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Sonographic examination of the abnormal scrotum
ClinicalRadiology (1980) 31,109-113
0009-9260/80/01410109502.00
01980 Royal t~ollegeof Radiologists
50nographic Examination of the Abnormal Scrotum DONALDP" ORR and M. LEON SKOLNICK
?resbyterian-University Hospital, Department of Radiology, Pittsburgh, Pennsylvania 50nography of scrotal masses is now being evaluated as an adjunct to clinical examination in assessment of scr0talmasses. The accuracy of ultrasound in discrimination of solid and cystic masses cannot be disputed. fhis paper will report on the reasons for referral, the sonographic diagnosis and effect on clinical manage#nt of 20 patients. Lesions examined include hydrocele, haematocele, epididymal lesions, abscess and solid testicular masses. A brief review of current literature will also be considered. An analysis will be made of diagnostic accuracy including ability to anatomically locate abnormalities.
S0nographic evaluation of scrotal masses has been in use at the Presbyterian-University Hospital for approximately three years. Initially, requests for such studies were unusual. Because of improved technology, increased clinical awareness of availability and useful clinical information generated by the examination, the scrotal scan is now a routine procedure. Nonetheless scrotal sonography remains in its infancy. Only a few studies (Gottesman et al., 1977, Miskin and Bain, 1974; Miskin et al., 1977) are available in the literature and, as yet, no one has clearly defined the indications for the examination. This paper will review the normal sonographic anatomy as well as the indications, sonographic findings, therapeutic implications, and pathologic findings in 20 scrotal scans performed in our department. METHODS The ultrasound studies of 20 consecutive patients referred during the past 15 months to the Ultrasound Division of the Presbyterian-University Hospital for scrotal sonography were reviewed. Eighteen patients presented because of unilateral enlargement of which 11 were acute, one presented with bilateral enlargement, and one with an extratesticular scrotal mass. Ab0ute one-half of the scrotal masses transilluminated and approximately one-third of the scrotal enlargements were painful. A common clinical reason for referral was for exclusion of testicular abscess. Routinely, scans are performed on a Unirad EP sonographic unit utilising a 6 m m diameter, 5.0MHz transducer focused at 0 - 3 cm. The scrotum is serially scanned longitudinally and transversely With both testes studied whenever possible. Both Water bath (Skolnick and Royal, 1975) and gel mediated contact scanning have been employed. The Water bath consigts of a rectangular metal frame
attached to a laboratory ring stand support with a polythene bag suspended from the rectangular frame. This bag is placed on the scrotum. A coating of mineral oil couples the scrotum to the bag. Several centimeters of warm tap water are placed within the bag. The transducer is scanned within the water approximately 1 - 2 c m above the scrotum. Gel mediated scanning is done simply by coating the scrotum with a thick layer of standard sonographic coupling gel. Although the gel mediated scan may be slightly more comfortable for patients with tender testes, the choice of technique is usually the preference of the sonographer. The testis is approximately 4 - 5 cm in length and usually bilaterally symmetrical. A homogeneous echo pattern on current grey scale equipment is normally seen. The epididymis is occasionally seen in normal patients as a prominent echogenic region on the cephalad pole. The tunica vaginalls cannot normally be appreciated as separate from the testis. Other normal structures not usually recognised include the ductus deferens, appendix testis, and various vascular and lymphatic structures. RESULTS A total of 39 testes (one patient had a previous unilateral orchiectomy) were scanned. Twenty-one were sonographically abnormal. Masses are reported here as cystic, mixed, or solid, and either testicular or extratesticular in location. Table 1 lists all findings as well as the final diagnosis in each case. The final diagnosis was provided either from surgical proof or from clinical remission in epididymitis responsive to antibiotics. Due to the coexistence of multiple lesions in several patients, a total of 27 abnormalities were detected in 21 abnormal hemiscrotums. Eleven cystic extratesticular lesions were identified. All were hydroceles (Fig. 1). A single mixed (solid with cystic compo-
