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Hamper Scrotal Emergencies LARS 2019 Sonography of Acute Scrotal Pain and Swelling-What not to Miss Ulrike M. Hamper, M.D.; M.B.A. Russell H. Morgan Department of Radiology and Radiological Sciences Johns Hopkins University School of Medicine Baltimore, Maryland Disclosures • Nothing to Disclose • No Conflict of Interest Acute Scrotal Pain/ Swelling • Management based on clinical assessment in many cases • Ultrasound is the most widely used and most versatile imaging examination • Nuclear Medicine Radionuclide study can be used to confirm testicular perfusion however are rarely performed anymore 1 Scrotal Ultrasound-Objectives • Scanning Technique / Anatomy • Causes of Acute Pain/ Swelling: * Epididymitis/Orchitis * Testicular Torsion * Torsion of Appendix testis/epididymis * Trauma * Masses Scrotal Ultrasound- Technique • High frequency, high resolution transducer (5-15 MHz), linear or curved • Supine position, testes elevated by towel • Longitudinal and transverse views • Oblique/coronal (“cleavage”) views (compare echogenicity of both testicles) Scrotal Ultrasound- Technique • Evaluate asymptomatic side first • Optimize settings for flow in normal testis • Then image symptomatic side • Image epididymis in body and tail • Confirm color Doppler US with pulsed Doppler 2 Testis Anatomy! • Ovoid gland • 3-5 cm length 2-3 cm AP 2-4 cm width • Medium level echogenicity Homogeneous echotexture Normal Testicles – “Cleavage View” 3 ! Epididymis - Anatomy! • Conglomerate of tubules • Carry sperm from testis to vas deferens - posterolateral • Head (globus major) 10-12 mm sup to testis • Body narrow posterolateral • Tail (globus minor) inferior to testis → vas deferens Epididymis - Anatomy! • Iso- or min " echogenicity with testicle • Appendix testis: Müllerian duct remnant, located between epididymis and testis • Appendix epididymis: Wolffian duct remnant- detached efferent duct- stalk like projection from epididymis • Only seen with hydrocele 4 Normal Epididymis Appendix Testis Vascular Supply- Anatomy • Testicular Artery (aorta) - supplies testicle → Capsular arteries → intratesticular → branches, low resistance flow • Deferential Artery (internal iliac artery) supplies vas deferens and epididymis, high resistance flow pattern 5 Vascular Supply- Anatomy • Cremasteric Artery (vesicle artery) supplies scrotal wall, muscles - high resistance • Venous Drainage Pampiniform plexus → testicular vein Left → left renal vein Right → IVC Arterial Supply Venous Drainage Normal Color Doppler US Symmetric perfusion Low resistance waveform 6 Side- to Side Comparison Symmetric echotexture and perfusion Causes of the “Acute Scrotum” • Epididymitis Epididymo-orchitis • Fournier’s Gangrene • Torsion • Trauma Epididymitis / Epididymo-orchitis • Most common cause of acute scrotum • 75% of acute intrascrotal inflammation • Retrograde spread of bacterial infection from bladder, prostate or sexually transmitted disease (STD) • Less common: mumps, syphilitic orchitis, caffeine or alcohol induced epididymo-orchitis 7 Epididymitis / Epididymo-orchitis: US Gray-Scale Findings • Thickened enlarged epididymis or heterogeneous echotexture • Reactive hydrocele • Skin thickening • Extension into testis (20%) - hypoechoic area, focal or diffuse Epididymo- Orchitis Enlarged and swollen epididymis and testicle, hydrocele Epididymitis / Epididymo-orchitis: US • CDUS blood flow to epididymis and testicle • Complication Occlusion of blood supply due to edema → ischemia → infarction → absent flow 8 Hypervascular right epididymis Normal left side Epididymo-Orchitis Hypervascular right testis Normal left testicle Epididymo-Orchitis Right Epididymitis and Orchitis Right Left Skin thickening, enlarged testicle, complex right hydrocele/septations Right 9 Epididymitis and Orchitis Enlarged, hypervascular right epididymis and testicle Normal Left testicle Tail and Body Epididymitis/Orchitis Enlarged, hypervascular epididymis Tail and Body Epididymitis/ Orchitis 10 Post Epididymo-Orchitis with Pyocele and T Testicular Infarction Intrascrotal/ T T Extratesticular Abscess in HIV Patient Peripherally increased vascularity Fournier’s Gangrene • Necrotizing fasciitis of perineum and genitalia • Described by Jean Fournier in 1883 • Rapidly progressive, lethal • Often seen in diabetic patients • US: gas in soft tissues, bright echogenic foci