A review of ultrasound imaging in scrotal emergencies

Qualitative and quantitative spermatic cord abnormalities at CT predict symptomatic scrotal pathology

PURPOSE

To evaluate quantitative and qualitative spermatic cord CT abnormalities and presence of unilateral or bilateral symptomatic scrotal pathology (SSP) at ultrasound.

METHODS

This retrospective study included 122 male patients (mean age 47.8 years) undergoing scrotal ultrasound within 24 h of contrast-enhanced CT (n = 85), non-contrast CT (NECT, n = 32) or CT-Urogram (n = 5). CECT quantitative analysis assessed differential cord enhancement using maximum Hounsfield unit measurements. Three fellowship trained body radiologists independently assessed qualitative cord abnormalities for both CECT and NECT. Qualitative and quantitative findings were compared with the presence of SSP. Reader performance, interobserver agreement and reader confidence were assessed for NECT and CECT. Quantitative cutoff points were identified which maximized accuracy, specificity, negative predictive value, and other measures.

RESULTS

SSP was present in 36/122 patients (29.5%). Positive cases were unilateral in 30 (83.3%) and bilateral in 6 (16.6%). At quantitative assessment, 25% differential cord enhancement had the highest diagnostic accuracy (88.9%), with 90.5% positive predictive value, 88.4% negative predictive value, 96.8% specificity, and 70.4% sensitivity. At qualitative evaluation, CECT reader performance was excellent (aggregate AUC = 0.86; P < .001); NECT was poorly discriminatory, although remained significant (aggregate AUC = 0.67; P = .002). Readers had significantly higher confidence levels with CECT (P < .001). Qualitative inter-observer agreement was high for both CECT and NECT (ICC = 0.981 and 0.963, respectively).

CONCLUSION

Simple quantitative assessment of differential cord enhancement is highly accurate and specific for SSP at CECT. Qualitative abnormalities at CECT and NECT are also both predictors of SSP, however, CECT significantly out-performs non-contrast exams.

Multiparametric Ultrasound for Diagnosing Testicular Lesions: Everything You Need to Know in Daily Clinical Practice

BACKGROUND

Ultrasonography (US) represents the gold standard imaging method for the assessment of testicular lesions (TL). The gray-scale (GSUS) and color-Doppler (CDUS) ultrasound examination allow sonographers to investigate the size, margins, echotexture, and vascular features of TLs with the aim to differentiate benign from malignant lesions. Recently, the use of contrast-enhanced US (CEUS) and sonoelastography (SE) has led to further improvements in the differential diagnosis of TL. Although GSUS and CDUS are often sufficient to suggest the benign or malignant nature of the TL, CEUS can be decisive in the differential diagnosis of unclear findings, while SE can help to strengthen the diagnosis. The contemporary combination of GSUS, CDUS, CEUS, and SE has led to a new diagnostic paradigm named multiparametric US (mp-US), which is able to provide a more detailed characterization of TLs than single techniques alone. This narrative and pictorial review aimed to describe the mp-US appearance of several TLs.

METHODS

An extensive Medline search was performed to identify studies in the English language focusing on the mp-US evaluation of TLs.

RESULTS

A practical mp-US "identity card" and iconographic characterization of several benign and malignant TLs is provided herein.

CONCLUSIONS

The mp-US characterization of TL reported herein can be useful in daily clinical practice.

Role and added value of contrast enhanced ultrasound of the painful scrotum in the emergency setting

Emergency imaging of the scrotum is part of routine medical practice. Indications include epididymitis/epididymo-orchitis, testicular torsion, trauma, tumors and infarction. Prompt diagnosis and management are needed to ensure optimal patient outcome. Ultrasound (US) is the initial, and often the only, imaging modality for testicular pathologies. Usually, B-mode and color Doppler US are adequate. In challenging cases, contrast-enhanced US (CEUS) facilitates final diagnosis or increases the examiner's confidence by confirming findings on non-enhanced US. This paper elaborates on the examination technique of CEUS for testicular pathologies, thereby showing its added value over baseline US techniques in the emergency setting.

