Acute scrotum. Acute Epididymo-orchitis. Phyllis Yan, APDR (QEH)

Transcription

1 Acute scrotum Acute Epididymo-orchitis Phyllis Yan, APDR (QEH)

2 Conditions leading to acute pain Torsion Acute Epididymitis / Epididymoorchitis Scrotal trauma Inguinal hernias Testicular tumors

3 Epididymitis/epididymo -orchitis Inflammation of epididymis / epididymis & testis The most common causes of acute scrotal pain in postpubertal men (Dorga & Bhatt, 2006, Gorman & Carrol, 2005)

4 Causes lower UTI such as urethritis or prostatitis - aged<35, sexually transmitted - older men, caused by E. coli & proteus Underlying genitourinary abnormality e.g. congenital anomaly or prior surgery Systemic disease e.g. tubercolosis & mumps Drug induced ( Sandra, 2001, Herbener, 2004)

5 Sign & symptom Fever c/o: swelling, redness & tenderness of scrotum Urinary sign: dysuria, pyuria & uretheral discharge (Goldberg, 1998)

6 Ultrasound appearance

7 Gray scale Epididymis Enlarged, hypoechoic or hyperechoic (hemorrhage) Testis diffuse: enlarged, hypoechoic or inhomogeneous focal: focal area of hypoechogenicity, mimic a tumor or focal infarct (Dorga & Bhatt, 2004, Dogra & Bhatt, 2006, Herbener, 1996)

8 Color Doppler 20% epididymitis & 40% orchitis, gray scale U/S is normal. Hyperemia is the diagnostic finding. (Horstman, 1991) Increase blood flow: important diagnostic criterion readily demonstrated flow: suspicion of inflammation (Dogra & Bhatt, 2006, Herbener, 1996)

9 Spectral Doppler Not standard procedure, additional information Normal testis, RI (resistive index) is (mean: 0.62), rarely less than 0.5 (Dorga & Bhatt, 2006, Siegel, 1997, Middleton, Thorne, Melson, 1989)

10 Spectral Doppler >50% epididymo-orchitis, RI less than 0.5 In Severe epididymo-orchitis, Increased RI + reversed diastolic flow component impending venous infarction (occluded venous flow) ( Dogra & Bhatt, 2006)

11 Complications Common: - Abscess & pyocele formation Rare: - gangrene & infarction Recurrent inflammation leads to infertility (Herbener, 1997, Ahuja et al, 2007)

12 Scrotal anatomy Scrotal anatomy (Krone, 1985)

13 Testis Oval-shaped structure, one in each hemiscrotum (5cm x 3cm x 2cm, LXWXAP) (Gorman & Carrol, 2005) U/S: medium-level homogeneous echogenicity

14 L/S of normal testis

15 T/S of normal testis

16 Epididymis Head, body & tail Located posterolateral to the testis Head - largest part - pyramidal, 5-14mm u/s: usually isoechoic, may be slightly echogenic & coarser than testis (Dorga & Bhatt, 2006)

17 L/S normal testis & epididymal head

18 L/S normal testis & epididymal tail

19 Reminders of scanning technique Scan asymptomatic side first Compare both testes by - T/S of scrotum - Dual mode Scale of color/power Doppler: low

20 T/S scrotum

21 Dual image

22 Reminders of scanning technique Scan asymptomatic side first Compare both testes by - T/S of scrotum - Dual mode Scale of color/power Doppler: low

23 Low vascular flow in testis

24 Remember Patient s privacy Avoid too much pressure Use warm acoustic gel

25 Case study

26 Patient history M/40 End stage renal failure on chronic haemodialysis Previous CAPD, repeated peritoneal abscess formation & drainage after removal of catheter Admitted for lower abd pain & Lt scrotal pain No history of scrotal trauma

27 Sign & Symptom Acute painful & swollen scrotum P/E: swollen left hemiscrotum, firm & tender Lt testicular mass Fever

28 Ultrasound findings

29 Ultrasound findings T/S of scrotum, left hydrocele is evident

30 Ultrasound findings Rt testis Lt testis

31 Ultrasound findings RT testis Lt testis

32 Ultrasound findings Heterogeneous lesion lower pole testis/epididymal tail

33 Ultrasound findings T/S of the heterogeneous lesion

34 Ultrasound findings Hypoechoic area Subtle hypoechoic area adj. to the heterogeneous lesion

35 Ultrasound finding Rt testis Lt testis Hyperemia in left testis

36 Ultrasound findings Markedly increased vascularity in swollen left epididymis

37 Ultrasound findings Hypoechoic lesion within heterogeneous mass: almost avascular

38 Ultrasound findings Left hydrocele & scrotal wall thickening

39 Ultrasound findings Left hydrocele & scrotal wall thickening

40 Ultrasound findings Enlarged lymph nodes at the bilateral groins

41 Discussion

42 Discussion Indications: - Diagnose epididymo-orchitis - To rule out testicular mass

43 Discussion Scrotal mass intratesticular extratesticular

44 Discussion Most of malignant tumors found in the scrotum are intratesticular (Gorman & Carrol, 2005) important to exclude intratesticular mass

