Resistive index of the intrascrotal artery in scrotal inflammatory disease

Ultrasound-Based Technologies for the Evaluation of Testicles in the Dog: Keystones and Breakthroughs

Ultrasonography is a valuable diagnostic tool extensively used in the andrology of human and domestic animals, including dogs. This review aims to provide an overview of various technologies based on ultrasound, from the basic B-Mode ultrasonography to the more recent advancements, such as contrast-enhanced ultrasonography (CEUS) and ultrasound elastography (UEl), all of which are utilized in the evaluation of canine testicles. The review outlines the principles behind each of these technologies and discusses their application in assessing normal and abnormal testicular conditions. B-mode canine testicular ultrasonography primarily focuses on detecting focal lesions but has limitations in terms of objectivity. Other technologies, including Doppler ultrasonography, B-Flow, and CEUS, allow for the characterization of vascular patterns, which could be further measured using specific applications like spectral Doppler or quantitative CEUS. Additionally, ultrasound elastography enables the assessment of parenchyma stiffness both qualitatively and quantitatively. These ultrasound-based technologies play a crucial role in andrology by providing valuable information for evaluating testicular function and integrity, aiding in the identification of pathological conditions that may impact the health and quality of life of male dogs.

Doppler Examination of the Testicular Artery of Beagle-Breed Dogs from Birth to Puberty

The objectives were (a) the study of haemodynamic parameters of blood flow within the testicular artery, (b) the assessment of differences in these parameters at different segments of the artery (i.e., sequentially, as the artery flows through different regions of the testis), and (c) the identification of potential associations with measures of testicular maturation. Eight healthy beagle-breed male dogs were monitored at fortnightly intervals from the 4th to the 40th week of life, by using clinical, seminological, and ultrasonographic (B-mode, pulsed-wave Doppler) examinations. Haemodynamic parameters were assessed at four different segments of the testicular artery: at the distal supra-testicular, the marginal testicular at the cranial pole of the testis, the marginal testicular at the caudal pole of the testis, and the intratesticular. The study period was divided into three time slots (pre-puberty, puberty, and post-puberty) depending on testicular maturation and sperm production. No clinically evident abnormalities were seen in any animal throughout the study. Semen ejaculates were first collected on the 28th week, and spermatozoa were first seen on the 30th week of life. The results of B-mode examination indicated that in all dogs, the echogenicity of the testicular parenchyma was homogeneous. The waveforms of the blood flow in the testicular artery were monophasic with systolic peaks, low diastolic flow, and low vascular resistance. Most cases of significant differences between the three age periods were noted for the comparison of the pre-pubertal to pubertal periods (n = 11); among the parameters studied, the blood volume (n = 9) showed most instances of significant differences; finally, most cases of significant differences were noted in the distal supra-testicular artery (n = 12). Correlations were mainly seen for the end diastolic velocity, the peak systolic velocity and the blood volume (each with two semen evaluation parameters). The distal supra-testicular and the marginal artery at the cranial pole of the testis are recommended as the most appropriate segments of the vessel for performing a Doppler examination in the testicular artery due to the adequate size and the clear spectral waveforms as early as the 12th week of age of the animals.

The Relationship between the Testicular Blood Flow and the Semen Parameters of Rams during the Selected Periods of the Breeding and Non-Breeding Seasons

The study aimed to conduct advanced semen evaluation tests during routine ram examination periods in the breeding and non-breeding seasons and to investigate their correlation with the dynamics of testicular blood flow. Semen was collected from eighteen rams, and pulse wave Doppler examination before (BBS), during (BS), and after the breeding season (ABS). Routine and advanced semen analysis, including computer-assisted sperm analysis (CASA), sperm chromatin dispersion test (SCD), and motile sperm organelle morphology examination (MSOME), were conducted. In Doppler ultrasonography, the peak systolic velocity (PSV), end-diastolic velocity (EDV), resistive index (RI), and pulsatility index (PI) were calculated. In BS period, high sperm concentration (p < 0.0001) and total sperm number/ejaculate (p = 0.008) were noted. During the BBS period, a low percentage of forwarding motility (p = 0.017) and high sperm abnormalities (p = 0.005) were found. Also during this period, both SCD and MSOME revealed high sperm DNA fragmentation (p < 0.0001) and signs of vacuolization (Grade II-IV, p < 0.05). The advanced features of higher sperm abnormalities (Grade IV of MSOME) correlated with an increase RI (ρє <0.60;0.61>) and PI (ρє <0.46;0.52>), whereas the basic percentage of sperm abnormalities correlated with the EDV (ρє <0.44;0.73>) value. One may conclude that the current preliminary study requires further research concerning the monthly examination of a ram to provide full yearly characteristics of the relation between advanced semen evaluation tests and the dynamics of testicular blood flow.

