- Email: [email protected]
IS ROUTINE SCROTAL ULTRASOUND ADVANTAGEOUS IN INFERTILE MEN?
0022-5347/99/1625-1618/0
Vol. 162,1618-1620,November 1999 Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright 0 1999 by AMERICAN U R O ~ I CASSOCIATION, AL INC.
IS ROUTINE SCROTAL ULTRASOUND ADVANTAGEOUS IN INFERTILE MEN? M. VAN MUISWINKEL, J A N T. M. WEEBURG
FRANK H. PIERIK, GERT R. DOHLE, J("NES AND ROBERTUS
F. A. WEBER
From the Departments of Andrology, Urology, Radiology, Medical Informatics, and Endocrinology and Reproduction, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
ABSTRACT
Purpose: We determine the value of routine scrota1 ultrasonography in the evaluation of male infertility. Materials and Methods: Scrota1 color Doppler ultrasonography reports of 1,372 infertile men were reviewed to assess the prevalence of scrotal abnormalities and compared to clinical findings. Results: The prevalence of scrotal abnormalities was 38%.Testicular tumor was found in 0.5%, varicocele in 29.7%, testicular cyst in 0.7%, testicular microlithiasis in 0.9%, epididymal cyst in 7.6% and hydrocele in 3.2% of the cases. Overall, 67% of sonography findings were not evident on palpation, and only 1 of 7 testicular tumors was suspected. Of the varicoceles 60% were not found on physical examination. The rate of testicular tumors (U200) was higher than that reported for the general European population (lI20,OOO). Conclusions: Routine scrotal ultrasound provides valuable information in the diagnostic evaluation of infertile men and substantially more pathological conditions are detected compared to clinical palpation. The high prevalence of testicular malignancies underlines the clinical relevance of routine scrotal ultrasonography in infertile men. KEY WORDS: infertility, male; ultrasonography, Doppler, color; varicocele; testicular neoplasms
Examination of the scrotal contents may reveal pathological conditions affecting male fertility. Varicocele is the most common abnormal finding in infertile men with subnormal semen. In general, screening for varicocele is performed with palpation. Although a varicocele can be diagnosed as a palpable distention of the spermatic cord, poor accuracy of palpation has been reported.' Therefore, we use color Doppler ultrasonography as an alternative to varicocele palpation in infertile men. Ultrasonography combined with color Doppler examination is the method of choice for imaging scrotal organs,2 and allows more objective and precise assessment of varicoceles.3 Concomitant with screening of the scrotal contents for varicocele, color Doppler ultrasonography can reveal other abnormalities not identified by history taking and physical examination. The prevalence of scrotal abnormalities in infertile men, in particular testicular and epididymal anomalies, has not been studied extensively until now, since scrotal color Doppler ultrasonography is generally not used routinely in the evaluation of the infertile man. In recent years a higher incidence of testicular tumors in infertile men compared to the normal population has been reported. This finding suggests that male infertility is associated with an increased risk of testicular malignancy.4 Routine scrotal color Doppler ultrasonography in the high risk group of infertile men may reveal testicular tumors not detected on physical examination. We investigated the value of routine scrotal ultrasonography in infertile men, and compared it to physical examination findings.
initial semen analysis revealed abnormal semen quality, and underwent thorough evaluation according to the World Health Organization (WHO) manual for the standardized investigation of the infertile couple.5 This evaluation included estimation of testicular volume with the Prader orchidometer, varicocele palpation, and assessment of location, size and consistency of testes and epididymides. Of the patients 99% had abnormal semen on 2 analyses, according to WHO6 guidelines. Color Doppler ultrasonography of the scrotal contents was executed on a routine basis with a high frequency duplex echo transducer (7.5 MHz. and higher) equipped with color flow imaging. Varicocele was diagnosed on the basis of a venous diameter of 3 mm. or more with increasing diameter during Valsalva's maneuver or when changing from supine to upright position.7 Increased venous retrograde flow in the pampiniform plexus in the upright position or during Valsalva's maneuver was used as supporting evidence of varicocele.8 Although scrotal ultrasound originally was performed to detect varicoceles, other abnormalities were also reported. Retrospectively the reports were searched for scrotal anomalies classified as varicocele, testicular cysts, testicular microlithiasis (characterized by diffise punctate nonshadowing hyperechoic foci in the testicular parenchyma), testicular tumors, epididymal cysts and hydrocele. Scrotal palpation and color Doppler ultrasonography were performed independently by several investigators.
