20:33

Like, how is that happening?

20:36

So it's probably all a lie.

20:38

Okay.

20:39

Even the, um, filariasis stance is likely

20:43

related to, uh, lymphatic obstruction.

20:47

And this patient had a prior vasectomy, which can

20:49

also cause lymphatic obstruction as a result of,

20:53

resulting in this, um, mega sperm

20:56

appearance on the ultrasound.

20:58

So when you see that mega sperm appearance,

21:01

we're all super excited to say filariasis,

21:03

because, like, that's a good time.

21:05

Um, but most likely it's just

21:07

a result of prior intervention.

21:10

If they're from an endemic area, sure.

21:12

But, um, still, it's probably, even when you're

21:15

seeing that kind of characteristic dance, it's

21:17

still, um, an appearance consistent with, uh,

21:21

the lymphatic obstruction resulting from that little worm.

21:24

But I love parasites.

21:26

All right.

21:28

Now, this is where usually I lose a lot of the audience.

21:30

Because every time I lecture, I'm usually

21:32

for emergency radiologists, and it's all men.

21:34

So I lose a lot of the audience in this.

21:36

Everyone goes to get a cup of coffee, but.

21:39

Let's start with the scenario.

21:40

Um, it's spring in Boston.

21:42

It's May, it's cold, and it is a Little League time of year.

21:47

And if you have children, um, if you've ever been a

21:50

parent on the side of Little League, you'll realize

21:52

that there's the first year your kids do kid pitch

21:55

Little League, and it is horrific because not one

22:00

ball goes over the plate.

22:01

So you all sit there for six innings of cold

22:04

spring, terrible baseball, only for a dad

22:07

to finally get out there to pitch a ball.

22:10

And that father isn't prepared in many ways.

22:13

And as a result, that first line

22:15

drive goes straight to the parts.

22:18

Um, so here is your 35-year-old Little League

22:21

coach who's gone out there to pitch to the boys.

22:24

And you'll see during this sweep a

22:26

very irregular, um, testicular shape,

22:29

along with echogenic material in the scrotum.

22:34

So this is a classic testicular rupture.

22:37

Look at our normal testicle.

22:39

Always confined to that ovoid shape.

22:41

On the sagittal view, our sagittal view of the right

22:44

testicle is irregular in shape, kind of like a

22:47

little, little, I don't know, Smurf hat here.

22:50

Um, and that's a result of avulsion of the tunica

22:53

albuginea; that thick fibrous sheath has been cracked.

22:56

And the seminiferous tubules of the

22:59

testicle have spilled out of it.

23:01

Um, there's also blood products in the testicle,

23:04

so loss of your normal, um, testicular shape is,

23:09

like, and any blood in the testicle, good enough.

23:12

Call it a ruptured testicle.

23:13

This one was indeed ruptured and

23:16

partially avulsed at, uh, surgery.

23:17

Those are your little seminiferous tubules.

23:20

Um, and there's that thick fibrous sheath.

23:24

All right.

23:26

Um, and again, here is your echogenic, uh,

23:31

tunica albuginea, um, kind of with those lacerations

23:35

in the testicular parenchyma itself. It takes

23:37

110 pounds of force to, uh, rupture a testicle.

23:41

I'm not sure who did that science,

23:43

but, you know, more power to them.

23:45

Right.

23:46

Um, since that makes it known that

23:48

we can pretty much publish anything.

23:51

Okay, so here is your karate guy.

23:54

This is another history we see frequently.

23:57

Um, we're going to watch this come through.

23:58

You're going to see that the testicle is irregular in shape.

24:01

Again, once we look at the still image, you're

24:04

going to see that there's actually extrusion again of

24:06

testicular material through that ruptured tunica albuginea.

24:11

This is, again, a ruptured testicle.

24:15

At times, you may notice a very

24:17

large display, um, uh, hematocele.

24:22

There's very mixed echogenic material

24:25

in the scrotum in that tunica vaginalis.

24:27

That is a large volume of blood products, and

24:31

that is consistent with testicular rupture.

24:33

Again, we have the, um, extruded testicular

24:37

material and the large hematocele adjacent to it.

