 Hi friends, having understood the sono anatomy of the scrotum which included a good b-mode ultrasound as well as color doctor of the scrotum, let's move with the cases which we commonly see in our day to day practice. The most common presentation for which a patient will present in your clinic will be an acute scrotum or pain in scrotum. Let me take you through this series of cases that how you will view approach cases of acute scrotum in day to day practice. When we evaluated this case, we could see that this ovoid structure or a homogenous organ was the cell legion was lying in the scrotal wall and the testes were completely normal. In fact, if you see these are hypoechoic dermal elements whenever any very human body you see something like that, legion lying in the superficial subcutaneous soft tissue, unless proved otherwise, you can make an antipini diagnosis of an epidermal inclusion cyst. Now, some interesting cases. This was on a Sunday where a nephew of an MD physician walked in with sudden onset scrotal swelling in our one-year-old nephew of hers and that clinically suspected torgen of the testes. See the clinical picture. Entire testes was edematous. In fact, there was penile edema also and the MD physician was very scared that this is nothing but torgen. Now, when we started evaluating this case again by systematic approach, what we saw that the testes underneath were completely normal. In fact, the vascularity within the testes was also well preserved. So, definitely not torgen. But what we picked up that the scrotal wall was completely edematous. In fact, we could see fluid in between this scrotal wall layers. Now, looking at both testes being normal, both epidermis being normal, you know that this is nothing but a scrotal wall edema. So, these are panoramic images where testes were completely normal. Penile edema was seen. This condition is nothing but scrotal wall edema. Now, see this 17-year-old male who presented with high-grade fever and pain and swelling in scrotal. When we started evaluating this, the testes bang were completely normal. The epidermis was also surprisingly normal. Day one, when we scanned him, we picked up this ill-defined hypoechoic area in the scrotal wall. I alerted the surgeon saying that this look area is not looking good. It looks infective in origin. The surgeon started the patient on antibiotics. But see on day three, there was a complete breakdown of this hypoechoic area and it was nothing but scrotal wall abscess in evolution seen on day one and day three. You see internal echos, moving echos, unless otherwise the legion is lying completely in the scrotal wall. This is nothing but a scrotal wall abscess. This was a patient who had undergone fistuline aeno surgery and suddenly developed right scrotal wall swelling pain. He was having a discharging sinus at the base of the scrotum. Now interestingly, when we started scanning him, what we picked up that there was lot of scrotal wall edema. So by now, you know that there was scrotal wall edema in this case as we have seen in previous cases. But what we saw here was that in the scrotal wall, there was this hyper-reflective area with dirty posterior acoustic shadowing. By virtue of imaging, we know that this is nothing but air. So there was air in the scrotal wall. Then when we evaluated his contralateral left side, we saw that he had a cryptorchid testis in the left inguinal canal. This was the base of the perineum where he was having this discharging sinus abscess, which seems to be the culprit for causing the scrotal wall infective etiology with air. This was the air seen very beautifully on ultrasound. Then when we evaluated his testis, he also had epididymitis on the same side. So we gave a diagnosis that this looks to be a very bad infective etiology where the scrotal wall is filled up airy course. There is epididymitis on the right and the culprit for this wall seems to be the massive infection at the base of scrotum. Similar scenario, we had a diabetic patient who was 80 years male and who again presented an acute abdomen bilateral scrotal swelling. And when we started scanning him, his liver, gallbladder, kidneys were banged normal. Again, when we went to the area of interest, we saw that the testis were completely normal. And again, see at this scrotal wall here, we saw that there was air echoes again in the scrotal wall. Now see, this video is running here, how beautifully ultrasound can demonstrate air in the scrotal wall. There was a significant amount of hydrocele, which was reactive. And if ever you see this air shadows in the scrotum, this is nothing but four years gangrene in a diabetic. Now, trust me, this patient by day three or day seven completely deteriorated. There was shameful exposure of the testis and by day seven, the patient died in ICU. So you as a radiologist can make so much difference that we alerted the physician that this seems to be a bad infection in the scrotal wall, mostly an impending four year gangrene and see the actually by day three, day four, the patient landed up with this. So how ultrasound can be of such a paramount importance to pick up these bad infective pathologies. Now this guy was very smart. He was trying to concede his area of pathology. He was sent for abdomen pelvis evaluation, where abdomen pelvis was completely normal. So he said there is left sided pain, left sided pain. So out of interest, we screened his in vinyl