SUBJECTS AND METHODS
RESULTS
The study comprised 1,372 infertile men 20 to 58 years old who were referred to our andrology outpatient clinic from 1990 to 1996. Infertility was defined as the inability to achieve pregnancy within 1 year. Patients were referred after
In 38% of the infertile men (521 of 1,372) scrotal color Doppler ultrasonography revealed 1 or more abnormalities (table 1). Tumor was suspected in 7 patients on the basis of a circular inhomogeneous area. The diagnosis of a tumor was confirmed by surgery in all cases. Tumors were classified by pathologists as Leydig cell in 5 cases and seminoma in 2. In
Accepted for publication June 11, 1999.
1618
1619
SCROTAL ULTRASOUND IN INFERTILE MEN TABLE1. Findings on scrotal color Doppler ultrasonography in 1,372 infertile men No. Cases (%) Varicocele* Testicular cyst Testicular tumor Testicular microlithiasis EDididymal cyst Hydrocele * Bilateral in 1170 (45of 407 cases).
407 (29.7) 9 (0.7) 7 (0.5) 12 (0.9) 104 (7.6) 44 (3.2)
only 1 of these patients was the testicular tumor suspected on the basis of palpation of a testis with hard consistency and a volume larger than the contralateral testis (25versus 12 ml.). The diameter of this spherical tumor was 3 cm., and the 6 nonpalpable tumors had a maximum diameter of 0.5,0.5,0.8, 1.0, 1.5 and 2.5 cm., respectively. The latter tumor had a soft consistency, and palpation of the testis was complicated by a high scrotal location. This patient had a history of unilateral cryptorchidism of the affected testis. Of the other men with a nonpalpable testicular tumor 1 had a history of epididymoorchitis and 1 bilateral cryptorchidism. Varicocele was the most frequent finding during scrotal color Doppler ultrasonography. The results of palpation and color Doppler ultrasonography as a method to detect a varicocele are compared in table 2. The sensitivity of palpation to detect a varicocele was 40%, specificity 91% and positive predictive value 66%compared to color Doppler ultrasonography. Of 12 patients with testicular microlithiasis 4 had a history of cryptorchidism and 1 had a history of a large cell calcifymg Sertoli cell tumor in the removed contralateral testis. Testes were retractile in 1 patient with testicular microlithiasis. Of the 44 hydroceles detected with color Doppler ultrasonography 4 were palpable. Of 15 hydrocele cases 3 had a history of testicular trauma, 10 had undergone urogenital surgery (inguinal hernia, varicocele repair, orchiectomy, vasectomy, vasovasostomy or orchiopexy), and 2 had a history of epididymitis. In 1 of 9 cases the testicular cyst was palpable. Epididymal cysts were palpable in 22 of 104 patients. Of these patients 4 had pain in the scrotum, 3 had undergone vasovasostomy and 8 had a history of urogenital infection. DISCUSSION
The prevalence of 38% scrotal abnormalities found during scrotal color Doppler ultrasonography in our infertile population was unexpectedly high. Palpation of the scrotal contents revealed abnormalities in only 33% of patients with ultrasonographic abnormalities. Examination of the scrotal contents with color Doppler ultrasonography was primarily performed for detection of varicocele. The prevalence of varicocele was 29.7%.These varicoceles were generally on the left side and bilateral in 11%of the cases. Alithough the color Doppler ultrasonography reports were not standardized for other scrotal findings, hydroceles were reported in 3.2% epididymal cysts in 7.6%,testicular cysts in 0.7%,testicular tumors in 0.5% and testicular microlithiasis in 0.9% of the cases. Due to the retrospective design of our study a fertile control group was not available. Two other studies using T A ~ L 2E. Palpation compared to color Doppler ultrasonography in diagnosing varicocele No. Palpation