110
CLINICAL RADIOLOGY Table 1 - Sonographic findings and final diagnosis in 39 testes Ultrasound
Final diagnosis
Normal Abnormal Extratesticular CYstic Mixed Solid Testicular Cystic Mixed
18
Normal
18
11 1 3
Hydrocele Inflamed hydrocele Epididymitis
11 1 3
Solid
6
Indeterminate location Cystic
1
nents) extratesticular mass was i n f l a m e d h y d r o cele. Three solid extratesticular masses were correctly i n t e r p r e t e d as epididymitis because o f their typical l o c a t i o n and n o r m a l appearance o f the testis. A single lesion was felt to be cystic and intratesticular in
Spermatocele Infarcted testis Tuberculosis Embryonal carcinoma Metastatic sarcoma Epididymo- orchitis Seminoma Haematocele Thickened tunica
1 1 1 1 1 3 1 1 1
Spermatocele
1
l o c a t i o n . This case was incorrectly localised as the lesion was ultimately proven to be a spermatocele. F o u r cases were interpreted as m i x e d and intratesti. cular. These included an infarcted testis (Fig. 2), e m b r y o n a l carcinoma, a p r e s u m e d tubercul0ul
Fig. 1 - On a longitudinal scan (H denotes cranial end) the normally echogenic testis is surrounded by an echo-free fluid structure typical of hydrocele,
SONOGRAPHIC EXAMINATION OF THE ABNORMAL SCROTUM
111
Fig. 2 - A young male presented with a six-week history of painful swelling of the right testis_ On a longitudinal scan tlumerous small echo-free areas representing haemorrhage and necrosis are distributed within a swollen densely echogenic
testis. At operation an infarcted testis was found. The sonographic appearance is indistinguishable from abscess or necrotic tumour.
orchitis (in a patient with extensive biopsy proven peritoneal tuberculosis), and a metastatic fibrosarcoma (Fig. 3). At surgery the fibrosarcoma was actually a large extratesticular mass compressing the testes into a small portion o f the inferior scrotal sac. This was a second error o f localisation. Six solid testicular enlargements were identified. Two were epididymo-orchitis without abscess, one a semin0rna, and one merely a thickening of the tunica vaginalis. Also included in these six were two errors of localisation - an epididymitis with no testicular involvement and a haematocele. In one case we could not determine whether a clearly cystic lesion was intra- or extratesticular in location. The pathological diagnosis was spermatocele (Fig.4). The data were reviewed to examine the accuracy of determining the solid mixed or cystic nature o f a lesion. A single error was made in 27 lesions. In that
patient, a haematocele was erroneously interpreted as a solid testicular mass. Hence, an accuracy rate o f 26/27 or 96% was achieved. Of note is the fact that cystic lesions were always benign while mixed or solid lesions were more ominous in many o f our patients. Likewise, the accuracy o f anatomic localisation of a lesion as intra- or extratesticular was reviewed. Five lesions were incorrectly localised. The accuracy was thus 22/27 or 81%.
DISCUSSION Despite the fact that the scrotal contents are among the most accessible to clinical examination, serious diagnostic dilemmas occur. Hydroceles which do not transilluminate, coexistence o f hydroceles and testicular masses, as well as the differentiation between testicular and extratesticular location o f
112
CLINICAL
Fig. 3 - This atrophic testis (arrowhead) is displaced into the inferior portion of the scrotum by a large mass with m i x e d
RADIOLOGY
echogenic and sonolucent properties. An extratesticul~ metastatic fibrosareoma was surgically proven.
Fig. 4 - At the cephalid (H) pole of this testis a I cm long cystic lesion was found which could n o t be clearly localised as intra- or extratesticular. Aspiration revealed a spermatocele.