A case report of Fournier's gangrene: Imaging ultrasound and computed tomography (CT) scan

Necrotizing fasciitis and/or Fournier's Gangrene is a rare, life-threatening soft tissue infection that, if not treated promptly, can immediately develop into systemic toxicity. It affects the genital, perineal, and perineal tissues, predominantly affecting men but can be seen in women. The diagnosis is often made clinically but radiologic examinations are helpful to determine the extent of the infection and can aid preoperative planning. Treatment consists of immediate and aggressive surgical debridement of necrotized tissue, broad-spectrum antibiotics, and early resuscitation. Here, we present a 56-year-old male patient with Fournier's gangrene and describe the physical examination, bedside sonographic, and computed tomography findings. These findings can aid in the evaluation of patients with worrying symptoms so that antibiotics can be administered immediately and specialists can be consulted as needed.

The diagnostic value of ultrasound in pediatric testicular torsion with preserved flow

BACKGROUND

Testicular torsion is the reduction of blood flow to the testis after spermatic cord torsion. For patients, the diagnosis of testicular torsion is controversial and complicated by the fact that ultrasound blood flow signals are not significantly reduced in comparison to the unaffected, healthy, testis, despite persistent symptoms on the affected side. Our study aims to investigate the diagnostic characteristics of high-resolution ultrasonography (US) in pediatric testicular torsion with the preserved flow to increase diagnostic accuracy.

METHODS

Seven pediatric patients aged 49 days to 15 years old, with the preserved blood flow, but surgically diagnosed as testicular torsion, from October 2017 to August 2019, were retrospectively included in the study. The imaging manifestations of high-frequency ultrasonography were evaluated.

RESULTS

All cases had preserved testicular blood flow, but the surgical findings showed various degrees of twist, from 90 to 540 degrees. Preoperative ultrasound showed spermatic cord distortion in all cases, and testicular long axis tilting in four cases (4/7 = 57.1%).

CONCLUSION

In some testicular torsion cases, Color Doppler may show normal or increased blood flow signals in the testis. We should further observe the morphology and position of the testes and epididymides, the echo of the testicular parenchyma, and, especially evaluate the "whirlpool sign" in the spermatic cord, to avoid missing testicular torsion with blood flow signals.

Ultrasonography of the scrotum: Revisiting a classic technique

Conventional US is the primary imaging modality for the evaluation of the scrotum, due to its high resolution, availability, cost-effectiveness and absence of ionizing radiation. Grayscale and color Doppler US provide a comprehensive assessment of scrotal diseases. The technique represents the mainstay for imaging of acute scrotum. US is highly accurate in the detection, localization and characterization of scrotal masses. Multiparametric US, including conventional US, contrast-enhanced US and tissue elastography has improved the diagnostic performance of the technique in the assessment of testicular diseases. MRI represents a valuable supplemental imaging tool for the investigation of scrotal pathology, mainly recommended in cases of indeterminate US findings. Recommendations recently issued by the European Society of Urogenital Radiology Scrotal and Penile Imaging Working Group (ESUR-SPIWG) refer to the use of scrotal sonography for the evaluation of pathologic entities, including testicular microlithiasis, small, non-palpable incidentally detected testicular masses, varicocele and scrotal trauma. In this review, the technical specifications for scrotal US and the normal sonographic findings are presented. Grayscale and color Doppler US findings of common acute scrotal diseases and scrotal masses are discussed. The complimentary role of multiparametric US and scrotal MRI is addressed. ESUR-SPIWG's guidelines are also reviewed.

Role of multiparametric ultrasound in testicular focal lesions and diffuse pathology evaluation, with particular regard to elastography: Review of literature

BACKGROUND

Ultrasound is the main requested technique for the assessment of traumatic, vascular, neoplastic, and inflammatory testicular pathology. Moreover, the role of ultrasound has broadened over the years along with the introduction of new techniques, such as contrast enhanced ultrasound and ultrasound elastography.

OBJECTIVE

An updated representation of the pre-existing Literature evidence for multiparametric ultrasound imaging with particular regard to elastography, in the evaluation of focal and diffuse testicular pathologies, has been presented.

METHODS

The search was performed in PubMed, Cochrane, EMBASE, Web of Science and Scopus databases from the earliest available article (1977) until January 2021. Based on the evidence of the Literature, the current role of US imaging for focal and diffuse testicular pathologies has been reported and illustrated, with emphasis on examination technique, classification, and pitfalls.

RESULTS

Multiparametric Ultrasound has a recognized role for testicle focal and diffuse disease. Elastography is nowadays recognized as an essential part of the multiparametric ultrasound examination. However, in the setting of testicular pathology this method showed some promising results in the setting of varicocoele and for focal lesions characterization. In the remaining field its role is still under debate.