24:42

Now in Boston, we have, um, bike

24:45

week right up in New Hampshire.

24:46

Uh, and that brings us some fun in the spring as well.

24:50

So this is a patient who was in a motorcycle

24:52

accident and has your classic, uh, open-book

24:54

fracture of the pelvis with diastasis of the

24:57

symphysis pubis and right sacroiliac joint.

25:00

That posterior sacroiliac joint

25:02

is the binding of that open book.

25:05

Well, what else did he hit?

25:07

This guy has bilateral testicular injuries.

25:10

Um, on the right you can see you've

25:12

lost that normal shape of the testicle.

25:14

It is gone.

25:15

It's just kind of featureless.

25:17

Right here on the left, we have the normal shape of

25:20

the testicle, but it's very heterogeneous in nature.

25:24

This was a ruptured testicle with

25:25

full avulsion of the tunica albuginea.

25:28

Basically, it was just seminiferous tubules

25:30

hanging out in the scrotal sac, as opposed to

25:32

the heterogeneous, contused testicle on the left.

25:36

Of interest, um, I guess the right testicle is

25:39

a little higher than the left, and it is more

25:41

likely to get injured, um, in general, because

25:44

it will hit against the symphysis pubis.

25:48

All right, so here is a 16-year-old, um, who was kicked, and

25:53

you can see these little hypoechoic regions in the testicle.

25:56

So that is concerning for intratesticular, um, lacerations.

26:02

But the configuration of the testicle is confined.

26:05

So the other ones were surgical emergencies.

26:07

Once you have a ruptured testicle, you have to go and

26:09

debride and try to seal it up as much as possible, because

26:12

your immune system could attack your testicular, um,

26:16

tissues, and then you're going to be infertile, and, um,

26:20

and you're just trying to salvage as much testicular

26:22

parenchyma as well.

26:24

Um, but in this case, you don't have a testicular rupture.

26:26

You just have intratesticular lacerations.

26:29

So these, um, with that good history of, uh,

26:33

of an actual direct blow, can be followed. In this

26:36

case, um, they will resolve within six weeks.

26:39

That's the hope.

26:40

So this one resolved in six weeks, and we were

26:42

okay, but, um, we always want to follow these to make

26:45

sure that they resolve, just like those segmental

26:47

infarcts, because of any concern, um, that, uh,

26:52

that we have over the possibility of

26:54

an underlying, um, testicular tumor.

26:59

All right, so here, do my earphones work?

27:02

I think so, hopefully.

27:04

Um, here is, uh, just to recap, interesting.

27:09

You know,

27:10

in the sport of hockey.

27:11

Hockey, the cup came in in 1874 and the helmet in 1974.

27:15

So, you know, priorities, right?

27:17

Um, so these are just the various

27:19

appearances of our ruptured testicle.

27:23

Next case, 23-year-old with back pain.

27:27

We're at the level of the renal hilum, and we have

27:28

large-scale lymphadenopathy surrounding the kidney.

27:32

All right, let's bring it up.

27:34

Let's bring up embryology.

27:36

Ah, all right.

27:38

So always remember that the testicles begin

27:41

their embryological life, um, up at the renal

27:44

hilum, and then descend down into the testicle.

27:47

So that is why if you find, um, lymphadenopathy

27:50

at the renal hilum, you have to be concerned

27:52

that there's an underlying malignancy.

27:54

This patient was then ultrasounded, and you could

27:56

see this hypoechoic lesion within the testicle.

27:59

This was a seminoma. Notice, not very vascular.

28:03

So that's huge.

28:04

You know, you don't want to ever use vascularity as

28:07

a reason to exclude a testicular tumor, all right?

28:10

Because frequently they're hypovascular.

28:14

All right, let's move on to, um, the penis.

28:17

Okay.

28:18

The penile anatomy.

28:19

All right.

28:20

We're going to start with, here's your MRI down here.

28:22

Here's your nice little gray-scale drawing

28:24

here, and here's your ultrasound.

28:26

Um, here we have the paired corpora cavernosa.

28:29

Um, make sure that everything, we have

28:33

our paired corpora cavernosa, okay?

28:35

Those are the erectile bodies of the penis.

