Acute Painful Scrotum
AhmetT.Turgut, MDa, Shweta Bhatt, MDb,Vikram S. Dogra, MDb,*
KEYWORDS
 Ultrasound  Orchitis  Testis  Torsion
The acute painful scrotum is the most common
urologic emergency and may present a diagnostic
challenge even to the most experienced clinicians.
The main goal for the imaging of patients who have
acute scrotal pain is to differentiate patients
warranting surgery from those who would benefit
from conservative management alone so that
unnecessary surgical exploration can be avoided
as much as possible. Gray-scale ultrasound (US)
combined with pulsed and color Doppler modes
helps suggest more specific diagnoses, which is
crucial for the determination of the appropriate
treatment. The aim of this article is to provide
familiarity with the US features of scrotal patholo-
gies associated with a painful scrotum and to
describe the pitfalls of scrotal US examination of
patients presenting with acute scrotal pain.
ULTRASOUND EVALUATION
Sonographic Scrotal Anatomy
The scrotum is divided by a midline septum into
two compartments, each containing a testis and
associated structures. The normal ovoid-shaped
adult testis measures 3 to 5 cm in length and 2
to 3 cm in the transverse and anteroposterior
dimensions.1 Sonographically, it has a smooth
surface, and its echo texture is homogenous with
an intermediate echogenicity unlike the prepuber-
tal testis, which has low-to-medium echogenicity.
The tunica albuginea, the fibrous covering of the
testis, is seen as a thin echogenic line. It is covered
by tunica vaginalis consisting of visceral and
parietal layers merging at the posterolateral side
of the testis and normally separated by only
a few milliliters of fluid.2 Multiple fibrous septa
emerge from the tunica albuginea toward the
a
Department of Radiology, Ankara Training and Research Hospital, TR-06530, Ulucanlar, Ankara, Turkey
b
Department of Imaging Sciences, University of Rochester School of Medicine, 601 Elmwood Ave., Box 648,
Rochester, NY 14642, USA
* Corresponding author.
E-mail address: vikram_dogra@urmc.rochester.edu (V.S. Dogra).
Ultrasound Clin 3 (2008) 93107
doi:10.1016/j.cult.2007.12.004
1556-858X/08/$ see front matter 2008 Elsevier Inc. All rights reserved.
interior of the testis, dividing the testis into numer-
ous lobules (Fig. 1). The tunica albuginea is re-
flected posteriorly into the testis forming the
incomplete septum known as the mediastinum
testis. Each lobule consists of one to three
seminiferous tubules in which spermatogenesis
occurs. The seminiferous tubules converge toward
the mediastinum testis and open into a network of
dilated channels within the testicular stroma, the
rete testis, which drains into the epididymal
head. In some patients the normal rete testis
can be detected sonographically as a striated
hypoechoic area near the mediastinum; in
contrast, the appearance of fluid-filled dilated
structures indicates tubular ectasia of the rete
testis (Fig. 2).2
The epididymis is composed of a head, body,
and tail. The head of the epididymis is located
superolaterally to the testis and has a relatively
coarser echotexture compared with the testis.
The normal narrow body of the epididymis lies
adjacent to the posterolateral margin of the testis
and may be seen with careful scanning.3 The tail
of the epididymis lies on the inferolateral surface
of the testis and continues as the vas deferens.
The appendix testis and the appendix epididymis
are testicular appendages that are Mullerian duct
and mesonephric remnants, respectively.4
Typically, they are detectable sonographically
only when a hydrocele is present. The appendix
testis, an ovoid structure about 5 mm in length,
lies in the groove between the testis and the
epididymis and is found at the superior aspect of
the testis beneath the head of the epididymis.2 It
is isoechoic to the testis, although occasionally it
may be cystic. The appendix epididymis, on the
other hand, is a small stalk projecting off the
ultrasound.theclinics.com
94 Turgut et al
epididymis and is of the same approximate
dimensions as the appendix testis.5
The vascular supply of the testis is by the right
and the left testicular arteries, which originate
from abdominal aorta. After coursing along the
posterior surface of the testis, they penetrate the
tunica albuginea and form the capsular arteries,
giving rise to centripetal branches and recurrent
rami in turn. A transmediastinal branch of the
testicular artery, which is present in 50% of normal
testes, supplies the capsular arteries and usually is
accompanied by a large vein.2 The deferential
artery arises from the vesicular artery and supplies
the epididymis and vas deferens. The epididymis,
however, is supplied mainly by the superior epidid-
ymal artery, which is a branch of the testicular
artery. The cremasteric artery arising from the epi-
gastric artery supplies the paratesticular tissues.
Furthermore, there are anastomoses between the
posterior epididymal, deferential, and cremasteric
arteries. The scrotal wall, on the other hand, is
Fig. 2. Sagittal US scan demonstrates fluid-filled
dilated tubular structures corresponding to ectasia
of the rete testes (arrow) with a nearby intratesticular
cyst (bold arrow).
Fig. 1. Diagrammatic cross section of
a normal testis.
supplied by branches of the pudendal artery.6
The venous drainage is via the pampiniform plexus
of draining veins.
