Testicular ultrasound in acute scrotal pain - beyond testicular torsion

Transcription

1 Testicular ultrasound in acute scrotal pain - beyond testicular torsion Poster No.: C-1284 Congress: ECR 2015 Type: Educational Exhibit Authors: I. Rolla, M. Nogueira, M. J. Aguiar, D. S. Garrido, J. A. Machado; Matosinhos/PT Keywords: Education and training, Education, Diagnostic procedure, Ultrasound-Colour Doppler, Ultrasound, Genital / Reproductive system female DOI: /ecr2015/C-1284 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 21

2 Learning objectives To acknowledge ultrasound findings suggestive of testicular torsion. To identify alternative causes of acute scrotal pain in emergency department, other than testicular torsion. To recognize findings on ultrasound indicating these alternative causes, such as infection, abscess, tumor, hydrocele, varicocele. To characterize incidental findings on testicular ultrasound, such as cysts and calcifications. Background Ultrasound is the most used imaging technique when evaluating acute scrotal pain in the emergency department. The most common causes of acute scrotal pain are torsion of the spermatic cord and acute epididymitis / epididymo-orchitis [1]. Although main concern is frequently about testicular torsion, which demands early identification and adequate management, other alternative causes must be considered. Differential diagnosis of scrotal pain include epididymitis or epididymo-orchitis, abscess, hydrocele, varicocele, neoplasm, among others. Incidental findings, such as cysts or calcifications, are not infrequent and should be accordingly characterized. Findings and procedure details Ultrasound plays an important role in the evaluation of acute scrotal pain, mostly to detect or exclude signs of testicular torsion. In fact, testicular torsion is an important cause of acute scrotal pain, mainly in prepubertal males. [1] Sonographic findings (fig. 1) include an enlarged testicle, which is hypoechoic compared with the contralateral side, heterogeneous (later finding), with absent or significantly decreased blood flow, often with reactive hydrocele and scrotal skin thickening. [1-3] Color Doppler ultrasound is essential to confirm or exclude testicular torsion. [2]. In early torsion, the testicle may appear normal at ultrasound [2]. However, most testicular ultrasounds performed in our center as investigation of acute scrotal pain do not show signs suggesting testicular torsion. If not testicular torsion what then? What are the alternative causes? Page 2 of 21

3 The purpose of this exhibit is to characterize some of the most common ultrasound findings when evaluating patients presenting with acute scrotal pain. Besides testicular torsion, we will access other important scrotal conditions (epididymo-orchitis, abscess, hydrocele and varicocele). Epididymitis and/or orchitis The most common cause of acute scrotal pain in postpubertal men is epididymitis. [1] Ultrasound shows thickening and enlargement of the epididymis, with low echogenicity (occasionally high echogenicity due to hemorrhage), heterogeneous echotexture and increased blood flow (figs. 2-3). Reactive hydrocele and skin thickening may also be present and support the diagnosis.[1, 4] Epididymo-orchitis implies extension of inflammation to the testicle, which will also appear hypoechoic, enlarged and with increased blood flow (figs. 4-5). Isolated orchitis may also occur. [1] Hypervascularity is a well-established criterion for the diagnosis of epididymo-orchitis and may be the only finding. [4] Abscess Testicular abscesses are usually a complication of epididymo-orchitis [1]. On ultrasound, findings of epididymitis or epididymo-orchitis with a central region of liquefaction and lack of blood flow suggest abscess formation (fig. 6). [2] Abscesses appear as a fluid-filled mass with hypoechoic or mixed echogenic areas and may rupture, causing a pyocele or fistula. Hydrocele, hematocele and pyocele Accumulation of fluid between the layers of the tunica vaginalis may also be a cause of scrotal pain. [5] Hydrocele (accumulation of serous fluid) is seen as an anechoic collection with occasional low-level echoes (figs. 7-8). It may be congenital or adquired, in the presence of epididymo-orchitis, testicular torsion or neoplasm. Hematoceles and pyoceles present on ultrasound with internal septations and loculations (figs. 9-11). Hematoceles (accumulation of blood) can result from trauma, surgery, tumors or torsion. The sonographic appearance of hematoceles depends on its age: acute hematomas Page 3 of 21

