Quantitative Doppler assessment of acute scrotal inflammation

Evaluation of Scrotal Pathologies by Ultrasound and Color Doppler

Introduction Due to its ease of use, lack of ionizing radiation exposure, noninvasive nature, reproducibility, low cost, and ease of accessibility, ultrasound (US) is the preferred imaging modality for evaluating scrotal disease. High-resolution US and color Doppler better highlight scrotal and testicular diseases because of the scrotum's superficial anatomy. The genital organs are subjected to damaging ionizing radiation during CT, while MRI is both costly and uncommon. Aims and objectives The aim of this study is to use ultrasonography (USG) to examine various scrotal diseases and to diagnose and identify different disorders utilizing high-resolution US and color Doppler. Materials and methods The study was done on 60 patients who were referred to the Department of Radiodiagnosis by the General Surgery and Urology departments for the scrotal US and Doppler study. This study was conducted between October 2021 and March 2022 at the Indira Gandhi Institute of Medical Sciences, Patna, India. Results Out of 60 patients, hydrocele was seen in 25 cases, scrotal hernia in 12 cases, undescended testis in eight cases, varicocele and epididymal cysts in seven cases, etc. In acutely painful scrotal disorders, high-frequency US with color Doppler sonography successfully distinguishes between testicular ischemia/torsion and acute inflammatory illnesses. Eighteen cases of inflammatory scrotal pathologies and one case of testicular torsion were seen.  Conclusion In detecting and assessing scrotal diseases, high-frequency USG and color Doppler sonography have good sensitivity and specificity. Furthermore, the lack of ionizing radiation, simplicity, wide availability, cost-efficiency, and reproducibility make it a highly important method for scrotal diseases.

Testicular infarction and spontaneous scrotal rupture secondary to acute epididymo-orchitis

Epididymo-orchitis is a common cause of acute unilateral testicular pain. Both infectious or non-infectious causes have been proposed and, rarely, testicular abscess formation and even infarction can occur as a severe complication. We present here a case of acute epididymo-orchitis leading to testicular abscess formation, infarction and spontaneous rupture through the scrotal wall despite appropriate antibiotic treatments. Orchidectomy and partial scrotectomy were performed during surgical exploration for management of the non-viable testis and associated scrotal sinus. Clinical vigilance is important to prevent this complication by close clinical follow up with ultrasonography and even early surgical decompression to prevent testicular loss.

Ultrasonography of the scrotum: Revisiting a classic technique

Conventional US is the primary imaging modality for the evaluation of the scrotum, due to its high resolution, availability, cost-effectiveness and absence of ionizing radiation. Grayscale and color Doppler US provide a comprehensive assessment of scrotal diseases. The technique represents the mainstay for imaging of acute scrotum. US is highly accurate in the detection, localization and characterization of scrotal masses. Multiparametric US, including conventional US, contrast-enhanced US and tissue elastography has improved the diagnostic performance of the technique in the assessment of testicular diseases. MRI represents a valuable supplemental imaging tool for the investigation of scrotal pathology, mainly recommended in cases of indeterminate US findings. Recommendations recently issued by the European Society of Urogenital Radiology Scrotal and Penile Imaging Working Group (ESUR-SPIWG) refer to the use of scrotal sonography for the evaluation of pathologic entities, including testicular microlithiasis, small, non-palpable incidentally detected testicular masses, varicocele and scrotal trauma. In this review, the technical specifications for scrotal US and the normal sonographic findings are presented. Grayscale and color Doppler US findings of common acute scrotal diseases and scrotal masses are discussed. The complimentary role of multiparametric US and scrotal MRI is addressed. ESUR-SPIWG's guidelines are also reviewed.

Radiological patterns of incidental epididymitis in mild-to-moderate COVID-19 patients revealed by colour Doppler ultrasound

The testis is a potential target organ for SARS-CoV-2 infection. Our study intended to investigate any testicular involvement in mild-to-moderate COVID-19 men. We conduct a cross-sectional study in 18 to 55-year-old men hospitalised for confirmed COVID-19. A senior radiologist executed the ultrasound with multi-frequency linear probe in all participants, regardless of any scrotal complaints. Exclusion criteria involved any situation that could impair testicular function. Statistical analysis compared independent groups, classified by any pathological change. Categorical and numerical outcome hypotheses were tested by Fisher's Exact and Mann-Whitney tests, using the Excel for Mac, version 16.29 (p < .05). The sample size was 26 men (mean 33.7 ± 6.2 years; range: 21-42 years), all without scrotal complaints. No orchitis was seen. Eleven men (32.6 ± 5.8 years) had epididymitis (42.3%), bilateral in 19.2%. More than half of men with epididymitis displayed epididymal head augmentation > 1.2 cm (p = .002). Two distinct epididymitis' patterns were reported: (a) disseminated micro-abscesses (n = 6) and (b) inhomogeneous echogenicity with reactional hydrocele (n = 5). Both patterns revealed increased epididymal head, augmented Doppler flow and scrotal skin thickening. The use of colour Doppler ultrasound in mild-to-moderate COVID-19 men, even in the absence of testicular complaints, might be useful to diagnose epididymitis that could elicit fertility complications.