Scanning Technique
Scrotal US is performed with the patient in the
supine position and the scrotum supported by
a folded towel placed between the thighs; the
penis is positioned over the suprapubic region
with a second towel. The optimal scanning should
be with 7- to 10-MHz high-frequency linear-array
transducer. In cases with marked scrotal swelling,
a high-frequency curved linear-array transducer
increasing the field of view may be useful for the
depiction of extratesticular findings. At least two
planes along the transverse and longitudinal axes
should be used for scanning, although obtaining
serial images is preferable. Both testes and epidid-
ymis should be compared for size, echogenicity,
and vascularity. The skin thickness in each hemi-
scrotum should be evaluated also. Targeted
images including the area of concern should be
obtained in patients referred for palpable scrotal
lesions. The best method to localize and evaluate
small palpable lesions is to palpate the lesion
oneself and then put the probe directly on the
palpated lesion. The parameters for color and
pulsed Doppler US should be optimized to display
low-flow velocities so that the blood flow in the
testis and surrounding scrotal structures is de-
tected with highest sensitivity. Additionally, power
Doppler US may be useful for depicting intratestic-
ular flow, particularly in prepubescent patients. In
this way, spectral Doppler analysis of the intrates-
ticular vasculature of both testes is performed. In
patients presenting with acute scrotum, the
asymptomatic side should be scanned first so
that gray-scale and color Doppler gain settings
are set optimally and to obtain a baseline for
comparison with the affected side. Additionally,

a Valsalva maneuver or upright positioning can be
used for a better evaluation of venous return.
Spectral Doppler Analysis
With Doppler imaging, the spectral waveform of
the testicular artery, its intratesticular branches,
and the artery supplying the epididymis character-
istically has a low-resistance pattern2,7 Diastolic
arterial flow may not be detectable in prepubertal
boys.8 A high-resistance flow pattern may be
detected in the cremasteric and deferential
arteries.7
ETIOLOGY
Inflammatory Conditions
Cellulitis
Scrotal wall cellulitis can develop in obese, dia-
betic, or immunocompromised patients. Clinically,
the scrotum is swollen, tense, warm, and red. The
sonographic features of the disease are increased
scrotal wall thickness and hypoechoic areas
showing hypervascularity on color Doppler US.
Scrotal wall cellulitis may progress to form a scrotal
abscess that usually is identified by the presence
of irregular walls and low-level internal echoes.2
Fournier gangrene
Fournier gangrene is a rapidly progressive polymi-
crobial necrotizing fasciitis of the perineum that
may extend to involve the skin of the scrotum or
lower abdominal wall.2 It is a urologic emergency
necessitating an early diagnosis for a prompt sur-
gical and medical treatment because of the high
rate of mortality associated with this condition.
The disease may occur at any age and typically
has a sudden onset of perineal pain and swelling.
The diagnosis of the disease can be established
by imaging findings when the clinical findings are
inconclusive.
Currently, conventional radiography, US, CT,
and MR imaging have been reported to be useful
for the evaluation of the disease.9,10 On abdominal
radiographs, soft tissue edema and subcutaneous
emphysema along the involved tissue planes can
be detected.10 Sonographically, thickening of the
scrotal skin can be seen with the testicle being
normal because of its separate blood supply.11
Gas within the scrotal skin, seen as multiple,
hyperechoic foci with reverberation artifact, is the
pathognomonic US finding.10 The other condition
to be considered for the differential diagnosis of
gas at US examination is a scrotal hernia with
gas-containing bowel, in which the gas is within
the protruding bowel lumen and is located away
from the scrotal wall.2 Rarely, gas within the scro-
tal wall and scrotal cavity may be seen secondary
Acute Painful Scrotum 95
to penetrating trauma to the scrotum. CT can
show the extent of soft tissue gas more clearly
and often can show the etiology of Fournier gan-
grene, such as perianal abscesses, incarcerated
inguinal hernias, or fistulous tracts.10 CT also
reveals the fascial thickening and fat stranding of
the involved areas.10 The main advantage of MR
imaging over other modalities is its ability to depict
the extension of the infection to perineum and
fascial planes more distinctly than US; this
depiction assists in planning the debridement.9
Epididymitis and epididymo-orchitis
Epididymitis, representing at least 75% of all
inflammatory scrotal disease processes, is the
most common cause of painful scrotal swelling in
men older than 18 years of age.7 The etiology for
epididymitis and epididymo-orchitis is usually an
ascending infection from the urinary tract. Initially
the inflammation occurs in the tail and spreads to
the body and head of the epididymis in turn.