28:38

Then we have the deep arteries

28:40

within the, um, corpus cavernosum.

28:43

All right, the deep arteries.

28:44

Those are going to be important in a minute.

28:45

Don't worry.

28:46

Then you have your corpus spongiosum,

28:48

that surrounds your urethra.

28:52

Then you have your tunica albuginea.

28:54

It's this dark, dark, low-signal, um, structure on

28:59

the MRI with the septation between the corpora cavernosa.

29:03

So that's the thick fibrous sheath that actually covers

29:06

the, um, corpora cavernosa, similar to the testicle.

29:09

And then we have Buck’s fascia, which is a looser

29:12

kind of fascia around all three bodies.

29:15

And don't forget, there's a dorsal vein

29:17

on the dorsum of the penis as well.

29:20

Okay, so our first case is a 17-year-old with sickle cell

29:24

disease complaining of continuous erection for 24 hours.

29:27

So he has priapism, um, painful priapism, mind you.

29:31

And when we look at this patient, um, we have,

29:35

this is our patient, and this is the normal.

29:37

On this side, we have these engorged corpora cavernosa

29:40

with lots of little engorged sinusoids of the, um, of the

29:44

corpora cavernosa, as opposed to the more normal, collapsed

29:48

appearance here.

29:51

So, um, these corpora cavernosa are not compressible.

29:55

What's your ultrasound problem?

29:56

And that's because this patient has no

29:59

flow in the deep arteries, no flow in the

30:01

deep arteries, um, on any of these views.

30:04

This is a sagittal view, nor the transverse view.

30:06

And this is low-flow ischemic priapism, very

30:09

typical of the veno-occlusive priapism that

30:12

you're going to find in sickle cell disease.

30:15

Um, now they're going to, your technologist is

30:17

going to bring you these images as well, and the

30:19

urologists are going to be hounding on your back.

30:21

Is this low- or high-flow priapism?

30:23

Now, just because there is dorsal vein and

30:26

artery flow, that is not what we're talking

30:29

about when we're talking high or low flow.

30:32

We're talking about the deep dorsal veins, uh, and

30:35

arteries of, um, pardon me, arteries of the penis.

30:38

This is a normal trace of a flaccid penis.

30:41

It should be a high-resistance waveform.

30:43

Um, but there should be arterial flow in that deep,

30:46

deep artery of the corpus cavernosum.

30:53

All right, so almost all, um, all the sickle, like I say,

30:57

sickle cell, you say low flow; sickle cell, low flow;

30:59

sickle cell, low flow, like that's going to be one of the more

31:01

common reasons why a patient will come in with priapism.

31:04

This is not as common, but I think it's

31:06

always one that you're going to be tested on.

31:07

So let's do it.

31:08

Here is a 17-year-old who had,

31:11

um, a painless, non-painful priapism.

31:13

Um, and after an automobile accident, and again, you're

31:16

gonna see those very dilated sinusoids of the corpus

31:20

cavernosum, um, on both sagittal and, uh, transverse views.

31:26

But notice there's intact vessel flow, arterial flow

31:29

in those deep arteries of the corpus cavernosum.

31:33

This is high-flow traumatic priapism.

31:37

It's going to be different.

31:39

First of all, it's usually non-painful.

31:40

Number two, it's compressible.

31:42

So here are the corpora cavernosa

31:43

with, without, and with compression.

31:46

So that's typical, because it's not a venous

31:48

occlusive; it's a high-flow situation.

31:51

Normally this is a result of fracture

31:55

of injury to the base of the penis.

31:57

Usually there's even a pelvic fracture,

31:59

causing, um, an arteriovenous, uh, um,

32:04

and pseudoaneurysm of the perineum,

32:07

resulting in unabated flow to the penis.

32:09

Okay, so we're gonna see this on, we have a

32:12

little, uh, fracture here, the symphysis pubis.

32:15

Um, and as we come down, we're gonna see this beautiful

32:19

pseudoaneurysm of the base at the base of the

32:22

penis, and that results in that unabated blood flow.

32:25

High-resistance, high-flow traumatic priapism.

32:29

Um, so it's a, it's a unique case, but, uh, it is,

32:35

um, the cause for high-flow traumatic priapism.

