Sonography of the scrotum

Sonography of the Acute Scrotum: The Four T’s of Testicular Imaging

The scrotum is frequently imaged on an emergent basis. The differential diagnosis of the acute scrotum can be divided into four categories-torsion, trauma, tumor, and "testiculitis" (epididymo-orchitis). Although testicular neoplasms are not imaged emergently, 15% are detected incidentally when performing an emergent scrotal ultrasound. Therefore, the emergent sonographic examination of the testicles should include a thorough search for malignancy. Images demonstrating the sonographic and color Doppler appearances of each of the "four T's" will be reviewed. The radiographic review will focus on the imaging features, which are the keys to arriving at the correct diagnosis.

Doppler sonography in diagnosis of the acute scrotum

Doppler sonography has been reported to be a reliable technique for diagnosing acute scrotum significantly decreasing the number of unnecessary surgeries. The aim of this paper was to demonstrate the superiority and validity of Doppler sonography over conventional sonography for differential diagnosis of the acute scrotum. In the period from 2002-2004, 300 patients underwent ultrasound examination of the testicles at the Institute of Radiology in Novi Sad. This prospective randomized study included 100 patients, whereas the target group consisted of 50 patients with the diagnosis of the acute scrotum. The control group consisted of 50 patients with the diagnosis of varicocele. The examinations were done using Siemens Versa Pro equipment and 7,5 MHz probes. On the basis of ultrasound examination, the target group was divided into three groups: 1. Inflammation, 2. Torsion, 3. Miscellaneous. Depending on the disease, the accuracy of diagnosis was confirmed by surgery, clinical findings and control sonographic examination. A functional correlation exists between Doppler diagnosis and final diagnosis in the inflammation and torsion. Resistive indexes (RI) were lower in inflammation, because of hyperemia. In cases with intratesticular hyperemia, the average RI was 0,454 and in those with supratesticular hyperemia 0,575. In cases with torsion, only one patient with appendiceal torsion had normal intratesticular blood flow. In diagnostics of the acute scrotum, Doppler sonography is superior over conventional sonography and more precise in differential diagnostics. RI are good quantitative parameters of hyperemia. .

Comparison of brucella and non-specific epididymorchitis: gray scale and color Doppler ultrasonographic features

OBJECTIVE

The aim of this study is to find out if it is possible to differentiate between brucellar and non-specific epididymorchitis by comparing ultrasonography (US) and color Doppler ultrasonography (CDUS) findings.

MATERIAL AND METHODS

Fifty-six patients diagnosed to have epididymorchitis both clinically and ultrasonographically were included to study. All of the patients were investigated serologically for brucella. Twenty-eight of those patients were admitted brucella epididymorchitis because of high agglutinations titers for brucella. The other 28 patients were admitted non-specific epididymorchitis because of normal agglutinations titers for brucella. Testicular size, echogenicity, hydrocele, internal echoes and/or septations within hydrocele, and scrotal skin thickness of normal and involved testis were compared by ultrasonography. Besides, pick systolic velocity, end diastolic velocity, resistive index and pick systolic velocity ratio values were measured by bilateral testicular color Doppler ultrasonography in both groups. When the p-value is <0.05, the difference between groups is accepted as statistically significant.

RESULTS

Thickening of scrotal skin was seen in 17 of 28 patients with brucella epididymorchitis (BEPO) (67%) and in 25 of 28 patients with non-specific epididymorchitis (NEPO) (89.2%) (p < 0.01). There was no difference between groups regarding presence of hydrocele. However hydrocele seen in all patients was anechoic except for two patients (8.6%). Hydrocele seen in 18 of 22 patients with BEPO and hydrocele had internal echogenicity or septation (p < 0.001). Sizes of testes and epididymis were found to be increased in involved testis compared to normal testis. Testes of all patients with NEPO were homogenous with decreased echogenicity except for five patients (17.8%). However, 23 patients with BEPO (82%) found to have heterogenous testis (p < 0.001). Spectral measurements showed increased PSV and EDV values and decreased RI values in involved sides in both groups. There was statistical significant difference in respect to maximum and minimum flow velocity between two groups (p < 0.05). There was no difference between the two groups regarding RI values. PSV ratio was 3.1+/-1.3 in patients with BEPO and 2.2+/-0.7 in patients with NEPO.

CONCLUSION

Heterogenicity, focal echogenicity differences and hydrocele with granularity and/or septation seen in a patient presenting with scrotal infection in brucella endemic areas must rise the possibility of brucellosis rather than NEPO. By this way, effective treatment can commence immediately and complications can be avoided.

Cystic appendix epididymis: a sonomorphologic study

We aimed to describe the morphologic characteristics of the appendix epididymis that appears cystic on ultrasound (US) examinations. Two hundred and seventy-two patients (544 testes) were examined by US for various scrotal complaints. The patients were prospectively evaluated for the presence of testicular appendages. Cystic appendix epididymis on US examinations was classified according to the presence of the stalk and size of the cyst. Testicular appendages have been identified in 337 out of 544 testes (61.9%). Of them, 241 were appendix testis (44.3%) and 96 (17.6%) were appendix epididymis. Of the appendix epididymises, 35 were cystic in nature (36.4%). The most common morphology in our study was the stalked appendix epididymis with nonseptated unilocular cysts (31.4%). In conclusion, cystic appearance of the appendix epididymis on sonographic examinations is frequent and it should not be mistaken with a torsed testicular appendage.

Gray-Scale and Color Doppler Sonography of Scrotal Disorders in Children: An Update

Ultrasonography (US) is well suited to the study of pathologic conditions of the scrotum in children. US provides excellent anatomic detail; when color Doppler and power Doppler imaging are added, testicular perfusion can be assessed. Gray-scale, color Doppler, and power Doppler US were used to study a spectrum of scrotal disorders in 750 boys aged 1 day to 17 years. The entities studied included processus vaginalis-related disorders (cryptorchidism, inguinal-scrotal hernia, and hydrocele); varicocele; acute scrotum (epididymo-orchitis, torsion of the testicular appendages, and testicular torsion); scrotal tumors; testicular microlithiasis; scrotal trauma; and systemic diseases with scrotal involvement. When combined with the results of clinical and physical examination, the information obtained with US is sufficient to enable diagnosis in most cases of scrotal disease. Moreover, color Doppler imaging is essential for differentiation between processes such as epididymo-orchitis or torsion of the testicular appendages and testicular torsion, which have similar clinical manifestations (pain, swelling, and redness) but are managed differently.

Scrotal sonographic findings in equestrians

OBJECTIVE

Sports-related injuries are among the major causes of testicular trauma. In this study, we aimed to determine sonographically whether chronic urogenital trauma during horse riding increases the prevalence of scrotal sonographic abnormalities. To our knowledge, there are no studies in the literature that have focused on this topic.

METHODS

Group 1 included 26 male riders with a mean age +/- SD of 31 +/- 2.9 (range, 26-38) years and with a mean riding experience of 5 +/- 2.6 (range, 1-10) years, whereas group 2 included 26 healthy nonriding men with a mean age of 31 +/- 3.2 (range, 26-41) years. After the clinical evaluation, all patients underwent scrotal sonographic examination.

RESULTS

The prevalence of overall scrotal sonographic abnormalities in group 1 was significantly higher than that in group 2 (77% versus 38%; P < .05). The detected sonographic findings in group 1 were varicocele (46%), hydrocele (19%), testicular cyst (4%), epididymal cyst (35%), testicular calcification (19%), epididymal calcification (8%), scrotal calculus (8%), and inhomogeneity of parenchymal echo texture (4%). However, only varicocele (19%), epididymal cyst (19%), testicular calcification (12%), and scrotal calculus (4%) were detected in group 2. Between the 2 groups, the difference was significant for varicocele prevalence (P < .05) and marginally significant for hydrocele prevalence (P = .051).

CONCLUSIONS

We recommend scrotal sonographic examination of equestrians when they have a palpable mass or related symptoms, the etiology of which was found in our study to be closely related to horse riding.

Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys

BACKGROUND

Diagnosis of testicular torsion in children is challenging, as clinical presentation and findings may overlap with other diagnoses.

OBJECTIVE

To define the clinical and ultrasound criteria that best predict testicular torsion.

MATERIALS AND METHODS

The records of children hospitalized for acute scrotum from 1997 to 2002 were reviewed. The clinical and ultrasound findings of children who had a final diagnosis of testicular torsion were compared with those of children who had other diagnoses (torsion of the testicular appendix, epididymitis, and epididymo-orchitis).

RESULTS

Forty-one children had testicular torsion; 131 had other diagnoses. Stepwise regression analysis yielded three factors that were significantly associated with testicular torsion: duration of pain < or =6 h; absent or decreased cremasteric reflex; and diffuse testicular tenderness. When the children were scored by final diagnosis for the presence of these factors (0-3), none of the children with a score of 0 had testicular torsion, whereas 87% with a score of 3 did. The ultrasound finding of decreased or absent testicular flow had a sensitivity of 63% and a specificity of 99%. Eight of ten children with testicular torsion and normal or increased testicular flow had a coiled spermatic cord on ultrasound.

