Nussbaum Blask and Pe d i a t r i c I m a g i n g • O r i g i n a l R e s e a r c h

Rushton
Sonography of Testicular
Torsion in Pediatric Patients

A C E N T U
R Y O F Sonographic Appearance
of the Epididymis in
MEDICAL IMAGING
Pediatric Testicular Torsion
Anna R. Nussbaum Blask1 OBJECTIVE. The purpose of this study was to determine the frequency of an enlarged epi-
H. Gil Rushton2 didymis in pediatric patients with testicular torsion and to determine whether an altered epi-
didymis might be a helpful ancillary sonographic sign of testicular torsion.
Nussbaum Blask AR, Rushton HG MATERIALS AND METHODS. The sonograms of 50 pediatric patients (age range, ne-
onate–17 years) with testicular torsion were retrospectively reviewed for the size, appearance,
and blood flow of the epididymis. Medical records were reviewed for surgical and pathologic
findings and to determine whether testicular salvage had been possible.
American Journal of Roentgenology 2006.187:1627-1635.

RESULTS. The epididymis was enlarged (maximum dimension, 5.5 cm) in 47 of the 50 pa-
tients with acute or late phase torsion and after manual or spontaneous detorsion. The average dif-
ference in volume between the ipsilateral epididymis and the contralateral epididymis was 30
cm3, highly significant (p < 0.0001). The shape of the epididymis was altered in 92% of the cases
(globular, bilobular, or multilobular). Seventy-three percent showed increased echogenicity and
27% appeared isoechoic. Of those with active torsion, 93% of the epididymides were avascular;
2%, hypovascular; and 5%, hypervascular. After detorsion, 100% of the epididymides (10/10)
had blood flow. In patients with testicular loss due to infarction, pathology showed engorgement
and enlargement of the epididymis with hemorrhagic infarction. In one patient with a hypervas-
cular epididymis, surgery showed inflammation and erythema of the epididymis. Testicular loss
occurred in each type of epididymal flow pattern.
CONCLUSION. A markedly enlarged, echogenic, and avascular or hypovascular epididymis
is an ancillary sonographic sign in pediatric patients with testicular torsion. A hypervascular en-
larged epididymis infrequently occurs (5% of cases) and should not be mistaken for epididymitis.
In addition, the return of epididymal blood flow is an ancillary sign of successful testicular detorsion.

he acutely painful scrotum is a Radiologic imaging studies are performed

Keywords: color Doppler sonography, emergency

radiology, epididymis, genitourinary tract imaging,
pediatric radiology, testicular torsion
DOI:10.2214/AJR.05.0461
Received April 14, 2005; accepted after revision
November 10, 2005.
1Department of Radiology, Children’s National Medical
Center, 111 Michigan Ave., NW, Washington, DC 20010.
Address correspondence to A. R. Nussbaum Blask
(ablask@cnmc.org).
2Department of Urology, Children’s National Medical
Center, Washington, DC 20010.
AJR 2006; 187:1627–1635
0361–803X/06/1876–1627
© American Roentgen Ray Society
T common clinical occurrence in pe-
diatric patients and is treated as a
clinical emergency because of the
possibility of testicular torsion. Testicular tor-
sion, which requires immediate surgical inter-
vention or manual detorsion, must be distin-
guished from the nonsurgical conditions of
torsion of the appendix testis, epididymitis, and
epididymoorchitis. If clinical suspicion of tes-
ticular torsion is high, surgery is performed
without additional imaging studies. However,
in most cases in the pediatric population, the
absolute differentiation of testicular torsion
from the nonsurgical conditions based on only
physical signs and symptoms is difficult. In ad-
dition, up to 70% of patients with an acute scro-
tum have nonsurgical conditions [1, 2]. The age
of the patient is not helpful in the differential di-
agnosis because testicular torsion can occur in
patients of any age, including neonates [3, 4].
frequently in the acutely symptomatic patient
to avoid unnecessary surgical exploration.
Over the past several years, testicular color
Doppler sonography has become the initial im-
aging study of choice because of its reported
high sensitivity (78.6–89%) and specificity
(77–100%), coupled with its lack of radiation
and rapidity of performance, replacing testicu-
lar scintigraphy in most cases [3–6]. In our in-
stitution, scintigraphy recently has served as an
ancillary second study reserved for cases that
were indeterminate for torsion on sonography
or showed decreased—but still present—flow
compared with the asymptomatic side.
The role of power Doppler sonography in
the examination of the testes has been inves-
tigated. Whether it provides an additional
advantage over color Doppler sonography
or might, in fact, increase the false-negative
rate because of its increased sensitivity to