32:40

All right, what about this guy? He fell off a building, so

32:45

I know you guys are always super excited about the, um,

32:49

uh, Throckmorton sign.

32:51

Yay.

32:52

So this is the ultimate Throckmorton sign right here.

32:55

So this is a case of neurogenic priapism

32:58

in a patient with spinal injury.

33:00

So that's something you want to look for.

33:01

If you ever receive this priapism on the, uh,

33:03

uh, X-ray there.

33:07

So, um, priapism, uh, it's an alert,

33:10

urological emergency, for sure.

33:12

Uh, frequently they'll have to have injections

33:14

or shunting, um, surgical shunts and the like.

33:18

Even with those, 50% of the patients will have

33:20

impotence as a result, which is really unfortunate.

33:23

Most frequent causes are your sickle

33:25

cell disease with veno-occlusive.

33:27

Um, sometimes, uh, leukemias, again, um, hypercoagulability,

33:31

uh, and certain medications such as trazodone, of course.

33:35

Um, the traumatic cases that we just showed are very

33:38

uncommon, but, uh, certainly a cause of priapism as well.

33:43

Okay, here is, um, a 38-year-old, uh, who presents

33:48

with penile pain and foreign body sensation,

33:50

firm mass palpable on the dorsum of the penis.

33:54

Now here we have images of that dorsal vein

33:57

that I told you you couldn't look at for

33:58

priapism, but you can look at for this case.

34:00

And here we have a nice thrombus within that dorsal vein.

34:04

This is thrombosis, or thrombophlebitis, of the deep dorsal

34:07

vein of the penis, known as Mondor disease of the penis.

34:10

It's treated as any other, um,

34:14

as any other superficial thrombophlebitis. It's,

34:17

uh, you know, but it's usually quite, um, painful.

34:21

So, uh, patients are very concerned.

34:23

I think that whenever I have seen this,

34:25

it's, um, usually kind of a new diagnosis

34:27

to the ER physicians you're working with.

34:29

So, um, it might, uh, necessitate a little

34:32

explanation, but it is a thrombophlebitis or

34:35

a thrombosis of that deep, of that superficial,

34:38

sorry, I'm losing my deep versus superficial thing,

34:40

um, penile vein.

34:43

Okay, so here's a 30-year-old who presents to the ED

34:47

with painful swelling and bruising after intercourse.

34:49

This is from, um, the show New Girl.

34:51

If you're looking for anything

34:52

to binge, it's really funny.

34:53

It's on Netflix.

34:54

Anyway, so here is the penis on MRI.

34:58

We choose to do our penile,

34:59

um,

35:01

uh, our penile, um, injuries on MRI whenever possible.

35:06

Um, it just gives really great visualization.

35:09

It's a major degloving surgery, so, uh, usually

35:13

it's helpful to have the, um, the best view

35:15

as possible, can minimize the impact of that.

35:18

Um, the need for, uh, extensive visualization, and

35:21

also, usually the patients are quite tender, so

35:24

the ultrasound probe can be difficult to utilize.

35:27

And we have an MRI scanner in the ER, so

35:29

we're always looking at MRI more stuff.

35:31

Um, anyway, so here we have our paired corpora,

35:34

and you can see that nice, uh, low-signal,

35:36

um, tunica albuginea of this,

35:39

uh, left corpus is intact here.

35:42

And as we come down, you're going to

35:43

see, oh, this is the eggplant sign.

35:46

From, uh, that's actually the medical term for the,

35:50

uh, sign of the, um, bruised penis on exam by urology.

35:54

They must be a fun group. Anyway, um,

35:57

as we come down, we're going to see that there's

36:00

dehiscence of the tunica albuginea, and that's

36:03

consistent here. It comes back as normal, um, with

36:06

a penile fracture here in the longitudinal plane.

36:09

You can see that dehiscence. It's usually about,

36:11

it's usually at the, um, base of the penis.

36:14

Uh, it's, and it is, uh, usually about a centimeter in size.

36:18

So this one went on for fixation.

36:21

This is a surgical emergency again as well.

36:24

Um, if they heal improperly, they can have

36:26

painful erections and/or, um, curved erections.