Although the epididymis is diffusely involved, focal
involvement may affect up to one third of the pa-
tients.12 Testicular involvement by direct spread
of the infection develops in 20% to 40% of the pa-
tients and usually is diffuse, although focal orchitis
may occur in 10% patients.2,12 Because it gener-
ally is difficult to differentiate epididymitis from
orchitis both clinically and sonographically, they
are grouped under the common heading of epidi-
dymo-orchitis. This approach is more useful, be-
cause therapy is directed against the agent
rather than the location of the infection. In adoles-
cents and men younger than 35 years, the disease
usually is secondary to sexually transmitted
Chlamydia trachomatis and Neisseria gonor-
rhoeae, whereas Escherichia coli and Proteus
mirabilis are frequently the causative agents for
the disease in prepubertal boys and men over
35 years of age.2 Additionally, epididymitis and
orchitis may be secondary to granulomatous
diseases including sarcoidosis, brucellosis, and
tuberculosis, Cryptococcus infection, and the
use of drugs such as amiodarone hydrochloride
(Fig. 3).13 Although the disease is insidious, a sig-
nificant proportion of patients complain of a sud-
den onset of pain which simulates testicular
torsion. The complications of acute epididymo-
orchitis include chronic pain, abscess, infarct,
gangrene, infertility, atrophy, and pyocele.2,12
The nonspecific gray-scale US findings for epi-
didymitis include enlarged, hypoechoic or hypere-
choic epididymis, reactive hydrocele or pyocele,
and scrotal wall thickening. In cases with isolated
epididymitis, the testis is normal sonographically.
Diffuse testicular involvement usually is mani-
fested by edema causing testicular enlargement,
96 Turgut et al

Fig. 3. Testicular granulomatous infection with abscess and ischemia. Sonogram of a 35-year-old man presenting
with acute scrotum shows an irregular, heterogeneous mass (M), which is difficult to marginate from the testis
(T). By color Doppler imaging the lesion was found to have no internal blood flow, whereas increased blood
flow was detected in the testis. (Courtesy of Hasan Ozcan, MD, Ankara, Turkey.)

inhomogeneous echotexture, and hypoechoic or and increased venous flow, which is difficult to
heterogeneous echogenicity, whereas a focal detect in healthy individuals.3 Gray-scale and
process usually appears as multiple hypoechoic color Doppler US features of epididymorchitis
lesions.2,14,15 When focal areas of heterogeneous are summarized in Box 1.
echogenicity in the testis are diagnosed as epidi-
dymorchitis, US follow-up after antibiotic treat- Acute orchitis
ment is necessary to confirm the diagnosis by Isolated orchitis without the involvement of epidid-
observing the resolution of the lesion so that other ymis is a rare phenomenon and is caused mostly
etiologies such as tumor, infarction, and by mumps or AIDS. Sonographically, the testis is
metastasis can be ruled out.2 enlarged and shows diffuse, focal or multifocal,
Color or power Doppler US is the most helpful hypoechoic lesions.7 Color Doppler examination
modality for the diagnosis of scrotal inflammation. reveals increased blood flow.
Rarely, increased vascularization in the affected
epididymis and testis, which, is a typical finding
for epididymo-orchitis, is the only evidence of
inflammation (Figs. 4 and 5). Diffuse testicular
hypervascularity, however, also can be seen with
infiltrative neoplasms such as lymphoma and
leukemia.12 In cases with focal orchitis appearing
as a focal, hypoechoic, hypervascular lesion, in-
volvement of the epididymis may differentiate the
lesion from a testicular neoplasm.12 Although the
vascularity of epididymis is increased in acute epi-
didymitis, resulting in a high-flow, low-resistance
flow pattern, comparison with the contralateral
testis would be more conclusive for a correct
diagnosis. Because the relevant inflammatory
process is associated with lower vascular resis-
tance than seen in healthy individuals, spectral
waveform analysis would be helpful as well. In
this regard, the peak systolic velocity in intratestic-
ular arteries increases 1.7- to 2-fold, or even
higher.7 Furthermore, the resistive index, which is Fig. 4. Orchitis complicated by pyocele. Sonogram
rarely less than 0.5 in the testicular artery and 0.7 demonstrates increased blood flow within the testis
in epididymal artery in healthy individuals, de- (T) as a component of epididymo-orchitis and the
creases in epididymo-orchitis.7,16 Another clue tunical fluid with thick internal septations represent-
for the diagnosis of orchitis is easily detectable ing pyocele (P).

Fig. 5. Epididymo-orchitis. (A) Longitudinal gray-scale and (B) color flow Doppler image of the testis and epidid-
ymis demonstrates heterogeneous echotexture of the testis (T) and epididymis (E) with enlargement of the
epididymal head and increased vascularity of both testis and epididymis. Reactive hydrocele (asterisk) is seen also.
