UOTW #16 Answer

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

  1. Dawson M, Mallin M, Introduction to bedside ultrasound volumes 1 + 2. [Inkling]
  2. Herbener TE. Ultrasound in the assessment of the acute scrotum. J Clin Ultrasound. 1996;24(8):405-21. [pubmed]
  3. Carkaci S, Ozkan E, Lane D, Yang WT. Scrotal sonography revisited. J Clin Ultrasound. 2010;38(1):21-37. [pubmed]
  4. Doniger SJ. Pediatric Emergency and Critical Care Ultrasound. Cambridge University Press; 2013. [Amazon]
  5. 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]

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