36:29

So that can be clinically significant.

36:33

Um, let's look at another one,

36:34

because people always, uh, like these.

36:35

So here is, um, the coronal view.

36:37

We have the eyes of the deep

36:39

arteries of the, um, corpus cavernosum.

36:41

They are surrounded by the tunica albuginea.

36:44

We're going to come forward. We're going to notice that one

36:46

little testicle has gone to, to, to its hiding place.

36:49

Um, but as we come forward, we're going to

36:51

see dehiscence of that, uh, lateral, um,

36:57

corpus cavernosum, and that is

36:59

consistent with a, uh, penile fracture.

37:03

Again, on the sagittal view, we always try to

37:05

position the patient in anatomic alignment.

37:07

Um, I usually, if you have any questions

37:10

what to do in a pinch, you just take

37:12

the T2 non-fat, high-resolution images off your

37:16

pelvic MRI and just tell them to do it on the penis.

37:19

It works great.

37:20

You're fine.

37:21

Um, that's all you really need.

37:22

Uh, and just those three sequences, you're kind of done.

37:25

Um, and here you can see that dehiscence

37:28

of the right, um, on that, uh, sagittal image.

37:33

Now at times, um, there may be urethral injuries

37:37

involved in these penile fractures. It's not that common.

37:39

But anytime they say that there's blood at the meatus,

37:42

you're going to have to do a RUG, or, you know, they're going to

37:44

basically have to go in cystoscopically to evaluate for

37:46

that, because likely there is, um, a urethral injury.

37:50

But things on MRI that can help you

37:52

with that are when you have high signal

37:55

of urine extravasated from the urethra,

37:58

here, it's coming into the corpora as well.

38:01

Um, or if you have, uh, air on ultrasound or air on MRI

38:04

coming from the urethra into the erectile bodies,

38:08

that can tell you that as well.

38:13

All right.

38:14

Well, thank you.

38:15

I tried to keep that to 40 minutes.

38:16

I hope that was done.

38:18

Um, anyway, I hope we made it through,

38:20

uh, testicular and scrotal emergencies.

38:23

Are there any questions?

38:26

Don't know how to do this.

38:33

Um, if you hover your mouse up by the top of your screen.

38:36

Okay.

38:36

Your

38:37

Zoom options.

38:38

Okay.

38:39

And the Q and A?

38:40

Yeah.

38:40

Okay.

38:41

I can read them.

38:42

Mm-hmm.

38:43

All right.

38:44

Um, when do you consider malignant findings

38:46

of microlithiasis, and how do you report it?

38:51

You know, I'm an ER radiologist, so I have to

38:54

say that I just, unless it's so dramatic, I

38:57

think that there's no good consensus on this,

39:00

so I just say scattered microlithiasis and leave it.

39:04

I don't suggest anything.

39:05

Um, I know that some of our, uh, other imagers, if there

39:09

were a sign, if there's a large volume of microlithiasis,

39:13

most of our abdominal imagers will suggest

39:16

follow-up with urology for your yearly urological exam.

39:21

Um, but I think it's still contentious regardless.

39:25

Uh, hello.

39:26

During ultrasound, the settings of the color flow may

39:29

falsely increase or decrease the apparent vascularity.

39:31

What are the color settings to ensure

39:33

you use during, um, during ultrasound?

39:38

I think the key is just that buddy view.

39:40

You really want to see the two together.

39:42

So that's kind of what we utilize, um, most significantly,

39:45

just so we have a comparison to the contralateral side.

39:49

Um.

39:50

This, almost all of this content is in a

39:52

Radiographics paper I wrote a couple years ago.

39:55

So if you're looking for a review of this,

39:57

um, uh, please feel free to look at that.

40:01

How do you recognize early torsion?

40:03

Um, so I think that really it's that, uh, enlargement

40:07

of the epididymis that could be an early sign.

40:10

Um.

40:11

And or, uh, the asymmetry of flow between the testicles.

40:16

So that's kind of how we try to do that.

40:18

Um, also, you know, we correlate with the exam, and we, we

40:22

see a lot of the urology, uh, residents come back, and we

40:25

really talk to them a lot about, um, what the findings are.