Intratesticular abscess
Intratesticular abscess usually develops second-
ary to epididymo-orchitis. Clinically, it cannot be
distinguished easily from acute epididymitis at
the early stage of infection. If the accompanying
testicular swelling does not resolve after appropri-
ate antibiotic treatment for epididymorchitis, the
diagnosis of testicular abscess should be consid-
ered. US examination reveals irregular walls, low-
level internal echoes, and hypervascular margins
of the lesion.17
Vascular Conditions
Testicular torsion
Testicular torsion, defined as rotation of the testis
in the longitudinal axis of the spermatic cord,12 is
Box 1
Ultrasound findings in epididymorchitis
Enlarged, hypoechoic, or hyperechoic
epididymis
Enlarged hypoechoic or heterogeneous testis
Reactive hydrocele
Skin thickening
Epididymal or testicular hypervascularity
Increased epididymal-intratesticular peak
systolic velocity
Decreased resistive index in epididymal-
testicular arteries
Easily detectable or increased intratesticular
venous flow
Acute Painful Scrotum 97
a surgical emergency, and a delay in intervention
may cause irreversible testicular damage. It is
associated with various degrees of abnormal re-
flection of the visceral tunica vaginalis resulting in
greater envelopment of the epididymis and
spermatic cord.1 Accordingly, the testis is fixed
and cannot rotate freely within the scrotum, caus-
ing torsion of the spermatic cord and interruption
of the testicular blood flow.1 Torsion also may be
encountered as a complication of crypto-orchism
(Fig. 6). Although testicular torsion can occur at
any age, including the prenatal period, it is most
common in adolescent boys. Testicular torsion
causes venous engorgement that results in
edema, hemorrhage, and arterial compromise
resulting in testicular ischemia. The severity of
the ischemia is related to the degree of torsion
ranging from 180 to more than 720 .
Clinically, patients who have torsion commonly
present with sudden onset of severe scrotal pain
and swelling.12 If the treatment is started within 4
to 6 hours after the onset of the symptoms, almost
every testis remains viable, but most testes that
are not detorsed by 10 to 12 hours are unsalvage-
able because of irreversible damage.7 Extravagi-
nal torsion, which is unique to newborns, occurs
outside the tunica vaginalis when the testes and
gubernacula are not fixed and are free to rotate.18
Intravaginal torsion is more common, with an
incidence of 65% between 12 and 18 years of
age.19 It occurs within the tunica vaginalis and
generally is associated with a fixation anomaly,
the bell-clapper deformity. In this condition,
the tunica vaginalis completely surrounds the
intrascrotal portion of the tunica vaginalis lacking
98 Turgut et al
Fig. 6. Testicular torsion in a crypto-orchid testis. The sonogram of a 6-year-old patient with crypto-orchism
presenting with acute scrotal pain reveals no intratesticular blood flow in the left inguinal testis compared
with the contralateral testis. (Courtesy of Hasan Ozcan, MD, Ankara, Turkey.)
posterior adhesion to the scrotum, thus predis-
posing the patient to rotation of the testis and
the spermatic cord.2,20
Earlier in the course of testicular torsion, gray-
scale US examination is absolutely normal. The
swelling of the testis and epididymis along with
slightly hypoechoic appearance usually develops
in the first 4 to 6 hours, although markedly
decreased echogenicity predominates thereafter.
Epididymal enlargement and hydrocele may also
be detected.1 In the late period, regions of
increased echogenicity with hemorrhage inter-
spersed with hypoechoic testicular parenchyma
representing hemorrhagic infarction predominate,
and this condition progresses to a smaller testis
with increased echogenicity.1,14
The combination of color and power Doppler US
has high sensitivity, particularly for evaluation in
the pediatric age group in which the identification
of blood vessels may be difficult.21,22 The main
finding is the absent or decreased blood flow on
the affected side (Fig. 7). Increased resistive indi-
ces may be detected as long as the intratesticular
arteries are visible.7 The absence of color flow on
Doppler US does not necessarily suggest the
diagnosis of ischemia, however, because other
conditions such as polyarteritis nodosa can also
mimic torsion.23 Earlier, the documentation of
testicular or epididymal venous flow by pulsed
Doppler was suggested to be indicative mostly
of inflammatory diseases or detorsion.24 Never-
theless, the detection of color or power Doppler
signal in a patient presenting with the clinical
findings of torsion does not exclude torsion.25
Color Doppler US findings in testicular torsion
are summarized in Box 2. Importantly, clinical cor-
relation should be incorporated in the evaluation of
acute painful scrotum, because color Doppler US
is not 100% sensitive.3,7,26
Torsion also may be categorized as complete,
incomplete, or transient. US evaluation of cases
with partial or transient torsion poses a diagnostic
difficulty, because the role of either color Doppler
US or spectral Doppler analysis has not been es-
tablished yet. Asymmetry in the testicular spectral
patterns with high-resistance flow or flow reversal
may be helpful. A pitfall for the diagnosis of testic-
ular torsion is that edema and venous thrombosis
associated with severe epididymo-orchitis may
lead to the development of testicular ischemia
that may mimic testicular torsion.15 Conversely,
hypervascularity depicted with a low-resistance
flow pattern can occur after partial torsion or
recent spontaneous detorsion of the testis
(torsiondetorsion).7 Recently, the detection by
US of a target-shaped, spiral twist of the cord at
the external inguinal canal, irrespective of the
degree of testicular vascularization, was found to
have high sensitivity and specificity for the
diagnosis of torsion.27,28 Moreover, a real-time
modification of the whirlpool sign produced by
the downward motion of the transducer along
the inguinal canal was concluded to be the most
definitive sign of torsion (either complete or incom-
plete), because it described the actual pathology
with 100% sensitivity and specificity.20
Intermittent testicular torsion is characterized by
unilateral acute, sharp, intermittent scrotal pain
and swelling with long intervals devoid of symp-
toms.29 US features of segmental testicular

Fig. 7. Testicular torsion. (A) Color flow Doppler image of the left testis demonstrates complete absence of flow
within the testis. (B) Corresponding transverse color flow Doppler image of the scrotum demonstrates absent
blood flow in the left testis with normal flow within the right testis.