Totals
Yes
No
163 85
240 873
CONCLUSIONS
No. color Doppler:
Yes
No Totals
routine scrotal sonography in large groups of infertile men demonstrated a prevalence of 50 and 57% scrotal abnormalThe somewhat ities in 1,048 and 200 cases, respe~tively.9.~~ higher prevalence in these studies may be explained by the additional classifications of enlarged epididymis, testicular inhomogeneity, abnormal testis location and testicular hypoechogenicity. Inhomogeneity of the testicular tissue has been associated with a reduced testicular biopsy score and sperm count." Another advantage of scrotal color Doppler ultrasonography is the more accurate estimation of testicular volume compared to clinical measurements.I2 A 98.5%sensitivity of ultrasound to detect scrotal abnormalities has been reported, with a diagnostic accuracy of 77 to loo%,depending on the type of abnormality.2 The addition of color Doppler technology to ultrasonography has amplified its diagnostic accuracy.2 I n 7 patients suspicion of a tumor was raised on color Doppler ultrasonography, and confirmed by surgery and pathological study. Only 1tumor was suspected on palpation of the testis. The prevalence of testicular tumors in our infertile population (Y200) is in agreement with the high rate of testicular tumors in infertile patients reported by others.9.13-14 Testicular cancer has been associated with cryptorchidism and infertility, and a common etiology has been suggested.4.15 Although we have not performed scrotal color Doppler ultrasonography in a control group of fertile men, the rate in our infertile population (lJ200) is higher than that reported in the general European population (Y20,000).16 On that the basis of this high frequency sonographic screening for testicular tumors in infertile men appears amenable. Early detection of testicular tumors is especially important in men pursuing paternity, so that sperm cryopreservation or assisted reproduction can be performed before spermatogenesis is h r t h e r affected by the tumor or its treatment. Early treatment may prevent more aggressive treatment, thereby limiting damage to spermatogenesis from radiation and chemotherapy in the contralateral testis.4 Testicular microlithiasis was noted in 12 of 1,372 patients. This phenomenon has been associated with Klinefelter's syndrome, infertility, a history of cryptorchidism and testicular neoplasm.17 In 1 of our patients with testicular microlithiasis a Sertoli cell tumor in the contralateral testis has been removed earlier. Of 12 testicular microlithiasis cases 4 had a history of cryptorchidism and in 1 the testes were retractile. Repeat testicular ultrasound to identify tumor development may be indicated in testicular microlithiasis cases. In 9 patients a testicular cyst was diagnosed, which was suspected on palpation in only 1. Intratesticular cysts require further differentiation to exclude from diagnosis the possibility of teratoma.l8 The incidence of epididymal cysts was 7.6% (104 of 1.372 cases). Of the cvsts 21%were also reDorted as a palpable' thickening of the epididymis. The clini'cal significance of epididymal cysts is unclear. They were not equivalent to epididymal obstruction, since azoospermia was observed in only 2 of 17 patients with bilateral epididymal cysts. Varicocele was noted in 407 of 1,372 men (29.7%)and was the most frequent finding. We report a low sensitivity of palpation (40%),which emphasizes that many varicoceles in the infertile population are undetected. The accuracy of palpation is disputed since low interobserver agreement,' sensitivity and specificity have been reported.3.8.19 Color Doppler ultrasonography is a more accurate and objective screening method? and allows grading on the basis of venous diameter or reflw characteristics.