40:28

Any other questions?

40:30

Oh, wait.

40:30

Oh, oh.

40:31

Is scrotal sonography obsolete or

40:33

still indicated in scrotal pain?

40:35

You know what, I actually don't know.

40:36

We would never use it in our ER, so we don't use it.

40:39

Um, it might be something that's utilized in, uh,

40:44

the, um, pediatric population. We don't go there.

40:48

Um, how can we differentiate early torsion epididymitis?

40:51

Again, the epididymitis should be hyperemic, lots of

40:56

blood flow in infection, and should have lack of blood flow

41:00

in torsion.

41:01

Um, are we supposed to indicate the

41:03

salvageability of the testes in our report?

41:07

Um, I would not, you know, I always just say, I do

41:09

talk about, I'll say with significant heterogeneity

41:12

of the parenchyma suggesting infarction.

41:14

Um, but it depends.

41:16

I, I mean, we have more, probably more

41:18

surgeons than we have patients, so.

41:20

They're probably going to try to do,

41:22

um, salvageability regardless.

41:24

That might be a more important point if a patient has

41:27

to be transferred, because the mode of transportation

41:31

to a different hospital can be important, right?

41:34

So if you had a testicle that looked

41:35

salvageable, and they're out on Nantucket Island,

41:38

they're probably going to airlift them over.

41:39

Whereas if that testicle already looks

41:42

like in the end stages of, um, infarction.

41:46

It may not be as, um, as quickly done.

41:48

So it also depends on the patient's

41:50

age, um, and reproductive status.

41:55

Oh, more, um, what is the accepted timeframe between, uh,

42:00

requesting an ultrasound to report for a case of torsion?

42:04

Um, so we usually get reports

42:08

from our ultrasound technologists.

42:10

Our ultrasounds are done very quickly, which is excellent.

42:12

And I have to say, if there's any abnormality,

42:14

I'm on the phone making a phone call right away.

42:17

Um, the ones that are normal, I probably will

42:19

take a half an hour to report, but if there is a

42:23

torsion, um, I am, like, dialing with one phone to

42:27

or getting on to page the clinician while

42:29

I'm still on the phone with a technologist.

42:32

Um, heterogeneous testicle after one day of trauma,

42:34

bicycle, with hyperemia of the residual testicular tissue.

42:38

No scrotal wall edema, no fluid in the sac, no rupture.

42:41

Should we think of underlying mass?

42:43

Yes, that is why you would get

42:46

follow-up.

42:47

So just like the case I showed of the intratesticular

42:50

laceration, um, hematomas, we always follow those up

42:53

in six weeks to make sure that they have resolved.

42:55

We are very fortunate because we have a pretty high, um,

42:59

uh, rate of patients coming back for their follow-up.

43:03

So, um, we're able to really safely follow a lot of stuff.

43:07

Uh,

43:08

that can be questionable in other places.

43:10

Um, do you do CEUS in ER?

43:15

Uh, I'm not sure what that is.

43:17

Um, uh, does presence of color flow rule

43:21

out torsion, um, current torsion or detorsion?

43:24

How, how do we image, um,

43:28

You know, we usually stop with, if you

43:29

have normal blood flow, you're okay.

43:32

Uh, again, taking out the people who've had

43:35

recent surgery, um, that can just be decreased

43:37

blood flow, which can be a little hard.

43:39

Um, but anytime you have abnormal, you

43:41

wanna look at that resistive index.

43:43

So if it's normal resistive index, or probably

43:45

within normal limits, um, should we include in our

43:48

reports small abscesses in cases of epididymitis?

43:52

And does it change management?

43:53

So that tail abscess I showed you

43:55

did go on to percutaneous drainage.

43:59

So they, under ultrasound, did needle-drain that.

44:02

So I do not see them very often.

44:06

Um, but when I do see them, I do report them.

44:08

Um, contrast ultrasound.

44:11

Yeah.

44:11

You know what?

44:13

We don't use contrast ultrasound for this.

44:15

Uh, I think that in our ER we're just too fast.

44:18

We're trying to get through stuff. That's an

44:19

interesting, um, possibility in the future.