AJR:187, December 2006 1627


decreased but still present arterial blood
flow is not yet known [7–11]. In several re-
ports, researchers have described false-neg-
ative color Doppler sonography findings in
patients with testicular torsion despite its
high reported sensitivities [12–15]. In addi-
tion, seeing flow in the normal prepubertal
testis may be difficult or impossible, making
the diagnosis of torsion on the contralateral
symptomatic side more difficult [3, 4, 10,
11, 16]. In fact, some authors have sug-
gested that radionuclide scintigraphy re-
main the imaging technique of choice in
prepubertal children [10].
In our previous study of 46 pediatric pa-
tients with an acute scrotum, we observed
that a markedly enlarged avascular epidid-
ymis was present in children with torsion of
the testis; it was a source of confusion in
several cases because of its masslike ap-
pearance [3]. In this study, we retrospec-
American Journal of Roentgenology 2006.187:1627-1635.
tively reviewed a series of pediatric patients
with the known diagnosis of testicular tor-
sion, including 13 patients with torsion from
our previous study, to determine the fre-
quency of this finding on testicular sonogra-
phy. Also, we wanted to determine whether
an abnormal appearance of the epididymis
might be a useful ancillary gray-scale and
color Doppler sign of testicular torsion. In
addition, we wanted to see whether there
were any differences in the appearance of
the epididymis during acute phase torsion,
during late phase torsion, or after spontane-
ous or manual detorsion, and we wanted to
correlate the appearance of the epididymis
with pathologic and surgical findings. Our
final aim was to determine whether the
sonographic appearance of the epididymis
could be of any assistance in predicting tes-
ticular salvage.
Materials and Methods
All patients with a hospital discharge diagnosis
of testicular torsion between January 1992 and
2002 were identified by performing a computerized
search of medical records. Patients who had under-
gone color Doppler sonography of the testis and
epididymis as part of their diagnostic evaluation
formed the study group, which was composed of 50
patients who ranged in age from neonate to 17
years. Institutional review board consent for the
study was obtained. Each sonogram was retrospec-
tively reviewed by one of the authors for all of the
parameters being evaluated. The reviewer was not
blinded to clinical information.
The size of the epididymis on both the symp-
tomatic and the contralateral asymptomatic
1628
Nussbaum Blask and Rushton
sides was determined. Sonographic studies had
been performed using a standardized method to
obtain longitudinal images parallel to the long
axis of the testis and transverse images perpen-
dicular to the long axis of the testis. The length
and depth of the entire visualized portion of the
epididymis were measured with calipers on a
single longitudinal image in the plane of maxi-
mal enlargement. The transverse measurement
was obtained from a single transverse image in
the plane of maximal enlargement.
On the symptomatic side, if only the head was en-
larged and the head was the only portion of the epi-
didymis visualized, it was used for the measure-
ments of epididymal size. A range of sizes was
obtained for the symptomatic side and for the
asymptomatic side. The epididymal size in the
asymptomatic hemiscrotum served as the control
sample in 41 of the 50 patients because there were no
cases of bilateral synchronous testicular torsion. In
the remaining nine patients, the epididymis in the
asymptomatic hemiscrotum could not be measured
retrospectively because images were insufficient or
the epididymis was not seen or because of prior re-
moval or atrophy of the contralateral testis and epi-
didymis (two patients). In eight of these nine
patients, the epididymis in the symptomatic hemis-
crotum was matched to that of an age-matched con-
trol subject. In one of the nine patients, no quantita-
tive analysis was performed because of the lack of
hard-copy images. Evaluation was qualitative only
