Ultrasound Case Series #2: Pain Down There

You are evaluating a patient who presents with right testicular pain and swelling. You order a radiology ultrasound of the testicles but the patient agrees to let you perform a bedside testicular ultrasound while he is waiting for radiology. You record the image below over the right hemiscrotum. What do you see, and what is your differential diagnosis for this finding?

 

Conclusion:

This ultrasound of the right hemiscrotum demonstrates air or gas in the scrotum. Note the hyperechoic line with deep shadow, much like bowel or lung air appears. A differential for air in the scrotum would include Fournier’s gangrene, inguinal hernia, or possibly trauma.
After this ultrasound, the providers were able to successfully reduce the hernia, and the patient was discharged with surgery follow up for elective repair. 
At Wash U, patients with a high suspicion for testicular pathology or torsion should have a radiology ultrasound performed. However, performing bedside ultrasound in the meantime can sometimes identify a cause for the patient’s problem.

 

Submitted by Laura Wallace, Ultrasound Fellow

Edited by Phil Chan (@PhilChanEM), PGY-4

Faculty reviewed by Deborah Shipley Kane, MD 


References:
Cosby, Karen S. and John L Kendall. Practical Guide to Emergency Ultrasound. Lippincott Williams & Wilkins, 2006.

Ultrasound Case Series #1: Not Pregnant, but...

A 32 year old woman presents to the ED with intermittent right lower quadrant pain. She states she has had intermittent pain since her tubal ligation 3 years ago, and she comes in today because of 1 day of worsening pain. She denies fevers, vaginal discharge, nausea, vomiting, or diarrhea. Her last menstrual period was 2 weeks ago, vitals signs are normal, and pregnancy test is negative.

What is your interpretation of these ultrasound images, and what is your differential?

 

Conclusion: 

The ultrasound image is obtained with the transvaginal probe at a depth of 10 cm. It is labelled right adnexa. The clip and still image demonstrate a large oval or cylindrical structure which is hypoechoic and appears simple (not septated) with irregular borders. There is no surrounding free fluid. This ultrasound image was interpreted as right hydrosalpinx. Normal Fallopian tubes are usually not visualized on ultrasound, but a Fallopian tube with fluid may have visible longitudinal folds as well (Note the scalloped appearance of the walls). In a patient with infectious signs, this could definitely be concerning for pyosalpinx or tubo-ovarian abscess as well. This patient however, had a history of chronic hydrosalpinx after her tubal ligation. Hydrosalpinx causing chronic abdominal pain and even fallopian tube torsion are both rare complications of tubal ligation.

Note: We often advise residents to avoid performing transvaginal ultrasounds in non pregnant patients who are going to have GYN consults, in order to avoid a patient undergoing 2 transvaginal ultrasounds in one visit. However, this is attending-dependent and there are always cases in which it may be indicated. However, it is important to practice looking at the adnexa for every transabdominal or transvaginal ultrasound you perform.

 

Submitted by Laura Wallace, Ultrasound Fellow

Edited by Phil Chan (@PhilChanEM), PGY-4

Faculty reviewed by Deborah Shipley Kane, MD 

 

Reference

Morse AN, et al.  The risk of hydrosalpinx formation and adnexectomy following tubal ligation and subsequent hysterectomy: A historical cohort study.  American Journal of Obstetrics & Gynecology.  2006;194(5):1273-76.