infarction and a horizontal position of the testis are
diagnostic of intermittent testicular torsion.20,29
Color Doppler US may reveal increased blood
flow in the affected testis at the asymptomatic
period or immediately after torsion.29
Finally, US may provide significant benefit for
the evaluation of the recovery of the testis after
detorsion. Recently, it has been suggested that
surgical removal of the testis should be reserved
for those cases with strong evidence of ischemic
damage. Sonographic follow-up is recommended
after surgical detorsion, because it is difficult to
assess for irreversibility of tissue damage
intraoperatively.30
Torsion of the epididymis
Isolated torsion of the epididymis is a very rare
cause of acute painful scrotum.31 Anatomically,
anomalies of the testicularepididymal junction or
the presence of a long and tortuous epididymis
with a long mesorchium have been suggested to
be the main predisposing factors. Such anomalies
are more common in patients who have unde-
scended testes than in the normal population.32
Sonographically, a normal testis with a normal
vascularization, a markedly enlarged, heteroge-
neous epididymal body with only few vascular
signals, and a highly vascularized epididymal
head can be detected.31
Acute Painful Scrotum 99
Torsion of appendages
Torsion of appendix testis and appendix epididy-
mis also can cause acute scrotal pain similar to
that experienced by testicular torsion, although
the onset is more gradual in torsion of the append-
ages. More than 90% of twisted appendages in-
volve appendix testis.29 In the pediatric age
group, appendiceal torsion is nearly as common
as testicular torsion and accounts for 20% to
40% of acute scrotum cases.7 The pathogno-
monic physical examination finding is a small,
firm, and palpable nodule on the superior aspect
of the testis, which may exhibit a bluish discolor-
ation through the overlying skin called the blue
dot sign.33
Box 2
Color Doppler ultrasound findings in testicular
torsion
Absent or decreased blood flow on the affected
side
Decreased flow velocity in the intratesticular
arteries
Increased resistive indices in the intratesticular
arteries
Hypervascularity with a low-resistance flow
pattern (after partial torsion)
100 Turgut et al
Fig. 8. Appendiceal torsion. Sonogram of an 8-year-
old boy with scrotal pain demonstrates an enlarged,
heterogeneous appendix (A) located between the
testis (T) and the epididymal head (E), with no internal
blood flow. (Courtesy of Hasan Ozcan, MD, Ankara,
Turkey.)
Sonographically, torsion of testicular append-
ages is diagnosed when both testis and epididy-
mis appear normal and an adjacent enlarged,
circular, and heterogeneous appendage is seen
(Fig. 8).1,34 A testicular appendage larger than
5.6 mm favors the diagnosis of torsion.29
Frequently, reactive hydrocele and skin thickening
may be detected. Color Doppler US reveals that
torsed testicular appendage has no internal blood
flow, and increased peripheral vascular signals
can be detected.7,34 Moreover, an enlarged
epididymal head and increased testicular blood
flow secondary to the inflammatory response
may be detected.35
Varicocele
Idiopathic varicocele A varicocele is an abnormal
dilatation of the pampiniform plexus veins caused
by the increased pressure secondary to the
venous backflow associated with incompetent
valves in the spermatic vein.2,3 In a recent study,
normal to increased intra-abdominal pressure
has been suggested to be an etiologic factor for
varicocele formation.36 Normally, the diameter of
the pampiniform plexus veins ranges from 0.5 to
1.5 mm.2 Idiopathic varicocele is present in 15%
of men in the general population, mostly between
ages of 15 and 25 years.2 It almost always occurs
on the left side and is bilateral in 30% of patients.7
Idiopathic varicocele distends when the patient
assumes an upright position or performs Valsalva
maneuver.37 Clinically, a large varicocele, unlike
a small one, manifests as a palpable scrotal
mass and requires no further diagnostic evaluation
other than physical examination. Patients who
have varicocele occasionally complain of scrotal
pain or discomfort,3 worsening particularly toward
the end of the day. Importantly, varicoceles may
be associated with infertility. Recently, Unsal and
colleagues38 suggested that increased resistive
and pulsatility indices in the capsular branches of
testicular arteries in patients who have clinical
varicocele may be an indicator of altered testicular
microcirculation; further investigation is needed to
reveal any correlation with the sperm counts.
