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Imaging of Penile and Scrotal Emergencies1 Note: This copy is for your personal non-commercial use only. To order presentation-ready copies for distribution to your colleagues or clients, contact us at www.rsna.org/rsnarights. GENITOURINARY IMAGING 721 Imaging of Penile and Scrotal Emergencies1 Laura L. Avery, MD • Meir H. Scheinfeld, MD, PhD SA-CME See www.rsna .org/education Penile and scrotal emergencies are uncommon, but when they do occur, /search/RG urgent or emergent diagnosis and treatment are necessary. Emergent con- ditions of the male genitalia are primarily infectious, traumatic, or vascular. LEARNING Infectious conditions, such as epididymitis and epididymo-orchitis, are well OBJECTIVES evaluated at ultrasonography (US), and their key findings include heteroge- FOR TEST 2 neity and hyperemia. Pyocele and abscess may also be seen at US. Fournier After completing this gangrene is best evaluated at computed tomography, which depicts sub- journal-based SA- cutaneous gas. Vascular conditions, such as testicular torsion, infarction, CME activity, partic- ipants will be able to: penile Mondor disease, and priapism, are well evaluated at duplex Doppler ■■Discuss the role of US. The key imaging finding of testicular torsion and infarction is a lack of imaging in scrotal blood flow in the testicle or a portion of the testicle. Penile Mondor disease emergencies, such as testicular torsion, is characterized by a lack of flow to and noncompressibility of the superfi- testicular rupture, cial dorsal vein of the penis. Clinical examination and history are usually and Fournier gan- grene. adequate for diagnosis of priapism, but Doppler US may help confirm the ■■Describe the role diagnosis. Traumatic injuries of the penis and scrotum are initially imaged of imaging in penile with US, which depicts whether the penile corpora and testicular seminif- emergencies, such as fracture, pria- erous tubules are contained by the tunicae albuginea; herniation of con- pism, and Mondor tents and discontinuity of the tunica albuginea indicate rupture. In some disease. cases, magnetic resonance imaging may be performed because of its ability ■■Identify the color Doppler US find- to directly depict discontinuity of the tunica albuginea. Radiologists must ings of testicular closely collaborate with emergency physicians, surgeons, and urologists torsion, rupture, and low-flow pria- to quickly and efficiently diagnose or rule out emergent conditions of the pism, all of which male genitalia to facilitate prompt and appropriate treatment. require immediate treatment. Introduction Male patients may present to the emergency department with penile and scrotal complaints, and a wide range of pathologic conditions, including infection, ischemia, and trauma, may affect the male genital region. Infectious scrotal conditions include epididymitis, orchitis, testicular abscess, pyocele, and Fournier gangrene. Ischemic events may occur in the setting of torsion, whereas ischemia of the penis may occur in patients with priapism or venous thrombosis. Traumatic injuries to the genitals vary and include blunt, penetrating, and degloving injuries. Many of these condi- tions are a surgical urologic emergency, and timely treatment is crucial to maintain fertility, hormonal activity, and erectile function. Because of this time factor, prompt imaging workup and rapid recognition of pathologic conditions are essential for ap- propriate intervention. RadioGraphics 2013; 33:721–740 • Published online 10.1148/rg.333125158 • Content Codes: 1From the Division of Emergency Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, FHD-210, Boston, MA 02114 (L.L.A.); and Division of Emergency Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (M.H.S.). Presented as an education exhibit at the 2011 RSNA Annual Meeting. Received July 16, 2012; revision requested August 13 and received August 20; accepted November 6. For this journal-based SA-CME activity, the authors, editor, and reviewers have no relevant relationships to disclose. Address cor- respondence to L.L.A. (e-mail: [email protected]). ©RSNA, 2013 • radiographics.rsna.org 722 May-June 2013 radiographics.rsna.org In this article, conditions that affect the testicles and scrotum are presented and followed by those that affect the penis. Infectious, ischemic, and primarily blunt traumatic injuries to the scrotum and penis are covered, and radiologic images and clinical photographs are presented, when available, to offer a complete imaging and clinicopathologic picture. The anatomy of male genitalia and opti- mal imaging techniques are also discussed. The Scrotum Acute scrotal pain is common among children and adults who present to the emergency de- partment, often with vague symptoms and non- specific clinical