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Use and misuse of testicular ultrasound in routine clinical practice in a UK teaching hospital
British Journal of Medical and Surgical Urology (2009) 2, 105—110
ORIGINAL ARTICLE
Use and misuse of testicular ultrasound in routine clinical practice in a UK teaching hospital Richard J. Parkinson ∗, T.J. Walton, R.J. Lemberger Department of Urology, Nottingham City Hospital, Nottingham NG51PB, UK Received 3 July 2008 ; received in revised form 1 December 2008; accepted 7 December 2008
KEYWORDS Testicle; Ultrasound; Testicular cancer; Testicular mass
Summary Testicular ultrasound is a non-invasive and accurate investigation for testicular abnormalities. However, the majority of testicular problems are amenable to diagnosis by clinical examination alone. Testicular USS requests and reports generated over an 18-month period (03/2006 to 09/2007) at Nottingham City Hospital were examined to determine the indication for the test and the ultrasound findings. 2475 scans were performed: 576 were requested by urologists; 1899 by GPs and other hospital specialists. The most common findings were a completely normal scan (825) and epididymal cyst (637). In the majority of cases, the ultrasound scan was not necessary to make a diagnosis and added nothing to the findings at clinical examination. Correlations of ultrasound findings with the clinical reason for the test are presented in order to suggest suitable indications for this investigation. The total cost of testicular scans performed was around £200,000. It is estimated that at least £130,000 per year could be saved in a single hospital by avoiding unnecessary testicular scans. However, where the clinical findings are equivocal, ultrasound remains an excellent diagnostic tool. © 2008 British Association of Urological Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction The use of ultrasound for the evaluation of testicular pathology has increased significantly since its first description in 1978. Improvements in ultrasound technology, including the advent of Doppler scanning, have improved the accuracy of ultrasound diagnosis, and the sensitivity of ultrasound for testicular cancer approaches 100% [1]. ∗
Corresponding author. E-mail address: [email protected] (R.J. Parkinson).
Ultrasound can accurately differentiate solid masses from cysts, and testicular masses (possibly malignant) from those adjacent to the testis (usually benign), making it a useful adjunct where clinical examination is equivocal. However, the majority of testicular abnormalities are amenable to diagnosis by clinical examination alone. The non-invasive nature of the test and ready access to ultrasound services have driven a steady increase in the number of testicular ultrasounds being performed, with an inevitable increase in
1875-9742/$ — see front matter © 2008 British Association of Urological Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjmsu.2008.12.004
106
R.J. Parkinson et al.
Fig. 1 Indications for testicular ultrasound. Indications accounting for 1% of scans or less have been grouped together as ‘‘other’’.
the proportion of normal or non-significant findings. There are currently no published guidelines to help clinicians select patients for further investigation. The injudicious use of any imaging modality has the effects of increasing pressure on radiology services, increasing physicians’ workloads and drives increasing healthcare costs; it is therefore important that enthusiasm for testicular ultrasound is tempered by sound clinical judgment, so that inappropriate requests are avoided. The use of testicular ultrasound in a large regional centre over an 18-month period is presented with analysis of the indication for scanning and the results. Implications for clinical practice are discussed.
Methods Testicular USS requests and reports generated over an 18-month period (03/2006 to 09/2007) were examined to determine the indication for the test
and the ultrasound findings. Ultrasound scans were performed by various ultrasonographers and radiologists at Nottingham City Hospital using a 7.5 MHz small parts probe. Correlation with clinical notes was used to clarify ambiguous data.
Results Over a period of 18 months, 2475 ultrasounds were conducted at Nottingham City Hospital: 576 (23%) of these scans were requested by members of the urology team and 1899 (77%) by other hospital specialists and GPs. The indications for testicular ultrasound in this cohort are shown in Fig. 1. The most common indication was a mass arising adjacent but separate from the testis. The ultrasound findings are presented graphically in Figs. 2—6, with a breakdown of findings for each indication. The most common finding was a normal scan (825/2475 or 33%). Epididymal cysts were a com-
Fig. 2 Findings at testicular ultrasound scan. Non-significant findings accounting for 1% of scans or less have been grouped together as ‘‘other’’.
The use of testicular ultrasound: is it always necessary
107
Fig. 3 Indications for ultrasound leading to a diagnosis of testicular cancer.