US evaluation should be performed in with the
patient in the supine position; additional scanning
with the patient in the upright position may be
necessary.39 The examination, including the mea-
surement of the diameters of veins and investiga-
tion of the presence and the duration of venous
reflux, always should be made both at rest and
during Valsalva maneuver. Sonographically, vari-
cocele appears as multiple, serpiginous, tubular
structures with diameters exceeding 2 mm that
are best visualized superior and lateral to the
testis, although a large varicocele may extend
posteriorly and inferior to the testis.2 Color Doppler
US is highly sensitive and specific for the detection
of varicocele, with rates approaching 100%.2 The
relevant findings are a venous flow pattern show-
ing phasic variation and retrograde filling with
Valsalva maneuver.2 A considerably increased
flow lasting longer than 1 second is expected in
the veins, with retrograde flow during Valsalva
maneuver followed by resolution with its release
(Fig. 9). It is noteworthy that flow enhancement
represented as a rapidly dissipating flash of
color can occur in patients who do not have
varicocele.40
Secondary varicocele Increased pressure on the
spermatic vein caused by various disease
processes such as hydronephrosis, cirrhosis, or
Fig. 9. Idiopathic varicocele. Color and spectral
Doppler analysis of a 23-year-old patient complaining
of scrotal pain. Reversed flow lasting longer than
1 second was detected during Valsalva maneuver
and resolved with its release.

a mass in the abdominal cavity or retroperitoneal
space may cause secondary varicocele. There-
fore, in older men the detection of a varicocele
that cannot be decompressed, on either the right
or left side, should prompt the investigation for
a retroperitoneal mass, which is the most likely
cause of varicocele in this age group.5 Interest-
ingly, chronic constipation has been reported to
be a causative factor for the development of left-
sided varicocele, which may be attributable to
the accompanying distension of the sigmoid colon
and distal part of the descending colon resulting in
compression of the left testicular vein in the
retroperitoneum.41
Intratesticular varicocele Intratesticular varicocele
is a relatively new and extremely rare phenomenon
characterized by dilatation of intratesticular veins,
predominantly subcapsular in location.42 Most of
the cases are associated with an ipsilateral extra-
testicular varicocele, suggesting a common path-
ogenesis.42 It may be detected unilaterally or
bilaterally. Testicular pain, the most common clin-
ical presentation,43 is attributable to the stretching
of the tunica albuginea after venous congestion.44
The sonographic findings are similar to those of
pampiniform plexus varicocele.45 Accordingly,
tubular or serpentine intratesticular varicoceles
can be differentiated from other focal intratesticu-
lar lesions easily and do not usually pose a diag-
nostic dilemma. Nevertheless, round or oval
intratesticular varicoceles may mimic focal testicu-
lar lesions, including cystic neoplasms.46 The
differentiation can be made by the use of color
Doppler US with Valsalva maneuver, which shows
Fig.10. Thrombosis of pampiniform plexus veins. Sonogram of a 34-year-old man presenting with acute scrotum
showing thrombus within the veins of the pampiniform plexus. The diagnosis of thrombophlebitis was suggested
by the presence of edematous skin and hypoechoic and thickened vessel walls. (Courtesy of Hasan Ozcan, MD,
Ankara, Turkey.)
Acute Painful Scrotum 101
a striking color Doppler response with complete
filling of the lesion without any evidence of an
associated soft tissue mass.42
Vasculitis (Henoch-Schonlein purpura
vasculitis)
Henoch-Schonlein purpura, mostly presenting
with palpable skin rash, colicky abdominal pain,
or arthralgia, is the most common systemic vascu-
litis in children.47 The incidence of scrotal manifes-
tations (eg, painful swelling and ecchymosis)
ranges from 2% to 38% of cases of Henoch-
Schonlein purpura, and approximately 3% of all
cases of acute scrotum are cause by scrotal
involvement of Henoch-Schonlein purpura.47,48
Although scrotal symptoms generally are milder,
they sometimes may mimic testicular torsion to
various degrees.49 The detection of normal or
increased blood flow by color Doppler US may
be helpful for differentiating scrotal involvement
of Henoch-Schonlein purpura from testicular
torsion, which shows a decrease or absence of
blood flow, but edema of the surrounding tissue
frequently leads to a false-positive result, creating
a diagnostic challenge.49
Thrombosis
Rarely, acute painful scrotum may be associated
with thrombosis of the internal spermatic vein50
or pampiniform plexus veins. Color Doppler US
may reveal the thrombus, which interrupts the
luminal patency (Fig. 10). The venous return of
the left testicle may be impaired for various
reasons, including the longer course of the left
spermatic vein and the nutcracker phenomenon
102 Turgut et al
corresponding to entrapment of the left renal vein
by the superior mesenteric artery anteriorly and
the aorta posteriorly. Theoretically this condition
may, in turn, be a predisposing factor for stasis
and thrombosis.