areas, which was surprisingly normal, but patient was looking sick and he was completely pointing out to the left side of the groin. So out of interest, we told him to requested him to see that we also wanted to evaluate the scrotum. See what you can see here. We were shocked. The right testes was completely normal, but here the left testes is completely hypoechoic inhomogeneous areas within the testes. Then the epidermis on the same side was engorged with increased vascularity. We switched on. This was the B mode appearance. We switched on the color Doppler. No flow within this hypoechoic inhomogeneous area. This was the game changer, where we picked up and evaluated his cord and every area of that cord showed a nice whirlpool, which was seen in this case. Our own Bhupati Sir has beautifully described this as a real-time whirlpool sign. I all want you to read this article given by Sir. It was a game changer in way that we looked at acute torgents because every case of acute torgents showed this whirlpool sign. See this one more case, severe onset pain and scrotum, the child got up from sleep. When we saw this, the testes was normal. See here, the axis of the testes had become horizontal, hypoechoic testes. Then when we saw this, this also showed no flow within the testes. This is a normal contralateral side. See this peritesticular flow. I was telling you because the testes get supplied, the wall gets supplied from other areas, you will see a kind of this contradictory flow around the testes. The epidermis was engorged and even this turned out to be torgents. So this is that beautiful whirlpool sign, which you should search in each and every case of torgents because tors testes can be beautifully picked up on by picking up this whirlpool sign. So another case which stresses the importance of this whirlpool, testes normal, in-homogeneous hypoechoic testes, no flow within the testes. So again, here in fact, we picked up this whirlpool beautifully on B mode and trust me, this video and the in-drop picture was just the same. Always stressing that we followed this Bhupati Sir's article. All of you should read it because it was a game changer in picking up torgen cases in day-to-day clinical practice. When you talk about torgen, you know that there is going to be some certain degree of twist. The testicle is going to get twist around its axis. Now, if you read literature on torgen, they say that the torgens extend from 90 degrees, 180 degrees, 360 degrees and 520 degrees. Whenever the twist is going to be so bad that it has crossed 360 degrees, it's going to cause complete torgen and most of the time it leads to non-salvageable testes. But anything less than 180, 90, all are going to lie in the category of an incomplete or partial torgen, which you sometimes may pick or may not pick up in your practice. So, see this another interesting case where we picked up the origin in this case. There was a reactive hydrosil with inward septation. But what was sitting at this upper pole of the testes was this hyper-echoic area with cystic areas within it. We were flummoxed by what this lesion could be and surprisingly even this lesion was devoid of blood flow. There was a lot of ecogenicity. Now, trust me by imaging, we knew that this is epididymis and it was a tors testes. We called up the surgeon and when he operated, he gave us a follow-up that this was a testicular and an epididymal torgen, both. So, that can also happen in practice. Then infant pediatric age group presenting with bilateral inguinal scrotal and again clinical suspicion was of torgen. So, this was asymptomatic side where there was this bayonet shift collection. Looking at this, you know that this is nothing but hydrosil. But when we again scan the symptomatic side, one, axis of the testes had completely changed in homogeneous hypo-echoic areas seen within this testes. Axis shifted no flow within this testes. In fact, what interestingly we saw that this whole testes and this collection extended up till the external inguinal ring. Putting two into perspective, this is the kind of picture we had. Axis altered no flow and this going up till the external inguinal ring, we gave a confident diagnosis of torgen of the testes. Now, stressing for last 10 minutes about torgen, why are we trying to tell you to pick up torgen so early in practice? So, if you look at this chart, it clearly tells you that if you are going to pick up testicular torgens in the first five or six hours, you are going to do benefit for the patient because if you operate in those first four or five hours and untwist or whatever you can do, you can almost have an 80 to 100 percent salvage rate. But as time passes and as the time goes by, you will lose most of the time the testes and hence it's very critical to make this diagnosis as prompt as possible. If you go back to all my cases, you know that we saw one pediatric torgen and we saw some adult torgen. So, very simple to remember that there are two types of torgen, the intravaginal and the extravaginal variety where in pediatric age group you will always see an extravaginal torgen which is occurring because of motility of the entire tunica vaginal is extending all the up till the external inguinal ring. As against at puberty onset or adult onset, you will always see intravaginal torgen which typically occurs because of bell clapper deformity where you must have read that the testes get suspended