65 year old M presents with significant swelling, discoloration and pain to the right scrotum and penis after inguinal hernia repair 2 days prior. On exam, patient with ecchymosis and erythema of the right testicle and shaft of the penis. There is significant swelling in the inguinal canal, which is not compressible or reducible. You take the ultrasound to bedside to see:
What is the diagnosis?
Answer: Scrotal hematoma
Differentials for this patient include hematoma, hydrocele, scrotal abscess or infection, failure of mesh causing strangulated or incarcerated hernia.
On imaging, you see mixed echogenic fluid collection with no vascular flow noted. This extends from the right groin into the scrotum, with hypoechogenic fluid tracking around bilateral testicles. This is consistent with a scrotal hematoma. There is no bowel noted, ruling out strangulated or incarcerated hernia. There is no “swirl” sign which would be more consistent with scrotal abscess/infection. The mixed echogenic fluid is most consistent with hematoma rather than hydrocele.
Pearls for the bedside scrotal ultrasound:
- Use the linear probe
- Place the patient supine, place a towel under the scrotum and drape the patient appropriately
- Obtain imaging of the unaffected side first for landmarks and comparison
- Compare to the affected side, noting echogenicity and landmarks
- Visualize both testicles in the same view
- Can utilize doppler to assess for flow in concerns for torsion
References:
- Davis JE. Male Genital Problems. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020. Accessed April 15, 2024. https://accessemergencymedicine-mhmedical-com.ezproxy.rowan.edu/content.aspx?bookid=2353§ionid=219643185
- https://www.acep.org/emultrasound/newsroom/mar2020/tips-and-tricks-time-is-testicle-mastering-the-testicular-ultrasound-exam
- Yusuf GT, Sidhu PS. A review of ultrasound imaging in scrotal emergencies. J Ultrasound. 2013 Sep 4;16(4):171-8. doi: 10.1007/s40477-013-0033-x. PMID: 24432171; PMCID: PMC3846954.
CT and radiology ultrasound imaging from case are below:
