Ultrasonography of Acute Scrotum
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1 Ultrasonography of Acute Scrotum Poster No.: C-0331 Congress: ECR 2012 Type: Educational Exhibit Authors: O. Nikolic, T. Mrdanin, M. Basta Nikolic, S. Stojanovic, K Petrovic, V. Vucaj Cirilovic, M. GOVORCIN, S. Senicar ; Novi 2 Sad/RS, NOVI SAD/RS Keywords: Genital / Reproductive system male, Ultrasound, UltrasoundColour Doppler, Ultrasound-Power Doppler, Diagnostic procedure, Acute, Ischemia / Infarction, Trauma DOI: /ecr2012/C-0331 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 31
2 Learning objectives To explain US, color and spectral doppler characteristics of acute scrotal diseases and learn differential diagnosis of acute scrotum. Acute scrotum accounts for 0.5% of ER visits. Most often it occurs in the age of full sexual and working capability, between the age of 20 to 50 years. Thus, its sequelae can have serious negative impact on sexual and psychic wellbeing. In this poster we will review the role of US, color and spectral Doppler in the diagnostics of acute scrotum, as well as imaging findings of different diseases which are the part of acute scrotum syndrome. Background Acute scrotum is accompanied by dramatic clinical features (pain, edema redness), which require prompt reaction, because torsion cannot be excluded until proven otherwise. Diseases which can cause acute scrotum can be divided into several groups: 1. acute disease with vascular origin (Fig. 1-8)- testicular torsion, torsion of appendages and testicular infarction, 2. acute inflammatory disease (Fig. 9-18)- acute epididymitis, acute epididymo-orchitis and acute orchitis, 3. trauma (Fig )- contusion, hematoma, rupture, fracture, acute intratumoral hemorrhage and 4. acute disease of scrotal wall (Fig )- i.e. Gangrean de Fournier, sebaceous cyst, urinoma. These diseases are rarely fatal, but can provoke serious sequele as testicular atrophy, sterility, sexual and psychological disorders. Based on clinical examination, it is often difficult to make the precise diagnosis of this potentially urgent condition, especially when intensity of pain and edema do not allow palpation of scrotal contents. With the introduction of US and doppler sonography, which are considered the methods of choice in the diagnostics of scrotal diseases, the number of unnecessary operations has significantly decreased. From January 2002 to October 2011 we performed 1047 urgent scrotal ultrasound examinations. During doppler sonographic examination we measured resistive indexes (RI) in intra and supratesticular blood vessels. Images for this section: Page 2 of 31
3 Fig. 1: Normal color doppler signal in the right testicle Page 3 of 31
4 Fig. 2: Absence of color flow in the left testicle indicating torsion Page 4 of 31
5 Fig. 3: Intraoperative finding of the same patient, partial torsion of the left testicle, which was salvaged, as patient was operated in the first 12 hours from the onset of pain. Fig. 4: The same patient, badly fixed gubernaculum was the cause of testicular torsion. Page 5 of 31
6 Fig. 5: Wedge shaped hypoechoic lesion in the anterior aspect of the right testicle suggesting focal testicular infarction following inguinal hernia operation. Page 6 of 31
7 Fig. 6: The same patient-absence of color doppler signal in the region of testicular infarction. Page 7 of 31
8 Fig. 7: Diffusely hypoechoic left testicle following hernioplasty. Page 8 of 31
9 Fig. 8: Absence of color doppler signal in the same patient indicating ischemic orchitis. Page 9 of 31
10 Fig. 9: Edematous hypoechoic inhomogeneous tail of the right epididymis- acute focal epididymitis. Page 10 of 31