SONOGRAPHIC
EXAMINATION
lesionS can be problematic. Our results are comparable with those of Gottesman et aL (1977) who reported results o f a similar series of scans on 27 patients. In their study 52 of 54 testes (including a0rmals) were correctly interpreted for an overall accuracy of 96%. Two incorrect interpretations in that series were a haemorrhagic hydrocele and a large scrotal carcinoma. These statistics should not be i0terpreted to mean that sonography makes diagnosis of the scrotum a simple matter. Clearly problems do exist- We are unable to clearly distinguish benign from malignant testicular masses. Abscesses, too, reRain problematic as they may have identical sonographic properties as necrotic tumour or even infarcted testes. Testicular haematomas could conceivably cause a similar appearance. Hence, the clinical history and expertise of the urologists are crucial in application and sonographic interpretation. The effect of the sonogram on patient management is difficult to ascertain at this stage. Certainly the majority of our patients came to surgery, but none needlessly as each had at least one surgically amenable lesion. Those who did not have surgery were patients with acute epididymo-orchitis with no abscess demonstrated 0a the sonogram who responded well to conservative management. Perhaps more important is the ability of the sonogram to provide a meaningful pre-
OF THE
ABNORMAL
SCROTUM
113
operative diagnosis in most cases or to exclude surgical indications, and hasten the initiation o f medical therapy as in cases of acute inflammation. The available literature as well as our own experience suggest that sonography has definite utility in evaluation of the enlarged or painful scrotum. Its strength lies in distinguishing the solid from the cystic lesion, extratesticular from intratesticular location and coexistence of multiple lesions. Experience to date indicates that the examination is accurate and with time should be widely accepted as a useful adjunct in diagnosis.
REFERENCES Gottesman, J. E., Sample, W. F., Skinner, D. G. & Ehrlich, R. M. (1977). Diagnostic ultrasound in the evaluation of scrotal masses. Journal of Urology, 118, 601 603. Miskin, M. & Bain, J. (1974). B-mode ultrasonic examination of the testes. Journal of Clinical Ultrasound, 2 (4) 307 311. Miskin, M, Buckspan, M. & Bain, J. (1977). Ultrasonographic examination of scrotal masses. Journal of Urology, 117, 185-187. Skolnick, M. L. & Royal, D. R. (1975). A simple and inexpensive water bath adapting a contact scanner for thyroid and testicular imaging_Journal of Clinical Ultrasound, 3,225 -227.
0009-9260/80/01410109502.00
01980 Royal t~ollegeof Radiologists
50nographic Examination of the Abnormal Scrotum DONALDP" ORR and M. LEON SKOLNICK
?resbyterian-University Hospital, Department of Radiology, Pittsburgh, Pennsylvania 50nography of scrotal masses is now being evaluated as an adjunct to clinical examination in assessment of scr0talmasses. The accuracy of ultrasound in discrimination of solid and cystic masses cannot be disputed. fhis paper will report on the reasons for referral, the sonographic diagnosis and effect on clinical manage#nt of 20 patients. Lesions examined include hydrocele, haematocele, epididymal lesions, abscess and solid testicular masses. A brief review of current literature will also be considered. An analysis will be made of diagnostic accuracy including ability to anatomically locate abnormalities.
