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)
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