Scrotal Sonographic Findings in Equestrians

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1 Article Scrotal Sonographic Findings in Equestrians Ahmet Tuncay Turgut, MD, Ugur Kosar, MD, Pinar Kosar, MD, Ayhan Karabulut, MD Objective. Sports-related injuries are among the major causes of testicular trauma. In this study, we aimed to determine sonographically whether chronic urogenital trauma during horse riding increases the prevalence of scrotal sonographic abnormalities. To our knowledge, there are no studies in the literature that have focused on this topic. Methods. Group 1 included 26 male riders with a mean age ± SD of 31 ± 2.9 (range, 26 38) years and with a mean riding experience of 5 ± 2.6 (range, 1 10) years, whereas group 2 included 26 healthy nonriding men with a mean age of 31 ± 3.2 (range, 26 41) years. After the clinical evaluation, all patients underwent scrotal sonographic examination. Results. The prevalence of overall scrotal sonographic abnormalities in group 1 was significantly higher than that in group 2 (77% versus 38%; P <.05). The detected sonographic findings in group 1 were varicocele (46%), hydrocele (19%), testicular cyst (4%), epididymal cyst (35%), testicular calcification (19%), epididymal calcification (8%), scrotal calculus (8%), and inhomogeneity of parenchymal echo texture (4%). However, only varicocele (19%), epididymal cyst (19%), testicular calcification (12%), and scrotal calculus (4%) were detected in group 2. Between the 2 groups, the difference was significant for varicocele prevalence (P <.05) and marginally significant for hydrocele prevalence (P =.051). Conclusions. We recommend scrotal sonographic examination of equestrians when they have a palpable mass or related symptoms, the etiology of which was found in our study to be closely related to horse riding. Key words: athletic injuries; scrotum; sonography. Received February 10, 2005, from the Departments of Radiology (A.T.T., U.K., P.K.) and Urology (A.K.), Ankara Research and Training Hospital, The Ministry of Health, Ankara, Turkey. Revision requested March 4, Revised manuscript accepted for publication April 6, Address correspondence to Ahmet Tuncay Turgut, MD, Kibris Caddesi, Deniz Apartmani 9/5 B- Blok, TR Kurtulus, Ankara, Turkey. ahmettuncayturgut@yahoo.com Horse riding, which has been popular worldwide since ancient times either as a recreational or competitive activity or for working purposes, has been considered one of the most dangerous sports. 1 Equestrian injuries constitute about 4.3% of all sports-related injuries, half of which are due to falling or crushing, whereas 4% occur while horse riding but not falling. The importance of horse riding related injuries comes from the fact that they have considerable severity. 2 4 Wearing hats with a retention strap and use of body protectors have been widely recommended to avoid serious injuries related to horse riding. 1,2,4 6 Although head injuries make up 18% to 31% of the total, major pelvic injuries have also been reported but not as commonly. 2,4 6 McAleer et al 7 reported that about 7% of testicular injuries in the pediatric population in the forms of hematoma, contusion, fracture, and avulsion occurring during recreational or team sports activities are due to equestrian sports. Classically, athletic and saddle injuries are among the causes of testicular trauma, 2005 by the American Institute of Ultrasound in Medicine J Ultrasound Med 2005; 24: /05/$3.50

2 Scrotal Sonographic Findings in Equestrians and more than half of testicular ruptures occur because of trauma to the groin during sporting activity. 8 Apart from the aforementioned acute traumatic injuries, the possibility of chronic urogenital trauma should be considered because the groin and the perineal region are in close contact with the horse through the saddle, and chronic repetitive trauma may be a serious problem, especially for jumping riders. In this sense, scrotal microtrauma during equestrian activities may be causative for pathologic changes, although, to our knowledge, the topic has not been reported before in the English literature. Sonography performed with a high-resolution transducer is the suggested method for detection of scrotal pathologic changes, and its role in the diagnosis of scrotal trauma is also expanding. 8 In addition, it allows detection of the exact location of the injury within the scrotum. 