Role of color flow Doppler ultrasound in the evaluation of acute scrotal pain

Color flow Doppler ultrasound is a critical tool in the assessment of the scrotum. Ultrasound is the first-line imaging modality and can rapidly differentiate between surgical and nonsurgical conditions, allowing for appropriate and prompt patient management. We review the role of color flow Doppler in the evaluation of acute scrotal pain, highlighting some of the most commonly seen pathologies such as epididymo-orchitis and testicular torsion.

The role of scrotal ultrasonography from infancy to puberty

Background

Scrotal ultrasonography is an essential diagnostic tool in daily clinical practice. The availability of new‐generation ultrasound machines characterized by clearly improved image quality, low health cost, and higher patient safety, represents only some characteristics of ultrasound investigation. The usefulness of scrotal ultrasonography is particularly evident in the period of life from infancy to puberty, during which males undergo important morphofunctional changes, and several pathological conditions may occur.

Objectives

This pictorial review primarily aimed to investigate the aspects of ultrasonography related to the normal physiological development of the gonads from mini‐puberty to pubertal onset. This study also aimed to provide an update on the use of ultrasonography in main andrological pathologies that may occur during this period. The conditions that are discussed in depth are: cryptorchidism, inguinoscrotal hernias, and hydrocele in the neonatal phase; acute scrotum, epididymo‐orchitis, and testicular cancers in childhood; and hypogonadism, varicoceles, testicular microlithiasis, and oncohematological pathology in puberty.

Discussion

We provided an ultrasound slant for all the above‐mentioned pathologies while purposely avoiding excessive deepening of the pathogenetic, clinical, and therapeutic aspects. Studying the ultrasound aspects of the gonads also facilitates differential diagnosis between various conditions and represents a good aid in evaluating therapeutic success (e.g., in hypogonadism or postsurgical evaluation of varicoceles and cryptorchidism).

Conclusion

Scrotal ultrasonography is now globally recognized as the necessary completion of clinical–laboratory overview in gonads evaluation. This diagnostic procedure is even more indispensable in the infancy–childhood–puberty period for the evaluation of normal gonadal development as well as diagnosis of other possible diseases.

Differential Diagnosis of Acute Scrotum in Childhood and Adolescence with High-Resolution Duplex Sonography

Acute testicular pain in childhood can be caused by testicular torsion, torsion of the appendix testis, or epididymo-orchitis. Quick and reliable diagnosis is essential for determining the further course of action (surgery or conservative approach). The diagnostic tool of choice is high-resolution sonography with a linear transducer (> 10 MHz) combined with color and spectral Doppler sonography. The Doppler device settings should include a low pulse repetition frequency (< 4 cm/s), a low wall filter (< 100 Hz), and adequate gain. Comparison with the unaffected healthy testis is essential. The most important of the three diseases is torsion of the spermatic cord because it requires immediate surgical intervention and detorsion. The affected testis is enlarged and has an inhomogeneous echotexture with hypoechoic and hyperechoic areas as well as an associated hydrocele. In testicular torsion, color Doppler shows reduced or absent intratesticular vessels in comparison with the healthy contralateral testis. Spectral Doppler shows decreased flow velocities especially during diastole in intratesticular arteries and an increased resistance index. The investigation should always include imaging of the spermatic cord from the outer inguinal ring to the upper pole of the testis. In contrast to a normal finding, the vessels and the ductus deferens are not displayed as linear tubular structures but in form of a spiral twist. Ultrasound shows a target-like structure with multiple concentric rings. Color Doppler sonography shows the typical whirlpool sign. In torsion of the appendix testis, the appendix testis is enlarged in the groove between the testis and epididymis. The longitudinal diameter of the appendix testis can be greater than 5 mm. The echogenicity of the torsed appendage can vary between hypoechoic (acute torsion) and hyperechoic (prior torsion). An associated hydrocele of varying size is usually seen. Color Doppler sonography reveals a lack of perfusion of the enlarged appendix testis and increased vascularity of the testis and primarily the epididymis. Epididymo-orchitis is characterized by an enlarged epididymis and/or testis with inhomogeneous echogenicity (hypoechoic - hyperechoic). Color Doppler sonography shows increased vascularity in comparison with the unaffected testis. Spectral Doppler reveals increased diastolic flow velocities and a decreased resistance index. Idiopathic scrotal edema and an incarcerated inguinal hernia must be ruled out in the differential diagnosis.