on a long stop of the spermatic cord. So, adult patients intravaginal torgen, pediatric infants extravaginal torgen. So, this is the way the twist goes and if it is extravaginal, it goes up till the external inguinal ring and if it is intravaginal, it limits itself down there. Now, pathologically what happens at the level of the testes is that first there is always going to be a venous outflow obstruction followed by the arterial obstruction and once that has occurred, it starts causing complete vascular engorgement and leads to completely a non salvageable testes. So, some charts for you to remember that if a patient comes to you within the first six hours, many of the times you might land up reporting it as a normal looking testes because the inhomogeneous appearance is not there in the first six hours. But whirlpool will always be there. Many a times you will see just hypoechoic testes. So, therefore, stressing the importance of looking contralateral asymptomatic with symptomatic side is that that hypoechoic ecotexture will alert you. But always, always you will look for whirlpool, you can promptly diagnose this condition within the first six hours. But if patient is going to come to you in your clinical practice after six hours, most of your time the job is easy, where you're going to see a heterogeneous hypoechoic testes straight forward diagnosis. You will see scrotal wall thickening, reactive hydro seal. You will see no flow on color Doppler, but you will see again a whirlpool, very easy diagnosis. Most of the time it's going to be a non viable testes. When we tried to prepare this lecture, I was trying to read up that can torsion occur in undecended testes? In a cryptorchid testes, it had a patient presented with the emergency and there was no flow within it. And the post-op appearance, there was a undecended testes lying in the deep environmental ring which had undergone torsion. Now, we saw over last five minutes that we talked about color Doppler evaluation, look at flow, look at whirlpool and pick up torsion. Now, can there be a theoretical situation that there is a torsion of the testes? You're still seeing color flow and there can be a torsion. Yes, it can happen. So, the whole importance of taking spectrum within the testicular parankaima is due to this, that in all cases of incomplete torsions or torsions which are less than 180 degrees, spectrum analysis is one of the most critical way you're going to evaluate acute scrotum. So, how does it help in practice to pick up incomplete torsions or torsions which are less than 180 degrees? See this case, 17-year-old guy, look at these testes. It shows this normal seesaw kind of pattern, good flow, asymptomatic side. But here, contralightly in the symptomatic side, we are seeing color flow within the testes. But when we did sampling or did a Pw evaluation, see what kind of pattern we are getting is that typical dampened monophasic waveforms, the way we see in critical ischemic limbs in the lower limb arteries. Looking at this spectrum, you know that this testes is undergoing some amount of ischemia. Sometimes in some cases, we saw that the diastolic component is minimal as it becomes less. So, always remember that in every testicular torsion, arterial flow need not be present. In fact, three patterns which you should remember is that if you are getting dampened monophasic waveform or a reduced end diastolic flow or reversal of diastolic flow, you will go and search for whirlpool. Even if you don't see whirlpool, twist and twist has occurred, you will write this finding in your report and tell the clinician that this testes seems to be undergoing ischemia and needs a close follow. So, see this case, reversal of diastolic flow, absent end diastolic flow, very minimal reversal senior, all these are nothing but as incomplete torsions or ischemic testes. Stressing the importance of ultrasound with Doppler, best tool in today's time to evaluate torsion of the testes, almost having an 100% specificity and 97% accuracy. Now, there are always going to be an overlapping many pathologies which are going to mimic torsions. So, what that could be? Any infective pathologies like epidermitis, epidermal orchitis, spreading contiguous infections, involving the tunica vaginalis and things like that. There could be a tunicitis and all going to present you as mimics of torsion. Trauma which we have seen can also mimic a torsion. So, see this case, we did 14 years old with pain in right scrotum. So, when we evaluated him, left testes was normal. Interestingly, what was seen at the upper pole of the testes near the epidermis, we saw this ovoid hypoechoic area which was showing peripheral vascularity and this fine ecogenic foci within. See this case, similar case given by Ravi Sir from UAE where testes were normal, epidermis normal, again an ovoid ecogenic area, peritational flow. Testes was normal. Whenever you see something like this sitting at the upper pole, very, very painful, unless proved otherwise, these are torsion of the testicular appendages. Now, there is some overlap that how you pick up torsion of the testicular appendages versus epidermal appendages. So, simple rule, anything at the upper pole of the testes and that ovoid ecogenic area is going to be torsion of the testicular appendage but similar kind of pathology lying at the tail of the epidermis unless proved otherwise these turned out to be torsion of the