9 By sonographic examination, the prevalence of pathologic changes, the most common of which are testicular and epididymal cysts, has been reported to be 29% for healthy men and 40% for infertile men. 10,11 In this study, scrotal sonographic examination with a high-resolution transducer was performed to detect whether equestrians have a higher prevalence of scrotal abnormalities in comparison with non horse riders. Materials and Methods From January through June 2003, 26 male amateur equestrians (mean age ± SD, 31 ± 2.9 years; range, years) with experience varying between 1 and 10 years (mean, 5 ± 2.6 years) who reported horse riding at least 2 hours per day, 6 days per week volunteered to participate in the study (group 1). In addition, 26 healthy non horse-riding men (mean age, 31 ± 3.2 years; age range, years) were included as a control group (group 2). By comparison, the ages of the equestrians and the control subjects were not statistically different from each other (P >.05, Mann-Whitney U test). This study was approved by our hospital Training Board, and all participants gave informed consent. Clinical evaluation of all subjects in the Urology Clinic for detection of a history of scrotal pain, discomfort, trauma, or inflammation or for any cutaneous lesion, tenderness, swelling, or mass and sonographic examination of the scrotum were performed by the same urologist and radiologist, respectively (A.K. and A.T.T). For sonographic examination, a color Doppler sonographic scanner (SDU-2200; Shimadzu Corporation, Kyoto, Japan) equipped with a 5- to 10-MHz linear transducer was used. During each examination, the size of each testis was calculated by the sonography machine with the ellipsoid formula for the detection of testicular volume by means of the dimensions measured in transverse and longitudinal planes in addition to evaluation of the parenchymal echo texture. In addition, scrotal abnormalities such as scrotal calculi, hydrocele, testicular and epididymal cysts, and calcifications as well as inhomogeneity of the echo texture of the testis and epididymis were searched for. At the same session, color Doppler sonographic examination was performed in addition to measuring the diameters of the veins of the plexus pampiniformis in gray scale for detection of varicocele. During the examination for varicocele, the patient was in the supine position, and the chest and abdomen were elevated about 15. The classic criteria for varicocele, which are diameters of the veins of plexus pampiniformis exceeding 2 mm at rest and a reversed flow duration of more than 1 second during the Valsalva maneuver on spectral Doppler analysis, were used to decide whether there was varicocele. In each vessel with reflux, the means of 3 consecutive measurements for vein diameter and duration of the reflux were calculated. The 2 groups were compared for the prevalence of scrotal sonographic findings by means of the Pearson χ 2 test, and the Mann-Whitney U test was used for comparison of testicular sizes. In addition, the frequencies of hydrocele, varicocele, testicular calcifications, and epididymal cysts in each group were compared by the Fisher exact test. Any association between the frequency of clinical findings and total riding experience in years was tested by means of the Fisher exact test again. Statistical significance was determined at P <.05. Results Half the participants in the horse-riding group (50% [13 of 26]) had symptoms such as scrotal pain or physical examination findings related to the urogenital region such as erythema or swelling with inspection or tenderness or a mass 912 J Ultrasound Med 2005; 24:

3 Turgut et al with palpation, whereas none of the subjects in group 2 had similar symptoms or physical examination findings. A statistically significant difference was calculated between groups 1 and 2 in terms of the presence of clinical findings. On sonographic examination, no statistically significant difference in testicular volume was observed between group 1 (right testis: mean, 15.7 cm 3 ; range, cm 3 ; left testis: mean, 15.2 cm 3 ; range, cm 3 ) and group 2 (right testis: mean, 15.9 cm 3 ; range, cm 3 ; left testis: mean, 15.2 cm 3 ; range, cm 3 ). A detailed analysis of scrotal sonographic findings is depicted in Table 1. Accordingly, varicocele was the most common sonographic finding with prevalence rates of 46% (12 of 26) and 19% (5 of 26) for groups 1 and 2, respectively (Figures 1 and 2). All these subjects had left-sided varicocele except 1 rider, who had a bilateral varicocele. Epididymal cysts (Figure 3) were seen in 35% (9 of 26) of equestrians and 19% (5 of 26) of the non horse-riding men. Sixteen