B-Mode and Doppler Ultrasonographic Findings of Prostate Gland and Testes in Dogs Receiving Deslorelin Acetate or Osaterone Acetate

Simple Summary

This article presents the use of ultrasonography (basic and advanced techniques) in dogs suffering from benign prostate hyperplasia (BPH) for the assessment of the effects of two different medications: osaterone acetate (Ypozane^TM), a registered drug for BPH in dogs, and deslorelin acetate (Suprelorin^TM), registered for pharmacological castration in dogs. Based on the obtained results it can be stated that both B-mode and color Doppler Ultrasound imaging techniques are suitable for diagnosis and progress assessment of dogs suffering from BPH. Both investigated medications (osaterone acetate and deslorelin acetate) led to a significant sonographic improvement. Deslorelin acetate reduced prostate volume more slowly, but its effect lasted longer than for osaterone acetate.

Abstract

This article presents B-mode and color Doppler imaging of the prostate and testes in dogs suffering from benign prostate hyperplasia (BPH), and receiving deslorelin acetate (Suprelorin^TM) or osaterone acetate (Ypozane^TM). The study was planned as a controlled clinical trial, dogs were divided into negative control (healthy dogs, n = 10), positive control (dogs with BPH, n = 10), and study groups, III (n = 15), receiving deslorelin acetate (DA), and IV (n = 10), receiving osaterone acetate (OA). The B-mode appearance of the prostate parenchyma improved in all investigated dogs from the DA group, and in 60% of OA dogs. Prostate volume was reduced more quickly with OA (from D14), but lasting for a shorter time (on average up to week 20), compared to DA that reduced the prostate volume more slowly (>8 weeks), but the reduction remained longer (>24 weeks). The systolic peak velocity (SPV) and mean velocity (Vmean) were higher in all dogs diagnosed with BPH, compared to Control Group I. The indices did not change in both Control Groups I and II, whereas in study Groups III and IV they decreased throughout the study period compared to day 0 and Control Group II. In Group III the highest reduction was noted from day 21 to week 8, whereas in Group IV the lowest Vmean was recorded before day 21. Testicular parenchyma and volume changed significantly in Group III receiving DA, and the velocity of blood flow in the testicular artery correlated positively with testicular volume only in this group (III). The present study proved the usefulness of B-mode and color Doppler US imaging techniques for diagnosis and progress assessment of dogs suffering from BPH. The blood flow kinetics (mainly SPV) demonstrated a time association between the blood flow changes registered in the prostatic artery, and the subsequent volumetric and sonographic improvement of the prostate parenchyma. The reduction in flow indices was noted prior to the reduction in prostate volume, suggesting that the sonographic recovery of the prostate tissue, occurs secondarily to the regression of the prostate vascular system. Both investigated medications (osaterone acetate and deslorelin acetate) led to a significant sonographic improvement. Deslorelin acetate reduced prostate volume more slowly, but its effect lasted longer than for osaterone acetate.

Advances in applications of color Doppler ultrasonography in the andrological assessment of domestic animals: A review

Compared to human cases, potential applications of Doppler imaging technology in farm animals' practice are still limited and are mostly concerned with females. Testicular blood perfusion (TBP) is the pathway through which all nutrients, oxygen, and regulatory agents pass through to the testis. TBP is crucial to the testis function because of the high metabolic rate and very low concentration of oxygen in the seminiferous tubules, which constitute about 70%-80% of the testicular mass. Color Doppler ultrasonography is one of the recent non-invasive technologies, which plays a vital role in the assessment of blood flow to the testis in various animal species. In the past 20 years, a significant number of studies have highlighted the importance of assessments of TBP using color Doppler ultrasonography to illustrate its potential uses for breeding soundness examination, diagnosis, and monitoring of infertility problems in farm animals. This review was aimed at providing, for the first time, updated knowledge on the potential clinical uses of color Doppler ultrasonography for the assessment of TBP in domestic animals. Additionally, a few essential details on the relationship between TBP and male fertility are discussed in this review. Furthermore, a number of caveats relating to the use of color Doppler ultrasonography are discussed, which collectively appear to constrain its routine, on-farm application for breeding soundness assessments, at least at the present. The new perspectives related to animal reproduction that researchers claim to do in further investigations are also discussed.

Overview of ultrasound applications for assessing scrotal disorders

The scrotum may be affected by a plethora of different disorders such as infections, vasculopathies, trauma, and manifestations of primary and secondary malignant masses. In addition to the patient's medical history and clinical examination, ultrasound represents the imaging modality of choice to assess scrotal disorders. Time-consuming contrast-enhanced ultrasound and elastography can provide further information to distinguish between benign and malignant testicular mass lesions. The following invited Special Communication gives a comprehensive overview of differential diagnoses of the scrotum and their corresponding sonomorphologic correlates based on representative cases of the Interdisciplinary Ultrasound Center of the University Hospital Munich.