DISCUSSION

B-mode ultrasound and color Doppler ultrasound have been for a long time the diagnostic gold standard for testicular pathologies. The introduction of both contrast enhanced ultrasound and elastography in the last two decades has brought to the emergence of the multiparametric ultrasound concept. These methods are currently able to increase diagnostic confidence especially for testicular lesions characterization, with different relevance depending on the pathology under consideration.

CONCLUSION

Multiparametric ultrasound testis assessment, with specific regard to elastography is nowadays recommended for focal and diffuse disease evaluation. Further and larger studies are however needed to validate these results and to understand if the role of elastography in testicular pathology may be broadened.

Contrast-Enhanced Ultrasound in Children: Implementation and Key Diagnostic Applications

Contrast-enhanced ultrasound (CEUS) utilization is expanding rapidly, particularly in children, in whom the modality offers important advantages of dynamic evaluation of the vasculature, portability, lack of ionizing radiation, and lack of need for sedation. Accumulating data establish an excellent safety profile of ultrasound contrast agents in children. Although only FDA-approved for IV use in children for characterizing focal liver lesions and for use during echocardiography, growing off-label applications are expanding the diagnostic potential of ultrasound. Focal liver lesion evaluation is the most common use of CEUS, and the American College of Radiology Pediatric LI-RADS Working Group recommends including CEUS for evaluation of a newly discovered focal liver lesion in many circumstances. Data also support the role of CEUS in hemodynamically stable children with blunt abdominal trauma, and CEUS is becoming a potential alternative to CT in this setting. Additional potential applications that require further study include evaluation of pathology in the lung, spleen, brain, pancreas, bowel, kidney, female pelvis, and scrotum. This review explores the implementation of CEUS in children, describing basic principles of ultrasound contrast agents and CEUS technique and summarizing current and potential IV diagnostic applications based on pediatric-specific supporting evidence.

Paratesticular lesions: Aetiology and appearances on ultrasound

BACKGROUND

Ultrasound (US) is the primary modality for the investigation of scrotal pathology, including both intra- and paratesticular abnormalities.

OBJECTIVE

To describe the abnormalities of the paratesticular space.

MATERIALS/METHODS

The paratesticular space contains the epididymis, spermatic cord and the tunica vaginalis cavity and is affected by a variety of inflammatory or tumoral entities. Differential diagnosis based on US criteria is frequently problematic, as the findings are non-specific.

RESULTS

Some general rules apply: (i) unlike testicular lesions, extra-testicular entities are usually benign in the adult, (ii) the first steps to accurate diagnosis include careful localization of the lesion and assessment of its consistency (solid or cystic) and (iii) magnetic resonance imaging can be useful for further tissue characterization of lesions suspected to contain fat, but surgical biopsy will often provide the definite diagnosis. Contrast-enhanced ultrasound (CEUS) has been applied with limited experience indicating a narrow role, primarily for the differential diagnosis of echogenic cystic entities and the delineation of a necrotic abscess from a solid neoplasm.

DISCUSSION

The various abnormalities are discussed and illustrated.

CONCLUSION

This manuscript summarizes the literature on paratesticular lesions and the value of US in diagnosis.

Comparison of Superb Microvascular Imaging With Other Doppler Methods in Assessment of Testicular Vascularity in Cryptorchidism

Superb microvascular imaging (SMI) is a new Doppler technique. Superb microvascular imaging can observe microvascular and low-velocity blood flow. Superb microvascular imaging is available in 2 modes: color SMI (cSMI) and monochrome SMI (mSMI). To evaluate testicular flow, we have compared color Doppler ultrasound (CDUS), power Doppler ultrasound (PDUS), Advanced Dynamic Flow (ADF), cSMI, and mSMI techniques.Fifty-six participants less than 36 months of age were included in the study (mean age, 18.21 ± 1.5 months). One of the testes examined was in the scrotal sac, and the other was undescended testis (UT), and its location was at the level of the lower/middle inguinal canal. Testicular vascularization was evaluated with the CDUS, PDUS, ADF, and SMI techniques. Spot and linear signal encoding detected in the parenchyma were recorded between 0 and III for each technique. At the level of the testicle hilus, the outer boundary of the testicle was drawn manually along the long axis of each testis, and the vascularity index (VI) was automatically calculated from this area on the cSMI method.There was no significant relationship between normal and undescended testicles in terms of age, weight, height, testicle volume, and VI. Superb microvascular imaging was found to be superior in showing testicular vascularity, especially UT. The power of detecting Doppler signal in mSMI is significantly higher than in other methods (P < 0.001). The most valuable method according to the power of detecting testicular vascularity was mSMI. Next were cSMI, ADF, PDUS, and CDUS.In conclusion, the SMI technique should be included in vascular examination in pediatric patients with UT. The SMI technique can play an important role in assessing vascularization of UT.