epididymal cysts were detected in the equestrians, whereas the nonriding subjects had only 6. Hydrocele (Figure 4) was observed in 19% (5 of 26) of riders in group 1, 3 of which were bilateral, and none of the subjects in group 2. As for testicular calcifications (Figure 5), the prevalence was 19% (5 of 26) for the equestrians and 11% (3 of 26) for the non horse-riding men, whereas 13 calcifications in group 1 and 5 calcifications in group 2 were detected. Scrotal calcifications (Figure 6) were observed in 8% (2 of 26) of the subjects in group 1 and 4% (1 of 26) of the subjects in group 2; each subject had a single calcification. The epididymal calcifications (Figure 7) were seen in 7% (2 of 26) of the riders, all of whom had a single calcification, whereas none were seen in group 2. Again, only 1 rider had a solitary testicular cyst (4%), whereas no subject in group 2 had any. Similarly, inhomogeneity of the testicular parenchymal echo texture was observed only in group 1 (4% [1 of 26]). A statistically significant difference was detected between the equestrians and nonriders for the prevalence values of overall scrotal sonographic abnormalities, which were calculated as 77% (20 of 26) for the former and 38% (10 of 26) for the latter (Table 2) (P =.005; P <.05, Pearson χ 2 test). A statistically significant difference was observed between the 2 groups for the presence of varicocele (P <.05, Pearson χ 2 test). Conversely, the difference between the 2 groups Table 1. Sonographic Findings in Equestrians and Nonriders Equestrians Nonriders Sonographic Finding (n = 26) (n = 26) Varicocele, n (%) 12 (46) 5 (19) Epididymal cyst, n (%) 9 (35) 5 (19) Hydrocele, n (%) 5 (19) 0 (0) Testicular calcification, n (%) 5 (19) 3 (12) Scrotal calculus, n (%) 2 (8) 1 (4) Epididymal calcification, n (%) 2 (8) 0 (0) Testicular cyst, n (%) 1 (4) 0 (0) Testicular parenchymal inhomogeneity, n (%) 1 (4) 0 (0) for hydrocele prevalence was found to be marginally significant (P =.051, Fisher exact test). When the equestrians were further subdivided as those with riding experience of 6 years or less and those with 7 years or more, no statistically significant association was found between riding experience and the radiologic findings. Discussion Although sports-related acute urogenital injuries have been reported before, the effects of chronic urogenital trauma due to such activities have not received much focus. In our study, the prevalence of scrotal sonographic findings was 77% for equestrians, which was significantly higher than that of non horse-riding men. In a similar study on the sonographic findings in the scrotums of extreme mountain bikers, Frauscher et al 12 reported higher prevalence, which was 94%. In their study, only 16% of the asymptomatic nonbikers had sonographic find- Figure 1. Increased calibration of the veins of the plexus pampiniformis (arrows) in a 33-year-old equestrian with left varicocele. J Ultrasound Med 2005; 24:

4 Scrotal Sonographic Findings in Equestrians Figure 2. Color and spectral Doppler findings showing reversed flow during the Valsalva maneuver in a 26-year-old equestrian with left varicocele. ings, which was lower than the 38% that we calculated as the prevalence of scrotal sonographic findings in a non horse-riding population. The above-mentioned prevalence values for the equestrians and the bikers seem to be quite higher than that of the asymptomatic young population, which has been reported to be 29% in a study by Leung et al. 10 In our study, half the equestrians had clinical findings, whereas Frauscher et al 12 reported that 46% of the bikers had similar clinical findings. Varicocele, with a prevalence rate of 46% being significantly higher than 19% of non horse-riding men, was the most common sonographic finding that we observed among the equestrians. Varicocele has been reported to have a prevalence of 4% to 23% in the general population, 13,14 whereas the prevalence is higher in the infertile and subfertile populations, being 21% to 39% Figure 3. Epididymal cyst with a diameter of 10 mm located on the head of the left epididymis (asterisk) in a 32-year-old equestrian. Frauscher et al 12 reported varicocele in only 11% of bikers, which is much lower than that of the equestrians included in our study. In a study by Di Luigi et al 16 of another group of sportsmen, athletes, the varicocele prevalence was calculated as 29%, which was higher than that of the general population. Although nutcracker phenomenon, referring to the internal compression of the venous