and based on the written report.
The shape of each epididymis in the sympto-
matic hemiscrotum was categorized as triangular,
round, or ovoid, and an estimated volume was ob-
tained using the formula for a pyramid, sphere, or
prolate ellipsoid, respectively, in 49 of the 50 pa-
tients. The estimated volume of the normal epidid-
ymis was calculated using the formula for a pyra-
mid because review of the images in our series
indicated the shape of the normal epididymis was
best approximated by the triangular shape; none
was globular, bilobular, or multilobular.
Other authors have previously described the
shape of the normal epididymis as pyramidal [17,
18]. Leung et al. [18] in their sonographic analysis
of 40 asymptomatic men suggested that the epi-
didymis has a triangle, crescent, or teardrop shape.
The volume of the epididymis on the symptomatic
side was compared with that of the contralateral
normal epididymis using a Student’s t test of the
difference between the means. Before statistical
tests were applied, the data were checked for nor-
mality and homogeneity of variance. Normalizing
variance-stabilizing data transformations were ap-
plied to satisfy the criteria for parametric analysis
before testing. Thereafter, a Student’s t test was ap-
plied to test whether the difference in epididymal
volume between the symptomatic side and the
asymptomatic side was a value other than zero. The
portion of the epididymis that was enlarged was
documented as the head, head and body, body and
tail, head and tail, or entire epididymis.
The gray-scale appearance of the epididymis
was evaluated. The shape was further analyzed to
determine if it maintained a triangular configura-
tion or if it was distorted into a globular, bilobular,
or multilobular shape. The echotexture of the epi-
didymis on the side of testicular torsion was evalu-
ated and characterized as isoechoic or hyperechoic
and as homogeneous or heterogeneous in texture.
The number of epididymides containing multiple
prominent cystic spaces was tabulated.
The vascularity of the ipsilateral epididymis
and the symptomatic testis was evaluated in all 50
subjects with color flow Doppler imaging using
low-flow settings (HDL 3000 or 5000, ATL). Each
sonographic examination was performed by one
of three experienced pediatric sonographers. The
epididymis was characterized as vascular if color
flow was seen, avascular if no color flow was de-
tected, and hypovascular if only minimal flow was
seen. If the epididymal flow was greater than the
flow seen in the asymptomatic side, it was consid-
ered hypervascular. Pulsed Doppler tracings of the
epididymis were not obtained except in two pa-
tients. The Doppler findings in the symptomatic
testis were correlated with the findings in the ipsi-
lateral epididymis. The number of cases with
manual detorsion or spontaneous detorsion was
tabulated, and color Doppler examinations were
assessed both before and after detorsion, if avail-
able, or only after detorsion if sonography had not
been performed before detorsion.
The patients’ medical records were reviewed for
surgical and pathologic findings and to determine
whether testicular salvage had been possible.
The diagnosis of testicular torsion was estab-
lished by surgery in 48 of the 50 patients; by late
testicular atrophy in one patient; and by nuclear
scintigraphy performed 24 hours after the initial
sonography in one patient, whose parents declined
giving consent for surgical intervention. Scans
were divided into those showing acute phase ver-
sus late phase torsion on the basis of the duration
of each patient’s symptoms, as described by Chen
et al. [19]: Acute phase torsion was defined
as < 24 hours of pain and late phase torsion as ≥ 24
hours of pain.
Results
Of the 50 cases, 34% were acute phase tor-
sion and 66% were late phase torsion. Of the
17 patients with acute phase torsion, 10
(59%) underwent manual detorsion and spon-
taneous detorsion occurred in one (6%).
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 Sonography of Testicular Torsion in Pediatric Patients

A B C
Fig. 1—Longitudinal images of epididymis in three patients with testicular torsion.
A, Sonogram of 16-year-old boy shows diffuse enlargement of head, body, and tail of epididymis (E) with bilobular shape. Note diffusely increased echogenicity.
American Journal of Roentgenology 2006.187:1627-1635.

B, Sonogram of 15-year-old boy shows heterogeneously increased echogenicity of epididymis (E) with globular shape.
C, Sonogram of 15-year-old boy shows head of epididymis (E) is enlarged, has isoechoic texture, and is slightly triangular. T = testis.

The average difference in volume between
the epididymis ipsilateral to testicular torsion
and the contralateral epididymis was 30 cm3
with a 95% CI of 18.8–47.9 cm3. This differ-
ence is highly statistically significant (p <
0.0001). Enlargement was evident in 47 of the
50 patients with acute phase or late phase tor-
sion and after manual and spontaneous detor-
sion. The size of the epididymis was normal in
the remaining three patients, one with acute
phase torsion and two with late phase torsion.
Of the latter two cases, one was in a neonate.
The epididymal size on the symptomatic
side ranged from
0.9 L × 0.5 D × 1 T cm
to
5.5 L × 4.5 D × 4.5 T cm.
The measurements on the asymptomatic side
ranged from
0.3 L × 0.3 D × 0. 3 T cm
to
0.9 L × 1.7 D × 1.1 T cm,
where L is length, D is depth, and T is trans-
verse. In most cases, epididymal enlargement
was visually obvious, even without obtaining
measurements. By contrast, epididymal en-
largement was less pronounced in infants and
in three boys with acute phase torsion. There
were five patterns of enlargement of the epi-
didymis: head only (39.1%); head and body
(13%); body and tail (4.3%); head and tail
(2.2%); and diffuse (41.3%) involving the
head, body, and tail with increased tissue
cephalad, lateral, and caudad, respectively, to
the testis (Figs. 1A–1C).
The shape of the epididymis was altered in
acute phase or late phase torsion and after man-
ual or spontaneous detorsion. The epididymis
maintained a triangular configuration in the re-
maining 8% of cases. In the cases in which the
normal triangular configuration was lost, the
shape was globular (87%), bilobular (9%), or
multilobular (4%) (Figs. 1A–1C).
The echotexture of the epididymis was al-
tered in patients with acute phase or late phase
torsion and in those examined after manual or
spontaneous detorsion. The most common
pattern was markedly increased echogenicity
(36/49 [73%]), either heterogeneous with in-
creased foci (n = 29 cases) or homogeneous
with a diffuse increase in echogenicity (n = 7)
(Figs. 1A–1C). Less commonly, the epidid-
ymis was isoechoic (13/49 [27%]).
Multiple cystic spaces were seen in 13
cases. Six of these cases showed no flow in the
epididymis or cystic spaces because they were
evaluated after testicular detorsion only. Two
of the cases with cystic spaces were in the pa-
tients with testicular torsion and hyperemic
epididymides, and most of the areas of sonolu-
cency were confirmed to be vascular channels
on the available color Doppler images. Be-
cause of the retrospective nature of our study,
we could not determine if the other spaces
without color fill-in were vascular channels as
well or if they were areas of necrosis, hemor-
rhage, or thrombus within vessels. In the five
other cases examined after manual or sponta-
neous detorsion, most, but again not all, of the
cystic and tubular spaces were confirmed to be
vascular. In two of the latter patients examined
both before and after detorsion, the cystic
spaces were seen to be primarily vascular
channels that filled in with color on Doppler
imaging after detorsion (Figs. 2A–2C).
Before undergoing surgery because of tes-
ticular torsion, 39 patients received no treat-
ment, 10 patients underwent manual detorsion,
and spontaneous detorsion occurred in one pa-
tient. Of the 10 patients with manual detorsion,
seven were sonographically examined only af-
ter detorsion, one only before detorsion, and
two were examined before and after detorsion.
The patient with spontaneous detorsion was
examined before and after detorsion. Epidid-
ymal blood flow was evaluated.
Of the 43 patients with active torsion at the
time of sonography, the epididymis was avas-
cular in 40 patients, hypovascular in one pa-
tient, and hypervascular in two patients
(Figs. 3A–3C). Of the 10 patients who were ex-

AJR:187, December 2006 1629

 Nussbaum Blask and Rushton

A B
American Journal of Roentgenology 2006.187:1627-1635.

C D
Fig. 2—15-year-old boy with acute phase torsion that resolved after spontaneous detorsion.
A, Epididymis contains multiple cystic spaces and no flow on sonogram obtained during acute phase torsion.
B, Testis is avascular on sonogram obtained during acute phase torsion.
C, Sonogram obtained after spontaneous detorsion shows that epididymis has regained flow. Cystic spaces in epididymis are vascular channels.
D, Sonogram obtained after spontaneous detorsion shows that testis also has regained flow.

amined after detorsion, either manual or spon-
taneous, all epididymides were vascular and six
of the 10 were hypervascular. Of the three cases
examined before and after detorsion, the transi-
tion from no epididymal flow to epididymal
flow was observed, similar to the observation of
flow in the corresponding testis (Fig. 2). The
testis was also avascular in 34 of the 40 patients,
whereas it was hypovascular in the remaining
six patients with an associated avascular epi-
didymis. The testis also showed decreased flow
in the one patient with a hypovascular epidid-
ymis and acute phase torsion. In the two pa-
tients with unexpected epididymal hyperemia,
the testis was avascular in one and hypovascu-
lar in the second. In the former, scintigraphy
also showed increased flow to the epididymis
and a photon-deficient testis.
Surgery and pathologic examination of 30
patients with testicular loss and avascular epi-
didymis, as shown by the Doppler flow pattern,
showed engorgement and enlargement of
the epididymis with hemorrhagic infarction
(Fig. 4). Two surgical cases after detorsion
showed congestion of the distal spermatic
cord. No other surgical or pathologic report in-
cluded an evaluation of the size of the sper-
matic cord. Information about the degree of
torsion of the spermatic cord was available in
11 cases. Seven patients with late phase torsion
had from 540° to 720° or more of cord torsion
with both an avascular epididymis and avascu-
lar testis at sonography; testicular salvage was
not possible. In one patient with acute phase
torsion with a twist of 540–720° who had both
avascular epididymis and avascular testis, tes-

1630 AJR:187, December 2006

 Sonography of Testicular Torsion in Pediatric Patients
American Journal of Roentgenology 2006.187:1627-1635.