Scrotal Trauma
Physical examination of a traumatized, swollen,
and tender testis may be difficult, because it may
cause the patient great discomfort. With US exam-
ination it is possible to evaluate the testicular and
epididymal integrity and assess the vascular
status. Furthermore, US is helpful for follow-up of
patients undergoing conservative management.7
Scrotal trauma may be secondary to athletic injury,
a motor vehicle accident, a direct blow, or a strad-
dle injury,2 penetrating injuries, iatrogenic and
postoperative injuries, electrical injuries, and,
rarely, vascular injury associated with blunt
trauma that may lead to formation of a
pseudoaneurysm.51
The most common findings are scrotal or testic-
ular edema, scrotal hematoma, hydrocele, hema-
tocele, and testicular fracture or rupture,13
several of which usually are concurrent. Recently,
an increased prevalence of scrotal US abnormali-
ties has been reported in two separate studies
conducted on mountain bikers and equestrians
and has been attributed to the associated chronic
trauma effect on the scrotum and the perineum.52,53
Scrotal trauma may have unusual complications
such as acute epididymitis, epididymo-orchitis,
and torsion.51 Testicular rupture necessitates emer-
gent surgery. The rate of orchiectomy after testicular
trauma increases to 56% when surgical repair is
delayed by more than 72 hours.7 Testicular fracture,
small testicular hematomas, and small hemato-
celes, however, do not require surgical intervention
if the tunica albuginea has not been disrupted and
testicular vascularization is found to be intact on
color Doppler US.54
US findings associated with testicular rupture
are an interruption of the hyperechoic tunica
albuginea, a heterogeneous testis with asymmet-
ric, irregular, poorly defined borders, thickening
of the scrotal wall, and a hematocele (Fig. 11).1,51
A discrete line as a direct evidence of testicular
rupture rarely can be visualized on US.55 Color
and power Doppler US allow detection of the
interruption of the normal capsular blood flow of
the tunica vasculosa, which supports the diagno-
sis of a ruptured tunica albuginea.2 US findings
of testicular fracture, which is a break in the normal
testicular architecture, are a linear hypoechoic
stripe crossing the testicular parenchyma, with
a well-defined testicular outline, an intact tunica
Fig. 11. Tunica albuginea rupture. Color flow Doppler
image of the testis (T) in a patient who had history
of testicular trauma demonstrates the site of discon-
tinuation of the tunica albuginea (arrows) with pro-
trusion of testicular contents from the ruptured
tunica, giving rise to a contour abnormality (arrow-
heads). Also seen is associated scrotal wall hematoma
(asterisk).
albuginea, and an associated hematocele.1,54
Additionally, detection of normal color Doppler
signals indicates that the testicular vascularization
is maintained.54 If Doppler signals are not de-
tected, surgical intervention is required, because
ischemia is very likely.54 Moreover, focal or diff-
use epididymal hypervascularity may be detected
after scrotal trauma, suggesting traumatic
epididymitis.56
Hydrocele, which is an uncommon cause of
acute scrotal pain, is the presence of fluid within
the leaves of tunica vaginalis and appears on US
as an anechoic collection (Fig. 12). It is either
idiopathic or acquired. Although, a hydrocele
usually appears as a painless scrotal swelling, it
sometimes may cause pain or discomfort because
of its mass effect. Up to 50% of acquired hydro-
celes may be secondary to trauma.57 Hematocele,
on the other hand, is a complex collection within
the tunical space caused by extratesticular or
intratesticular bleeding secondary to testicular
injury. Hematoceles usually are more painful than
hydroceles. The detection of internal echoes
distinguishes a hematocele from a simple serous
hydrocele.7 Acute hematoceles usually are echo-
genic, whereas chronic hematoceles, with thick
internal septa, wall thickening, and calcifications,
may resemble a chronic hydrocele or pyocele
(Fig. 13).7,54

Fig. 12. Bilateral hydrocele. Extended-field of view US
scan reveals a marked increase in the amount of tun-
ical fluid in the right (r) and left (l) hemiscrotums com-
pressing the respective testes.
A scrotal hematoma may be intratesticular or
may involve extratesticular soft tissues such as
the scrotal wall, tunica vaginalis, and epididy-
mis.1,12,51 The lesions, which usually are focal
and multiple, may be hyperechoic compared with
adjacent testicular parenchyma in the acute stage
and hypoechoic or complex with cystic compo-
nents at the hemorrhage ages.1,12,51 Hematomas
of the scrotal wall may appear as focal thickening
of the wall or as fluid collections within the wall.51 It
has been reported that 10% to 15% of testicular
tumors are found incidentally during imaging after
an episode of scrotal injury.14 Therefore, intrates-
ticular abnormalities detected with US during the
evaluation of a trauma require close follow-up,
Fig. 13. Chronic hematocele. Sonogram reveals com-
plex peritesticular collection (C) with thick internal
septations compressing the ipsilateral testis (T).
Acute Painful Scrotum 103
Fig. 14. Extratesticular hematoma. Sonogram reveal-
ing extratesticular hematoma (H) with heterogeneous
echotexture lacking vascularity. Note that flow signals
are detected within the ipsilateral testis (T).
because intratesticular hematoma may mimic a
tumor on US.12,14 Hematomas lack vascularity on
color Doppler US, and this characteristic may
help distinguish them from a tumor (Fig. 14).1,3,51
Furthermore, posttraumatic torsion also has been
described in the literature and therefore warrants
a testicular perfusion evaluation by color Doppler
US during scrotal injury evaluation.40,58 US find-
ings associated with scrotal trauma are summa-
rized in Box 3.