drainage of the testis, has been accepted as responsible for varicocele formation, 17 to our knowledge, no hypothesis has been proposed yet concerning any external pressure effect that may be possible for horse-riding activities. Despite the fact that no correlation has been reported yet between scrotal trauma or microtrauma and varicocele formation, chronic contact with the saddle may be a contributory factor for such an effect, which may be responsible for the pathogenesis of varicocele. In light of the fact that only half of these were detected by sonographic examination alone, whereas the rest were additionally palpable by physical examination, we think it is worth emphasizing the necessity of sonographic examinations in the horse-riding male population. Trauma, which has been reported to be one of the major causes of acquired hydrocele, 8 has been considered responsible in as many as 25% to 50% of cases in general. 18 Among the sonographic findings reported in the literature to be secondary to scrotal trauma, hydrocele was the most common in our study. In group 1, its prevalence was 19%, whereas none of the subjects in group 2 were shown sonographically to have an abnormal amount of fluid in the tunica vaginalis, which meant only a marginally significant statis- Figure 4. Right hydrocele (asterisk) in a 33-year-old equestrian. 914 J Ultrasound Med 2005; 24:

5 Turgut et al Figure 5. Two tiny calcifications (arrow) on the right testis of a 31-year-old equestrian. tical difference between the 2 groups. In the aforementioned study on bikers, 12 a moderately higher prevalence of hydrocele was reported, which was 28%. Scrotal calcifications, either testicular or extratesticular, have numerous etiologies, including trauma, which has been emphasized by different authors. 8,18,19 In our study, testicular, epididymal, and scrotal calcifications were observed in 19%, 7%, and 7% of equestrians, respectively. However, among the nonriders, only 12% had testicular calcifications, and 3% had scrotoliths, whereas no epididymal calcification was observed. Frauscher et al 12 reported much higher prevalence values of calcifications among bikers in their study, which were 32%, 40%, and 81% for calcifications of testicular, epididymal, and tunical origin, respectively, and thought that trauma was the major cause. We think that the slight difference between the equestrians and nonriders for the presence of calcifications, although statistically insignificant, might be closely related to the residual effects of testicular trauma during horse riding, a theory that needs to be supported by further research comprising larger study groups. A testicular cyst and heterogeneous testicular parenchymal echo texture were 2 other findings, each of which was detected in only 1 horse rider and was not observed among nonriders. Also, a higher prevalence for epididymal cysts was present in group 1 (35%) in comparison with group 2 (19%), although no significant difference was calculated. Simple cysts of the testis and epididymis are known to be sequelae of prior episodes of repetitive scrotal trauma. 8,12,18 In addition, alteration in the testicular echogenicity may be a sign of testicular injury in the form of hemorrhage or infarction occurring secondary to urogenital trauma. 8,18 Parallel to the data in the literature, we think that cystic lesions of the scrotal contents and the inhomogeneity of the testicular parenchyma are attributable to the trauma. It is evident that the palpable veins of the plexus pampiniformis and other less frequent scrotal masses such as epididymal cysts and scrotal calcifications might be worrisome for equestrians if they are incidentally detected by these men themselves because they might raise the suggestion of a testicular tumor. In addition, awareness of scrotal swelling might again suggest the possibility of a tumor, which is one of the etiologic factors that has been proved to be responsible for hydrocele. Finally, we can summarize our findings as a significantly higher prevalence of overall scrotal sonographic abnormalities in equestrians in Figure 6. Group of scrotal calculi located on the tail of the left epididymis (arrows) in a 28-year-old equestrian. Figure 7. Tiny calcification seen on the head of the left epididymis (arrow) in a 29-year-old equestrian. J Ultrasound Med 2005; 24:

6 Scrotal Sonographic Findings in Equestrians Table 2. Comparison of Prevalence of Sonographic Findings in Equestrians and Nonriders Sonographic Findings, n (%) Group Positive Negative Equestrians 20 (77) 6 (23) Nonriders 10 (38) 16 (62) A statistically significant difference was calculated between the 2 groups (P <.05, Pearson χ 2 test). References 1. Whitlock MR, Whitlock J, Johnston B. Equestrian injuries: a comparison of professional and amateur injuries in Berkshire. Br J Sports Med 1987; 21: Lloyd RG. Riding and other equestrian injuries: considerable severity. Br J Sports Med 1987; 21: Edixhoven P, Sinha SC, Dandy DJ. Horse injuries. Injury 1981; 12: comparison with nonriders, including the statistically significant difference of varicocele prevalence and the marginally significant difference of hydrocele prevalence. When compared with the study in the English literature by Frauscher et al 12 on bikers to focus on the chronic traumatic effect of sports activities on the scrotum, the relative paucity of sonographic findings that can be attributed with certainty to a trauma effect in equestrians can be explained speculatively by the relatively wider contact surface between the saddle on the horse and the scrotal region, which causes distribution over a wider area of possible force applied to the scrotum. However, we could not exactly explain the excess number of varicocele cases in the equestrian population with known mechanisms of varicocele formation. Therefore, only a minor traumatic effect of horse riding on the scrotum can be mentioned, but the possibility of the effect of trauma on the etiopathogenesis of varicocele formation should be kept in mind. Nevertheless, it is clear that further studies with larger numbers of subjects are needed to determine the mechanism of varicocele formation in equestrians, whether it depends on trauma or some other cause that has not been shown yet and that was beyond the scope of this study, performed with a limited number of cases. In conclusion, we strongly recommend sonographic examination of equestrians who have a palpable mass or related symptoms, the etiology of which was found in our study to be closely related to horse riding. Furthermore, additional safety measures such as frequent rests during riding or padding of the rider s shorts to prevent injury should be considered, although the necessity does not seem as strict for bikers. 4. Whitlock MR. Injuries to riders in the cross country phase of eventing: the importance of protective equipment. Br J Sports Med 1999; 33: O Farrell DA, Irshad F, Thorns BS, McElwain JP. Major pelvic injuries in equestrian sports. Br J Sports Med 1997; 31: Thompson JM, Von Hollen B. Causes of horse-related injuries in a rural western community. Can Fam Physician 1996; 42: McAleer IM, Kaplan GW, LoSasso BE. Renal and testis injuries in team sports. J Urol 2002; 168: Dogra VS, Gottlieb RH, Oka M, Rubens DJ. Sonography of the scrotum. Radiology 2003; 227: Black JAR, Patel A. Sonography of the abnormal extratesticular space. AJR Am J Roentgenol 1996; 167: Leung ML, Gooding GAW, Williams RD. High-resolution sonography of scrotal contents in asymptomatic subjects. AJR Am J Roentgenol 1984; 143: Nashan D, Behre HM, Grunert JH, Nieschlag E. Diagnostic value of scrotal sonography in infertile men: report on 658 cases. Andrologia 1990; 22: Frauscher F, Klauser A, Stenzl A, Helweg G, Amort B, Nedden DZ. US findings in the scrotum of extreme mountain bikers. Radiology 2001; 219: Meacham RB, Townsend RR, Rademacher D, Drose JA. The incidence of varicoceles in the general population when evaluated by physical examination, gray scale sonography, and color Doppler sonography. J Urol 1994; 151: J Ultrasound Med 2005; 24:

7 Turgut et al 14. Di Luigi L, Gentile V, Pigozzi F, Parisi A, Giannetti D, Romanelli F. Physical activity as a possible aggravating factor for the athletes with varicocele: impact on the semen profile. Hum Reprod 2001; 16: Karakoc E, Kiris A, Orhan I, Bozgeyik Z, Kanbay M, Ogur E. Incidence and importance of reflux in testicular veins of healthy men evaluated with color Doppler sonography. J Clin Ultrasound 2002; 30: Di Luigi L, Romanelli F, Pigozzi F, et al. Role of sport medicine in andrological prevention. Med Sport 1994; 47: Fretz PC, Sandlow JI. Varicocele: current concepts in pathophysiology, diagnosis, and treatment. Urol Clin North Am 2002; 29: Rickards D, Jones S. The scrotum, testis, and penis. In: Sutton D (ed). Textbook of Radiology and Imaging. 6th ed. New York, NY: Churchill Livingstone; 1998: Gersovich EO. High-resolution ultrasonography in the diagnosis of scrotal pathology, I: normal scrotum and benign disease. J Clin Ultrasound 1993; 21: J Ultrasound Med 2005; 24: