Pitfalls in Imaging for Acute Scrotal Pathology

Neglected trauma-induced testicular torsion: Clinical, sonographic, and surgical correlation in a 13-year-old adolescent

Post-traumatic testicular torsion is a rare condition, accounting for approximately 4%-8% of all reported cases of testicular torsion in the literature. Prompt clinical suspicion and intervention are crucial; as testicular torsion is considered a medical and surgical emergency that may lead to testicular necrosis. Ultrasound imaging plays an important role in assessing the integrity of the traumatized scrotum and facilitating early detection of associated testicular torsion. In this case report, we present a neglected post-traumatic testicular torsion in a 13-year-old child that led to orchiectomy.

Testicular Germ Cell Tumours—The Role of Conventional Ultrasound

Testicular tumours are the most common tumours found in young males and germ cell tumours account for 95% of testicular tumours. Ultrasound is the first-line radiological investigation for imaging of the testis. This article outlines how to undertake an ultrasound examination, including optimal patient position, scanning technique and imaging parameters. Classification of germ cell tumours is provided, and salient imaging features of different tumours are described. Difficulties and pitfalls of ultrasound are described, including tumours found after a trauma presentation, orchitis causing diagnostic difficulties and imaging of small testicular lesions. Other uses of ultrasound are outlined, including looking for a primary testicular tumour following the discovery of retroperitoneal lymph nodes, imaging when tumour-makers increase, local recurrence in the scrotum, and for solid organ biopsy in metastatic disease. Conclusion: Ultrasound remains the first-line of investigation for imaging of the testis, and conventional ultrasound still plays a large role in imaging. On ultrasound alone, accurate morphological characterisation of tumours remains a challenge, despite the imaging features that can be seen in different tumour types. Therefore, histology following orchidectomy of a germ cell tumour remains the gold standard for accurate tumour characterisation.

Do Not Get It Twisted: Common and Uncommon Manifestations of Testicular Torsion

Color flow and spectral Doppler ultrasound are the backbone of scrotal imaging when evaluating acute scrotal pain. Testicular Torsion is one of the most common causes of acute scrotal pain but can be a challenging diagnosis both clinically and sonographically. This article will review the pertinent Doppler ultrasound findings that can help make the diagnosis of both complete and partial torsion. A review of other causes of testicular ischemia will also be included as these pathologies can mimic Testicular Torsion.

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.

Historical trends for the standards in scrotal ultrasonography: What was, what is and what will be normal

BACKGROUND

Ultrasonography is the gold standard imaging method for scrotal investigation. Colour Doppler ultrasonography, contrast-enhanced ultrasonography and sonoelastography allow sonographers to assess size, echotexture, vascular features and stiffness of the scrotal organs and abnormalities. Scrotal ultrasonography has been used to investigate male reproductive health, scrotal pain, masses and trauma. However, ultrasonography thresholds/classifications used to distinguish normal and pathologic features of the scrotal organs have changed over time, and have not yet been fully standardized.

OBJECTIVES

To evaluate historical trends for the standards in scrotal ultrasonography: what was, what is and what will be normal.

METHODS

An extensive Medline search was performed identifying the most relevant studies in the English language from inception to date.

RESULTS

We provide here (i) a brief overview of the history of ultrasonography, (ii) current indications for scrotal ultrasonography and (iii) previous and current normal values, cut-offs and classifications of the main colour-Doppler ultrasonography parameters/characteristics of the scrotal organs, as derived from recent guidelines and evidence-based studies. In addition, we report recommendations and the clinical utility of contrast-enhanced ultrasonography and sonoelastography. Finally, we discuss critical issues needing further evidence and future directions to fill in the current gaps.

DISCUSSION

Several studies on scrotal ultrasonography are available. However, guidelines/recommendations dealing with specific ultrasonography applications have been published only in recent years. More recently, the European Academy of Andrology published evidence-based scrotal colour-Doppler ultrasonography reference ranges/normative parameters derived from a cohort of healthy, fertile men. In addition, a standardization of the methodology to evaluate qualitative and quantitative colour-Doppler ultrasonography parameters was reported. Other international societies reported indications, methodological standards, clinical utility and limitations of contrast-enhanced ultrasonography and sonoelastography.