Lesions Without Borders: Scrotal Lesions That Involve Both the Intratesticular and Extratesticular Regions

OBJECTIVE

Differentiation of scrotal lesions is often dictated by whether they are intraor extratesticular. However, these regions are not entirely isolated, and disease processes can span both spaces. We review a variety of lesions that can involve both regions, describe the relevant anatomy, and illustrate their imaging appearances.

CONCLUSION

Identification of involvement of both intra- and extratesticular regions by a single process can narrow the differential considerations and help arrive at the correct diagnosis.

Pulse wave Doppler ultrasound of testicular arteries and their relationship with semen characteristics in healthy bulls

BACKGROUND

Semen evaluation is used to estimate the testicular function. In bulls, the spermatozoa present in the ejaculate are the result of a process that begun more than 2 mo earlier, bequeathing a delayed depiction of the actual function of the testis. Since testis vascularization might be critical for the gonad function, selected pulse wave Doppler ultrasound parameters were assessed in this study, for instance the peak systolic velocity, the end diastolic velocity and the resistive index of the testicular artery along the spermatic cord, the marginal portion of the testicular artery and the intratesticular branches of the testicular artery both in healthy adult and young bulls. Correlations between these parameters and characteristics of semen that was collected numerous times, before and after the Doppler ultrasound examination.

RESULTS

The peak systolic velocity and the end diastolic velocity measured in the testicular artery along the spermatic cord (supratesticular artery - SA) were variable among the bulls and within individual bulls, likely due to the convoluted course of the vessel. The resistive index was found highly repeatable in the same bull. A reduction in the resistive index was found between the supratesticular artery and the marginal portion of the testicular artery (P < 0.01), and between the marginal portion of the testicular artery and the intratesticular branches of the testicular artery (P < 0.05). No differences were recorded for the pulse wave Doppler ultrasound parameters in young bulls compared with adults. A significant correlation was found between the resistive index of the marginal portion of the testicular artery and total sperm in the ejaculate (r = 0.516, P < 0.05), the immature sperm (r = 0.462, P < 0.05), the teratoid sperm (r = 0.375, P < 0.05), and the "Dag defect" sperm (r = 0.389, P < 0.05). Similarly, the resistive index of the intratesticular branches of the testicular artery were found correlated with the total sperm number in the ejaculate (r = 0.568, P < 0.05), the immature sperm (r = 0.523, P < 0.05), the teratoid sperm (r = 0.418, P < 0.05), and the "Dag defect" sperm (r = 0.341, P < 0.05).

CONCLUSIONS

The data presented in this study suggest that the resistive index, measured at the marginal portion of the testicular artery, could be an easy-to-perform parameter to evaluate the spermatogenesis quality in young bulls and normal adults.

Pulse Doppler ultrasound as a tool for the diagnosis of chronic testicular dysfunction in stallions

Testicular function is particularly susceptible to vascular insult, resulting in a negative impact on sperm production and quality of the ejaculate. A prompt diagnosis of testicular dysfunction enables implementation of appropriate treatment, hence improving fertility forecasts for stallions. The present research aims to: (1) assess if Doppler ultrasonography is a good tool to diagnose stallions with testicular dysfunction; (2) to study the relationship between Doppler parameters of the testicular artery and those of sperm quality assessed by flow cytometry and (3) to establish cut off values to differentiate fertile stallions from those with pathologies causing testicular dysfunction. A total of 10 stallions (n: 7 healthy stallions and n: 3 sub-fertile stallions) were used in this study. Two ejaculates per stallion were collected and preserved at 5°C in a commercial extender. The semen was evaluated at T0, T24 and T48h by flow cytometry. Integrity and viability of sperm (YoPro®-1/EthD-1), mitochondrial activity (MitoTracker® Deep Red FM) and the DNA fragmentation index (Sperm Chromatin Structure Assay) were assessed. Doppler parameters were measured at three different locations on the testicular artery (Supratesticular artery (SA); Capsular artery (CA) and Intratesticular artery (IA)). The Doppler parameters calculated were: Resistive Index (RI), Pulsatility Index (PI), Peak Systolic Velocity (PSV), End Diastolic Velocity (EDV), Time Average Maximum Velocity (TAMV), Total Arterial Blood Flow (TABF) and TABF rate. The capsular artery was the most reliable location to carry out spectral Doppler assessment, since blood flow parameters of this artery were most closely correlated with sperm quality parameters. Significant differences in all the Doppler parameters studied were observed between fertile and subfertile stallions (p ≤ 0.05). The principal components analysis assay determined that fertile stallions are characterized by high EDV, TAMV, TABF and TABF rate values (high vascular perfusion). In contrast, subfertile stallions tend to present high values of PI and RI (high vascular resistance). The ROC curves revealed that the best Doppler parameters to predict sperm quality in stallions were: Doppler velocities (PSV, EDV and TAMV), the diameter of the capsular artery and TABF parameters (tissue perfusion parameters). Cut off values were established using a Youden´s Index to identify fertile stallions from stallions with testicular dysfunction. Spectral Doppler ultrasound is a good predictive tool for sperm quality since correlations were determined among Doppler parameters and markers of sperm quality. Doppler ultrasonography could be a valuable diagnostic tool for use by clinical practitioners for the diagnosis of stallions with testicular dysfunction and could be a viable alternative to invasive procedures traditionally used for diagnosis of sub-fertility disorders.