Acute scrotal pain in pediatric patients: diagnosis with an innovative Doppler technique (MicroV)

Acute scrotal pain is one of the most frequent symptoms in pediatric patients visited in the Emergency Department. Ultrasonography with color and power Doppler represents the first-line method that clinicians use to carry out the differential diagnosis between spermatic cord torsion and inflammation, but sensitivity and specificity are 63-100% and 97-100%, respectively; this variability may be related to operator's experience and testis vascular hemodynamics and also to machine performance and patient age. Recent technological innovations have made possible to create a new Doppler mode called ultrasound microvascular imaging. This technique exploits algorithms capable of separating low frequencies of static tissue artifacts from ones of very weak flows. It is known as MicroV (from Esaote) and Superb microvascular imaging (from Toshiba). It provides both macrocirculation vascular maps, as a typical Doppler feature, and microcirculation vascular maps. Furthermore, the use of background subtraction could improve the visibility of small vascular structures. We report a case of a pediatric patient suffering from acute scrotal pain assessed ultrasonographically with this innovative Doppler technique (MicroV) that may give more confidence in detecting testicular vascular signals if compared with traditional Doppler techniques.

Overview of ultrasound applications for assessing scrotal disorders

The scrotum may be affected by a plethora of different disorders such as infections, vasculopathies, trauma, and manifestations of primary and secondary malignant masses. In addition to the patient's medical history and clinical examination, ultrasound represents the imaging modality of choice to assess scrotal disorders. Time-consuming contrast-enhanced ultrasound and elastography can provide further information to distinguish between benign and malignant testicular mass lesions. The following invited Special Communication gives a comprehensive overview of differential diagnoses of the scrotum and their corresponding sonomorphologic correlates based on representative cases of the Interdisciplinary Ultrasound Center of the University Hospital Munich.

The role of multiparametric ultrasound in the diagnosis of paediatric scrotal pathology

Multiparametric ultrasound (MPUS), combining conventional techniques (greyscale and colour Doppler ultrasound), ultrasound strain elastography, and contrast-enhanced ultrasound (CEUS), has been successfully used in the assessment of adult scrotal pathology. Contrast-enhanced ultrasound can confidently establish testicular tissue vascularity even in the small-volume paediatric testis. Elastography provides further assessment of tissue stiffness, potentially adding useful diagnostic information. In children, ultrasonography is particularly advantageous, being safe, radiation-free and negating the need for sedation or general anaesthesia during the imaging evaluation. In this review article, we aim to familiarise readers with the MPUS scanning protocol used for paediatric scrotal examination and provide an overview of scrotal MPUS features, with particular focus to clinical indications where MPUS may be advantageous over conventional ultrasonography.

The role of contrast-enhanced ultrasound (CEUS) in the evaluation of scrotal trauma: a review

Testicular trauma is common, usually trivial and rarely requires hospital attendance, but if it does, then imaging becomes essential as scrotal assessment may be difficult due to pain and/or scrotal disruption. Ultrasound (US) assumes a crucial role as other cross-sectional modalities have a limited use in the acute presentation. Despite the acceptable accuracy of conventional US techniques, there are limitations which hinder a thorough evaluation, critically the assessment of tissue viability, crucial for clinical management and prognosis. Contrast-enhanced ultrasound (CEUS) has been shown to offer improved flow visualisation and tissue perfusion compared with conventional Doppler techniques. CEUS can accurately and confidently demonstrate the viability of testicular parenchyma, delineate fracture lines and haematomas and guide treatment for testis-sparing surgery or orchidectomy. The purpose of this review is to present the literature, familiarise physicians with the principles of CEUS and findings of scrotal trauma and illustrate the main abnormalities through characteristic and educative cases.