S0nographic evaluation of scrotal masses has been in use at the Presbyterian-University Hospital for approximately three years. Initially, requests for such studies were unusual. Because of improved technology, increased clinical awareness of availability and useful clinical information generated by the examination, the scrotal scan is now a routine procedure. Nonetheless scrotal sonography remains in its infancy. Only a few studies (Gottesman et al., 1977, Miskin and Bain, 1974; Miskin et al., 1977) are available in the literature and, as yet, no one has clearly defined the indications for the examination. This paper will review the normal sonographic anatomy as well as the indications, sonographic findings, therapeutic implications, and pathologic findings in 20 scrotal scans performed in our department. METHODS The ultrasound studies of 20 consecutive patients referred during the past 15 months to the Ultrasound Division of the Presbyterian-University Hospital for scrotal sonography were reviewed. Eighteen patients presented because of unilateral enlargement of which 11 were acute, one presented with bilateral enlargement, and one with an extratesticular scrotal mass. Ab0ute one-half of the scrotal masses transilluminated and approximately one-third of the scrotal enlargements were painful. A common clinical reason for referral was for exclusion of testicular abscess. Routinely, scans are performed on a Unirad EP sonographic unit utilising a 6 m m diameter, 5.0MHz transducer focused at 0 - 3 cm. The scrotum is serially scanned longitudinally and transversely With both testes studied whenever possible. Both Water bath (Skolnick and Royal, 1975) and gel mediated contact scanning have been employed. The Water bath consigts of a rectangular metal frame
attached to a laboratory ring stand support with a polythene bag suspended from the rectangular frame. This bag is placed on the scrotum. A coating of mineral oil couples the scrotum to the bag. Several centimeters of warm tap water are placed within the bag. The transducer is scanned within the water approximately 1 - 2 c m above the scrotum. Gel mediated scanning is done simply by coating the scrotum with a thick layer of standard sonographic coupling gel. Although the gel mediated scan may be slightly more comfortable for patients with tender testes, the choice of technique is usually the preference of the sonographer. The testis is approximately 4 - 5 cm in length and usually bilaterally symmetrical. A homogeneous echo pattern on current grey scale equipment is normally seen. The epididymis is occasionally seen in normal patients as a prominent echogenic region on the cephalad pole. The tunica vaginalls cannot normally be appreciated as separate from the testis. Other normal structures not usually recognised include the ductus deferens, appendix testis, and various vascular and lymphatic structures. RESULTS A total of 39 testes (one patient had a previous unilateral orchiectomy) were scanned. Twenty-one were sonographically abnormal. Masses are reported here as cystic, mixed, or solid, and either testicular or extratesticular in location. Table 1 lists all findings as well as the final diagnosis in each case. The final diagnosis was provided either from surgical proof or from clinical remission in epididymitis responsive to antibiotics. Due to the coexistence of multiple lesions in several patients, a total of 27 abnormalities were detected in 21 abnormal hemiscrotums. Eleven cystic extratesticular lesions were identified. All were hydroceles (Fig. 1). A single mixed (solid with cystic compo-
110
CLINICAL RADIOLOGY Table 1 - Sonographic findings and final diagnosis in 39 testes Ultrasound
Final diagnosis
Normal Abnormal Extratesticular CYstic Mixed Solid Testicular Cystic Mixed
18
Normal
18
11 1 3
Hydrocele Inflamed hydrocele Epididymitis
11 1 3
Solid
6
Indeterminate location Cystic
1
nents) extratesticular mass was i n f l a m e d h y d r o cele. Three solid extratesticular masses were correctly i n t e r p r e t e d as epididymitis because o f their typical l o c a t i o n and n o r m a l appearance o f the testis. A single lesion was felt to be cystic and intratesticular in
Spermatocele Infarcted testis Tuberculosis Embryonal carcinoma Metastatic sarcoma Epididymo- orchitis Seminoma Haematocele Thickened tunica
1 1 1 1 1 3 1 1 1
Spermatocele
1
l o c a t i o n . This case was incorrectly localised as the lesion was ultimately proven to be a spermatocele. F o u r cases were interpreted as m i x e d and intratesti. cular. These included an infarcted testis (Fig. 2), e m b r y o n a l carcinoma, a p r e s u m e d tubercul0ul
Fig. 1 - On a longitudinal scan (H denotes cranial end) the normally echogenic testis is surrounded by an echo-free fluid structure typical of hydrocele,
SONOGRAPHIC EXAMINATION OF THE ABNORMAL SCROTUM
111
Fig. 2 - A young male presented with a six-week history of painful swelling of the right testis_ On a longitudinal scan tlumerous small echo-free areas representing haemorrhage and necrosis are distributed within a swollen densely echogenic
testis. At operation an infarcted testis was found. The sonographic appearance is indistinguishable from abscess or necrotic tumour.