Ultrasonography of pediatric urogenital emergencies: review of classic and new techniques

Urogenital emergencies are fairly common in the pediatric population, and a timely and correct diagnosis is necessary to avoid possible future infertility. In this field, ultrasonography is essential, as it has the advantages of being radiation-free and readily accessible. In particular, a high-frequency transducer allows precise evaluation of the morphology and vascularity of the scrotum, which is on the surface of the body. Beyond conventional techniques, new advanced imaging techniques have been developed, including elastography and contrast-enhanced ultrasonography. However, several pitfalls remain in the diagnosis of urogenital diseases using ultrasonography. Thus, accurate knowledge and sufficient experience with the technique are essential for making a correct diagnosis. This review provides an overview of pediatric urogenital emergency pathologies and recent ultrasonography techniques.

Incarcerated Inguinal Hernia Mesh Repair: Effect on Testicular Blood Flow and Sperm Autoimmunity

Background

The aim of our study was to determine an influence of incarcerated inguinal hernia mesh repair on testicular circulation and to investigate consequent sperm autoimmunity as a possible reason for infertility.

Material/Methods

This prospective study was performed over a 3-year period, and 50 male patients were included; 25 of these patients underwent elective open mesh hernia repair (Group I). Group II consisted of 25 patients who had surgery for incarcerated inguinal hernia. Doppler ultrasound evaluation of the testicular blood flow and blood samplings for antisperm antibodies (ASA) was performed in all patients before the surgery, on the second day, and 5 months after. Main outcome ultrasound measures were resistive index (RI) and pulsative index (PI), as their values are inversely proportional to testicular blood flow.

Results

In Group I, RI, and PI temporarily increased after surgery and then returned to basal values in the late postoperative period. Friedman analysis showed a significant difference in RI and PI for all measurements in Group II (p<0.05), with a significant decrease between the preoperative, early, and late postoperative periods. All final values were within reference range, including ASA, despite significant increase of ASA in the late postoperative period.

Conclusions

Although statistically significant differences in values of testicular flow parameters and immunologic sensitization in observed time, final values remained within the reference ranges in all patients. Our results suggest that the polypropylene mesh probably does not cause any clinically significant effect on testicular flow and immunologic response in both groups of patients.

Sonographic findings of typical and atypical scrotal trauma

This review article illustrates sonographic findings in the setting of accidental and nonaccidental scrotal trauma. Although sonographic findings may be irrespective of the type of trauma, the goals of sonographic evaluation are similar in both atypical and typical mechanisms of scrotal injury. Familiarity with findings such as disruption of testicular integrity or vascularity facilitates prompt diagnosis and plays a critical role in clinical management.

Color Doppler Evaluation of the Retrobulbar Hemodynamic Changes in Chronic Obstructive Pulmonary Disease: COPD and Retrobulbar Hemodynamic Changes

The aim of this study was to evaluate the hemodynamic changes in the extraocular orbital vessels of the patients with chronic obstructive pulmonary disease (COPD), using color Doppler ultrasonography, and to compare the results with those of healthy control subjects. The control group consisted of 35 healthy subjects who had no systemic problems, while the study group consisted of 60 patients with the diagnosis of COPD. Patients with COPD were grouped according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Twenty patients of stage 1 COPD (mild airflow limitation), stage 2 COPD (moderate airflow limitation), or stage 3 COPD (severe airflow limitation) were included in the groups 1, 2, and 3, respectively. Measurements were performed in both eyes of each participant. Peak systolic velocity (PSV), end-diastolic velocity (EDV), resistance index (RI), and pulsatility index (PI) were measured in the ophthalmic artery (OA), central retinal artery (CRA), and posterior ciliary artery (PCA). The RI and PI measurements of the OA, CRA, and PCA were significantly higher in group 3 when compared to the control group and groups 1 and 2. These significances were not observed when PSV and EDV values were compared. There were also no significant differences between groups 1, 2, and control patients, when mean PSV, EDV, RI, and PI values of all arteries were compared. None of the above parameters showed statistical significance when mean RI, PI, PSV, and EDV were compared between left and right eyes. Severe (stage 3) COPD is associated with impaired retrobulbar hemodynamics. Increased hypoxia and vascular mediators may be suggested in etiology.