403 958
-
-
-
248
1,113
1,361
Color Doppler ultrasonography is a valuable method for diagnosing scrotal abnormalities in the infertile population. Scrota1 ultrasonography frequently detected scrotal abnor-
SCROTAL ULTRASOUND IN INFERTILE MEN
1620
malities that were nonpdpable. The relatively high prevalence of testicular neoplasms emphasizes the importance of routine scrotal ultrasound in infertile men. REFERENCES
1. Hargreave, T. B.: Varicocele-a clinical enigma. Brit. J. Urol., 7 2 401, 1993. 2. H a m , B.: Sonography of the testis and epididymis. Andrologia, 2 6 193, 1994. 3. Trum, J. W., Gubler, F. M., Laan, R. and van der Veen, F.: The value of palpation, varicoscreen contact themography and colour Doppler ultrasound in the diagnosis of varicocele. Hum. Reprod., 11: 1232, 1996. 4. Petersen, P. M., Giwercman, A., Skakkebaek, N. E. and Rorth, M.: Gonadal function in men with testicular cancer. Sem. Oncol., 2 5 224, 1998. 5. World Health Organization: WHO Manual for the Standardized Investigation and Diagnosis of the Infertile Couple. Edited by p, J , Rowe, F, H. Cornhaire, T, B, Hargreave and H, J. Mellows. Cambridge: Cambridge University Press, 1993. 6. World Health Organization: WHO Laboratory Manual for the Examination of H~~~~ semen and ~ ~ ~ ~M~~~~ Interaction, 3rd ed. Cambridge: Cambridge University Press, 1992. 7. McClure, R. D., Khoo, D., Jarvi, K. and Hricak, H.: Subclinical varicocele: the effectiveness of varicocelectomy. J. Urol., 145: 789, 1991. 8. Petros, J. A., Andriole, G. L., Middleton, W. D. and Picus, D. A.: Correlation of testicular color Doppler ultrasonography, physical examination and venography in the detection of left vancoceles in men with infertility. J. Urol., 145 785, 1991.
9. Behre, H. M., Kliesch, S., Schadel, F. and Nieschlag, E.: Clinical relevance of scrotal and transrectal ultrasonography in andrological patients. Int. J. Androl., suppl., 1 8 27, 1995. 10. Patel, P. J. and Pareek, S.S.: Scrota1 ultrasound in male infertility. Eur. Urol., 1 6 423, 1989. 11. Lenz, S., Thomsen, J. K., Giwercman, A., Hertel, N. T., Hertz, J. and Skakkebaek, N. E.: Ultrasonic texture and volume of testicles in infertile men. Hum. Reprod., 9 878, 1994. 12. Rivkees, S. A., Hall, D. A,, Boepple, P. A. and Crawford, J. D.: Accuracy and reproducibility of clinical measures of testicular volume. J. Ped., 110 914, 1987. 13. West, A. B., Butler, M. R., Fitzpatrick, J. and OBrien, A.: Testicular tumors in subfertile men: report of 4 cases with implications for management of patients presenting with infertility, J. Urol., 133 107, 1985. 14, SkaUebaek,N, E.: Carcinoma in situ ofthe testis: frequency and relationship to invasive germ cell tumours in infertile men. Histopathology, 2 157, 1978. 15. Sharpe, R. M. and Skakkebaek, N. E.: Are oestrogens involved in falling sperm counts and disorders of the male reproductive tract? Lancet, 341: 1392, 1993. ~16. Moller, ~ f H.: Clues i ~to the ~ aetiology l oftesticular germ cell tumours from descriptive epidemiology. Eur. Urol., 2 3 8, 1993. 17. Parra, B. L., Venable, D. D., Gonzalez, E. and Eastham, J. A,: Testicular microlithiasis as a predictor of intratubular germ cell neoplasia. Urology, 4 8 797, 1996. 18. Heidenreich, A,, Engelmann, U. H., Vietsch, H. V. and Derschum, W.: Organ preserving surgery in testicular epidermoid cysts. J. Urol., 153 1147, 1995. 19. World Health Organization: Comparison among different methods for the diagnosis ofvaricocele. Fertil. Steril., 43 575, 1985.
