A 37-year-old heterosexual man presented to the ED with complaints of left-sided testicular pain for 2 days. The pain started suddenly and had been increasing since its onset. He denied testicular swelling. He also denied dysuria, penile discharge, urinary frequency, and fever.
Physical exam was significant for tenderness of the left testicle. There was no testicular enlargement or scrotal edema noted.
The differential for this patient included torsion, epididymitis, epididymo-orchitis, orchitis, infarction and hemorrhage. A UA and gonorrhea and chlamydia amplification tests were ordered, and a bedside testicular ultrasound was performed in the ED.
Here are the images of the right (unaffected) side:
This shows a grossly normal testicle. Notice how the echo texture throughout the testicle is homogenous.
Next, color Doppler was placed over the testicle:
You can see that there is color flow present. Pulsed-wave Doppler (not shown) did show normal venous and arterial waveforms.
The epididymis was then examined:
The epididymis demonstrates unremarkable color Doppler flow.
The left (affected) side was then examined:
What things do you notice about the images shown?
In the first clip, the epididymis is seen with a small amount of fluid surrounding it. In both clips, a focal hypoechoic area is seen within the testicle next to the epididymis (see area highlighted below). In the second clip, there is a small hydrocele seen (anechoic fluid). What do you make of these findings?
The clinicians taking care of the patient were concerned for either a focal orchitis or malignancy. To help further define the lesion, color Doppler was placed over the testicle:
The area in question is hyperemic or hypervascular.
Color Doppler was also placed over the epididymis:
There appears to be normal flow (not increased, not decreased).
The clinicians taking care of the patient felt that the ultrasound findings, history, and physical exam were most consistent with focal orchitis.
Focal orchitis occurs in about 10% of cases of orchitis. Malignancy in the testicle presents with sings of acute inflammation 10% of the time, and therefore, it is difficult to distinguish focal orchitis from malignancy.
Signs that point toward focal orchitis over malignancy:
- Poorly defined edges
- Crescent shaped
- Located near the periphery of the testicle
- Adjacent to the epididymis
- Resolution of ultrasound findings with administration of antibiotics
UA was negative for infection. After the work-up was complete, he was discharged with levofloxacin for empiric treatment of focal orchitis. He was scheduled for close follow-up with plans to repeat the ultrasound. Gonorrhea and chlamydia results were pending at the time of discharge.
At follow-up he reported that his symptoms had resolved after one day on the antibiotics. His gonorrhea and chlamydia testing came back negative. His follow-up ultrasound showed resolution of the hypoechoic area that was previously seen.
- Agrawal AM, Tripathi PS, Shankhwar A, Naveen C. Role of ultrasound with color Doppler in acute scrotum management. J Family Med Prim Care. 2014;3(4):409-412.
- Lentini JF, Benson CB, Richie JP. Sonographic features of focal orchitis. J Ultrasound Med. 1989;8(7):361-365.
- Plas E, Riedl CR, Hubner WA, Knoll M, Ulrich W, Pfluger H. Focal orchitis–a diagnostic dilemma. Br J Urol. 1997;79(6):995-996.