Complete testicular infarction secondary to epididymoorchitis and pyocele

Epididymoorchitis is a relatively common urologic condition involving the scrotum which presents with unilateral pain and swelling. It is typically treated with antibiotics but can progress to complications such as scrotal pyocele. Global testicular infarction is an exceedingly rare but devastating complication of epididymoorchitis. Grey scale and color Doppler ultrasound demonstrate testicular hypovascularity with subsequent hypoechoic changes of the testicular parenchyma. Scrotal MRI shows T2 hyperintense changes through the testicle with nonenhancement of the testicular parenchyma post contrast, consistent with infarction. The cause of global infarction in epididymitis is uncertain but may be due to mixed arterial and venous insufficiency. This case illustrates a 41-year-old male that developed acute left testicular pain. Initial ultrasound showed an enlarged left testicle with hyperemia. The patient's symptoms progressed and a scrotal MRI demonstrated a lack of left testicular enhancement consistent with global infarction, as well as an adjacent pyocele.

Acute Epididymo-orchitis-Related Global Testicular Infarction: Clinical and Ultrasound Findings With an Emphasis on the Juxta-epididymal String-of-Bead Sign

Acute epididymo-orchitis (AEO)-related global testicular infarction (GTI) is rare. We report herein the clinical and ultrasound findings of 6 patients with AEO-related GTI. Seventeen patients with torsion-related GTI were also reviewed and compared. The echotexture of AEO-related GTI ranged from mildly inhomogeneous to diffuse heteroechoic, depending on the severity of testicular necrotic changes. All of the patients showed a juxta-epididymal string-of-bead pattern on color Doppler ultrasound, which was ascribed to patent arteries (5/6, 87%) and collateral vessels (1/6, 13%) in the tunica albuginea. There were no significant differences in age, laterality, leukocyte count, testicular volume ratio (infarcted/normal), frequencies of heteroechoic testicular parenchyma, scrotal skin thickening, and hydrocele between the 2 groups. However, the left testis was predominantly affected in both groups. Compared with torsion-related GTI, patients with AEO-related GTI had significantly longer duration from scrotal pain onset to surgery (13.5 ± 5.2 vs 2.6 ± 2.0 days, P < 0.001), a higher level of serum C-reactive protein (110.0 ± 82.0 vs 41.2 ± 35.9 mg/dL, P = 0.013), a higher frequency of the juxta-epididymal string-of-bead sign (100% vs 12%, P < 0.001), and a lower frequency of the whirlpool/knot sign (0% vs 88%, P = 0.002). Although the testis in AEO-related GTI may appear variable from mildly to extensively heteroechoic on gray-scale ultrasound, this unusual disease can be characterized by an avascular testis with a juxta-epididymal string-of-bead sign on color Doppler ultrasound.

Color Doppler Imaging of the Scrotum

Sonographic evaluation of the scrotum provides an accurate method to evaluate normal anatomy and diagnose scrotal pathology. The anatomy, venous and arterial supply as well as the sonographic evaluation are described herein. This review also describes pathologies that may be encountered during sonographic evaluation.

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.

Testicular perfusion after standing laparoscopic peritoneal flap hernioplasty in stallions

