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.