Tumors
Testicular and paratesticular tumors are uncom-
mon causes of acute painful scrotum and may
Box 3
Ultrasound findings in scrotal trauma
Thickening of the scrotal wall
Asymmetric, irregular, and poorly defined
testicular borders (contour abnormality)
Interruption of tunica vasculosa (interruption
of the tunica albuginea)
Heterogeneous testicular echogenicity
Intra- or extratesticular hematoma with vari-
able echogenicity
Hydrocele, hematocele
A discrete line as a direct evidence of testicular
rupture (rarely)
Hypoechoic stripe crossing the testis revealing
fracture
104 Turgut et al

Fig. 15. Surgically proven mixed germ cell tumor. A 38-year-old patient with the initial diagnosis of orchitis pre-
sented with recurrent episodes of pain despite having been treated with antibiotics. (A) Gray-scale US revealed
multiple intratesticular hypoechoic areas and necrosis without scrotal thickening or epididymal involvement. (B)
Increased flow was detected in some of the lesions by color Doppler imaging. (Courtesy of Hasan Ozcan, MD,
Ankara, Turkey.)

present acutely when associated with epididymo-
orchitis or intratumoral hemorrhage.59 Approxi-
mately 95% of testicular tumors are germ cell
tumors (Fig. 15),1 including seminoma, which
accounts for nearly half of the cases.2 Testicular
tumors have nonspecific gray-scale US findings,
including a focal or diffuse area of hypoechogenic-
ity in an enlarged gland or an area of heteroge-
neous echogenicity caused by intratumoral
hemorrhage and necrosis.60 The lack of epididy-
mal enlargement and thickening of scrotal skin
favors the diagnosis of a tumor rather than an in-
flammatory process.60 Although hypervascularity
also can be detected in testicular tumors, it is not
distinguishable from the appearance of hypervas-
cularity seen in testicular inflammation.61 Based
on the observations regarding the normalization
of testicular peak systolic velocity values in pa-
tients who have orchitis, compared with the per-
sistently high velocities in those who have tumor,
Varsamidis and colleagues62 suggested that
follow-up examination in patients who have con-
servatively managed painful scrotum is important,
because it may be helpful for a reliable
differentiation.
Extratesticular tumors are more likely benign,
but intratesticular tumors are commonly malig-
nant. Adenomatoid tumor of the epididymis is the

Fig.16. Scrotal leiomyoma. (A) B-mode US examination reveals a well-defined solid mass (M) with heterogeneous
echotexture located inferior to the left testis (T) and distal to the left spermatic cord. (B) The mass shows the
presence of mild vascularity on color Doppler US.

most common extratesticular tumor in adults.
Lipomas, leiomyomas (Fig. 16), lymphangiomas,
sarcomas, and metastases are among the other
extratesticular tumors.
Inguinal Hernia
Inguinal hernia usually is diagnosed clinically. US
is helpful in patients who have equivocal findings.
It may present either as a painless mass or as
a painful swelling with an incarcerated bowel.2
The hernial sac most commonly contains bowel
and omentum. The US appearance of bowel
hernias includes a fluid- or air-filled bowel loop in
the scrotum; real-time visualization of peristaltic
activity helps confirm the findings (Fig. 17).2,7 An
omental hernia, on the other hand, is seen as a dif-
fusely echogenic paratesticular mass correspond-
ing to omental fat.1 Bowel strangulation, which is
more common with indirect hernia than with direct
hernia, appears as bowel in the hernial sac without
peristaltic activity.62 Hyperemia of the scrotal soft
tissue and bowel wall is an additional US finding
in incarceration.7,63
Acute Idiopathic Scrotal Edema
Idiopathic scrotal edema accounts for almost 70%
of acute scrotal cases in children younger than 10
years of age.64 It is very rare in adults.65 The cause
remains unknown. Patients may be asymptomatic
or may complain of scrotal discomfort65 or the
sudden onset of scrotal swelling and erythema.64
US may be helpful for differentiating idiopathic
scrotal edema from various conditions with a simi-
lar presentation, including torsion of the testis,
torsion of the appendages, epididymo-orchitis,
trauma, Fourniers gangrene, cellulitis, and
Fig. 17. Inguinal hernia. Gray-scale US scan shows
a bowel loop herniation (H) into the scrotum with in-
creased tunical fluid (F) surrounding the testis (T). The
diagnosis was supported by real-time visualization of
peristaltic activity.
Acute Painful Scrotum 105
testicular tumor.66 Sonographically, thickening of
the subcutaneous scrotal tissues and increased
vascularization of the scrotal wall can be
detected.67
SUMMARY
The main goal in imaging of patients who have
acute scrotal pain is to differentiate those warrant-
ing surgery from those who would benefit from
conservative management alone. Gray-scale and
color Doppler US are helpful for suggesting
specific diagnoses, which is crucial for the deter-
mination of the appropriate treatment. Epididymi-
tis is the most common cause of painful scrotal
swelling in men over 18 years of age. The use of
the combination of color and power Doppler US
is highly sensitive for the diagnosis of testicular
torsion, particularly for the evaluation of boys in
the pediatric age group. Scrotal trauma is
associated mostly with scrotal or testicular edema,
scrotal hematoma, hydrocele, hematocele, and
testicular fracture or rupture, several of which are
usually concurrent.
ACKNOWLEDGMENTS
The authors extend their sincere thanks to
Professor Hasan Ozcan, MD, for his comments
and suggestions and for providing Figures 3, 6,
8, and 10.
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