Office ultrasound for the urologist

Imaging of the genitourinary tract is essential in the workup of the majority of the conditions seen daily by urologists. The use of ultrasound in the office provides a safe, low cost, and efficient way for the clinician to evaluate the patient in real time. Ultrasound can allow for bedside diagnosis in many conditions and assist in treatment planning. This chapter covers the major applications of office ultrasound for the urologist as well as discusses future applications of ultrasound for the office setting.

The acute scrotum in childhood and adolescence

BACKGROUND

The acute scrotum in childhood or adolescence is a medical emergency. Inadequate evaluation and delays in diagnosis and treatment can result in irreversible harm, up to and including loss of a testis. Various diseases can produce this clinical picture. The testis is ischemic in only about 20% of cases.

METHODS

This review is based on a selective literature search, the existing clinical guideline, and the authors' experience.

RESULTS

The clinical approach to the acute scrotum must begin with a standardized, rapidly performed diagnostic evaluation. Dopper ultrasonography currently plays a central role. Its main use is to demonstrate the central arterial blood supply and venous drainage of the testis. The resistance index of the testicular vessels should also be determined.

CONCLUSION

Physical examination and properly performed Doppler ultrasonography enable adequate evaluation of the acute scrotum in childhood and adolescence. In the rare cases of diagnostic uncertainty, immediate surgical exposure of the testis remains the treatment of choice.

Xanthogranulomatous epididymitis: clinical report and immunohistochemical analysis

Xanthogranulomatous epididymitis is an uncommon non-neoplastic process with destruction of tissue and replacement by striking cellular infiltration of foamy macrophages, dense lymphocytes and plasma cells. We report on a 72-year-old man with a clinical history of inadequately treated arterial hypertension, who presented with a right scrotal mass associated with right scrotal pain for 10 days. Physical examination revealed pyogenic discharge from the hyperemic and edematous scrotum, with normal body temperature. Testicular tumor markers were normal. Ultrasonography (US) of the right testis showed edematous scrotal layers and a heterogeneous area of poorly defined margins within the testis and epididymis. There was minimal hydrocele, and the right funiculus was of normal diameter with no edema or pathologic formation. The progression of clinical findings, inflammatory parameters, US and color Doppler US findings with negative testicular tumor markers indicated surgical treatment. After preoperative treatment, right orchiepididymectomy was performed. Histology confirmed the diagnosis of xanthogranulomatous epididymitis.

Assessment of the intratesticular resistive index by colour Doppler ultrasonography measurements as a predictor of spermatogenesis

OBJECTIVE

To investigate the value of the resistive index (RI) of intratesticular arteries, and to establish diagnostic criteria for normal and pathological sperm counts on the basis of quantitative colour Doppler ultrasonography (CDUS), as the assessment of the testicular RI is widely used to measure intratesticular blood flow.

PATIENTS AND METHODS

In all, 160 men (aged 22-43 years, 320 testicles) were prospectively investigated; 80 had a normal and 80 a pathological sperm count, the latter having mild oligoasthenozoospermia. The RI was measured using a high-frequency Doppler ultrasound probe (14 MHz), three times on each testicle at an intratesticular artery in the upper, middle and lower testicular pole. The testicular volume was also measured by US. The RI values were compared between patients with normal and pathological sperm counts, and were compared statistically with testicular volumes. In addition, blood samples were obtained for DNA extraction, chromosome analysis and hormonal evaluations.

RESULTS

Patients with normal sperm counts had a mean (sd) RI of 0.54 (0.05) and a mean testicular volume of 18.7 (5.2) mL, the respective values in those with pathological sperm counts were 0.68 (0.06) and 16.8 (6.0) mL, with a significantly greater RI in the latter (P < 0.001), but with no statistically significant difference in testicular volume between the groups (P > 0.05).

CONCLUSION

These preliminary data suggest that an RI of >0.6 might be suggestive of a pathological sperm count in andrological patients. The intratesticular RI as measured by CDUS seems to be a reliable indicator for routine clinical use to identify subfertile men.

Hodentorsion: Diagnose, Differenzialdiagnose und Therapie im Kindesalter

Acute scrotum represents an emergency situation although testicular torsion is present in less than 20% of the cases. Sonography has meanwhile become the definitive modality for diagnosis. Its increasing use before surgical intervention has led to technical improvements in ultrasound diagnostics and critical assessment of ultrasound criteria to exclude testicular torsion as well as standardization of examination procedures. Central arterial and venous perfusion shown to be bilaterally equal on Doppler sonography is the most important criterion for excluding torsion. This article discusses other criteria such as the "resistance index," comparison of parenchymal structure of both testes, evidence for spermatic cord torsion, or differences between the sides in perfusion of the testicular parenchyma and highlights the difficulties involved in partial and intermittent testicular torsion. Alternative investigative methods and the significance of sonography in the differential diagnosis of other underlying causes are addressed. In summary, the combination of interpreting B-mode imaging, color Doppler, and power Doppler sonography and analyzing Doppler flow curves after clinical examination results in successful and conclusive evaluation of the testes in cases of acute scrotum in boys.