CONCLUSIONS

To date, colour-Doppler ultrasonography normative values for the scrotal organs are available. However, a wide international consensus on assessment and classification of several ultrasonography parameters is still lacking. An alignment of the world societies on these issues is advocated.

Nonscrotal Causes of Acute Scrotum

Acute scrotum is characterized by intense acute scrotal pain, which may be associated with other symptoms and signs such as abdominal pain, inflammation, and fever. Many pathologic conditions can present in this way, most which involve the scrotal contents. Nonscrotal conditions, however, can rarely present clinically only as acute scrotum: among them, renal colic, aneurysm rupture or other causes of retroperitoneal hemorrhage, primary abdominal or pelvic tumors and metastases, pancreatitis, pelvic inflammation, and muscle injuries. The pathophysiologic characteristics of the clinical presentation, clues for diagnosis, and imaging features of a series of nonscrotal lesions presenting clinically with acute scrotal pain are herein reported and illustrated. In patients presenting with acute scrotal symptoms and normal scrotal ultrasound findings, nonscrotal causes of acute scrotal pain should be considered in the differential diagnosis. Therefore, an ultrasound investigation of the abdomen, groin, and thighs is indicated.

Tension hydrocele as an additional cause of acute scrotum: case series and literature review

PURPOSE

To describe the correlation between acute scrotum pain and tension hydrocele, focusing on US and Doppler features.

METHODS AND MATERIALS

We evaluated retrospectively a series of five patients with a long history of hydrocele who were referred to our institutions for increasing acute scrotal pain. Patients were approached with gray scale US of both testes, as well as with color-Doppler and spectral analysis, comparing the results with those after aspiration and symptoms relief.

RESULTS

All patients had a "simple" hydrocele with no internal septa; the involved testicles had a "flattened" appearance and parenchymal Doppler signals showed increased intratesticular vascular resistance. One patient had a low diastolic flow, compared to the contralateral testis, with an increased RI value, one had no diastolic flow, two patients had retrograde diastolic flow, and the remaining one had no intratesticular flow visible. After decompression, there were disappearance of pain and improved flow with normalization of testicular vascularity; post-ischemic hyperemia was appreciated in the two patients examined immediately after fluid aspiration, while normal flow was seen in three studies carried out the day after.

CONCLUSION

To conclude, tension hydrocele is a rare condition that produces alterations of form and circulation of testicles, increase of intraparenchymal vascular resistances and strong and continuous pain, mimicking a testicular torsion. The increase in pressure produces an effect similar to that observed in a compartment syndrome. US findings, together with clinical assessment, indicate when emergency decompression may be appropriate to relieve testicular ischemia.

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.

Case - Tension hydrocele: A rare cause of acute scrotal pain

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Imaging Modalities in Genitourinary Emergencies

Emergency physicians rely on a multitude of different imaging modalities in the diagnosis of genitourinary emergencies. There are many considerations to be taken into account when deciding which imaging modality should be used first, as oftentimes several diagnostic tools can be used for the same pathologic condition. These factors include radiation exposure, sensitivity, specificity, age of patient, availability of resources, cost, and timeliness of completion. In this review, the strengths and weaknesses of different imaging tools in the evaluation of genitourinary emergencies are discussed.

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.

Magnetic resonance imaging of the scrotum: pictorial review with ultrasound correlation

The purpose of this review is to showcase the added value of scrotal magnetic resonance imaging (MRI) in the workup of neoplastic and non-neoplastic entities. While ultrasound (US) remains the first-line imaging modality for evaluating scrotal pathology, MRI may add valuable information, particularly when US findings are equivocal. The inherent soft tissue resolution characteristics of MRI, as well as the ability to detect subtle enhancement and provide wider field-of-view imaging, can prove useful in evaluating inconclusive US findings. The added value of MR in these instances is critical as it may have a significant impact on patient management.