Acquired inguinal herniation is a very common condition in stallions, usually leading to unilateral or bilateral castration to prevent future recurrence. Recently, several surgical techniques such as the standing laparoscopic peritoneal flap hernioplasty (SLPFH) have been developed to avoid herniation recurrence and also preserve the breeding activity of high economic value stallions. However, studies on SLPFH lack more comprehensive and systematic data about reproductive-related adverse effects and outcomes. The aim of this study was to evaluate whether SLPFH of the internal inguinal rings produces changes in the testicular blood flow in a 1-year follow-up. For that purpose, six healthy stallions were used and testicular blood flow was assessed before, 3, 6, and 12 months (T0, T3, T6, and T12) after the procedure. Blood flow was evaluated ultrasonographically, using the pulsed-wave color Doppler mode. Peak systolic velocity, end-diastolic velocity, the time-averaged maximum velocity, and the derived indexes (resistive index) and pulsatility index) of the testicular artery were measured in two localizations: in the spermatic cord and on the caudal epididymal edge of the testicle. On the spermatic cord, the peak systolic velocity of the testicular artery increased significantly at T12. However, on the epididymal edge location of the artery, the pulsatility and resistive indexes were decreased at T12 (P < 0.05). This pattern of blood flow was related to a hyperemic process. Furthermore, SLPFH might have compressed the spermatic cord, causing a slight occlusion of the testicular artery and triggering a compensatory hyperemia to compensate the deficit of blood flow that supplies the testes. The SLPFH of the internal inguinal ring affected the testicular perfusion in stallions in a 1 year follow-up, although there was no effect on sperm production during this time. The spectral Doppler ultrasound is a useful tool to asses the testicular perfusion after reproductive surgical procedure and provides information which anticipates vascular supply compromise of the stallion testicles.

Global testicular infarction in the presence of epididymitis: clinical features, appearances on grayscale, color Doppler, and contrast-enhanced sonography, and histologic correlation

Epididymitis is common, presenting indolently with unilateral scrotal pain and swelling. Diagnosis is based on clinical assessment and resolves with antibiotic therapy. Recognized complications are abscess formation and segmental infarction. Global testicular infarction is rare. Diagnosis is important and requires surgical management. On grayscale sonography, global infarction may be difficult to establish. The addition of color Doppler imaging is useful but is observer experience dependent with limitations in the presence of low flow. Contrast-enhanced sonography is useful for unequivocally establishing the diagnosis. We report global testicular infarction in 2 patients with epididymitis clearly depicted on contrast-enhanced sonography, allowing immediate surgical management.

Ultrasound of the Scrotum

Ultrasound is a vital adjunct to clinical examination in diagnosing scrotal disease, as a number of different processes may present similarly. Potential applications range from the acute emergency to long-term screening as well as cases in which a distinct scrotal abnormality may or may not be palpable. Differentiating acute epididymitis/epididymoorchitis from testicular torsion is possible sonographically, thereby guiding appropriate medical or surgical management. Distinguishing between cystic, solid, or complex scrotal masses is readily performed with this modality. It clearly depicts simple versus complex hydroceles and determines the presence of underlying testicular or epididymal disease. Not only is ultrasound the best imaging modality for longitudinal screening in patients (testicular microlithiasis, cryptorchidism) at risk for testicular tumors, it also provides valuable information in the infertile male by documenting the presence or absence of a varicocele.

Clinical Presentation of Acute Scrotum in Young Males

The purpose of this study was to assess the clinical presentation and ultrasonographic findings of acute scrotum in young males. A total of 87 patients (<or= 25 years old) with presentation of acute scrotum were retrospectively analyzed in Kaohsiung Medical University Hospital. The patients were divided into three groups according to their final diagnosis: 41 patients with testicular torsion (TT), eight patients with torsion of the testicular appendage (TTA), and 38 patients with epididymo-orchitis (EO). The mean ages of the TT group (14.0 +/- 5.7 years) and EO group (16.6 +/- 7.6 years) were higher than that of the TTA group (10.0 +/- 3.5 years) (p = 0.02). White blood cell count (> 10,000 cells/microL) was not found to be statistically different among groups. Pyuria was found in 10 (26%) patients with EO. Color Doppler ultrasound has high sensitivity (87.9%) and specificity (93.3%) rates to differentiate TT from other causes of acute scrotum. In cases with a lower risk of TT, we suggest that a technically adequate color Doppler ultrasound may be arranged to help differentiate diagnoses and prevent needless surgery. The importance of emergent management for acute scrotum should also be impressed upon the public through education to avoid delayed presentation to medical facilities.

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.

High-frequency color Doppler ultrasonography of the spermatic cord arteries: resistive index variation in a cohort of 51 healthy men

OBJECTIVE

The purpose of this study was to determine the normal range of Doppler ultrasonographic measurements of spermatic cord arteries in a cohort of healthy men.

METHODS

The spermatic cord arteries of 51 men were interrogated with color Doppler ultrasonography. The resistive index (RI) of each artery was measured for the entire cohort; peak systolic and end-diastolic velocity values were obtained in a smaller subgroup (n = 31). The artery with the lowest RI was labeled A; the other 2 arteries were identified as B and C.