Seeing the Unseen: Evaluating Testicular Vascularity in Neonates by Using the Superb Microvascular Imaging Ultrasound Technique

OBJECTIVES

To evaluate testicular vascularity in neonates by using the novel Superb Microvascular Imaging (SMI; Toshiba Medical Systems Corporation, Tokyo, Japan) ultrasound (US) technique and to compare this technique to conventional Doppler US techniques.

METHODS

A total of 140 healthy neonates between 2 and 60 days old who were admitted for routine screening were included in the study. However, in 9 cases, the Doppler study could not be completed. In the remaining 131 cases, color Doppler imaging (CDI), power Doppler imaging (PDI), Advanced Dynamic Flow (ADF; Toshiba Medical Systems), and monochrome SMI (mSMI) techniques were performed on a single representative testicle. Real-time cine images were captured for 5 to 10 seconds for each technique by using a high-frequency (7.2-14-MHz) linear transducer. The images were evaluated by 3 observers using a grading system to quantify the degree of vascularity and artifact interference.

RESULTS

A total of 131 testicles (74 right and 57 left) were evaluated, and vascularity was shown in 110 (84%) testicles with CDI, 109 (83%) with PDI, 94 (72%) with ADF, and 128 (98%) with mSMI by the consensus of all observers. The Doppler techniques were ranked from highest to lowest in the following order based on the degree of vascularity detected: mSMI > PDI > CDI > ADF (P < .001). Based on the presence of artifacts, the Doppler techniques were ranked as follows from high to low: ADF > CDI > PDI > mSMI (P < .001).

CONCLUSIONS

Superb Microvascular Imaging is a promising US technique that appears to detect testis vascularity better than conventional Doppler US techniques; however, further research is needed to support the results of this study.

[Segmental testicular infarction]

Segmental testicular infarction is a rare cause of acute scrotum and only a few cases have been reported. Torsion of the testis, testicular tumor and infection are important differential diagnoses. The present case report describes a 61-year-old man with left-sided testicular pain increasing over 24 h. The diagnosis of segmental testicular infarction was considered after color Doppler ultrasound of the left scrotum and it was confirmed by surgical exploration and pathological examination. Although it is uncommon, segmental testicular infarction should be taken into consideration when acute scrotal pain is encountered, especially for younger patients, since a testis-sparing treatment strategy can be performed.

Fountain’s Sign as a Diagnostic Key in Acute Idiopathic Scrotal Edema: Case Report and Review of the Literature

The acute idiopathic scrotal edema (AISE) is a self-limited disease of unknown etiology, characterized by edema and erythema of the scrotum and the dartos, without expansion to the underlying layers of scrotum’s wall or to the endoscrotal structures. Boys younger than 10 years old are usually involved in 60–90% of all cases. Diagnosis is made after exclusion of other causes of acute scrotum. We present a case of a 7-year old boy, who was admitted to the Emergency Department due to development of scrotal edema and erythema over the last 48 hours, which extended to the base of the penis. The patient mentioned that he first noticed the erythema on the anterior surface of the right hemiscrotum, which gradually extended. Physical examination did not reveal presence of pathology involving the endoscrotal structures, indicative of need for urgent surgical intervention. Transillumination was negative for blue dot sign. Ultrasonographic examination of the scrotum documented the homogeneity of the testicular parenchyma, while color Doppler revealed the presence of fountain’s sign (equal arterial blood supply to both testicles). Conservative strategy was followed and the patient gradually improved within the next three days. In conclusion, meticulous physical examination along with ultrasonographic examination of the suffering scrotum, especially with the highlighting of fountain’s sign with color Doppler, document the diagnosis of AISE. Thus, need for urgent surgical investigation of the suffering scrotum due to diagnostic doubt is limited.

Multiparametric US for scrotal diseases

Multiparametric US is increasingly recognized as a valuable problem-solving technique in scrotal pathologies. Compared to conventional Doppler modes, contrast-enhanced ultrasonography (CEUS) has higher sensitivity in assessing the presence or absence of flows, and to improve differentiation between poorly vascularized tumors and non-neoplastic, avascular lesions. Characterization of benign and malignant complex cysts is improved. In trauma patients, CEUS can help evaluating the viability of testicular parenchyma. In patients with severe epididymo-orchitis, it allows unequivocal assessment of post-inflammatory ischemic changes and abscess formation. CEUS does not add significantly to conventional Doppler modes in spermatic cord torsion. Attempt of differentiating benign and malignant tumors remains a research tool. In the clinical practice, elastography has a limited role for tumor characterization. The majority of malignant tumors are stiff at elastography, but they may display soft areas, or appear globally soft. A quantitative evaluation of testicular stiffness is feasible using shear-wave elastography. Potential clinical applications for elastographic modes could include work-up of infertile patients.