Fig. 4 Findings at ultrasound performed for ‘‘mass adjacent but separate from the testis’’.
Fig. 5 Findings at ultrasound performed for ‘‘painful testicle’’.
Fig. 6 Ultrasound diagnoses associated with testicular microlithiasis.
mon finding (637/2475 or 26%), but not necessarily relevant to the indication for investigation. 24% of cysts were 5 mm or less in diameter, and 27% were 10 mm or less. A large number of these cysts are likely to be of little clinical relevance. A total of 54 scans (2%) yielded a testicular tumour.
Discussion The ultrasound findings for each indication were not dependent on the referring physician (i.e., urologist or otherwise). The majority of ultrasound findings in this study were of doubtful clinical significance, which raises the possibility that many tests could
108 be avoided if appropriate clinical indications for ultrasound could be defined. Most testicular pathologies and complaints are amenable to diagnosis by clinical examination alone [2] and testicular ultrasound should only be necessary in those cases where the physical findings are equivocal or when ultrasound diagnosis is required before definitive management (e.g., testicular cancer).
Testicular cancer The indications for those ultrasounds that diagnosed testicular cancer in this series are shown in Fig. 3. The two patients scanned for ‘‘lump adjacent to the testis’’ and two for ‘‘hydrocele’’ were probably misclassified due to inaccurate clinical evaluation, and were actually found to be ‘‘mass in the body of the testis’’ and ‘‘swollen testis’’ respectively when evaluated by a urologist. ‘‘Search for cancer’’ refers to investigation for the clinical suspicion of cancer due to non-scrotal signs (e.g., raised markers, abdominal lymphadenopathy, gynaecomastia, etc.). In this case, the patient had a raised hCG tumour marker and an abdominal mass. Non-palpable testicular tumours are very uncommon. Intratesticular masses found on ultrasound in the context of normal clinical examination are benign in at least 80% of cases in historical series [3]. Rare instances of non-palpable tumours in men with infertility have been reported. Pierik et al. [4] found 7 testicular tumours among 1,372 infertile men (0.5%), six of which were impalpable. Carmignani et al. [5] also advocated ultrasound scanning in this group, although only 2 malignant tumours were detected in 462 patients, and both were palpable. Raman et al. [6] investigated 3,847 infertile men with abnormal sperm parameters and detected 10 testicular tumours (0.26%), 6 of which were impalpable (0.16%). The prevalence of atrophy in this group was not reported, however. The detection rate of serious pathology is thus very low in this group and the merit of routine ultrasonography is therefore dubious. It is not recommended as a routine investigation by either the EAU [7] or the WHO [8].
Mass adjacent but separate from the testis The most common indication for ultrasound in this series was for a ‘‘mass adjacent but separate from the testis’’ with 748 scans (see Fig. 4). Predictably, the most common findings were either an epididy-
R.J. Parkinson et al. mal cyst or a normal testicle. In 2 cases (0.3%) a testicular tumour was diagnosed. The original clinical diagnosis by the referring GP was an epididymal cyst in both cases, but when assessed in the urology clinic, the tumour was in fact palpable as a mass within the body of the testis. This is most likely to be indicative of unfamiliarity with testicular examination amongst some physicians as the diagnosis of testicular cancer is inconsistent with the clinical findings originally described. A possible epididymal tumour was reported in one instance in this group (representing 0.1%). Such tumours are rare and almost always benign. A firm, irregular, expanding epididymal mass might arouse suspicion, but the majority of scans can be avoided in the knowledge that the probability of missing a significant diagnosis is remote in the extreme. Thus, ‘‘mass adjacent but separate from the testis’’ should not be an indication for testicular ultrasound provided the examining physician is confident in their clinical findings. However, the two testicular cancers detected in this group would justify scrotal ultrasound when the clinician is uncertain of the physical signs.
