appendix testis and epididymis is beneficial before palpation of the testis itself ( Fig 61.2 ) Use of a cotton-tipped swab to discretely localize tenderness in these areas may be helpful, and also less threatening to an uncomfortable patient Appreciation of swelling, tenderness, and consistency should be noted for all intrascrotal structures Transillumination may be helpful in some cases ( Fig 61.9 ) Imaging Modalities Color Doppler imaging with pulsed Doppler is the standard imaging modality as it provides both visualization of scrotal anatomy and intratesticular arterial blood flow determination and comparison Widely available, this noninvasive study can differentiate scrotal wall from testicular blood flow and has replaced technetium99m pertechnetate nuclear scans Torsion is diagnosed when blood flow is diminished or absent, as compared with the contralateral testis In cases of a torsed testicular appendage or epididymitis, blood flow is increased to the affected area In trauma, ultrasound can localize blood, fluid collections, or swelling The operator-dependent nature of the study, the technical challenges in the very young patient with small, low-flow testes, and the need for clinical correlation must be heeded Any doubt in interpretation or concern about the adequacy of the signal should result in consideration of surgical exploration Magnetic resonance imaging of the scrotum has recently been proposed in cases of trauma to localize blood collections and determine the integrity of underlying structures when ultrasound is equivocal Suggested Readings and Key References Baker LA, Sigman D, Mathews RI, et al An analysis of clinical outcomes using color Doppler testicular ultrasound for testicular torsion Pediatrics 2000;105:604–607 Baldisserotto M Scrotal emergencies Pediatr Radiol 2009;39:516–521 Barbosa JA, Tiseo BC, Barayan GA, et al Development and initial validation of a scoring system to diagnose testicular torsion in children J Urol 2013;189:1859–1864 Broderick KM, Martin BG, Herndon CD, et al The current state of surgical practice for neonatal torsion: a survey of pediatric urologists J Pediatr Urol 2013;9(5):542–545 Buckley JC, McAninch JW Diagnosis and management of testicular ruptures Urol Clin North Am 2006;33:111–116