Vol. 162,1618-1620,November 1999 Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright 0 1999 by AMERICAN U R O ~ I CASSOCIATION, AL INC.
IS ROUTINE SCROTAL ULTRASOUND ADVANTAGEOUS IN INFERTILE MEN? M. VAN MUISWINKEL, J A N T. M. WEEBURG
FRANK H. PIERIK, GERT R. DOHLE, J("NES AND ROBERTUS
F. A. WEBER
From the Departments of Andrology, Urology, Radiology, Medical Informatics, and Endocrinology and Reproduction, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
ABSTRACT
Purpose: We determine the value of routine scrota1 ultrasonography in the evaluation of male infertility. Materials and Methods: Scrota1 color Doppler ultrasonography reports of 1,372 infertile men were reviewed to assess the prevalence of scrotal abnormalities and compared to clinical findings. Results: The prevalence of scrotal abnormalities was 38%.Testicular tumor was found in 0.5%, varicocele in 29.7%, testicular cyst in 0.7%, testicular microlithiasis in 0.9%, epididymal cyst in 7.6% and hydrocele in 3.2% of the cases. Overall, 67% of sonography findings were not evident on palpation, and only 1 of 7 testicular tumors was suspected. Of the varicoceles 60% were not found on physical examination. The rate of testicular tumors (U200) was higher than that reported for the general European population (lI20,OOO). Conclusions: Routine scrotal ultrasound provides valuable information in the diagnostic evaluation of infertile men and substantially more pathological conditions are detected compared to clinical palpation. The high prevalence of testicular malignancies underlines the clinical relevance of routine scrotal ultrasonography in infertile men. KEY WORDS: infertility, male; ultrasonography, Doppler, color; varicocele; testicular neoplasms
Examination of the scrotal contents may reveal pathological conditions affecting male fertility. Varicocele is the most common abnormal finding in infertile men with subnormal semen. In general, screening for varicocele is performed with palpation. Although a varicocele can be diagnosed as a palpable distention of the spermatic cord, poor accuracy of palpation has been reported.' Therefore, we use color Doppler ultrasonography as an alternative to varicocele palpation in infertile men. Ultrasonography combined with color Doppler examination is the method of choice for imaging scrotal organs,2 and allows more objective and precise assessment of varicoceles.3 Concomitant with screening of the scrotal contents for varicocele, color Doppler ultrasonography can reveal other abnormalities not identified by history taking and physical examination. The prevalence of scrotal abnormalities in infertile men, in particular testicular and epididymal anomalies, has not been studied extensively until now, since scrotal color Doppler ultrasonography is generally not used routinely in the evaluation of the infertile man. In recent years a higher incidence of testicular tumors in infertile men compared to the normal population has been reported. This finding suggests that male infertility is associated with an increased risk of testicular malignancy.4 Routine scrotal color Doppler ultrasonography in the high risk group of infertile men may reveal testicular tumors not detected on physical examination. We investigated the value of routine scrotal ultrasonography in infertile men, and compared it to physical examination findings.
initial semen analysis revealed abnormal semen quality, and underwent thorough evaluation according to the World Health Organization (WHO) manual for the standardized investigation of the infertile couple.5 This evaluation included estimation of testicular volume with the Prader orchidometer, varicocele palpation, and assessment of location, size and consistency of testes and epididymides. Of the patients 99% had abnormal semen on 2 analyses, according to WHO6 guidelines. Color Doppler ultrasonography of the scrotal contents was executed on a routine basis with a high frequency duplex echo transducer (7.5 MHz. and higher) equipped with color flow imaging. Varicocele was diagnosed on the basis of a venous diameter of 3 mm. or more with increasing diameter during Valsalva's maneuver or when changing from supine to upright position.7 Increased venous retrograde flow in the pampiniform plexus in the upright position or during Valsalva's maneuver was used as supporting evidence of varicocele.8 Although scrotal ultrasound originally was performed to detect varicoceles, other abnormalities were also reported. Retrospectively the reports were searched for scrotal anomalies classified as varicocele, testicular cysts, testicular microlithiasis (characterized by diffise punctate nonshadowing hyperechoic foci in the testicular parenchyma), testicular tumors, epididymal cysts and hydrocele. Scrotal palpation and color Doppler ultrasonography were performed independently by several investigators.
SUBJECTS AND METHODS
RESULTS
The study comprised 1,372 infertile men 20 to 58 years old who were referred to our andrology outpatient clinic from 1990 to 1996. Infertility was defined as the inability to achieve pregnancy within 1 year. Patients were referred after
In 38% of the infertile men (521 of 1,372) scrotal color Doppler ultrasonography revealed 1 or more abnormalities (table 1). Tumor was suspected in 7 patients on the basis of a circular inhomogeneous area. The diagnosis of a tumor was confirmed by surgery in all cases. Tumors were classified by pathologists as Leydig cell in 5 cases and seminoma in 2. In
Accepted for publication June 11, 1999.
1618
1619
SCROTAL ULTRASOUND IN INFERTILE MEN TABLE1. Findings on scrotal color Doppler ultrasonography in 1,372 infertile men No. Cases (%) Varicocele* Testicular cyst Testicular tumor Testicular microlithiasis EDididymal cyst Hydrocele * Bilateral in 1170 (45of 407 cases).
407 (29.7) 9 (0.7) 7 (0.5) 12 (0.9) 104 (7.6) 44 (3.2)
only 1 of these patients was the testicular tumor suspected on the basis of palpation of a testis with hard consistency and a volume larger than the contralateral testis (25versus 12 ml.). The diameter of this spherical tumor was 3 cm., and the 6 nonpalpable tumors had a maximum diameter of 0.5,0.5,0.8, 1.0, 1.5 and 2.5 cm., respectively. The latter tumor had a soft consistency, and palpation of the testis was complicated by a high scrotal location. This patient had a history of unilateral cryptorchidism of the affected testis. Of the other men with a nonpalpable testicular tumor 1 had a history of epididymoorchitis and 1 bilateral cryptorchidism. Varicocele was the most frequent finding during scrotal color Doppler ultrasonography. The results of palpation and color Doppler ultrasonography as a method to detect a varicocele are compared in table 2. The sensitivity of palpation to detect a varicocele was 40%, specificity 91% and positive predictive value 66%compared to color Doppler ultrasonography. Of 12 patients with testicular microlithiasis 4 had a history of cryptorchidism and 1 had a history of a large cell calcifymg Sertoli cell tumor in the removed contralateral testis. Testes were retractile in 1 patient with testicular microlithiasis. Of the 44 hydroceles detected with color Doppler ultrasonography 4 were palpable. Of 15 hydrocele cases 3 had a history of testicular trauma, 10 had undergone urogenital surgery (inguinal hernia, varicocele repair, orchiectomy, vasectomy, vasovasostomy or orchiopexy), and 2 had a history of epididymitis. In 1 of 9 cases the testicular cyst was palpable. Epididymal cysts were palpable in 22 of 104 patients. Of these patients 4 had pain in the scrotum, 3 had undergone vasovasostomy and 8 had a history of urogenital infection. DISCUSSION
The prevalence of 38% scrotal abnormalities found during scrotal color Doppler ultrasonography in our infertile population was unexpectedly high. Palpation of the scrotal contents revealed abnormalities in only 33% of patients with ultrasonographic abnormalities. Examination of the scrotal contents with color Doppler ultrasonography was primarily performed for detection of varicocele. The prevalence of varicocele was 29.7%.These varicoceles were generally on the left side and bilateral in 11%of the cases. Alithough the color Doppler ultrasonography reports were not standardized for other scrotal findings, hydroceles were reported in 3.2% epididymal cysts in 7.6%,testicular cysts in 0.7%,testicular tumors in 0.5% and testicular microlithiasis in 0.9% of the cases. Due to the retrospective design of our study a fertile control group was not available. Two other studies using T A ~ L 2E. Palpation compared to color Doppler ultrasonography in diagnosing varicocele No. Palpation
Totals
Yes
No
163 85
240 873
CONCLUSIONS
No. color Doppler:
Yes
No Totals
routine scrotal sonography in large groups of infertile men demonstrated a prevalence of 50 and 57% scrotal abnormalThe somewhat ities in 1,048 and 200 cases, respe~tively.9.~~ higher prevalence in these studies may be explained by the additional classifications of enlarged epididymis, testicular inhomogeneity, abnormal testis location and testicular hypoechogenicity. Inhomogeneity of the testicular tissue has been associated with a reduced testicular biopsy score and sperm count." Another advantage of scrotal color Doppler ultrasonography is the more accurate estimation of testicular volume compared to clinical measurements.I2 A 98.5%sensitivity of ultrasound to detect scrotal abnormalities has been reported, with a diagnostic accuracy of 77 to loo%,depending on the type of abnormality.2 The addition of color Doppler technology to ultrasonography has amplified its diagnostic accuracy.2 I n 7 patients suspicion of a tumor was raised on color Doppler ultrasonography, and confirmed by surgery and pathological study. Only 1tumor was suspected on palpation of the testis. The prevalence of testicular tumors in our infertile population (Y200) is in agreement with the high rate of testicular tumors in infertile patients reported by others.9.13-14 Testicular cancer has been associated with cryptorchidism and infertility, and a common etiology has been suggested.4.15 Although we have not performed scrotal color Doppler ultrasonography in a control group of fertile men, the rate in our infertile population (lJ200) is higher than that reported in the general European population (Y20,000).16 On that the basis of this high frequency sonographic screening for testicular tumors in infertile men appears amenable. Early detection of testicular tumors is especially important in men pursuing paternity, so that sperm cryopreservation or assisted reproduction can be performed before spermatogenesis is h r t h e r affected by the tumor or its treatment. Early treatment may prevent more aggressive treatment, thereby limiting damage to spermatogenesis from radiation and chemotherapy in the contralateral testis.4 Testicular microlithiasis was noted in 12 of 1,372 patients. This phenomenon has been associated with Klinefelter's syndrome, infertility, a history of cryptorchidism and testicular neoplasm.17 In 1 of our patients with testicular microlithiasis a Sertoli cell tumor in the contralateral testis has been removed earlier. Of 12 testicular microlithiasis cases 4 had a history of cryptorchidism and in 1 the testes were retractile. Repeat testicular ultrasound to identify tumor development may be indicated in testicular microlithiasis cases. In 9 patients a testicular cyst was diagnosed, which was suspected on palpation in only 1. Intratesticular cysts require further differentiation to exclude from diagnosis the possibility of teratoma.l8 The incidence of epididymal cysts was 7.6% (104 of 1.372 cases). Of the cvsts 21%were also reDorted as a palpable' thickening of the epididymis. The clini'cal significance of epididymal cysts is unclear. They were not equivalent to epididymal obstruction, since azoospermia was observed in only 2 of 17 patients with bilateral epididymal cysts. Varicocele was noted in 407 of 1,372 men (29.7%)and was the most frequent finding. We report a low sensitivity of palpation (40%),which emphasizes that many varicoceles in the infertile population are undetected. The accuracy of palpation is disputed since low interobserver agreement,' sensitivity and specificity have been reported.3.8.19 Color Doppler ultrasonography is a more accurate and objective screening method? and allows grading on the basis of venous diameter or reflw characteristics.
403 958
-
-
-
248
1,113
1,361
Color Doppler ultrasonography is a valuable method for diagnosing scrotal abnormalities in the infertile population. Scrota1 ultrasonography frequently detected scrotal abnor-
SCROTAL ULTRASOUND IN INFERTILE MEN
1620
malities that were nonpdpable. The relatively high prevalence of testicular neoplasms emphasizes the importance of routine scrotal ultrasound in infertile men. REFERENCES
1. Hargreave, T. B.: Varicocele-a clinical enigma. Brit. J. Urol., 7 2 401, 1993. 2. H a m , B.: Sonography of the testis and epididymis. Andrologia, 2 6 193, 1994. 3. Trum, J. W., Gubler, F. M., Laan, R. and van der Veen, F.: The value of palpation, varicoscreen contact themography and colour Doppler ultrasound in the diagnosis of varicocele. Hum. Reprod., 11: 1232, 1996. 4. Petersen, P. M., Giwercman, A., Skakkebaek, N. E. and Rorth, M.: Gonadal function in men with testicular cancer. Sem. Oncol., 2 5 224, 1998. 5. World Health Organization: WHO Manual for the Standardized Investigation and Diagnosis of the Infertile Couple. Edited by p, J , Rowe, F, H. Cornhaire, T, B, Hargreave and H, J. Mellows. Cambridge: Cambridge University Press, 1993. 6. World Health Organization: WHO Laboratory Manual for the Examination of H~~~~ semen and ~ ~ ~ ~M~~~~ Interaction, 3rd ed. Cambridge: Cambridge University Press, 1992. 7. McClure, R. D., Khoo, D., Jarvi, K. and Hricak, H.: Subclinical varicocele: the effectiveness of varicocelectomy. J. Urol., 145: 789, 1991. 8. Petros, J. A., Andriole, G. L., Middleton, W. D. and Picus, D. A.: Correlation of testicular color Doppler ultrasonography, physical examination and venography in the detection of left vancoceles in men with infertility. J. Urol., 145 785, 1991.
9. Behre, H. M., Kliesch, S., Schadel, F. and Nieschlag, E.: Clinical relevance of scrotal and transrectal ultrasonography in andrological patients. Int. J. Androl., suppl., 1 8 27, 1995. 10. Patel, P. J. and Pareek, S.S.: Scrota1 ultrasound in male infertility. Eur. Urol., 1 6 423, 1989. 11. Lenz, S., Thomsen, J. K., Giwercman, A., Hertel, N. T., Hertz, J. and Skakkebaek, N. E.: Ultrasonic texture and volume of testicles in infertile men. Hum. Reprod., 9 878, 1994. 12. Rivkees, S. A., Hall, D. A,, Boepple, P. A. and Crawford, J. D.: Accuracy and reproducibility of clinical measures of testicular volume. J. Ped., 110 914, 1987. 13. West, A. B., Butler, M. R., Fitzpatrick, J. and OBrien, A.: Testicular tumors in subfertile men: report of 4 cases with implications for management of patients presenting with infertility, J. Urol., 133 107, 1985. 14, SkaUebaek,N, E.: Carcinoma in situ ofthe testis: frequency and relationship to invasive germ cell tumours in infertile men. Histopathology, 2 157, 1978. 15. Sharpe, R. M. and Skakkebaek, N. E.: Are oestrogens involved in falling sperm counts and disorders of the male reproductive tract? Lancet, 341: 1392, 1993. ~16. Moller, ~ f H.: Clues i ~to the ~ aetiology l oftesticular germ cell tumours from descriptive epidemiology. Eur. Urol., 2 3 8, 1993. 17. Parra, B. L., Venable, D. D., Gonzalez, E. and Eastham, J. A,: Testicular microlithiasis as a predictor of intratubular germ cell neoplasia. Urology, 4 8 797, 1996. 18. Heidenreich, A,, Engelmann, U. H., Vietsch, H. V. and Derschum, W.: Organ preserving surgery in testicular epidermoid cysts. J. Urol., 153 1147, 1995. 19. World Health Organization: Comparison among different methods for the diagnosis ofvaricocele. Fertil. Steril., 43 575, 1985.