|Nicholas Otts, MD||Staten Island University Hospital, Northwell Health, Department of Emergency Medicine, Staten Island, New York|
|Ryan L. Webb, MD||Staten Island University Hospital, Northwell Health, Department of Radiology, Staten Island, New York|
|Josh Greenstein, MD||Staten Island University Hospital, Northwell Health, Department of Emergency Medicine, Staten Island, New York|
|Barry Hahn, MD||Staten Island University Hospital, Northwell Health, Department of Emergency Medicine, Staten Island, New York|
An 11-year-old boy presented to the emergency department (ED) with sudden onset severe atraumatic right testicular pain, associated with nausea and vomiting. On examination, the patient exhibited a slight horizontal lie of the right testicle as well as an absent cremasteric reflex on the right. Urology was emergently consulted. Though vascular flow was noted bilaterally on spectral Doppler (Images 2), the patient underwent surgical detorsion due to the whirlpool sign seen on point-of-care ultrasound (POCUS) of spermatic cord (Image).
Testicular torsion with whirlpool sign: Testicular torsion occurs when twisting of the spermatic cord results in a subsequent loss of blood supply to the ipsilateral testicle. Testicular torsion is primarily a pediatric problem, with a bimodal age distribution of the first year of life and early adolescence. Evaluation of testicular flow by color and spectral Doppler is the primary method of diagnosis.1 However, evaluation with Doppler can be non-diagnostic due to the presence of low-velocity blood flow. Direct visualization of the spermatic cord by POCUS may elicit the whirlpool sign or an echogenic mass twisted around a central axis. As demonstrated by this case, whirlpool sign is diagnostic of torsion and can help identify torsion when Doppler is non-diagnostic.2,3 Thus, the whirlpool sign, although not frequently mentioned in emergency medicine literature, can be critical to the diagnosis of torsion in the ED and should be an ultrasound finding known to all emergency physicians.
What do we already know about this clinical entity?
The whirlpool sign is an important diagnostic marker in the evaluation of suspected testicular torsion by point- of-care ultrasound.
What is the major impact of the image(s)?
The whirlpool sign is a characteristic sonographic finding indicative of testicular torsion.
How might this improve emergency medicine practice?
Visualization of the whirlpool sign allows confident diagnosis of testicular torsion.
Section Editor: Manish Amin, DO
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
Address for Correspondence: Josh Greenstein, MD, Staten Island University Hospital, Department of Emergency Medicine, 475 Seaview Avenue, Staten Island, NY 10305. Email: JGreenstein1@northwell.edu. 2:97 – 98
Submission history: Revision received September 25, 2017; Submitted November 21, 2017; Accepted November 29, 2017
Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.
1. Prando D. Torsion of the spermatic cord: the main gray-scale and Doppler sonographic signs. Abdom Imaging. 2009;34(5):648-61.
2. Vijayaraghavan SB. Sonographic differential diagnosis of acute scrotum: real-time whirlpool sign, a key sign of torsion. J Ultrasound Med. 2006;25(5):563-74.
3. Baud C, Veyrac C, Couture C, et al. Spiral twist of the spermatic cord: a reliable sign of testicular torsion. Pediatr Radiol. 1998;28(12):950-4.