Testicular pain Scrotal or testicular pain is a common condition, accounting for almost 1% of male urology clinic attendances [9], and most are idiopathic. Testicular pain affects approximately 20% of men following vasectomy and is longstanding in 5% [10—14]. Many will also have lumps adjacent to the testis due to sperm granulomata or general epididymal congestion. Where infection is the cause, the symptoms are usually acute and associated with other features of epididymitis. The majority of testicular cancers are painless and non-tender, and it is very rare for pain to be the only presenting feature. In one series 23.5% of patients with testicular cancer presented with pain [15], although only 10% had pain as their only symptom. As the authors did not report on clinical findings it is unclear whether any had impalpable tumours. The most common finding amongst the 482 ultrasound scans performed for this indication in the current series was a completely normal scan (60%), and the second most common was an abnormality of no clinical significance such as a small epididymal cyst (see Fig. 5). Varicocele was evident in 11%, but when clinically undetectable, the significance of this is moot. Smaller or sub-clinical varicoceles are frequently an incidental finding and not responsible for the symptoms described: the use of ultrasound
The use of testicular ultrasound: is it always necessary to try to detect impalpable varicoceles is therefore of doubtful value. It may be concluded that testicular pain alone does not merit testicular ultrasound, and that potentially treatable causes, such as a significant varicocele or epididymitis, can be detected by examination alone. No testicular cancers were detected in this series where testicular pain was the only indication for scan.
Haematospermia Extensive investigations have been recommended by some for the evaluation of haematospermia. Although occasionally positive, the results of these investigations are almost always of no clinical importance. There is no evidence that haematospermia is associated with an increased prevalence of testicular cancer, and all of the 22 scans performed in this series for haematospermia were either normal (14), or detected insignificant incidental findings such as small hydroceles or cysts.
Epididymitis The diagnosis of epididymitis is usually possible by clinical evaluation alone. Routine ultrasound for the follow-up of epididymitis is not required as resolution is best assessed by clinical evaluation. There is no evidence that epididymitis is attended by a higher incidence of other significant testicular pathologies than in the general population. In this series, the 120 scans performed for epididymitis yielded no significant abnormalities.
Hydrocele Many practitioners advocate ultrasound for the assessment of a hydrocele that prevents palpation of the underlying testis. Testicular cancer is a rare but well recognised cause of hydrocele and cystic tumours masquerading as hydrocele have been described. Ultrasound evaluation may be particularly important in young patients, when the hydrocele is of sudden onset or if it does not transilluminate. In the current series, ultrasound performed to investigate hydroceles diagnosed an occult tumour in 3/71 (4%), one of which had been originally assessed by a urologist and transilluminated. This tumour was seen to be cystic in nature on ultrasound. The other 2 exhibited no cystic features and no hydrocele was detected on ultrasound, suggesting inaccurate clinical evaluation. Although the
109 most common finding by far was a normal underlying testis (86%), the possibility of an underlying tumour should always be considered in this group, particularly in younger patients with a short history.
Monitoring of known ultrasound abnormalities 109 scans were repeated at the suggestion of the ultrasonographer to confirm the resolution of a nonspecific finding where a tumour could not be ruled out, or for surveillance of testicular microlithiasis (TM). In 30%, the lesion resolved, in 59% there was no change and in 10% a diagnosis of a benign condition was made. One lesion was ultimately diagnosed as a tumour (a metastatic gastric cancer). None of the 15 patients undergoing surveillance for TM developed a tumour. Historically, TM has been a common indication for ultrasound surveillance. There are numerous reports of the association between testicular cancer, carcinoma in-situ (CIS) and TM in symptomatic men undergoing ultrasound, yet none that show a longitudinal risk of the development of testicular cancer in those with TM alone. In the current cohort, TM was found in 81 (3.3%) patients. Testicular cancer was found in 54 (2.2%) patients. 7% of patients with TM had an associated tumour. 11% of patients with testicular cancer had associated TM. TM was also associated with a number of other conditions (Fig. 6). A large study of a screened population of asymptomatic men with testicular ultrasound confirmed that TM is common and testicular cancer is rare [16], although no systematic follow-up of these patients was reported. There is no evidence that TM is an independent risk factor for the development of testicular cancer, and ultrasound surveillance is therefore not recommended. Physical examination alone would provide adequate surveillance of this group as there is no evidence that ultrasound screening is superior to physical examination and impalpable tumours are very rare. Teaching selfexamination is a simple and cost effective means of follow-up for such patients.
Good indications for testicular ultrasound The principle purpose of most testicular ultrasound scans is to diagnose or rule out a suspected testicular tumour. Occasionally, other indications will arise, such as suspected abscesses, TB or epididymal tumours.
110
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The argument that scans are frequently performed for patient reassurance is not compatible with our practice in other disciplines: not all patients with back pain are investigated with MRI; not all patients with hypertension are investigated with renal ultrasound. And nor should they be. If significant pathology can be excluded without diagnostic imaging, then none is necessary. Such practice also begs the question ‘‘do patients find investigation reassuring?’’ Immediate reassurance after clinical evaluation might be preferable to a period of uncertainty whilst the patient awaits the scan and its results, particularly as the patient might well infer that the need for a further test is indicative of a suspected serious diagnosis [2].
Conclusions The majority of scans requested in this series were for indications that were inconsistent with testicular cancer or any other significant finding. This may represent a deficiency in general medical training with respect to the eliciting of physical signs or their interpretation, but may also be, in part, attributable to habit. It is acknowledged that some scans are requested at the patient’s behest. It is not proposed that access to testicular ultrasound should be restricted; this would most likely precipitate an increase in urology outpatient referrals. Where the clinician is in doubt or lacks confidence then ultrasound is entirely appropriate: providing an accurate diagnosis without the need for referral in most cases. However these data should reassure clinicians that, provided they feel confident in their interpretation of the clinical signs, the majority of patients can be reassured without need for ultrasound or urology referral. At around £80 per scan, the cost of ultrasounds performed over an 18-month period at Nottingham City Hospital was almost £200,000, of which at least £130,000 might have been avoidable. Such figures should give some pause for thought by both urologists and others when requesting testicular ultrasound.
Conflict of interests
References [1] Pearl MS, Hill MC. Ultrasound of the scrotum. Semin Ultrasound CT MR 2007;28(4 (August)):225—48. [2] Adeyoju AB, Collins GN, Pollard AJ, Liaw J, Brooman PJ, O’Reilly PH. A prospective evaluation of scrotal ultrasonography in clinical practice. BJU Int 2000 Jul;86(1):87—8. [3] Horstman WG, Haluszka MM, Burkhard TK, Urol J. Management of testicular masses incidentally discovered by ultrasound 1994;151(5 (May)):1263—5. [4] Pierik FH, Dohle GR, van Muiswinkel JM, Vreeburg JT, Weber RF. Is routine scrotal ultrasound advantageous in infertile men? J Urol 1999;162(5 (November)):1618—20. [5] Carmignani L, Gadda F, Gazzano G, Nerva F, Mancini M, Ferruti M, et al. High incidence of benign testicular neoplasms diagnosed by ultrasound. J Urol 2003;170(5 (November)):1783—6. [6] Raman JD, Nobert CF, Goldstein M. Increased incidence of testicular cancer in men presenting with infertility and abnormal semen analysis. J Urol 2005;174(5 (November)):1819—22. [7] Dohle GR, Weidner W, Jungwirth A, Colpi G, Papp G, Pomerol J, Hargreave TB. Guidelines on Male Infertility. European Association of Urology Guidelines; 2006. [8] World Health Organization. WHO Manual for the Standardised Investigation: Diagnosis and Management of the Infertile Male. Cambridge: Cambridge University Press; 2000. [9] Nickel JC, Teichman JM, Gregoire M, Clark J, Downey J. Prevalence, diagnosis, characterization, and treatment of prostatitis, interstitial cystitis, and epididymitis in outpatient urological practice: the Canadian PIE study. Urology 2005;66(5 (November)):935—40. [10] Schmidt SS. Vasectomy by section, luminal fulguration and fascial interposition: results from 6248 cases. Br J Urol 1995;76:373—5. [11] McMahon AJ, Buckley J, Taylor A, Lloyd SN, Deane RF, Kirk D. Chronic testicular pain following vasectomy. Br J Urol 1992;69:188—91. [12] Choe JM, Kirkemo AK. Questionnaire-based outcomes study of nononcological post-vasectomy complications. J Urol 1996;155:1284—6. [13] Ahmed I, Rasheed S, White C, Shaikh NA. The incidence of post-vasectomy chronic testicular pain and the role of nerve stripping (denervation) of the spermatic cord in its management. Br J Urol 1997;79:269—70. [14] Morris C, Mishra K, Kirkman RJE. A study to assess the prevalence of chronic testicular pain in post-vasectomy men compared to non-vasectomised men. J Fam Plann Reprod Health Care 2002;28:142—4. [15] Wilson JP, Cooksey G. Testicular pain as the initial presentation of testicular neoplasms. Ann R Coll Surg Engl 2004;86(4 (July)):284—8. [16] Peterson AC, Bauman JM, Light DE, McMann LP, Costabile RA. The prevalence of testicular microlithiasis in an asymptomatic population of men 18 to 35 years old. J Urol 2001;166(6 (December)):2061—4.
