The role of ultrasonography with colour Doppler in the acute scrotum

Transcription

1 The role of ultrasonography with colour Doppler in the acute scrotum Poster No.: C-1509 Congress: ECR 2016 Type: Educational Exhibit Authors: M. S. R. O. Faustino, A. L. Amado Costa, J. J. B. Leitão, I Távora ; Lisboa/PT, Lisbon/PT Keywords: Emergency, Ultrasound-Colour Doppler, Diagnostic procedure, Ischemia / Infarction, Infection DOI: /ecr2016/C-1509 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 17

2 Learning objectives To illustrate the imaging features of acute scrotal pathology detected by ultrasound and color Doppler. Emphasize the important role of ultrasound and color Doppler on the emergency setting, and its importance to obtain a rapid differencial diagnosis that distinguishes the need of emergent surgical treatment. Background Acute scrotum is clinically defined by the presence of unspecific local signs such as acute scrotal pain, edema and redness. The most common differential diagnosis include: testicular torsion, torsion of appendages and testicular infarction, acute epididymitis, acute orquitis and acute orquiepididymitis, testicular trauma, acute hydrocele, incarcerated scrotal hernias and Fournier's gangrene. Acute scrotum requires a quick diagnosis, because testicular torsion requires immediate surgery and the probability of testicular salvage decreases as the duration of torsion increases. The ultrasound and Doppler sonography are considered the methods of choice in the diagnosis of scrotal diseases. Scanning is performed with a high frequency (8-15 MHz) transducer in sequential sagital and transverse planes. Color Doppler examination is performed optimized to low-velocity flow. Findings and procedure details In this exhibit we present a pictorial review of the US findings regarding acute scrotum pathology based on a retrospective review of cases in our department. TESTICULAR TORSION Page 2 of 17

3 Clinical manifestations can be unilateral scrotal swelling and pain; It is most common in a child or teenager; The salvage rate is nearly 100% if surgery is performed within the first 6 hours after the torsion (decreases to only 20% after 12 hours); In complete torsion, the testicle has no detectable blood flow; An infarcted testicle will initially maintain a normal echogenicity and increase in size, later becoming heterogenous with areas of hypoechogenicity. Fig. 1: Torsion of the left testicle A - Right testicle with normal blood flow B - Left testicle with incresed size and no detectable blood flow on Doppler evaluation Fig. 2: A - Twisted cord B - Left testicle with incresed size and no detectable blood flow on Doppler evaluation SCROTAL TRAUMA Page 3 of 17

4 The purpose of imaging in trauma is to detect points of discontinuity of the tunica albuginea which indicate testicular rupture; Hematocele and intratesticular hematoma are major indicators of rupture; Rupture is a surgical emergency (If surgical treatment is done within 72h 90% of ruptured testes can be salvaged) Fig. 3: Testicular rupture There are multiple points of discontinuity of the tunica albuginea (arrows) and resulting hematocele (*). Theres also small intratesticular hematomas (arrowhead) Fig. 4: Testicular blunt trauma with resulting testicular hematoma (*). In the image there is a well delimited hipoechoic intratesticular area with no blood flow on Doppler evaluation coresponding to testicular hmatoma. EPIDIDYMITIS AND/OR ORCHITIS Page 4 of 17

5 Epididymitis is the inflammation/ infection of the epididymis. Orchitis is the inflamation/ infection of the testis and is often associated with epididymitis (in one fifth of cases); isolated orchitis being less common; Onset of pain and swelling is typically slower than in testicular torsion; it's usually associated with erythema, a feature that is not usually seen in torsion. US features include an enlarged hypoechoic epididymis and or testicle due to edema and hyperaemia on the Doppler evaluation. A reactive hydrocoele and thickening of the scrotal wall may also be seen. Fig. 5: Orchiepididymitis Enlarged and hyperemic epididymis (*). There is involvement of the teste which is heterogeneous and hyperemic (*). ABSCESS AND PYOCELE Pyocele and abscess can complicate advanced or untreated epididymoorchitis. These appear as complex scrotal fluid collections with associated systemic symptoms. Page 5 of 17

6 Neisseria gonorrhoeae, Clamydia trachomatis, or Escherichia coli are common etiologies. Fig. 6: The epididymis is enlarged, heterogeneous and hypoechoic (*). The testicle is also involved - a small, well delimitated and hipoechoic area is seen in the upper pole testicular abscess (arrow). FOURNIER GANGRENE Consists polymicrobial necrotizing fasciitis of the scrotum that can extend to the lower abdominal wall; Fournier gangrene is a life threatening emergency due to infection of the perineal skin with gas forming bacteria. It requires urgent aggressive surgical debridement. US findings include thickening and stratification of the scrotal wall; Testes and epididymis usually have normal features; Scrotal wall presents with hyperemia; The pokets of gas appears as numerous, discrete, hyperechoic foci with reverberation artefacts. Page 6 of 17

