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Necrotic testicle with increased blood flow on doppler ultrasonic examination
NECROTIC
TESTICLE
INCREASED DOPPLER ANTHONY JOSI?
0.
ARTHUR
BLOOD FLOW ON ULTRASONIC
J. PERRI, MORALES,
M.D.
KENDALL,
KARAFIN,
EXAMINATION
M.D.
E. FELDMAN,
A. RICHARD LESTER
WITH
M.D. M.D.
M.D.
From the Departments of Urology, Temple University Medical Center and the Medical College of Pennsylvania, and the Division of Nuclear Medicine, Episcopal Hospital, Philadelphia, Pennsylvania
ABSTRACT -A twelve-year-old male with a five-day history of scrotal swelling and pain had increased bloodjow on ultrasonic examination. A testicular&w and scan indicated an ischemic testicle. Surgical exploration revealed complete torsion of the spermatic cord. In chronic cases of torsion, the Doppler stethoscope may give a false negative result because of reactive hyperemia.
Recent reports by Levy,l Pedersen, Helm, and Hald,2 Thompson and associates3 and Perri et al. ,4 have demonstrated the accuracy of the Doppler ultrasonic stethoscope in the differential diagnosis of acute scrotal swellings. Perri et al5 found total accuracy and complete agreement between testicular scans and the ultrasound examinations in a series of animals whose spermatic cords were surgically twisted. A positive result on ultrasonic examination for torsion ofthe spermatic cord is defined as decreased or absent blood flow. In all of these series, no false negatives were observed in cases of acute torsion of the cord. The following case is presented to demonstrate one of the inherent limitations of ultrasonic diagnosis of a torsion, the value of using a scan to complement the Doppler stethoscope, and the necessity to continue to rely on one’s clinical judgment. Case Report A twelve-year-old of painfully swollen,
UROLOGY
male with a five-day history tender, erythematous, and
/ SEFTEMBER
1976 / VOLUME
VIII.
NUMBER
indurated right hemiscrotum was seen in the emergency room. The patient denied injury, fever, or any urinary tract symptoms. Physical examination revealed a well-developed, wellnourished male in significant pain. His temperature was 101” F., pulse 110, and blood pressure 110/60. The remainder of the physical examination findings were within normal limits except for the right scrotal contents which were indurated, tender, enlarged, and erythematous. The testis could not be differentiated from the epididymis. Laboratory data: Urinalysis showed clear, yellow urine, pH-6, protein negative, no white blood cells, and no bacteria; urine cultures were negative; white blood cell count was 8,800 with 47 neutrophils, 39 lymphocytes, and 14 monocytes. A Doppler ultrasonic examination demonstrated increased blood flow in the involved testis. A technetium-99m scan was performed which revealed a cold area in the region of the right testis surrounded by reactive hyperemia. He underwent scrotal exploration that showed complete torsion of spermatic cord with
3
265
necrotic testicle. The scrotal skin was extremely edematous and inflamed. Orchiectomy was performed, followed by contralateral orchidopexy after the marked inflammation had resolved. Method
The Medsonic Ultrasonsic Stethoscope (Model BF4A) was used to evaluate the blood flow in the
ggmTc scans. (A) At five seconds iliac arFIGURE 1. teries well visualized and isotope beginning to appear in right side of scrotum, and(B) atfifteen seconds area of increased vascularity shown, as compared with left. Note avascular region (arrow). (C) At thirty seconds left side of scrotum and left testis show adequate perfusion. (D) At five minutes, cold nodule on right (arrow) shown, representing necrotic testicle surrounded by hyperemic area of injikmmation; normal left testicle adjacent to this area.
266
UROLOGY
/ SEPTEMBER
1976 / VOLUME
VIII,
NUMBER 3
involved testicle. According to the method described by Levy,’ the untiected testicle was arbitrarily designated 2 plus on a 0 to 4 plus scale. The affected testicle was then auscultated and the blood flow graded accordingly. The testicular scan was performed by placing the patient in the supine position. He was then injected with 10 mCi ggmTc sodium pertechnetate. An Ohio Nuclear Gamma Camera was used to image the patient after the scrotum was centered. At first a flow study was performed by imaging the scrotum every three seconds for thirty seconds at high intensity for periods of one-half second. Scans were obtained by obtaining images at one and five minutes with 300,000 counts.
Results The Doppler stethoscope demonstrated increased blood flow in the involved testicle, and according to the scale mentioned, it was graded as 4 plus. However, the testicular scan revealed a cold area in the right side of the scrotum that we believed was a necrotic testis due to a twisted spermatic cord. The nuclear studies explain these apparently contradictory results. On the flow studies, we first see the iliac arteries well demonstrated (Fig. lA), and then the earlier appearance of the technetium in the right scrotum before its appearance on the left side (Fig. 1B). At this time, an avascular region in the right side of the scrotum is apparent. At twenty-five seconds after the injection, the left side of the scrotum is visualized along with the left testicle (Fig. 1C). The images obtained after five minutes show the cold nodule on the right surrounded by an area of increased vascularity; the left testicle shows a normal degree of perfusion (Fig. 1D). Comment The necrotic testicle obviously elicited an inflammatory response that resulted in a region of
UROLOGY /
increased vascularity; it was this area of augmented perfusion that was demonstrated by the Doppler stethoscope. This case demonstrates the importance of being able not only to utilize the modern modalities of diagnosis but also being able to interpret and evaluate appropriately the results obtained by these instruments. The Doppler stethoscope cannot diagnose torsion of the spermatic cord for the urologist it can only inform him of the absence or presence of blood flow. How the urologist uses this information is based on his own judgment and ability. We do not imply that the testicular scan is more accurate than the ultrasound examination, In this particular case, the chronicity of the torsion was responsible for the false negative Doppler reading. In acute scrotal swellings, we continue to be impressed by the accuracy of the Doppler stethoscope to demonstrate whether or not a testicle is ischemic. However, whenever there is a question of diagnosis, we do not hesitate to obtain a scrotal scan and, if necessary, surgically explore the scrotum. Temple University Hospital 3401 N. Broad Street Philadelphia, Pennsylvania 19140 (DR. PERRI) References 1. LEVY, B. : The diagnosis of the testicle using the Doppler ultrasonic stethoscope, J. Urol. 113:63 (1975). 2. PEDERSEN, J., HOLM, H. H., and HALD, T.: Torsion of the testis diagnosed by ultrasound, ibid. 113:66 (1975). 3. THOMPSON, J., et al. : Diagnosis of testicular torsion using Doppler ultrasonic flowmeter, Urology 6: 706 (1975). 4. PERRI, A., et al.: The Doppler stethoscope and the diagnosis of the acute scrotum, to be published in J. Urol. 5. PERRI, A., et al. : An evaluation of the role of the Doppler stethoscope and the testicular scan in the diagnosis of torsion of the spermatic cord, submitted to J. Urol.
SEPTEMBER 1976 / VOLUME VIII. NUMBER 3
267
TESTICLE
INCREASED DOPPLER ANTHONY JOSI?
0.
ARTHUR
BLOOD FLOW ON ULTRASONIC
J. PERRI, MORALES,
M.D.
KENDALL,
KARAFIN,
EXAMINATION
M.D.
E. FELDMAN,
A. RICHARD LESTER
WITH
M.D. M.D.
M.D.
From the Departments of Urology, Temple University Medical Center and the Medical College of Pennsylvania, and the Division of Nuclear Medicine, Episcopal Hospital, Philadelphia, Pennsylvania
ABSTRACT -A twelve-year-old male with a five-day history of scrotal swelling and pain had increased bloodjow on ultrasonic examination. A testicular&w and scan indicated an ischemic testicle. Surgical exploration revealed complete torsion of the spermatic cord. In chronic cases of torsion, the Doppler stethoscope may give a false negative result because of reactive hyperemia.
Recent reports by Levy,l Pedersen, Helm, and Hald,2 Thompson and associates3 and Perri et al. ,4 have demonstrated the accuracy of the Doppler ultrasonic stethoscope in the differential diagnosis of acute scrotal swellings. Perri et al5 found total accuracy and complete agreement between testicular scans and the ultrasound examinations in a series of animals whose spermatic cords were surgically twisted. A positive result on ultrasonic examination for torsion ofthe spermatic cord is defined as decreased or absent blood flow. In all of these series, no false negatives were observed in cases of acute torsion of the cord. The following case is presented to demonstrate one of the inherent limitations of ultrasonic diagnosis of a torsion, the value of using a scan to complement the Doppler stethoscope, and the necessity to continue to rely on one’s clinical judgment. Case Report A twelve-year-old of painfully swollen,
UROLOGY
male with a five-day history tender, erythematous, and
/ SEFTEMBER
1976 / VOLUME
VIII.
NUMBER
indurated right hemiscrotum was seen in the emergency room. The patient denied injury, fever, or any urinary tract symptoms. Physical examination revealed a well-developed, wellnourished male in significant pain. His temperature was 101” F., pulse 110, and blood pressure 110/60. The remainder of the physical examination findings were within normal limits except for the right scrotal contents which were indurated, tender, enlarged, and erythematous. The testis could not be differentiated from the epididymis. Laboratory data: Urinalysis showed clear, yellow urine, pH-6, protein negative, no white blood cells, and no bacteria; urine cultures were negative; white blood cell count was 8,800 with 47 neutrophils, 39 lymphocytes, and 14 monocytes. A Doppler ultrasonic examination demonstrated increased blood flow in the involved testis. A technetium-99m scan was performed which revealed a cold area in the region of the right testis surrounded by reactive hyperemia. He underwent scrotal exploration that showed complete torsion of spermatic cord with
3
265
necrotic testicle. The scrotal skin was extremely edematous and inflamed. Orchiectomy was performed, followed by contralateral orchidopexy after the marked inflammation had resolved. Method
The Medsonic Ultrasonsic Stethoscope (Model BF4A) was used to evaluate the blood flow in the
ggmTc scans. (A) At five seconds iliac arFIGURE 1. teries well visualized and isotope beginning to appear in right side of scrotum, and(B) atfifteen seconds area of increased vascularity shown, as compared with left. Note avascular region (arrow). (C) At thirty seconds left side of scrotum and left testis show adequate perfusion. (D) At five minutes, cold nodule on right (arrow) shown, representing necrotic testicle surrounded by hyperemic area of injikmmation; normal left testicle adjacent to this area.
266
UROLOGY
/ SEPTEMBER
1976 / VOLUME
VIII,
NUMBER 3
involved testicle. According to the method described by Levy,’ the untiected testicle was arbitrarily designated 2 plus on a 0 to 4 plus scale. The affected testicle was then auscultated and the blood flow graded accordingly. The testicular scan was performed by placing the patient in the supine position. He was then injected with 10 mCi ggmTc sodium pertechnetate. An Ohio Nuclear Gamma Camera was used to image the patient after the scrotum was centered. At first a flow study was performed by imaging the scrotum every three seconds for thirty seconds at high intensity for periods of one-half second. Scans were obtained by obtaining images at one and five minutes with 300,000 counts.
Results The Doppler stethoscope demonstrated increased blood flow in the involved testicle, and according to the scale mentioned, it was graded as 4 plus. However, the testicular scan revealed a cold area in the right side of the scrotum that we believed was a necrotic testis due to a twisted spermatic cord. The nuclear studies explain these apparently contradictory results. On the flow studies, we first see the iliac arteries well demonstrated (Fig. lA), and then the earlier appearance of the technetium in the right scrotum before its appearance on the left side (Fig. 1B). At this time, an avascular region in the right side of the scrotum is apparent. At twenty-five seconds after the injection, the left side of the scrotum is visualized along with the left testicle (Fig. 1C). The images obtained after five minutes show the cold nodule on the right surrounded by an area of increased vascularity; the left testicle shows a normal degree of perfusion (Fig. 1D). Comment The necrotic testicle obviously elicited an inflammatory response that resulted in a region of
UROLOGY /
increased vascularity; it was this area of augmented perfusion that was demonstrated by the Doppler stethoscope. This case demonstrates the importance of being able not only to utilize the modern modalities of diagnosis but also being able to interpret and evaluate appropriately the results obtained by these instruments. The Doppler stethoscope cannot diagnose torsion of the spermatic cord for the urologist it can only inform him of the absence or presence of blood flow. How the urologist uses this information is based on his own judgment and ability. We do not imply that the testicular scan is more accurate than the ultrasound examination, In this particular case, the chronicity of the torsion was responsible for the false negative Doppler reading. In acute scrotal swellings, we continue to be impressed by the accuracy of the Doppler stethoscope to demonstrate whether or not a testicle is ischemic. However, whenever there is a question of diagnosis, we do not hesitate to obtain a scrotal scan and, if necessary, surgically explore the scrotum. Temple University Hospital 3401 N. Broad Street Philadelphia, Pennsylvania 19140 (DR. PERRI) References 1. LEVY, B. : The diagnosis of the testicle using the Doppler ultrasonic stethoscope, J. Urol. 113:63 (1975). 2. PEDERSEN, J., HOLM, H. H., and HALD, T.: Torsion of the testis diagnosed by ultrasound, ibid. 113:66 (1975). 3. THOMPSON, J., et al. : Diagnosis of testicular torsion using Doppler ultrasonic flowmeter, Urology 6: 706 (1975). 4. PERRI, A., et al.: The Doppler stethoscope and the diagnosis of the acute scrotum, to be published in J. Urol. 5. PERRI, A., et al. : An evaluation of the role of the Doppler stethoscope and the testicular scan in the diagnosis of torsion of the spermatic cord, submitted to J. Urol.
SEPTEMBER 1976 / VOLUME VIII. NUMBER 3
267