A 36 y/o male with no previous medical history presents with sudden onset of testicular pain that occurred while at work. The pain that is worse with movement radiates to his suprapubic abdomen. The patient is sexually active with multiple partners, and usually uses condoms. He denies recent trauma to the area, dysuria or hematuria.
On evaluation, his vitals are recorded to be: HR: 106, BP 115/79, O2 100%, Temp 98.8°F. Examination reveals left scrotal swelling and pain with elevation w/o discoloration or bruising. An ultrasound was brought to the bedside, and the following ultrasound is obtained:
Answer: Indirect inguinal hernia
This patient presented with sudden onset testicular pain. When evaluating a patient with this complaint, the differential diagnosis should include torsion, epididymitis, orchitis, testicular trauma, and inguinal hernias.1,2 While many hernias can be diagnosed clinically, ultrasound can be used in cases that are more ambiguous.3
- A linear, high-frequency probe should be used to evaluate the scrotum, evaluating both sides in multiple orientations.1
- An indirect inguinal hernia is suspected when peristalsing bowel loops are seen within the scrotum, surrounding the testicle. The peristaltic movement can help differentiate between bowel and a varicocele.4
- The absence of peristalsis on ultrasound without internal flow is highly suggestive of strangulation.5 Here is an example clip of a strangulated hernia:
- Normally, a scant amount of hypoechoic fluid can be seen surrounding the testicles, which measure an average 4 x 3 x 2.5 cm. The epididymis is usually found superior and posterior to the testicle, and is slightly more hyperechoic than the rest of the testicle.1
- Testicular torsion can be diagnosed by observing for diminished or absent flow in the affected testicle. Power Doppler may have to be used to detect blood flow.1
- Epididymitis or orchitis is suggested when increased color Doppler flow is seen in the epididymis or testicle on the affected side.1
Written by: Jacob Avila, MD, RDMS
- Dawson M, Mallin M, Introduction to bedside ultrasound volumes 1 + 2. [Inkling]
- Herbener TE. Ultrasound in the assessment of the acute scrotum. J Clin Ultrasound. 1996;24(8):405-21. [pubmed]
- Carkaci S, Ozkan E, Lane D, Yang WT. Scrotal sonography revisited. J Clin Ultrasound. 2010;38(1):21-37. [pubmed]
- Doniger SJ. Pediatric Emergency and Critical Care Ultrasound. Cambridge University Press; 2013. [Amazon]
- Ogata M, Imai S, Hosotani R, Aoyama H, Hayashi M, Ishikawa T. Abdominal ultrasonography for the diagnosis of strangulation in small bowel obstruction. Br J Surg. 1994;81(3):421-4. [pubmed]