44:22

Um, but it's only been, we use it for liver

44:26

lesions now, but it hasn't been approved

44:28

for that long, so we haven't used it.

44:30

That'd be kind of cool.

44:31

Let's do a project.

44:32

Um, the torsion of the rete testis is, uh,

44:36

common.

44:36

Please tell us diagnostic findings of them.

44:39

So the rete testis are the convergence of the

44:41

seminiferous tubules at the, um, mediastinum.

44:44

So they're not torsed, ’cause they're

44:45

actually within the parenchyma of the, um,

44:49

testicular tissue. They can dilate,

44:52

um, as I showed you in those initial

44:53

images, be very cystic in appearance.

44:56

You just wanna make sure you don't call

44:57

that a tumor, or if you see cystic dilatation,

45:01

that it is indeed in the mediastinum.

45:03

’Cause some very infrequent, um, I wanna say

45:08

teratomas or choriocarcinomas, one of the forms of

45:11

testicular cancer, can have a, uh, cystic appearance.

45:16

I think it's just

45:18

teratoma types.

45:19

Um, when I call urology, he asks one question,

45:24

is there any flow? If I try to discuss torsion,

45:27

detorsion with him, uh, he closes the line.

45:30

How to convince him that torsion is highly

45:33

expected, uh, to perform again?

45:36

You know what?

45:37

I would say you really should take the images

45:39

of the, again, the spectral Doppler and show

45:42

if there's any difference there, and explain

45:44

that spectral Doppler, um, that we only have.

45:47

Uh, um, flow during the, you know, if you have a high

45:51

resistant flow, that you're cutting off blood flow.

45:53

So that can be, um, something that they'll listen to.

45:56

’Cause last week we had the urologist being like,

45:58

there's still some flow with the vasectomy case.

46:00

And we were like, no, it's, you know,

46:02

minimal flow, and that flow that

46:04

we have is very high resistant.

46:06

And then they, they did, um, listen to us.

46:08

So, you know, if you can kind of prove to them some

46:11

information, how to differentiate delayed presentation

46:15

of torsion and delayed presentation of epididymitis, or,

46:20

you know, I don't think I've ever had to think that out.

46:24

Um, uh, so I don't know.

46:28

Uh, that could be hard.

46:30

Um, delayed torsion should have no blood flow,

46:33

where epididymitis should have avid blood flow.

46:36

So I would say that that's, um, the biggest problem.

46:39

Now, torsion detorsion, those are just hard

46:41

cases, uh, to deal with, but, um, pretty infrequent.

46:46

So I would say if you have significant

46:49

blood flow, there's also something with

46:52

physical exam. One of them is more painful when

46:54

you lift the testicles above the symphysis pubis.

46:57

And one of them isn't.

46:58

That's like a classic, but I don't really remember,

47:00

because that was like a boards question when I was a resident.

47:02

Um, but probably like increased blood flow,

47:05

we're gonna worry about the epididymitis, the decreased

47:07

blood flow, the torsion, and I think, um, I don't

47:13

have any cases of undescended testicle injury.

47:15

That would be cool.

47:17

Um, if I find one, I will put it in, um, because we,

47:23

I have some undescended testicles, but not a lot.

47:26

Uh,

47:29

Alright.

47:30

And I think that's all.

47:31

Um, so.

47:33

I hope that was somewhat, uh, educational in nature.

47:38

Um, and I appreciate the opportunity to lecture to you

47:42

today, and I really appreciate MRI Online for inviting me.

47:45

Um, and I hope that we have,

47:48

uh, another opportunity to meet.

47:51

I have some other fun lectures, so thank you very much.

47:55

All right, everyone.

47:56

This has business to close.

47:57

I wanna thank Dr. Avery for this excellent

47:59

lecture, and thanks to all you guys for

48:00

participating in our noon conference.

48:02

Reminder, this conference will be

48:03

available on demand at mriline.com.

48:06

In addition to all the previous noon conferences,

48:08

be sure to join us tomorrow for a lecture

48:10

from Dr. Elizabeth Lee on cardiac tumors.

48:13

You can register for that one at mriline.com and

48:15

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48:18

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48:21

Thanks again, everyone, and have a great day.