One of these is not like the other

Written by: Dr. Dylan Nguyen

Edited by: Dr. Joann Hsu

Case

Patient is a 30 year-old male with no PMH presenting for evaluation of left testicular swelling for the past one year. The swelling was initially painless, but he presented to the ED after he experienced pain to the left testicle. There are no associated fevers, nausea, vomiting, dysuria, hematuria, or penile discharge. He is sexually active with one partner and has no history of STI.


On exam, he has a firm and enlarged left testicle that is tender to palpation.


Bedside ultrasound shows…

First the buddy view / owl’s eye view:

You can’t really see the two sides well but you can already tell that they do not look the same.

Next, the unaffected right side:

Notice the hyperechoic dots throughout the testicle: testicular microlithiasis. This is not actually pathologic in itself but may be associated with future testicular malignancy.

There is also a small hydrocele here, but overall the echotexture of the testicle looks fine.

And now the left affected side:

whoa.

You see multiple areas of different echotextures, a very abnormal heterogenous appearance to the testicle. Also seems to have loculations and debris.

Very abnormal.

Differential for Testicular Pain

  • Testicular torsion

  • Torsion of the testicular appendage

  • Fournier’s gangrene

  • Epididymitis

  • Orchitis

  • Testicular rupture

  • Malignancy



Scrotal POCUS

  1. Have the patient assume a “frog-leg” position. Place a rolled towel underneath the scrotum to elevate the testes. Place the penis against the abdominal wall and drape with another towel.

  2. Make sure your linear probe is in the appropriate setting: ocular or testicle/small parts preset depending on your machine - this is a low thermal index setting which is safer for the testicle (and eye).

  3. Buddy view or owl’s eye view: compare echogenicity of the normal and affected testicle. Use power Doppler to compare blood flow in the testes.

  4. Start with the unaffected testicle to establish a baseline. Scan through the testicle, epididymis, and soft tissue in longitudinal and short planes. Repeat on the affected side.

  5. You may measure blood flow in each testicle if torsion is on your differential.


Testicular Malignancy

  • Can see intratesticular lesions that have reduced or heterogeneous echogenicity 

  • Heterogenous appearance of this mass, especially compared to other (normal) side

  • Increased blood flow

A caveat:

  • Always take the physical exam and clinical context into consideration! POCUS is used as an extension of your physical exam but not in isolation.

  • This patient didn’t have a cellulitic / infectious presentation or exam, but this ultrasound could potentially be interpreted as an abscess as well in the right clinical context.

Case Conclusion

After urologic consultation, the patient was admitted for further workup of malignancy. He underwent a left orchiectomy. Pathology results pending.


Happy scanning!

Booth EM