11 Fig. 10: Color doppler- hyperemic epididymal tail in the same patient. Page 11 of 31
12 Fig. 11: Spectral doppler in epididymitis. Hyperemic supratesticular arterial blood flow. RI below 0.7 Page 12 of 31
13 Fig. 12: Spectral doppler- hyperemic supratesticular venous blood flow in patient with acute epididymitis. Page 13 of 31
14 Fig. 13: Abscess of epididymal tail- B mode. Page 14 of 31
15 Fig. 14: Abscess of epididymal tail- color doppler. Page 15 of 31
16 Fig. 15: Acute epididymo-orchitis- color doppler- hyperemia, dif.dg. leukemia, vasculitis Page 16 of 31
17 Fig. 16: Spectral doppler in acute epididymo-orchitis showing increased diastolic flow in testicular hyperemia. RI below 0.5 Page 17 of 31
18 Fig. 17: Pyocele, consequence of acute epididymo-orchitis. Page 18 of 31
19 Fig. 18: Abscess of hemiscrotum, dirty shadowing indicating the presence of gas. Page 19 of 31
20 Fig. 19: Testicular rupture, irregular contour and hematomas. Page 20 of 31
21 Fig. 20: Hematocele. Page 21 of 31
22 Fig. 21: Subcapsular hematoma. Page 22 of 31
23 Fig. 22: Gangrean de Fournier -necrotizing fasciitis of perineum and scrotum in diabetic, immunocompromised patient. Gangrenous infection with fat necrosis and gas bubbles. Page 23 of 31
24 Fig. 23: Gangrean de Fournier- confirmation of gas by CT is mandatory. Page 24 of 31
25 Fig. 24: Inflamed sebaceous cyst in the region of interscrotal septum. Page 25 of 31
26 Fig. 25: Incision of the sebaceous cyst-the same patient. Page 26 of 31
27 Imaging findings OR Procedure details We performed B-mode + Color/ Power Doppler scrotal ultrasound examination using ultrasound equipment GE Logiq 7 with high frequency high resolution transducer (12-14 MHz). Patient is in supine position, supports scrotum-holds penis. Comparative transverse and sagittal scans are performed, and sometimes targeted scanning is needed. Images for this section: Page 27 of 31
28 Page 28 of 31
29 Fig. 26 Fig. 27 Page 29 of 31
30 Conclusion In spite of rapid development and enhancement of modern imaging modalities, ultrasound still remains the metod of choice in scrotal diagnostics. Doppler sonography allowe more precise differentiation of acute scrotal diseases, especially in torsion and inflammation.resistive indexes in intra and supratesticular blood vessels are good quantitative indicators of hyperemia. Even though the diagnostics has been significantly improved, including the use of most up-to-date US equipment, acute scrotum still presents important diagnostic challenge. Personal Information O. Nikolic, T. Mrdanin, M. Basta Nikolic, S. Stojanovic, K. Petrovic, V.Vucaj Cirilovic, M. Govorcin, S. Senicar, Center of Radiology, Clinical Center of Vojvodina, Hajduk Veljkova 1-9, Novi Sad, Serbia. mail to: References 1. Woodward PJ et al. Radiographics 2002;22: Praveen Bilagi et al. Clinical et ultrasound features of segmental testicular infarction: Six years experiance from a single centre. Eur Radiol (2007) 17: Vikram SD, Ronald HG, Mayumi O, Deborah JR. Sonography of the scrotum. Radiology 2003; 227 (1): Ragheb D, Higgins JL. Ultrasonography of the scrotum. J Ultrasound Med. 2002; 21: Rifkin, M, Cochlin, D. (2002) Imaging of the scrotum and penis. London: Mrtin Dunitz 6. Oyen, R.H. Scrotal ultrasound. Eur Radiol 2002, 12(1): Nikolic O, Lukac I. Doppler sonography in diagnosis of the acute scrotum. Med Pregl 2006; 59 (3-4): Page 30 of 31
31 8. Nikolic O. Doppler ultrasonografija u dijagnostici sindroma akutnog skrotuma. Magistarska teza (MS thesis). Medicinski fakultet u Novom Sadu; Page 31 of 31
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