Acute testicular torsion in children: the role of sonography in the diagnostic workup

Acute testicular torsion in children is an emergency and has to be diagnosed urgently. Doppler sonography is increasingly used in imaging the acute scrotum. Nevertheless, in uncertain cases, surgical exploration is required. In this study, we attempted to define the role of Doppler sonography in the diagnostic workup of the acutely painful scrotum. All patients admitted between 1999 and 2005 with acute scrotal pain were included. After clinical assessment, patients were imaged by Doppler sonography with a ''high-end'' instrument. In cases of absent arterial perfusion of the testis in Doppler sonography, surgical exploration was carried out. Patients with unaffected perfusion were followed clinically by ultrasound for up to 2 years. Sixty-one infants and children aged 1 day to 17 years (median: 7.9 years) were included. In 14 cases, sonography demonstrated absent central perfusion, with abnormal parenchymal echogenicity in six. Absence of venous blood flow together with reduction of central arterial perfusion was found in one infant. In these 15 patients, surgical exploration confirmed testicular torsion. Among the other 46 patients, we found four cases with increased testicular perfusion and 27 with increased perfusion of the epididymis. In one infant, a testicular tumour was found sonographically, and orchiectomy confirmed diagnosis of a teratoma. Follow-up examinations of the conservatively treated patients showed good clinical outcome with physiologic central perfusion as well as normal echogenic pattern of both testes. No case of testicular torsion was missed. By means of Doppler sonography, an unequivocal statement regarding testicular perfusion was possible in all cases. The initial Doppler diagnosis was confirmed by operative evaluation and follow-up ultrasound. Testicular torsion can therefore be excluded by correctly performed ultrasound with modern equipment.

Comparison of brucella and non-specific epididymorchitis: gray scale and color Doppler ultrasonographic features

OBJECTIVE

The aim of this study is to find out if it is possible to differentiate between brucellar and non-specific epididymorchitis by comparing ultrasonography (US) and color Doppler ultrasonography (CDUS) findings.

MATERIAL AND METHODS

Fifty-six patients diagnosed to have epididymorchitis both clinically and ultrasonographically were included to study. All of the patients were investigated serologically for brucella. Twenty-eight of those patients were admitted brucella epididymorchitis because of high agglutinations titers for brucella. The other 28 patients were admitted non-specific epididymorchitis because of normal agglutinations titers for brucella. Testicular size, echogenicity, hydrocele, internal echoes and/or septations within hydrocele, and scrotal skin thickness of normal and involved testis were compared by ultrasonography. Besides, pick systolic velocity, end diastolic velocity, resistive index and pick systolic velocity ratio values were measured by bilateral testicular color Doppler ultrasonography in both groups. When the p-value is <0.05, the difference between groups is accepted as statistically significant.

RESULTS

Thickening of scrotal skin was seen in 17 of 28 patients with brucella epididymorchitis (BEPO) (67%) and in 25 of 28 patients with non-specific epididymorchitis (NEPO) (89.2%) (p < 0.01). There was no difference between groups regarding presence of hydrocele. However hydrocele seen in all patients was anechoic except for two patients (8.6%). Hydrocele seen in 18 of 22 patients with BEPO and hydrocele had internal echogenicity or septation (p < 0.001). Sizes of testes and epididymis were found to be increased in involved testis compared to normal testis. Testes of all patients with NEPO were homogenous with decreased echogenicity except for five patients (17.8%). However, 23 patients with BEPO (82%) found to have heterogenous testis (p < 0.001). Spectral measurements showed increased PSV and EDV values and decreased RI values in involved sides in both groups. There was statistical significant difference in respect to maximum and minimum flow velocity between two groups (p < 0.05). There was no difference between the two groups regarding RI values. PSV ratio was 3.1+/-1.3 in patients with BEPO and 2.2+/-0.7 in patients with NEPO.

CONCLUSION

Heterogenicity, focal echogenicity differences and hydrocele with granularity and/or septation seen in a patient presenting with scrotal infection in brucella endemic areas must rise the possibility of brucellosis rather than NEPO. By this way, effective treatment can commence immediately and complications can be avoided.

Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys

BACKGROUND

Diagnosis of testicular torsion in children is challenging, as clinical presentation and findings may overlap with other diagnoses.

OBJECTIVE

To define the clinical and ultrasound criteria that best predict testicular torsion.