4 present with high echogenicity; later, it undergoes liquefaction and may appear cystic. [3, 4] Pyoceles (accumulation of pus) is usually caused by a ruptured abscess. Varicocele A varicocele is a collection of abnormally dilated and tortuous veins of the pampiniform plexus. On ultrasound, a varicocele appears as anechoic serpiginous structures, measuring more than 2 mm in diameter, located at the upper pole of the testicle and head of the epididymis (figs ). Incidental findings Incidental findings, such as cystic lesions or calcifications, are not infrequent when performing testicular ultrasound and although they are not usually responsible for acute scrotal pain, they require clinical correlation and, eventually, further follow-up. Well-defined, anechoic lesions with thin and smooth walls are considered simple cysts (fig. 14) and can be managed conservatively. [1, 4, 6-7] Benign cystic lesions include intratesticular simple cysts, tubular ectasia, epidermoid cyst, tunica albuginea cysts, intratesticular varicocele, abscess and hemorrhage. [1, 6] On the other hand, testicular tumors may undergo cystic degeneration from hemorrhage or necrosis,[1, 8] so the distinction between benign or malignant characteristics becomes of crucial importance. Testicular microlithiasis (figs ) remains a controversial subject regarding its significance and association with malignancy [1, 4, 9-13]. Images for this section: Page 4 of 21

5 Fig. 1: Left testicle slightly hypoechoic and with no detectable blood flow, suggesting testicular torsion. Page 5 of 21

6 Fig. 2: Epididymitis: enlarged and heterogenous epididymis. Page 6 of 21

7 Fig. 3: Epididymitis: hypervascularity Page 7 of 21

8 Fig. 4: Epididymo-orchitis: testicle with marked heterogeneity. Page 8 of 21

9 Fig. 5: Epididymo-orchitis: hypervascularity. Fig. 6: Testicular abscess. Page 9 of 21

10 Fig. 7: Hydrocele Page 10 of 21

11 Fig. 8: Hydrocele Page 11 of 21

12 Fig. 9: Hematocele: multiple internal echoes and septations. Page 12 of 21

13 Fig. 10: Hematocele: multiple internal echoes and septations. Page 13 of 21

14 Fig. 11: Hematocele: multiple internal echoes and septations. Page 14 of 21

15 Fig. 12: Varicocele: anechoic serpiginous structures with caliber above 2 mm Page 15 of 21

16 Fig. 13: Varicocele: anechoic serpiginous structures with caliber above 2 mm Page 16 of 21

17 Fig. 14: Simple cyst incidentally discovered in a patient with acute scrotal pain. Page 17 of 21

18 Fig. 15: Testicular calcifications incidentally discovered in patients with acute scrotal pain. Page 18 of 21

19 Fig. 16: Testicular calcifications incidentally discovered in patients with acute scrotal pain. Page 19 of 21

20 Conclusion Ultrasound provides accurate information and plays an important role in differencial diagnosis of acute scrotal pain. Besides testicular torsion, other conditions can be associated with acute scrotal pain, such as infection/inflammation, hydrocele, and varicocele, among others. Incidental findings are not uncommon in testicular ultrasound and demand adequate manage and correlation. Personal information References [1] Gorman, B. The Scrotum in: Rumack CM et al Diagnostic Ultrasound, 4 ed, Philadelphia, Mosby, 2011, p [2] Avery LL, Scheinfeld MH. Imaging of Penile and Scrotal Emergencies. Radiographics 2013; 33: [3] Bhatt S, Dogra VS. Role of US in Testicular and Scrotal Trauma. Radiographics 2008; 28: [4] Kim W et al. US-MR Imaging Correlation in Pathologic Conditions of the Scrotum. Radiographics 2007; 27: [5] Davis JE, Silverman M. Scrotal Emergencies. EmergMed Clin N Am 2077; 29: [6] Dogra VS et al. Benign Intratesticular Cystic Lesions: US Features. Radiographics 2001; 21:S273-S281 [7] Gooding GAW, Leonhardt W, Stein R. Testicular Cysts: US Findings. Radiology 1987; 163: [8] Hamm B, Fobbe F, Loy V. Testicular Cysts: Differentiation with US and Clinical Findings. Radiology 1988; 168:19-23 [9] Middelton WD, Teefey SA, Santillan CS. Testicular Microlithiasis: Prospective Analysis of Prevalence and Associated Tumor. Radiology 2002; 224: Page 20 of 21

21 [10] Bennet HF et al. Testicular Microlithiasis: US Follow-Up. Radiology 2001; 218: [11] Cooper ML et al. Testicular Microlithiasis in Children and Associated Testicular Cancer. Radiology 2013; 270: [12] Bach AM et al. Testicular Microlithiasis: What Is Its Association with Testicular Cancer? Radiology 2001; 220:70-75 [13] Backus ML et al. Testicular Microlithiasis: Imaging Appearances and Pathologic Correlation. Radiology 1994; 192: Page 21 of 21