A B
Fig. 3—Acute phase torsion with hyperemic epididymis.
A and B,15-year-old boy who underwent imaging after 20 hours of pain. Sonograms
show hyperemic epididymis (E) (A) and decreased flow in testis (T) (B). Testis was not
salvaged.
C, 5-year-old boy who underwent imaging after 12 hours of pain. Sonogram shows
hyperemic epididymis (E) with no flow in testis (T). Testis was salvaged.

ticular salvage was successful. In three pa-
tients, a 360° twist of the spermatic cord was
seen. One of the three patients had late phase
torsion and an avascular epididymis and avas-
cular testis; testicular salvage was not possible.
The second case was also in a patient with late
phase torsion with an avascular epididymis,
minimal flow in the testis, and no testicular sal-
vage. The third was a patient with acute phase
torsion and a hyperemic epididymis, avascular
testis, and testicular salvage.
Surgery revealed an inflamed erythematous
epididymis in one of the two patients with a hy-
peremic epididymis. The testis, which ap-
peared avascular at Doppler imaging, was is-
chemic with 360° of torsion but was salvaged;
the patient had a 12-hour history of pain
(Fig. 3C). In the second case of hyperemic epi-
didymis, surgery revealed hemorrhagic infarc-
tion of the epididymis, and testis salvage was
not possible; that patient had a 20-hour history
of pain and minimal flow in the testis at Dop-
pler imaging (Figs. 3A and 3B).
The success rates of immediate testicular
salvage were assessed. Of the 17 patients with
acute phase torsion, two experienced testicular
loss: One had a delay in treatment and the other
had testicular infarction with a history of 20
hours of pain. Of the remaining 15 patients
with acute torsion, the testis was salvaged. In
14 of 15, pain was present for 7 hours or less,
and in the remaining patient, pain was present
for 12 hours. Three of the 33 testes in late
phase torsion were not removed because of
possible viability. These three testes subse-
quently atrophied, and testicular salvage was
not possible in any of the remaining cases of
late phase torsion. Testicular loss occurred in
each type of epididymal flow pattern.
Discussion
Color Doppler sonography is the imaging
technique that is most frequently used to differ-
entiate between surgical (testicular torsion)
versus nonsurgical (epididymitis, torsion of the
appendix testis, or epididymoorchitis) condi-
tions in pediatric patients with an acutely pain-
ful scrotum. In some cases, differentiation be-
tween surgical versus nonsurgical disease may
be difficult because of low flow in the prepu-
bertal testis and because arterial flow, albeit di-

AJR:187, December 2006 1631


Fig. 4—Pathologic
specimen of infarcted
testis (T) and epididymis
(E) from 17-year-old boy
with late phase torsion
shows diffusely
swollen epididymis.
C = spermatic cord.
American Journal of Roentgenology 2006.187:1627-1635.
minished in comparison with the asympto-
matic side, is still detected on sonograms. In
cases of partial torsion (180–360°), subtle
asymmetry in color blood flow may be over-
looked [20]. Bentley et al. [21] suggested that
a testicular color Doppler pattern symmetric
with the asymptomatic testis initially may be
seen in patients with a thick spermatic cord and
a long helix that is twisted. However, patients
with intermittent testicular torsion or spontane-
ous detorsion may undergo the study when
they are pain free, so imaging may show a nor-
mal testis or increased flow in the testis [2].
Our sonographic study suggests that an an-
alysis of the appearance and vascularity of the
epididymis will add ancillary information
that may assist in the diagnosis of testicular
torsion in pediatric patients and that an aware-
ness of the associated finding of epididymal
enlargement may avoid confusion with a
mass or erroneous diagnosis of epididymitis,
even though the diagnosis of testicular torsion
is still primarily based on the flow pattern in
the testis. Enlargement of the spermatic cord
may also be a finding associated with testicu-
lar torsion [20–24].
Our study population consisted of pediatric
patients with a proven diagnosis of either
acute or late phase testicular torsion over a
10-year period. This review showed that en-
largement of the epididymis in conjunction
with altered echotexture, most frequently in-
1632
Nussbaum Blask and Rushton
creased echogenicity, was a consistent find-
ing in almost all of the cases. This appearance
was also present in the patients who were ex-
amined after spontaneous or manual detor-
sion of the testis. Although the retrospective
nature of the study necessitated epididymal
measurements from 2D images, rather than
the more ideal 3D volumetric measurements,
the same methodology was applied to evalu-
ate both the symptomatic and the asympto-
matic hemiscrotum and the differences be-
tween the sides were highly significant. Also,
although the estimated measurements were
necessary for statistical analysis, epididymal
enlargement—in conjunction with altered
shape and echotexture in the symptomatic
hemiscrotum—was visually obvious without
comparison of epididymal measurements and
was marked in most of the cases.
In the absence of or before manipulation
of the testis or spontaneous detorsion, the
epididymis was avascular or hypovascular
on color Doppler sonography in 95% of the
cases of acute or late phase torsion. Surpris-
ingly, the epididymis was hyperemic in 5%
of the cases of acute or late phase torsion
(12% of the cases of acute torsion). Our
sonographic evaluations of patients exam-
ined both before and after detorsion indi-
cated that return of blood flow to the epi-
didymis can be observed in real time, similar
to flow to the testis, and can be used as addi-
tional evidence of a successful manual detor-
sion. Epididymal hyperemia was the pre-
dominant finding after testicular detorsion.
Spontaneous detorsion should be a strong
consideration in a patient whose pain has
abated suddenly or who reports episodes of
intermittent pain because epididymitis can
have the same sonographic appearance.
Marked enlargement of the epididymis
when the studies were initially performed was
a confusing finding in several of our cases, and
the possibility of an extratesticular mass or he-
matoma was considered. Enlargement of the
epididymis in patients with testicular torsion
has not been previously emphasized. However,
our observations confirmed findings described
previously by a few investigators. In one study,
epididymal enlargement with hemorrhage was
identified on gray-scale sonography in seven
adult patients with testicular torsion [25]. The
sonographic findings in seven pediatric pa-
tients with testicular torsion suggested a mis-
leading diagnosis of tumor or epididymitis that
resulted in delay of surgery and in testicular
loss [12–15]. Four of these cases evaluated on
color Doppler imaging showed testicular blood
flow that was thought to be normal on the
symptomatic side. In a recent case of testicular
torsion that we reviewed, not part of this series,
sonography showed avascular epididymal en-
largement that was thought to be a tumor be-
cause flow was present within the testis in the
symptomatic hemiscrotum. Diagnosis was de-
layed; a repeat study 9 hours after the first at
our institution showed no testicular flow, and
testicular loss occurred.
Retrospective review of the cases in our
study group suggests that the diagnosis would
have been altered or made earlier in two cases
of testicular torsion, both of which resulted in
testicular loss. The two cases of hyperemic epi-
didymides had potential for delay in diagnosis
because epididymitis with testicular ischemia
was the leading sonographic diagnosis, but tes-
ticular torsion was thought to be the most likely
diagnosis after testicular scintigraphy. Al-
though two additional patients were prospec-
tively thought to have traumatic testicular con-
tusion with epididymal hemorrhage, the
outcome would not have been different be-
cause both underwent surgical exploration and
had late phase testicular torsion.
As these cases point out, an enlarged avas-
cular epididymis has the potential to change
or expedite the diagnosis in cases of acute tor-
sion in which testicular flow is still present
but is decreased or is still visually normal, be-
cause these cases may be interpreted as a
AJR:187, December 2006
 Sonography of Testicular Torsion in Pediatric Patients

TABLE 1: Sonographic Patterns and Differential Diagnosis in Pediatric
Testicular Torsion
Diagnosis
Testicular torsion
Spontaneous detorsion (pain
resolved or intermittent)
Partial torsion or thick spermatic Enlarged
cord
American Journal of Roentgenology 2006.187:1627-1635.
testicular flow findings, sonography depicted
the twist as a “snail shell–shaped mass.” Arce
Sonographic Pattern et al. [24] also described additional sono-
Epididymis Testis graphic findings related to specific color Dop-
pler assessment of the spermatic cord.
Enlarged No change echotexture (A)
In our series, the surgical, pathologic, and
Hyperechoic Altered echotexture (L)
sonographic findings suggested that the extra-
Altered shape Avascular (A or L) testicular mass was primarily due to an en-
Congested or twisted spermatic Hypovascular (A or L) larged epididymis. The mass not only was su-
cord pratesticular in location, but also was frequently
Avascular (A or L) Hypervascular halo (L) paratesticular and infratesticular. Also, a sepa-
Hypovascular (A or L) Resistive index elevated rate epididymal structure was not seen, and
Hypervascular (A or L),
epididymal enlargement was present at patho-
uncommon logic examination. However, a portion or por-
Enlarged Hypervascular or normal color tions of the tissue cephalad to the testis could
flow possibly have been an engorged spermatic cord
Hypervascular or normal color
merged with the epididymal head, even though
flow this possibility could not be confirmed by ret-
Avascular, hypovascular, or
rospective review of the pathologic or surgical
normal color flow reports or by reanalysis of the sonograms. All
of the sonograms were of the scrotum only; the