Testicular ultrasensitive Doppler preliminary experience: a feasibility study

Background Ultrasensitive Doppler is a novel non-invasive ultrasound (US) Doppler technique that improves sensitivity and resolution for the detection of slow flow. Purpose To investigate the feasibility of ultrasensitive Doppler (USD) for testicular disease diagnosis, using both qualitative and quantitative results. Material and Methods This prospective study was conducted in 160 successive men referred for scrotal US including B-mode and conventional Color-Doppler. A new USD sequence and algorithm dedicated to academic research were implemented into the US system. The quality criterion for a successful examination was the detection of well delineated intratesticular vessels. Qualitative USD results were described in terms of tumor vascular architecture and flow intensity for different pathologies for 41 patients. The testicular vascularization (TV), defined as a vessel's surface ratio, was quantified using customized MATLAB® software and compared in azoospermic and normal patients. Results USD was acquired successfully in 153/160 patients (95.6%). The tumor vascular architecture differed depending on the nature of the tumors. Leydig cell tumors exhibited mostly circumferential vascularization, while germ cell tumors exhibited straight vessels through the tumors, or anarchic vascular maps. USD improved the diagnostic performance of testicular Doppler US in a case of incomplete spermatic cord torsion and acute epididymitis. The reproducibility of TV measurements established an interclass correlation of 0.801. Non-Klinefelter syndrome non-obstructive azoospermia patients exhibited a lower TV compared to normal patients, to Klinefelter syndrome, and to obstructive azoospermia patients ( P < 0.002, P < 0.005, and P < 0.05, respectively). Conclusion Testicular USD can become a promising technique for improving US diagnosis of tumors, acute scrotum, and for determining infertility status.

Scrotal Ultrasound for Pain: Low Frequency of Absolute Surgical Indications

OBJECTIVE

To examine the results of scrotal ultrasounds (US) conducted for scrotal or testicular pain and review the pathologic findings of orchiectomies done for lesions that were suspicious for malignancy on US.

MATERIALS AND METHODS

We retrospectively reviewed the indications and findings of all scrotal US completed at our institution from 2002 to 2014. If a patient underwent an orchiectomy for an intratesticular lesion that was concerning for malignancy on US, the pathology report was also reviewed.

RESULTS

There were 18,593 scrotal US performed, with 7,668 (41.2%) conducted for scrotal pain. Of the US performed for pain, 80.4% revealed benign or normal findings, and only 2.2% demonstrated a finding that is an absolute indication for surgery (intratesticular lesion suspicious for malignancy 0.8%, abscess 0.7%, torsion 0.6%, infiltrative process such as lymphoma 0.1%). For those patients undergoing an orchiectomy, 75% had malignancy on pathologic analysis.

CONCLUSION

The majority of the 7668 US performed to evaluate scrotal or testicular pain reveal normal or benign findings. A low percentage demonstrates a finding that necessitates urgent or emergent surgery.

A Case of Testicular Rupture Diagnosed by Point-of-Care-Ultrasound

Point-of-care ultrasound is an expanding diagnostic tool in the pediatric emergency department. We describe a case of testicular rupture diagnosed by ultrasound at the bedside, which led to prompt surgical intervention and repair.

Ultrasound Diagnosis of Clinically Unsuspected Ureteral Stone Presenting as Acute Scrotum: Case Series

Ureteral colic is not generally included in the differential diagnoses of acute scrotal pain, although ureteral pathology is a recognized cause of pain referred to the scrotum. We report 3 patients presenting with acute scrotal pain who had normal scrotal color Doppler ultrasound scans; subsequent ultrasound of the ipsilateral kidney revealed hydronephrosis, which ultimately led to the clinically unsuspected diagnosis of ureteral colic. We conclude that ureteral colic should be included in the differential diagnosis of acute scrotal pain, and we further suggest that a survey ultrasound of the kidney on the side of the pain should be performed in patients presenting with acute scrotal pain and a normal color Doppler ultrasound examination of the scrotum.