findings. Frequently, imaging is required to further pinpoint the causes of scrotal pain. Generally, ultrasonography (US) is well tolerated and widely available, making it ideal for scrotal evaluation. High-resolution gray-scale and color Doppler US enable prompt and ac- curate differentiation among possible causes of scrotal pain without the use of ionizing radia- tion (1–3). Magnetic resonance (MR) imaging is limited by its relatively long examination time, lack of portability, and frequent unavailability; however, it may have a role in equivocal cases for problem solving (4). US is best performed with a linear high- frequency (7.5–12.0 MHz) transducer with the Figure 1. Scrotal anatomy. Illustration shows the main components of the testicles. The sem- penis placed in an anatomic position over the ab- iniferous tubules (S), in which sperm are pro- domen. A towel may be used to elevate the scro- duced, converge in the mediastinum testes as a tal sac. Images of each testicle and the epididymis network of tubules called the rete testes (RT). are obtained in transverse and sagittal planes, The efferent ductules (curved black arrow) with transverse images covering both testicles to bridge the testicle and epididymal head (EH), allow for comparison. Color Doppler US is nec- which leads to the epididymal body (EB) and essary to depict blood flow in patients with sus- tail (ET). Sperm eventually exit the scrotum pected torsion or hyperemia in the setting of in- through the vas deferens (straight black ar- fection. Appropriate color Doppler settings must row). The tunica albuginea (A) surrounds the testicle. The tunica vaginalis (arrowhead) has be used to optimize depiction of slow flow (5,6). two layers and also partially surrounds the tes- Because it is independent of the Doppler angle, ticle. The testicular (internal spermatic) artery power Doppler US is useful in imaging low-flow (white arrow) supplies the testicle. states, such as in the pediatric setting; however, power Doppler US also has increased sensitivity to motion (“flash”) artifacts (7). internal spermatic fascia; and tunica vaginalis, a two-layered serous membrane that derives from Anatomy and Imaging Appearance the process vaginalis of the peritoneum (9–12). The normal adult testis measures approximately The inner visceral layer of the tunica vaginalis en- 5 cm in length and 2–3 cm in its transverse di- velopes most of the testis and epididymis, and the mensions (Figs 1, 2) (8). Each testicle is located outer parietal layer lines the internal spermatic within a hemiscrotum that is separated from the fascia of the scrotal wall. Hydroceles or other contralateral compartment by a septum (9). The fluid collections (eg, blood or pus) may accumu- scrotal sac is made up of multiple layers, includ- late in the potential space between the layers of ing the skin; Dartos muscle and fascia; external the vaginalis. spermatic fascia; cremaster muscle and fascia; The visceral layer of the tunica vaginalis closely adheres to the tunica albuginea of the testis, a fi- brous capsule that covers the testis and appears as RG • Volume 33 Number 3 Avery and Scheinfeld 723 Figure 2. Normal testicular and epididymal anatomy. (a) Sagittal US image shows the tunica albuginea (ar- rows), which is seen as a thin echogenic line, enveloping the testicle, which has uniform intermediate echotex- ture. (b) Sagittal US image shows the epididymal head (calipers) superior to the testicle. (c) Sagittal US image of the scrotum shows the mediastinum testes (arrows) as a horizontal echogenic band running longitudinally through the testicle. The epididymal body (calipers) is seen posterior to the testicle. Scrotal Emergencies Epididymitis and Epididymo-orchitis.—Epididy- mitis and epididymo-orchitis are two of the most an echogenic rim surrounding the testis at US. It common causes of acute scrotal pain and, if left has low signal intensity at MR imaging, a result of untreated, may be complicated by abscess forma- its fibrous content (13). The tunica albuginea gives tion and testicular infarction. In general, acute rise to septa that extend deep into the testicle and cases of epididymitis and epididymo-orchitis are divide it into lobules. The posterior surface of the caused by retrograde bacterial infection from a tunica albuginea reflects into the interior of the lower urinary tract infection. In men who are testicle and forms an incomplete vertical septum sexually active and younger than 35 years old, called the mediastinum testis, which appears as an Neisseria gonorrhoeae and Chlamydia trachomatis echogenic band at US (8). are the most common pathogens, and in children In general, the testicular parenchyma has a and men who are older than 35 years old, urinary homogeneous echotexture
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