Hypovascular or avascular
Epididymitis or torsion of Enlarged Hypervascular or normal color
appendix testis Hypervascular flow
Extratesticular true solid mass Separate normal epididymis Normal color flow
Note—A = acute phase torsion, L = late phase torsion.
TABLE 2: Suggested Management Protocol
Sonographic Diagnosis Management
Acute phase testicular torsion Emergent surgical exploration or may attempt manual
detorsion
Late phase testicular torsion Nonemergent surgical exploration
Spontaneous detorsion Nonemergent surgical exploration
Partial testicular torsion Emergent surgical exploration
Indeterminate testicular sonogram If < 12 h of symptoms, surgical exploration
If > 12 h of symptoms, scintigraphy or surgical exploration
Epididymitis or torsion of appendix testis Nonsurgical management
Extratesticular true solid mass Nonemergent surgical exploration
false-negative. These cases are likely ones in in the affected testis. Other authors have sug-
which there are fewer degrees of spermatic gested that analysis of Doppler waveform pat-
cord torsion (partial torsion) and the patient terns may also be helpful in cases of incom-
presents earlier in the time course or has a plete or partial torsion [26].
thicker spermatic cord [21]. This sign theoret- A study by Baud et al. [22] of patients with
ically has the potential to be of value when no testicular torsion showed features that paral-
testicular flow can be seen in the asympto- leled our results. They also described an extra-
matic testis, although this did not occur in our testicular mass present in cases of testicular
series. Sanelli et al. [20] reported a case of torsion, but not detorsion. They indicated the
partial torsion (360°) of the spermatic cord mass was due to the engorged, twisted sper-
with visually normal color flow in the testis. matic cord. Kalfa et al. [23] suggested examin-
They noted a masslike lobular appearance of ing the spermatic cord along its complete
the spermatic cord with a coiled configuration length to detect a twist. They found that in all
of the vessels and an elevated resistive index cases of torsion, even those with ambiguous
inguinal regions were not examined.
Other causes of supratesticular masses
need to be considered. Torsion of the testicu-
lar appendages may be associated with a su-
pratesticular mass. However, the complete
constellation of findings are dissimilar to
those associated with testicular torsion; in-
stead, a distinct 4- to 16-mm extratesticular
extraepididymal avascular mass is identified
in most cases at the upper pole of the testis
(the epididymis testis or the appendix testis)
in conjunction with an enlarged epididymis
and testis with increased flow [27].
Isolated torsion of the epididymis has also
been reported, although it seems to be a rare
occurrence. A 9-year-old boy with acute scro-
tal pain, associated with a long, tortuous epi-
didymis and long mesorchium, had this diag-
nosis established at surgery [28]. Clinically,
tender swelling at the inferior pole of the tes-
tis was present and the testis was not tender to
palpation. A sonogram was not obtained. Two
other patients with an acute scrotum and with
“dissociation of the testis and epididymis”
have been reported, one in a 6 month old and
one in an 18 year old [29]. The epididymis
was completely infarcted in the infant, requir-
ing epididymectomy.
In most of our patients, the absence of color
Doppler flow in the enlarged epididymis was
the key feature differentiating testicular torsion
from inflammatory epididymitis. However, the
epididymis infrequently was hyperemic—
even when testicular torsion was present. Spec-
tral analysis was not performed in either of our
two patients with hyperemic epididymis, so
whether the increase in flow was arterial or