Ultrasonography of pediatric urogenital emergencies: review of classic and new techniques

Urogenital emergencies are fairly common in the pediatric population, and a timely and correct diagnosis is necessary to avoid possible future infertility. In this field, ultrasonography is essential, as it has the advantages of being radiation-free and readily accessible. In particular, a high-frequency transducer allows precise evaluation of the morphology and vascularity of the scrotum, which is on the surface of the body. Beyond conventional techniques, new advanced imaging techniques have been developed, including elastography and contrast-enhanced ultrasonography. However, several pitfalls remain in the diagnosis of urogenital diseases using ultrasonography. Thus, accurate knowledge and sufficient experience with the technique are essential for making a correct diagnosis. This review provides an overview of pediatric urogenital emergency pathologies and recent ultrasonography techniques.

Role of Strain Elastography in the Evaluation of Testicular Torsion: An Experimental Study

OBJECTIVES

To evaluate the utility of real-time strain elastography in experimentally induced testicular torsion at different degrees and torsion hours.

METHODS

Thirty-one Wistar albino rats were divided into 4 torsion groups by twisting left testes (group I, sham operated; group II, 360°; group III, 720°; and group IV, 1080°). Elastography was applied at the 8th and 24th hours of torsion. Elasticity patterns (pattern 1, soft testis; pattern 2, moderately soft testis; pattern 3, predominantly hard testis; and pattern 4, almost entirely hard testis) and strain ratios were recorded. Histopathologic evaluation was done at the 24th hour. Interobserver agreement was analyzed.

RESULTS

Changes in elastographic patterns and strain ratios among groups II, III, and IV were statistically significant at both hours as determined by both radiologists (P < .01). Elastographic patterns changed from 2 to 3 in groups II and III to 4 in group III between the 8th and 24th hours (P < .05), but in group IV, patterns were reversed, and pattern 1 was observed at both hours. Pathologically severe necrosis (grade 4) was seen in left testes in group IV. In the other groups, pathologic grading in the left testes was as follows: mostly grade 1 in groups I and II and mostly grade 2 in group III. Elastography showed that right testes were affected in group IV, with significant differences in elastographic patterns and strain ratios (P < .01). Interobserver agreement for elastographic patterns in right testes was substantial at the 8th hour (κ = 0.72) and otherwise excellent (κ = 0.81-0.85). Concordance of strain ratios between observers was excellent for right and left testes at the 8th and 24th hours (intraclass correlation coefficients, 0.990 at the 8th hour and 0.987 at the 24th hour).

CONCLUSIONS

Our results show that real-time strain elastography can be a complementary method in the evaluation of testicular tissue in testicular torsion and can guide surgeons in their surgical approach.

[Segmental testicular infarction. Unusual complication of intravenous immunoglobulin therapy for multifocal motor neuropathy]

We describe the previously unknown case of segmental testicular infarction as an iatrogenic complication of intravenous immunoglobulin administration in a patient with multifocal motor neuropathy.

Role of ultrasound with color Doppler in acute scrotum management

Background and Objective:

An acute scrotum is defined as acute pain with or without scrotal swelling, may be accompanied by local signs or general symptoms. Acute scrotal pain is a medical emergency. Depending on cause, the management is entirely different. Torsion of testis and strangulated hernia are surgical emergency; whereas, epididymo-orchitis is treated by medicines. Testicular trauma and obstructed hernia can be differentiated by taking history from patient. Physical examination adds only a little information. Color Doppler ultrasound (US) is the modality of choice to differentiate testicular torsion from inflammatory conditions and can thus help in avoiding unnecessary surgical explorations.

Subjects and Methods:

A study on 50 patients was conducted who were referred with history of acute scrotal pain to our department between January 2013 and January 2014. Trauma and scrotal mass were excluded from the study. The clinical presentation, outcome, and US results were analyzed.

Results:

Color Doppler sonography yielded a positive and negative predictive value (PPV and NPV) of 100% each for torsion, whereas, 93.9 and 70.6% for epididymo-orchitis, respectively; a sensitivity and specificity of 100% for torsion, whereas, for epididymo-orchitis it was found to be 86.1 and 85.7%, respectively. In cases of incomplete or early torsion, some residual perfusion may be detected leading to false-negative results.

Conclusion:

We therefore conclude that color Doppler sonography can reliably rule out testicular torsion and can thus help in avoiding unnecessary surgical explorations. Hence, it can significantly improve outcome and decrease morbidity of patient. It is an accurate, rapid, nonexpensive, nonionizing, important adjunct to clinical assessment of scrotum.