orchitis (in a patient with extensive biopsy proven peritoneal tuberculosis), and a metastatic fibrosarcoma (Fig. 3). At surgery the fibrosarcoma was actually a large extratesticular mass compressing the testes into a small portion o f the inferior scrotal sac. This was a second error o f localisation. Six solid testicular enlargements were identified. Two were epididymo-orchitis without abscess, one a semin0rna, and one merely a thickening of the tunica vaginalis. Also included in these six were two errors of localisation - an epididymitis with no testicular involvement and a haematocele. In one case we could not determine whether a clearly cystic lesion was intra- or extratesticular in location. The pathological diagnosis was spermatocele (Fig.4). The data were reviewed to examine the accuracy of determining the solid mixed or cystic nature o f a lesion. A single error was made in 27 lesions. In that
patient, a haematocele was erroneously interpreted as a solid testicular mass. Hence, an accuracy rate o f 26/27 or 96% was achieved. Of note is the fact that cystic lesions were always benign while mixed or solid lesions were more ominous in many o f our patients. Likewise, the accuracy o f anatomic localisation of a lesion as intra- or extratesticular was reviewed. Five lesions were incorrectly localised. The accuracy was thus 22/27 or 81%.
DISCUSSION Despite the fact that the scrotal contents are among the most accessible to clinical examination, serious diagnostic dilemmas occur. Hydroceles which do not transilluminate, coexistence o f hydroceles and testicular masses, as well as the differentiation between testicular and extratesticular location o f
112
CLINICAL
Fig. 3 - This atrophic testis (arrowhead) is displaced into the inferior portion of the scrotum by a large mass with m i x e d
RADIOLOGY
echogenic and sonolucent properties. An extratesticul~ metastatic fibrosareoma was surgically proven.
Fig. 4 - At the cephalid (H) pole of this testis a I cm long cystic lesion was found which could n o t be clearly localised as intra- or extratesticular. Aspiration revealed a spermatocele.
SONOGRAPHIC
EXAMINATION
lesionS can be problematic. Our results are comparable with those of Gottesman et aL (1977) who reported results o f a similar series of scans on 27 patients. In their study 52 of 54 testes (including a0rmals) were correctly interpreted for an overall accuracy of 96%. Two incorrect interpretations in that series were a haemorrhagic hydrocele and a large scrotal carcinoma. These statistics should not be i0terpreted to mean that sonography makes diagnosis of the scrotum a simple matter. Clearly problems do exist- We are unable to clearly distinguish benign from malignant testicular masses. Abscesses, too, reRain problematic as they may have identical sonographic properties as necrotic tumour or even infarcted testes. Testicular haematomas could conceivably cause a similar appearance. Hence, the clinical history and expertise of the urologists are crucial in application and sonographic interpretation. The effect of the sonogram on patient management is difficult to ascertain at this stage. Certainly the majority of our patients came to surgery, but none needlessly as each had at least one surgically amenable lesion. Those who did not have surgery were patients with acute epididymo-orchitis with no abscess demonstrated 0a the sonogram who responded well to conservative management. Perhaps more important is the ability of the sonogram to provide a meaningful pre-
OF THE
ABNORMAL
SCROTUM
113
operative diagnosis in most cases or to exclude surgical indications, and hasten the initiation o f medical therapy as in cases of acute inflammation. The available literature as well as our own experience suggest that sonography has definite utility in evaluation of the enlarged or painful scrotum. Its strength lies in distinguishing the solid from the cystic lesion, extratesticular from intratesticular location and coexistence of multiple lesions. Experience to date indicates that the examination is accurate and with time should be widely accepted as a useful adjunct in diagnosis.
REFERENCES Gottesman, J. E., Sample, W. F., Skinner, D. G. & Ehrlich, R. M. (1977). Diagnostic ultrasound in the evaluation of scrotal masses. Journal of Urology, 118, 601 603. Miskin, M. & Bain, J. (1974). B-mode ultrasonic examination of the testes. Journal of Clinical Ultrasound, 2 (4) 307 311. Miskin, M, Buckspan, M. & Bain, J. (1977). Ultrasonographic examination of scrotal masses. Journal of Urology, 117, 185-187. Skolnick, M. L. & Royal, D. R. (1975). A simple and inexpensive water bath adapting a contact scanner for thyroid and testicular imaging_Journal of Clinical Ultrasound, 3,225 -227.