AJR:187, December 2006 1633


venous flow is not known. Recently, Arce et al.
[24] described increased flow in the spermatic
cord distal to the site of rotation and attributed
it to venous engorgement. That theory could
also explain the hyperemic epididymis cases in
our series. Those cases were a diagnostic di-
lemma, and the possibility of epididymitis with
secondary ischemia of the testis from venous
outflow compromise was entertained [30]. The
fact that the confirmed diagnosis was testicular
torsion in both of these patients suggests that
surgical exploration is warranted when an
avascular or hypovascular testis is seen in con-
junction with what appears to be a hyperemic
epididymis, distal spermatic cord, or both.
If a patient has undergone known manual
detorsion of the testis, the presence of flow
within an enlarged epididymis and in the tes-
tis suggests manipulation was successful, as
shown by the resumption of blood flow. In the
patient whose acute symptoms have resolved,
American Journal of Roentgenology 2006.187:1627-1635.
spontaneous detorsion should be considered
when an enlarged hyperemic epididymis and
testicular flow are present.
An analysis of the vascular supply to the
scrotum and its contents explains these sono-
graphic findings. The spermatic cord contains
the testicular, deferential (artery of the ductus
deferens), and cremasteric arteries. The testicu-
lar artery supplies the testis and epididymis,
and the artery of the ductus deferens and crem-
asteric arteries supply the epididymis, vas def-
erens, and peritesticular tissues [19, 30]. The
testicular artery is a branch of the abdominal
aorta, and the artery of the ductus deferens is a
branch of the superior vesical artery [31]. The
epididymis therefore has a dual blood supply
via the testicular artery and via its anastomosis
with the artery of the ductus deferens [31]. The
venous drainage of the scrotal contents also
passes through the spermatic cord. Because the
vascular supply of the epididymis passes
through the spermatic cord, the twisting of the
spermatic cord, similar to twisting of the testis,
will compromise its blood supply and venous
drainage. This explains the presence of epi-
didymal enlargement and engorgement seen on
sonographic examination and the ischemic
changes identified at pathologic examination.
Our patients with hypervascular epi-
didymides and lower cord complex associated
with testicular torsion are more difficult to ex-
plain unless the artery to the ductus deferens,
which travels centrally in the cord, cannot be
compressed to the same degree as the testicular
artery. Theoretically, vessels that do not pass
through the spermatic cord, such as the puden-
dal vessels, may provide blood flow, although
1634
Nussbaum Blask and Rushton
no anastomoses have been described. The
scrotal wall derives its blood supply from
branches of the pudendal artery, which do not
pass through the spermatic cord and therefore
maintain its supply during testicular torsion
[19, 32]. In late phase torsion, peritesticular in-
flammatory changes occur and account for the
halo of peripheral hypervascularity seen at
both sonography and scintigraphy [32]. Alter-
natively, venous engorgement, due to obstruc-
tion of the distal spermatic cord as proposed by
Arce et al. [24], is a possibility for the hyper-
vascular epididymis.
Testicular viability depends on both the de-
gree and the duration of torsion. After 10 hours
of symptoms, most testes cannot be saved [33].
Some testes that are saved at surgery atrophy
over time [33]. This occurred in three of our
patients. In our series, an enlarged avascular
epididymis was present in cases of both acute
and late phase torsion; therefore, it was not a
helpful sign for predicting which testes could
be salvaged. Because we had only two cases of
hyperemic enlarged epididymides with testic-
ular torsion, one with and one without testicu-
lar salvage, whether this sign could be of any
predictive value for testicular salvage is not
known. In all of our patients with manual or
spontaneous detorsion and reestablishment of
blood supply to the testis and epididymis, im-
mediate testicular salvage was achieved, even
in those cases in which testicular flow after
detorsion was diminished in comparison with
the asymptomatic side.
The enlarged hyperechoic epididymis is a
consistent finding in pediatric testicular torsion
that may assist in the diagnosis of torsion, es-
pecially in the prepubertal testis and in difficult
cases in which arterial supply to the testis is
still maintained but is decreased. Sonographic
findings and the associated management sug-
gestions are summarized in Tables 1 and 2.
The primary diagnosis of testicular torsion is,
nevertheless, still based on testicular flow pat-
tern. The epididymis can resemble an extrates-
ticular mass or hematoma. The avascular or
hypovascular nature of the epididymis in most
cases of testicular torsion (95%) allows these
cases to be distinguished from epididymitis,
which can have a similar gray-scale appear-
ance. An enlarged hyperemic epididymis that
is not due to epididymitis may be seen infre-
quently in cases of torsion (5%).
The epididymis, in addition to the testis,
should be sonographically examined for re-
turn of color Doppler vascularity after spon-
taneous or manual detorsion; the presence of
epididymal flow in conjunction with flow in
the testis is additional evidence of successful
detorsion. After detorsion, either manual or
spontaneous, the epididymis is frequently hy-
pervascular. The appearance of the epidid-
ymis is abnormal in both acute and late phase
torsion, and its appearance does help not pre-
dict testicular salvage.
Acknowledgment
We thank Dr. Robert J. McCarter for per-
forming the statistical analysis for this project.
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