Ultrasound Emergencies of the Male Pelvis

Conceptos para la identificación y abordaje de la gangrena de Fournier

Introducción. La gangrena de Fournier es una fasciitis necrosante fulminante y progresiva, de origen infeccioso sinérgico polimicrobiano, que afecta las regiones perianal, perineal, genital y abdominal. Su incidencia es mayor en hombres, la edad promedio de presentación reportada está en los 54,7 ± 15,6 años, su mortalidad es del 3-67 %, aunque hay estudios que informan una mortalidad en hombres del 7,5 % y en las mujeres del 12,8 %. Métodos. Se hizo una revisión de la literatura en las bases de datos y fuentes de información PubMed, Scielo y Google Scholar, publicados entre 1950 y 2018, utilizando términos como "fournier gangrene", "fasciitis, necrotizing”, “wound infection”, "therapy"[subheading] y “GRADE approach". Se realizó una segunda revisión para artículos latinoamericanos en español hasta 2020 usando las mismas fuentes y palabras claves. Resultados. Se seleccionaron artículos que reportaron definiciones, datos históricos, actualizaciones en diagnóstico y terapéutica para hacer una revisión actualizada. Para el uso de las imágenes se solicitó consentimiento informado. Conclusión. La gangrena de Fournier continúa siendo una emergencia quirúrgica potencialmente letal. Gracias a las investigaciones realizadas se ha avanzado en su tratamiento, mejorando los resultados. Es importante analizar los factores de riesgo en cada paciente y su etiología para establecer el tratamiento más adecuado.

ACR Appropriateness Criteria® Newly Diagnosed Palpable Scrotal Abnormality

Palpable scrotal abnormalities are caused by a variety of disorders, ranging from indolent benign conditions to aggressive tumors, and infectious and vascular processes. In these patients the diagnostic workup typically begins with a complete clinical, history, and physical examinations, including analysis of risk factors. If imaging is required, ultrasound examination is the diagnostic modality of choice. In few select patients with very large scrotal masses, MRI may be appropriate. However, the use of gadolinium-based contrast should be evaluated critically depending on specific patient factors. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Novel prognostic grayscale ultrasonographic findings in the testis from a comprehensive analysis of pediatric patients with testicular torsion

INTRODUCTION

Although grayscale and Doppler ultrasound (US) findings of testicular torsion (TT) have previously been described in the literature, other US findings may provide more prognostic information to families.

OBJECTIVE

The authors hypothesized that a comprehensive analysis of US findings of TT that focused on time-dependent changes would lead to additional ultrasonographic morphologic findings and clinically relevant prognostic information.

STUDY DESIGN

The authors reviewed the records of pediatric patients with acute TT from 2010 to 2017. The sizes and parenchymal characteristics of the torsed and contralateral testes on US were analyzed in relation to the time duration from the onset of scrotal pain to the time of surgery (0-6 h, 6-12 h, 12-24 h, 24-48 h, and >48 h), torsion degree, and clinical outcomes of the testes.

RESULTS

Patient demographics, time intervals, and US measurements of the torsed and contralateral testes showed significant differences with respect to testicular viability (Summary Table). The mean volume ratios of torsed to contralateral testis showed significant differences between the 0-6 h and the 12-24 h time groups as well as the 6-12 h and the 12-24 h time groups (P = 0.003 and P = 0.035, respectively), as well as significant differences between the viable and non-viable testes (P = 0.005). Regarding testicular heterogeneity, two novel grayscale sonographic findings were noted: (1) multiple hypoechoic lines that were termed 'testicular fragmentation' and (2) hyperechoic patches that were termed 'testicular patching'. The presence of these two findings were significantly increased as TT time duration increased (P < 0.001), and these findings were significantly associated with testicular non-viability (P < 0.001). Torsion degree was also noted to be significantly higher in the non-viable testes (P < 0.001). Presence of hydrocele or scrotal edema also showed significant differences between the TT time groups (P < 0.001).

DISCUSSION

The results of this study demonstrated ultrasonographic findings related to time dependent changes in TT and provided prognostic information regarding testicular viability.

CONCLUSIONS

Specific US grayscale findings in torsed testes (testicular fragmentation and testicular patching) were identified that provide prognostic information regarding time duration of testicular torsion and testicular viability. Testicular fragmentation and testicular patching significantly increased as TT time increased, with increasing risk for testicular non-viability.

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.

Scrotal Ultrasound

Ultrasound is the imaging modality of choice to evaluate the scrotum because of its high resolution, Doppler capabilities, availability, and lack of ionizing radiation. Acute urologic emergencies diagnosed with ultrasound include testicular torsion, testicular rupture, and Fournier gangrene. The radiologist's knowledge of sonographic features of vascular, infectious, traumatic, and benign and malignant processes that occur in the scrotum coupled with the patient's presenting symptoms, age, and physical examination allows for the correct diagnosis of a wide spectrum of scrotal pathology.