45 Discussion Seminoma: most common tumor presents similar to inflammation - tumor infiltrate & obstruct seminiferous tubules, resulting in orchitis (Gorman & Carrol, 2005) Any abnormal echogenicity in the testis can be any kind of lesion including focal inflammation, abscess, infarct, or tumor mass (Herbener, 2004)

46 Limitation Epididymis is markedly swollen, margin of lower pole testis and epididymal tail cannot be delineated, and therefore the focal hypoechoic lesion U/S alone cannot differentiate abscess/infarction/tumor

47 Diagnosis Hyperemia and swollen epididymis & testis are suggesting epididymo-orchitis. Hypoechoic lesions at the epididymal tail/lower pole of testis can be an inflammatory tumor or abscess in view of onset pain and fever. However an intratesticular/extratesticular neoplasm cannot be excluded. Subtle hypoechoic area in testis, DDX: focal inflammation, co-existing testicular tumor (less unlikely) U/S follow up scan is suggested

48 Treatment Patient was prescribed with antibiotics. Blood test: normal AFP, tumor marker level U/S follow up scan was arranged after six-week to - assess the response to antibiotic treatment - follow up the hypoechoic lesions

49 CT scan was performed 2 days after US scan because of persistent lower abd pain. Prostatic abscess was diagnosed, abscess drainage was done.

50 Follow up scan

51 U/S FU scan Rt testis Lt testis Increase vascularity in left testis

52 U/S FU scan Heterogeneous lesion at upper pole testis

53 U/S follow up findings Heterogeneous lesion between lower pole of testis and epididymal tail was not seen Left testis: - Mildly enlarged, increase vascularity, scrotal wall thickening - Heterogeneously hypoechoic lesion at upper pole of testis, can be spread of inflammation

54 Another 8-week interval follow up scan was further arranged. Patient defaulted the exam and found to be dead because of septic shock complicated by peritonitis

55 Take home message Hyperemia in swollen epididymis and testis with associating scrotal wall thickening and hydrocele are features of epididymoorchitis. Although sonographic features for testicular tumor is non-specific. Combining with clinical history, testicular inhomogenicity in conjunction with epididymitis, accompanying orchitis is more likely.

56 Take home message Malignancy cannot be totally excluded until proven otherwise. Therefore, follow up ultrasound scan should be performed after adequate therapy is given.

57 The end

58 Reference Ahuja, A. T., Griffith, J.F., Wong, K.T., Antonio, G.E., Chu, W.C.W., Ho, S. Y. S et al (2007). Diagnostic Imaging: Ultrasound (1 st ed.). Utah: Amirsys. Dorga, V.S. & Bhatt, S. (2004). Acute scrotal pain. Radiologic Clinics of North America, 42(2), Dorga, V.S. & Bhatt, S. (2006). Acute scrotal pain: Imaging evaluation for a more specific diagnosis. RSNA Categorical Course in Diagnostic Radiology: Genitourinary Radiology (PP, ). Rochester: University of Rochester Medical Center.

59 Reference Gorman, B. & Carroll, B.A. (2005). The scrotum. In Rumack, C.M., Wilson, S.R., Charboneau, J.W. & Johnson, J.M., Diagnostic Ultrasound (3 rd ed.) (pp ). St. Louis, Missouri: Elsevier Mosby Horstman, W.G., Middleton, W.D., Melson, G.L. Siegel, B.A. (1991). Color Doppler US of the scrotum. Radiographics, 11, Herbener, T.E. (1996). Ultrasound in assessment of the Acute Scrotum [Electronic version]. Journal of Clinical Ultrasound, 24, 8,

60 Reference Middleton, W.D., Throne, D.A., Neksib, G.L. (1989). Color Doppler ultrasound of the normal testis. AJR Am J Roentgenol, 152, Siegel, M. J. (1997). The acute scrotum. Radiologic Clinics of North America, 35, Goldberg, B. B., McGahan, J. P., & (1998). Diagnostic Ultrasound: A Logical Approach. Philadelphia: Lippincott-Raven.