with shadowing • US positive before crepitus on physical examination 11 Fournier’s Gangrene Subtle air in scrotal wall Fournier’s Gangrene Extensive air in scrotal wall Fournier’s Gangrene Air in scrotal sac on plain x-ray and CT 12 Severe Scrotal Edema May mimic Fournier’s Severe Scrotal Edema Sagittal view Transverse view Testicular Torsion • Abnormal suspension of testis within scrotum • “Bell and Clapper” deformity = embryologic abnormality predisposes twisting of testicle around vascular pedicle → occluding vasculature 13 Testicular Torsion • More common in children/adolescents • Prompt diagnosis and repair !!! (Detorsion and orchipexy) • Salvage rate: 80-100% 5-6 hours 70% 6-12 hours 20% > 12 hours Testicular Torsion - Color Doppler US • Acute Absent flow to testicle nl flow contralateral testis • Chronic Absent intratesticular flow ↑ flow peritesticular tissues • Intermittent Reactive hyperemia hyperactive blood flow to testis and epididymis Testicular Torsion No flow on CDUS 14 Testicular Torsion At surgery: viable testicle, detorsion & orchipexy Testicular Torsion with Infarction Testicular Infarction Heterogeneous right testicle No flow on PDUS 15 Testicular Torsion with Infarction Right No flow left testicle Normal flow right testicle Testicular Torsion with Infarction Twisted spermatic cord without flow Testicular Torsion- Pitfalls • Incomplete torsion (360o or less) • Intermittent torsion • Torsion of testicular appendages 16 Intermittent Torsion • Symmetric testicular flow No flow left testicle after exercise Left Testicular Pain Gray-scale US of both testicles at 2:33 AM CDUS US of both testicles at 2:34 AM Right Left No flow left testicle 17 Power Doppler US of the left testicle at at 2:35 AM Left No flow left testicle Color Doppler US at 2:37 AM Left Right Minimal flow left testicle Doppler US 2:43 AM Restored flow to left testicle 18 CDUS at 3:13 AM Intermittent Torsion No flow left testicle Torsion of the Appendix Testis/ Epididymis • Mimics testicular torsion • Appendages may be enlarged or edematous • Reactive hydrocele, skin thickening, • Epididymis may be ⇑ normal or ⇑ testicular perfusion May infarct and calcify-”scrotal pearls” “Scrotal Pearls” Torsed Appendices Testis 19 Testicular Trauma • Ruptured testis - surgery • Salvage rate: 90% < 72 hours 45% > 72 hours • Contusion/hematocele Conservative Rx Testicular Trauma- US • US used to plan management • Focal echotexture abnormality (hemorrhage, infarction) • Discrete fracture plane • Disrupted vascular supply (CDUS) • Hematocele • Epididymitis/orchitis Shattered Testicle Disrupted testicular architecture 20 Fractured Testicle S/P Gunshot Wound Intratesticular air Fractured Testicle S/P Gunshot Wound Right Left Left Fractured right testicle Normal flow left testicle Gunshot Wound-Fractured Testis Air within right testicle and scrotal wall 21 Gunshot Wound-Fractured Testis Gunshot Wound-Intrascrotal Hematoma Normal Testes T T T Gunshot Wound Normal Testicles 22 Testicular Tumors • Unusual cause of acute scrotal pain/swelling • 1-2% of malignant neoplasms in men • Most common cancer in 25-35 year old • Symptoms: Painless or mildly painful testicular enlargement • Focal ischemia, hemorrhage or necrosis may cause pain Large Cell Lymphoma Diffusely enlarged left testicle with increased vascularity Large Cell Lymphoma Diffusely enlarged left testicle 23 Bilateral Lymphoma Hypoechoic, hypervascular mass left testicle Bilateral Lymphoma Hypoechoic, hypervascular masses right testicle Testicular Lymphoma-Adenopathy Aorto- Caval mass 24 Testicular Seminoma Hypoechoic, hypervascular left testicular mass Mixed Germ Cell Tumor Enlarged right testicle Normal left testicle with microlithiasis Mixed Germ Cell Tumor-Adenopathy 25 Multifocal Seminoma Multiple hypoechoic masses Scrotal Ultrasound: Conclusion • Complement to bimanual exam • Gray scale: highly accurate in detection of testicular abnormalities and differentiation of intra - vs extratesticular lesions Scrotal Ultrasound: Conclusion • Color Doppler US: physiologic information re scrotal perfusion • Greatest application: urgent diagnosis of torsion or trauma and differentiation from inflammatory diseases • Helps triage into medical (epididymitis/ orchitis) versus urgent surgical management (Fournier’s gangrene, torsion, trauma) 26 THANK YOU ! [email protected] 27.
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