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appendix testis and epididymis is beneficial before palpation of the testis itself (
Fig. 61.2 ). Use of a cotton-tipped swab to discretely localize tenderness in these
areas may be helpful, and also less threatening to an uncomfortable patient.
Appreciation of swelling, tenderness, and consistency should be noted for all
intrascrotal structures. Transillumination may be helpful in some cases ( Fig. 61.9
).

Imaging Modalities
Color Doppler imaging with pulsed Doppler is the standard imaging modality as
it provides both visualization of scrotal anatomy and intratesticular arterial blood
flow determination and comparison. Widely available, this noninvasive study can
differentiate scrotal wall from testicular blood flow and has replaced technetium99m pertechnetate nuclear scans. Torsion is diagnosed when blood flow is
diminished or absent, as compared with the contralateral testis. In cases of a
torsed testicular appendage or epididymitis, blood flow is increased to the
affected area. In trauma, ultrasound can localize blood, fluid collections, or
swelling. The operator-dependent nature of the study, the technical challenges in
the very young patient with small, low-flow testes, and the need for clinical
correlation must be heeded. Any doubt in interpretation or concern about the
adequacy of the signal should result in consideration of surgical exploration.
Magnetic resonance imaging of the scrotum has recently been proposed in
cases of trauma to localize blood collections and determine the integrity of
underlying structures when ultrasound is equivocal.
Suggested Readings and Key References
Baker LA, Sigman D, Mathews RI, et al. An analysis of clinical outcomes using
color Doppler testicular ultrasound for testicular torsion. Pediatrics
2000;105:604–607.
Baldisserotto M. Scrotal emergencies. Pediatr Radiol 2009;39:516–521.
Barbosa JA, Tiseo BC, Barayan GA, et al. Development and initial validation of a
scoring system to diagnose testicular torsion in children. J Urol
2013;189:1859–1864.
Broderick KM, Martin BG, Herndon CD, et al. The current state of surgical

practice for neonatal torsion: a survey of pediatric urologists. J Pediatr Urol
2013;9(5):542–545.
Buckley JC, McAninch JW. Diagnosis and management of testicular ruptures.
Urol Clin North Am 2006;33:111–116.