CONCLUSION

We suggest that all children with acute scrotal pain and a clinical score of 3 should undergo testicular exploration, and children with a lower probability of testicular torsion (score 1 or 2) should first undergo diagnostic ultrasound. Because the presence of testicular flow does not exclude torsion, the spermatic cord should be meticulously evaluated in all children with acute scrotum and normal or increased testicular blood flow.

Torsion of a communicating hydrocele in a child

Among the diseases presenting as acute scrotum, torsion of a communicating hydrocele is extremely rare. A 5-year-old boy was referred with discomfort and swelling of the left scrotum. Operative findings revealed a torsion of a communicating hydrocele. We report a case of torsion with preoperative findings of ultrasonography and magnetic resonance imaging. We also emphasize the awareness of this disease as a differential diagnosis of the acute scrotum.

Torsed appendix testis: gray scale and color Doppler sonographic findings compared with normal appendix testis

OBJECTIVE

The purpose of this study was to compare the size, shape, echogenicity, and blood flow of the appendix testis on sonography in control subjects and in patients with a torsed appendix testis and to evaluate the usefulness as well as the limitations of these criteria.

METHODS

This was a retrospective analysis of 11 lesions with torsed appendix testes and 15 normal appendix testes in 12 children. The following gray scale and color Doppler sonographic features were analyzed: size, shape, echogenicity, and blood flow of the appendix testis.

RESULTS

The size of the appendix testis was larger in patients with a torsed appendix testis than in the control subjects (P < .05). A spherical shape of the appendix testis was more common in patients with a torsed appendix testis (P < .05). There was no blood flow within both the torsed and normal appendix testes. However, the frequency of increased periappendiceal blood flow was higher in patients with a torsed appendix testis (P < .05). There was no significant difference in the echogenicity between the torsed and normal appendix testes.

CONCLUSIONS

Gray scale and color Doppler sonography may be helpful in the diagnosis of torsion of the appendix testis. A size of 5 mm or larger, spherical shape, and increased periappendiceal blood flow are indicative of a torsed appendix testis.

Epidermoid cyst in a solitary testis: A case for non-surgical management

This is a case report of a 71-year-old man who presented with an incidental finding of a mass in a solitary right testis. A scrotal ultrasound scan showed the typical features of a testicular epidermoid cyst. Tumour markers were not elevated and the patient was managed non-operatively. On reviewing the literature, we found no previous report on the non-operative management of testicular epidermoid cysts

Intratesticular Angioleiomyoma

Angioleiomyomas are common benign smooth muscle tumors that occur in the subcutis of the extremities and to a lesser extent, of the head and trunk. Rarely, these tumors have been reported in other deeper tissues, but never within the testis. We present what we believe to be the first report of intratesticular angioleiomyoma, occurring in a 58-year-old man with a painless testicular swelling. Orchidectomy was the treatment of choice in this patient, as there was no reliable imaging technique to clinically distinguish this benign lesion from the more common malignant intratesticular tumors.

Testicular ultrasound

Acute scrotal pain makes up approximately 0.5% of all complaints presenting to an emergency department. Some of the most com-mon diagnoses for this complaint are testicular torsion and epididymitis. Misdiagnosing testicular torsion can lead to organ loss,cosmetic deformity, and compromised fertility. Modem ultrasound examination of the scrotum is the test of choice for acute scrotal pathology and yields high accuracy compared with surgical exploration. A key component of the testicular examination is use of power and spectral Doppler ultrasonography. Examination of the acute scrotum should not be undertaken unless Doppler capability is available because the evaluation of blood flow is such an important part of diagnosis of testicular torsion, orchitis, epididymitis,trauma, and hemorrhage into a mass.

Enlargement and hypervascularity of both the epididymis and testis do not exclude involvement with lymphoma or leukemia

We present 3 cases of diffuse infiltration of the testes and epididymides by malignant lymphoma and leukemia. Gray-scale and color Doppler sonograms showed diffuse hypoechoic enlargement and hypervascularity of the involved testes and epididymides. The authors emphasize that enlargement and hypervascularity of both the epididymis and testis can be caused by lymphomatous/leukemic involvement and is not always indicative of epididymo-orchitis.

