The use of point-of-care ultrasound (POCUS) for the evaluation of patients with acute scrotal pain is a valuable clinical tool to promote more rapid diagnosis, particularly in an office / emergency department setting where ultrasound coverage is not consistently available.
Acute scrotal pain makes up roughly 0.5% of all emergency department complaints. History and physical examination may be relatively non-specific, resulting in a broad differential diagnosis. Among these, testicular torsion is the most important “time-sensitive” diagnosis to make.
Torsion
Complete torsion occurs when the testis twists 360° or greater, usually leading to absence of intratesticular flow on color Doppler exam; although testicular flow can be decreased but still preserved. Intermittent torsion is defined as sudden onset of unilateral testicular pain of short duration with spontaneous resolution. In partial or incomplete torsion, the degree of spermatic cord twist is less than 360°, allowing for some residual flow to the testis. Intermittent torsion may present as hyperemic flow on ultrasound and early torsion may dampen only the venous flow.
Whirlpool Sign
The “Whirlpool Sign” is a spiral twist of the spermatic cord visualized on greyscale ultrasound. This is a direct sign of both complete and incomplete torsion (<360°) and is considered to be the most specific and sensitive sign for testicular torsion.
The portion of the spermatic cord adjacent or just superior to the epididymis is typically where the whirlpool sign is visualized.
Absent intra-testicular flow vs normal testes can rule In torsion. Color, Spectral, and Power Doppler play an important role in POCUS of the acute scrotum. Adjusting Color Doppler Imaging parameters to low flow (PRF) setting and using a low wall filter is very helpful for detecting blood flow within the testicle. Power Doppler Imaging (PDI) has an even greater sensitivity to low or slow flow but also comes with the disadvantage of flash artifacts caused by transducer and/or patient movement.
References:
Whirlpool sign (testicular torsion)
Cases That Count: Whirlpool Sign in Testicular Torsion
Sonographic differential diagnosis of acute scrotum: real-time whirlpool sign, a key sign of torsion
Advanced Emergency Medicine Ultrasound
Dates: September 12 - 13, 2024
- Most comprehensive Advanced Emergency Medicine Ultrasound course featuring expert faculty, interactive case presentations, and extensive 3:1 participant to faculty ratio hands-on skills training with standardized patient models
- All topics based on current ACEP, ACGME, and WINFOCUS guidelines
- Includes popular topics including Advanced Ultrasound Evaluation of Shock, Fluid Responsiveness in the Critically Ill, and Emergency Medicine Nerve Blocks (see topics section for more details)
- POCUS Certification Academy Preferred Education Provider– All GCUS participants receive 40% off Fundamentals Certificate and 20% off ANY POCUS Clinical Certificates (discount code provided during course)
- Lifetime access to digital course materials
- Destination education in sunny St. Petersburg, Florida
The Advanced Emergency Medicine Ultrasound Live Training Course is designed to build on the knowledge base of experienced emergency medicine and critical care ultrasound professionals using the most up-to-date ACEP/WINFOCUS advanced ultrasound topics. This course is taught by leading emergency medicine & critical care ultrasound experts and incorporates comprehensive lectures, interactive case presentations, and extensive hands-on skills training. All hands-on sessions feature a 3:1 participant to expert faculty ratio with standardized patient models and inanimate phantoms ensuring all participants gain improved competence and are able to immediately integrate the skills learned into clinical practice. Each participant receives scanning checklists and a log of exams performed to use for certification or credentialing if needed.