MATERIALS AND METHODS

The records of children hospitalized for acute scrotum from 1997 to 2002 were reviewed. The clinical and ultrasound findings of children who had a final diagnosis of testicular torsion were compared with those of children who had other diagnoses (torsion of the testicular appendix, epididymitis, and epididymo-orchitis).

RESULTS

Forty-one children had testicular torsion; 131 had other diagnoses. Stepwise regression analysis yielded three factors that were significantly associated with testicular torsion: duration of pain < or =6 h; absent or decreased cremasteric reflex; and diffuse testicular tenderness. When the children were scored by final diagnosis for the presence of these factors (0-3), none of the children with a score of 0 had testicular torsion, whereas 87% with a score of 3 did. The ultrasound finding of decreased or absent testicular flow had a sensitivity of 63% and a specificity of 99%. Eight of ten children with testicular torsion and normal or increased testicular flow had a coiled spermatic cord on ultrasound.

CONCLUSION

We suggest that all children with acute scrotal pain and a clinical score of 3 should undergo testicular exploration, and children with a lower probability of testicular torsion (score 1 or 2) should first undergo diagnostic ultrasound. Because the presence of testicular flow does not exclude torsion, the spermatic cord should be meticulously evaluated in all children with acute scrotum and normal or increased testicular blood flow.

Color Doppler ultrasound evaluation of testicular blood flow in stallions

The objectives of this study were to evaluate the potential use of color Doppler ultrasound to characterize blood flow to the stallion testis, and to establish reference values for Doppler measures of blood flow in the testicular artery of the stallion. Both testes from each of 52 horses were examined using a pulsed-wave color Doppler ultrasound with a sector array 5/7.5 MHz transducer with a 1mm gate setting. Peak systolic velocity (PSV), end diastolic velocity (EDV), resistive index (RI), and pulsatility index (PI) of the testicular artery were measured in each of two locations, the convoluted aspect (spermatic cord) and the marginal aspect of the artery (on the epididymal edge of testis). We found that: (1) all measures were obtainable; (2) except for EDV, the majority of the measures were higher at the cord location than at the marginal aspect of the artery (P < 0.05); and (3) measures for left and right testes were similar (P > 0.10). Resulting measures from 41 of these stallions (82 testes) that appeared free of testicular pathology provide useful reference values for clinical evaluation. Evaluation of 11 cases with testicular pathology suggested further investigation of possible effects of these various conditions on testicular blood flow and testicular function.

Acute painful scrotum

The ability of US to diagnose the pathogenesis of the acute scrotum is unsurpassed by any other imaging modality. It is the first imaging performed in patients with acute scrotum. Knowledge of the normal and pathologic sonographic appearance of the scrotum and proper sonographic technique is essential for accurate diagnosis of acute scrotum. High-frequency transducer sonography combined with color flow Doppler sonography provides the information essential to reach a specific diagnosis in patients with testicular torsion, epididymo-orchitis, and testicular trauma.

Sonography of the scrotum

Ultrasonography (US) with a high-frequency (7.5-10-MHz) transducer has become the imaging modality of choice for examination of the scrotum. US examination can provide information valuable for the differential diagnosis of a variety of disease processes involving the scrotum that have similar clinical manifestations (eg, pain, swelling, or presence of mass). The pathologic condition that may be at the origin of such symptoms can vary from testicular torsion to infection to malignancy. The ability of color and power Doppler US to demonstrate testicular perfusion aids in reaching a specific diagnosis in patients with acute scrotal pain. This review covers the anatomy of the scrotum and the scanning protocol for scrotal US, as well as detailed descriptions of disease processes and their US appearances. Newly described conditions such as intratesticular varicoceles and other benign intratesticular cystic lesions are also discussed.

Torsion of the spermatic cord: sonographic diagnosis

This article describes the ultrasound guidelines for evaluating patients with spermatic cord torsion, including gray-scale, Doppler with spectral analysis, and color and power Doppler sonography. The sonographic and Doppler features of acute, subacute, and chronic torsion of the spermatic cord are demonstrated and discussed.

[Usefulness of Doppler-color ultrasonography and identification of resistance indexes as early indicators of testicular infarction secondary to orchiepididymitis]

The testicular infarction can be a rare complication of the orchiepididymitis. The ultrasonography appearance of the partial infarctions creates confusion with expansive intratesticular processes. We present three cases of focal testicular infarction associated with orchiepididymitis, stressing the usefulness of the Color doppler sonography for detecting the avascular nature o these lesions. The determination of de indeces of resistance (IR) in the doppler spectrum of intratesticular arteries showed a highly increased vascular resistance in respect of the healthy testicle. In patients with grave orchiepididymitis vein drainage can be affected due to compressive edema or to thrombosis, causing the raising of the resistance indeces. Acknowledging the avascular resistance of the focal post-orchiepididymitis infarction we can prevent unnecessary orchiectomy.