Magnetic resonance imaging and ultrasound evaluation of penile and testicular masses

The purpose of this study is to present the role of ultrasonography and MRI in the investigation of testicular and penile masses, as well as to review the literature. This article is based on our experience with 230 patients who presented with acute or subacute scrotal pain or painless enlargement of the scrotum or penis. Gray scale and color Doppler ultrasonography (CDU) were applied in all cases. In 73 cases, the final diagnosis was established by surgery and in 157 cases by follow-up. MRI was performed in 48 cases. Ultrasonography was the initial imaging modality in all cases. It provided detailed anatomic information with high sensitivity and accuracy in cases of torsion, inflammation, varicocele and trauma. In cases of tumor, US showed the presence of the mass in all cases, while it additionally revealed certain characteristic features of tissue constitution and blood supply. In most cases, differentiation between various types of tumors or differentiation between malignant and benign lesions was impossible. MRI, besides the detailed anatomic imaging, also provided a certain degree of tissue specificity. MRI could help in the detection and staging of penile cancer and in the evaluation of testicular and scrotal masses, especially when a diagnostic dilemma occurred on ultrasonographic examination. Ultrasonography, combining gray scale and color techniques, is irreplaceable in the diagnostic work-up of scrotal and penile masses, while MRI can serve as a problem solving diagnostic modality.

Torsion and beyond: new twists in spectral Doppler evaluation of the scrotum

OBJECTIVE

To illustrate how spectral Doppler waveform analysis plays an adjunctive but very definite role in scrotal sonography.

METHODS

The cases illustrate a variety of testicular disorders that were collected at a referral tertiary care center.

RESULTS

Normal and a variety of pathologic conditions of the testes are discussed, along with their signature spectral waveforms.

CONCLUSIONS

Analysis of the spectral waveform provides important additional information in various scrotal disorders with acute pain. Spectral waveform analysis is critical to diagnosing incomplete torsion when color and power Doppler examinations are indeterminate.

Benign intrascrotal lesions

PURPOSE

We summarize important clinical, pathological and diagnostic features of benign intrascrotal lesions, including paratesticular lesions (adenomatoid tumors, fibrous pseudotumors, cystadenomas, spermatoceles, hydroceles, varicoceles and hernias) and intratesticular lesions (tunica albuginea cysts, testicular simple cysts, epidermoid cysts, cystic ectasia of the rete testis, intratesticular varicocele, adrenal rest tumors and splenogonadal fusion). This review provides the reader with a better understanding of benign lesions that occur in the scrotum.

MATERIALS AND METHODS

A directed MEDLINE literature review of benign scrotal lesions and of each individual lesion was performed. This information was enhanced with relevant information from select journals and texts. Particular emphasis was placed on clinical, pathological and diagnostic features.

RESULTS

Intrascrotal lesions continue to provide a diagnostic challenge for physicians. A diagnosis can be made with a thorough history, physical examination and understanding of the pathophysiological processes of the structures contained within the scrotum. Lesions that are suspicious for malignancy should prompt urological consultation and radiological imaging. Ultrasound aids in the diagnosis in instances of uncertainty. Ultimately surgery may be necessary to make a histological diagnosis.

CONCLUSIONS

Clinical assessment, physical examination and an understanding of benign intrascrotal processes are key to making a diagnosis. Ultrasound has an important role and adds essential information. If surgery is necessary and a benign process is recognized, a testis sparing procedure should be performed.

Ultrasound of Tropical and Infectious Diseases That Affect the Scrotum

Ultrasonography of the scrotum permits assessment of testicular and extratesticular masses with high sensitivity. It can differentiate a variety of conditions involving the scrotum, testicles, and epididymis with similar clinical manifestations, including infectious and tropical diseases. The authors performed conventional and color Doppler ultrasonographic examinations in 76 patients who presented with scrotal pain, swelling, and/or tenderness. Their diagnoses included sexually transmitted disease (eg, gonorrhea, syphilis, chlamydial infection), tuberculosis, mumps, and various tropical diseases (eg, filariasis, leishmaniasis, schistosomiasis, paracoccidioidomycosis). The most common imaging findings were enlarged hypoechoic testes, hypervascularity, small hydroceles, and cutaneous edema. This report reviews these and other possible presentations of tropical and infectious diseases affecting the scrotum, emphasizing ultrasound findings that facilitate diagnosis.

Acute painful scrotum

The ability of US to diagnose the pathogenesis of the acute scrotum is unsurpassed by any other imaging modality. It is the first imaging performed in patients with acute scrotum. Knowledge of the normal and pathologic sonographic appearance of the scrotum and proper sonographic technique is essential for accurate diagnosis of acute scrotum. High-frequency transducer sonography combined with color flow Doppler sonography provides the information essential to reach a specific diagnosis in patients with testicular torsion, epididymo-orchitis, and testicular trauma.