RESULTS

Three separate arteries were identified within the spermatic cord in all individuals. The median RI values for arteries A, B, and C were 0.70 (range, 0.48-0.82), 0.84 (0.67-0.90), and 0.84 (0.72-0.92), respectively. One-way analysis of variance showed a significant difference between the mean RIs of arteries A and B (P < .0001) and arteries A and artery C (P < .0001) but not between B and C (P = .49). Peak systolic and end-diastolic velocity values differed significantly between arteries A and B (P < .0001) and arteries A and C (P < .0001) but not between B and C (P = .31). No age effect was shown for the RI measurements of the cohort.

CONCLUSIONS

Color Doppler ultrasonography enables the objective quantification of Doppler measurements of arteries within the spermatic cord. Knowledge of the normal range of Doppler measurements for spermatic cord arteries that supply the testes may be a useful adjunct to the assessment of the testes.

Ultrasound of the scrotum

Ultrasound plays an important role in the diagnostic workup of scrotal diseases. It can differentiate a testicular mass from an extratesticular mass and determine whether the mass is cystic, solid, or complex. Using this information a likely diagnosis can be ascertained. In the acute scrotum, acute epididymitis/epididymo-orchitis can in most cases be distinguished from testicular torsion. Following scrotal trauma, surgery is needed to salvage the testis if there is testicular disruption and ultrasound can help with this diagnostic dilemma. When a large hydrocele is present, ultrasound allows evaluation of the underlying testis and epididymis and it can detect varicoceles, especially in the infertile male. In patients at risk for a testicular tumor (cryptorchid testis, testicular microlithiasis), ultrasound is the best imaging modality for follow-up. CT, MRI, and nuclear medicine scanning may be necessary for further evaluation of scrotal diseases and this will be briefly addressed.

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.

Scrotal ultrasonography with emphasis on the extratesticular space: anatomy, embryology, and pathology

Sonography is the imaging modality of choice in detecting and characterizing pathologic conditions affecting the extratesticular space. Although most abnormalities are benign, many may simulate or represent malignant processes. Accurate diagnosis is therefore essential and must be based not only on the sonographic findings but also on accurate clinical history and physical examination findings. This article reviews the anatomy, embryologic development, and pathologic conditions affecting the extratesticular space.

Clinical and imaging features of testicular torsion: role of ultrasound

The early and accurate diagnosis of testicular torsion remains a clinical challenge. The implications of a missed diagnosis have emphasized the need for a non-invasive test for confirming testicular ischaemia; a problem highlighted by difficulties in establishing the diagnosis clinically. Understandably, the advent of colour Doppler ultrasound (CDUS) (and subsequently 'power' Doppler and microbubble ultrasound contrast), has been greeted with enthusiasm. However, as in other fields of medicine, a policy placing sole reliance on a single technique is likely to be flawed. This review will critically evaluate the role of CDUS and other imaging modalities in the diagnosis of testicular torsion.

The acute scrotum

Every boy with acute onset scrotal pain and swelling requires an immediate evaluation. Our protocol (Fig. 6) for the evaluation of these children is based on the history and physical examination combined with the selective use of imaging studies. When used appropriately, this protocol facilitates the rapid identification of children with torsion and minimizes the number of unnecessary scrotal explorations. When the duration of the pain is brief, and history and physical examination suggest that torsion is the most likely diagnosis, urgent surgical exploration without additional imaging studies is recommended. When it is not possible to definitely diagnose or exclude the diagnosis of testicular torsion, or when the duration of pain is greater than 12 hours, then diagnostic imaging can provide significant information. Color Doppler sonography is, in the authors' opinion, preferable to nuclear imaging for the evaluation of children with acute scrotums. When normal or increased blood flow is present, scrotal exploration is not required. When the study demonstrates decreased blood flow or does not provide a definite diagnosis, scrotal exploration is recommended. The authors recommend this approach because less than one third of these children have testicular torsion, and if routine scrotal exploration is performed for all boys with acute scrotums, a significant number of unnecessary surgical procedures will result.

Ultrasound in the assessment of the acute scrotum

Color Doppler imaging (CDI) has become the study of choice in evaluation of the scrotum due to technological advances resulting in superior resolution and sensitive Doppler systems. CDI has become particularly helpful in evaluating the scrotum in the setting of acute disorders, such as torsion of the spermatic cord, epididymal and testicular inflammation, and scrotal trauma. CDI should be the study of choice to evaluate for torsion of the spermatic cord and demonstrates a high degree of accuracy. CDI in such a setting, however, does require operator experience, sensitive Doppler ultrasound equipment, and operator knowledge of the limitations of CDI. With epididymitis or epididymo-orchitis, CDI has proven to be quite helpful in evaluating the scrotal contents for the presence of inflammation and associated complications. In scrotal trauma, CDI's utility remains somewhat controversial, but with further investigation its appropriate application in this situation may become clear.