7 Fig. 7: Fournier gangrene Scrotal wall thickening with stratified appearance (line). There's also parietal gas which appear as multiples small hiperechogenic foci with reverberation artifacts (*) Page 7 of 17

8 Fig. 8: Fournier gangrene Multiplanar reconstructed TC images illustrating the necrotizing fasciitis process (*) with presence of gas along the scrotal wall (arrow). HYDROCELE Hydrocele consists in the abnormal serous fluid collection within the layers of the tunicas vaginalis; Is the most common form of testicular enlargement; It usually presents with progressive scrotal mass with/ swelling, with no pain associted. US findings consist in a simple fluid collection surrounding the testis; It is avascular on Doppler evaluation; It may contain septations and calcifications. Page 8 of 17

9 Fig. 9: Large hidrocele (*) - anechoic fluid collection Fig. 10: Large left hidrocele (*) and moderate right hidrocele (*) in a patient with ascites. TESTICULAR TUMOUR 10% of patients with testicular tumour may present with acute scrotal pain due to haemorrage and necrosis; The peak incidence of testicular cancer occurs between the ages of 25 to 35 years; Page 9 of 17

10 The testis are occasionally the site of metastatic lesions - 6% of all tumours. Fig. 11: Testicular Tumour Hypoechoic, well-defined and homogeneous intratesticular solid mass in a patient who also presented testicular microlithiasis - it was a seminoma. Fig. 12: Testicular tumour in a patient with a palpable mass the ultrasonography reveals multiple nodular hipoechogenic nodules with internal blood flow on Doppler evaluation. The histology demostrated hat they were several lung tumour metastasis. Images for this section: Page 10 of 17

11 Fig. 1: Torsion of the left testicle A - Right testicle with normal blood flow B - Left testicle with incresed size and no detectable blood flow on Doppler evaluation Fig. 2: A - Twisted cord B - Left testicle with incresed size and no detectable blood flow on Doppler evaluation Fig. 3: Testicular rupture There are multiple points of discontinuity of the tunica albuginea (arrows) and resulting hematocele (*). Theres also small intratesticular hematomas (arrowhead) Page 11 of 17

12 Fig. 4: Testicular blunt trauma with resulting testicular hematoma (*). In the image there is a well delimited hipoechoic intratesticular area with no blood flow on Doppler evaluation coresponding to testicular hmatoma. Fig. 5: Orchiepididymitis Enlarged and hyperemic epididymis (*). There is involvement of the teste which is heterogeneous and hyperemic (*). Page 12 of 17

13 Fig. 6: The epididymis is enlarged, heterogeneous and hypoechoic (*). The testicle is also involved - a small, well delimitated and hipoechoic area is seen in the upper pole - testicular abscess (arrow). Page 13 of 17

14 Fig. 7: Fournier gangrene Scrotal wall thickening with stratified appearance (line). There's also parietal gas which appear as multiples small hiperechogenic foci with reverberation artifacts (*) Page 14 of 17

15 Fig. 8: Fournier gangrene Multiplanar reconstructed TC images illustrating the necrotizing fasciitis process (*) with presence of gas along the scrotal wall (arrow). Fig. 9: Large hidrocele (*) - anechoic fluid collection Page 15 of 17

16 Fig. 10: Large left hidrocele (*) and moderate right hidrocele (*) in a patient with ascites. Fig. 11: Testicular Tumour Hypoechoic, well-defined and homogeneous intratesticular solid mass in a patient who also presented testicular microlithiasis - it was a seminoma. Fig. 12: Testicular tumour in a patient with a palpable mass the ultrasonography reveals multiple nodular hipoechogenic nodules with internal blood flow on Doppler evaluation. The histology demostrated hat they were several lung tumour metastasis. Page 16 of 17

17 Conclusion Several causes of the acute scrotum represent surgical emergencies. Sonography with color and power Doppler are the methods of choice in the imaging assessment of the acute scrotum allowing a rapid diagnosis and treatment. Personal information References Rumack CM, Wilson SR, Charboneau JW. Diagnóstico por ecografía. 2a ed. Reimp ed. Madrid: Marbán Bhatt S, Dogra VS. Role of US in testicular and scrotal trauma. Radiographics 2008; 28: Dogra VS, Gottlieb RH, Oka M, Rubens DJ. Sonography of the scrotum. Radiology 2003; 227:18-36 Horstman WG, Middleton WD, Melson GL, Siegel BA. Color Doppler US of the scrotum. Radiographics 1991; 11: Pavlica P, Barozzi L. Imaging of the acute scrotum. Eur Radiol 2001; 11: Deurdulian C, Mittelstaedt CA, Chong WK, Fielding JR. US of acute scrotal trauma: optimal technique, imaging findings, and management. Radiographics 2007; 27: Page 17 of 17