epidermal appendage. Sometimes you scan a testes and you see a segmental hypoechoic area like this, cleavage kind of hypoechoic area, flow senior, no flow senior. These are testicular infarcts. Now, testicular infarcts, whether pathology is mainly arterial thrombosis or an arterial vessel has got thrombosis. So, always there is some kind of a background history which the patient will give. Torgens in the testes typically occur because of venous occlusion or venous outflow impairment but testicular infarcts are always always arterial in origin where the arteries are got embolized or thrombosis. You will have a patient with sickle cell or you will have a patient of epidermal arthritis and where one of the areas has suddenly undergone infarction and you will see that area devoid of blood flow. Now, the problem area is that any other such pathology can it mimic a testicular infarct. Yes, if you see a mass within the testes even that's going to look as a avoid hypoechoic area. Now, what happens in practice is that testicular infarcts will be completely devoid of blood flow in paladoplar as well as paladoplar but neoplasm within the testes will show some degree of blood flow. So, that's the way you are going to diagnose it in practice. Now, going to few interesting cases. I think you all are very confident of picking up epidermitis in day-to-day practice where most of the time you have an incidental history of a patient having underlying urinary tract infection or GU infection where you see echogenic inflamed epidermis typically lying at the upper pole of testes when you switch on color, increase vascularity, compare it with the contralateral side unless otherwise this turns out to be epidermitis. Now, epidermis is one of the cryptic side for all areas of infection. It can spread to the testes and cause arthritis. It can test go to the cord and cord having connective tissue gets inflamed and that leads to funiculitis. So, in practice you could have a very overlapping picture between epidermitis, epidermal architis as well as funiculitis. So, you need to go systematically and see this case. Now, see this case testes was completely normal and see this when the cord gets involved we are going to label this confidently as a epidermal architis with funiculitis. Now, this guy was a very, very close friend of mine. He came to my clinic and he said he had some vague trauma and pain and he is having severe pain in the right testes, some kind of malaise and fever. Now, when we evaluated this, we saw that the testes showed this hypoechoic areas. If you look at it with the previous slides, the most prom diagnosis you would make is a segmental testicular infarct. His epidermis was normal but when we switched on color, we were shocked that this area which was hypoechoic ill-defined should increase vascularity like this, putting two and two picture. This is nothing but focal architis. So, any inflammatory pathology causing this kind of hypoechoic area, increased vascularity, trauma being background history, you can confidently give a diagnosis of focal architis. In fact, he came after four weeks of antibiotics and was this legion completely disappeared. Then, sometimes history and clinical presentation is very easy to make a diagnosis. So, bilateral submandibular swellings with right scrotal swelling and high-grade fever. When we evaluated, testes was hypoechoic, increased vascularity, epidermis was engorged, inflamed. You know, this is a case of epidermoarchitis. But if you look at the area of interest, which was a submandibular glands, which was also inflamed and large hypoechoic, surprisingly, the parotids were preserved, putting two into picture. We said that this is nothing but epidermoarchitis sequelae to mumps. So, viral infections involving, you know that parotids, submandibular and scrotum, you know that with clinical perspective, you know that this is nothing but mumps. Now, see this interesting case given by Hemal Banyar, my fellow colleague, the patient landed up with him with an acute swelling and replacing these testes was a disorganized testes with this ecogenic cystic area with fine ecogenic echoes. Contralateral right testes was normal. Again, beautifully, we could pick up air in the scrotal wall. I said, Hemal, this looks to be infected. We saw that this definitely is looking like air echoes, but air echoes within the testes. Then we screened his epidermis and patient had bad infection in the scrotal wall with scrotal wall air. But this testes, which was the symptomatic side, was replaced by this cystic collection with this fine echoes within it, which was giving an appearance of air. I told Hemal that this is definitely a bad infective pathology. They too, in fact, Hemal scanned that patient again and trust me, this was a bad scrotal wall infection with involvement of the testes. That time I scratched my mind. I said, why is the testes full of air? I did some Google research that time, and then this work has been done by our own fellow colleagues, Anita and Prabhakar, where in IGR, this article is that this entity is called as emphysematist, epidermoarchitis, where in diabetics, the epidermis and the testes is so badly involved that it gets completely replaced with air. Just out of interest, we took a radiograph of the scrotum and we could see air fluid level there, and this was nothing but a bad emphysematism or epidermoarchitis typically usually seen only in diabetics.