All authors confirm that they have nothing to declare. Available online at www.sciencedirect.com
ORIGINAL ARTICLE
Use and misuse of testicular ultrasound in routine clinical practice in a UK teaching hospital Richard J. Parkinson ∗, T.J. Walton, R.J. Lemberger Department of Urology, Nottingham City Hospital, Nottingham NG51PB, UK Received 3 July 2008 ; received in revised form 1 December 2008; accepted 7 December 2008
KEYWORDS Testicle; Ultrasound; Testicular cancer; Testicular mass
Summary Testicular ultrasound is a non-invasive and accurate investigation for testicular abnormalities. However, the majority of testicular problems are amenable to diagnosis by clinical examination alone. Testicular USS requests and reports generated over an 18-month period (03/2006 to 09/2007) at Nottingham City Hospital were examined to determine the indication for the test and the ultrasound findings. 2475 scans were performed: 576 were requested by urologists; 1899 by GPs and other hospital specialists. The most common findings were a completely normal scan (825) and epididymal cyst (637). In the majority of cases, the ultrasound scan was not necessary to make a diagnosis and added nothing to the findings at clinical examination. Correlations of ultrasound findings with the clinical reason for the test are presented in order to suggest suitable indications for this investigation. The total cost of testicular scans performed was around £200,000. It is estimated that at least £130,000 per year could be saved in a single hospital by avoiding unnecessary testicular scans. However, where the clinical findings are equivocal, ultrasound remains an excellent diagnostic tool. © 2008 British Association of Urological Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction The use of ultrasound for the evaluation of testicular pathology has increased significantly since its first description in 1978. Improvements in ultrasound technology, including the advent of Doppler scanning, have improved the accuracy of ultrasound diagnosis, and the sensitivity of ultrasound for testicular cancer approaches 100% [1]. ∗
Corresponding author. E-mail address: [email protected] (R.J. Parkinson).
Ultrasound can accurately differentiate solid masses from cysts, and testicular masses (possibly malignant) from those adjacent to the testis (usually benign), making it a useful adjunct where clinical examination is equivocal. However, the majority of testicular abnormalities are amenable to diagnosis by clinical examination alone. The non-invasive nature of the test and ready access to ultrasound services have driven a steady increase in the number of testicular ultrasounds being performed, with an inevitable increase in
1875-9742/$ — see front matter © 2008 British Association of Urological Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjmsu.2008.12.004
106
R.J. Parkinson et al.
Fig. 1 Indications for testicular ultrasound. Indications accounting for 1% of scans or less have been grouped together as ‘‘other’’.
the proportion of normal or non-significant findings. There are currently no published guidelines to help clinicians select patients for further investigation. The injudicious use of any imaging modality has the effects of increasing pressure on radiology services, increasing physicians’ workloads and drives increasing healthcare costs; it is therefore important that enthusiasm for testicular ultrasound is tempered by sound clinical judgment, so that inappropriate requests are avoided. The use of testicular ultrasound in a large regional centre over an 18-month period is presented with analysis of the indication for scanning and the results. Implications for clinical practice are discussed.
Methods Testicular USS requests and reports generated over an 18-month period (03/2006 to 09/2007) were examined to determine the indication for the test
and the ultrasound findings. Ultrasound scans were performed by various ultrasonographers and radiologists at Nottingham City Hospital using a 7.5 MHz small parts probe. Correlation with clinical notes was used to clarify ambiguous data.
Results Over a period of 18 months, 2475 ultrasounds were conducted at Nottingham City Hospital: 576 (23%) of these scans were requested by members of the urology team and 1899 (77%) by other hospital specialists and GPs. The indications for testicular ultrasound in this cohort are shown in Fig. 1. The most common indication was a mass arising adjacent but separate from the testis. The ultrasound findings are presented graphically in Figs. 2—6, with a breakdown of findings for each indication. The most common finding was a normal scan (825/2475 or 33%). Epididymal cysts were a com-
Fig. 2 Findings at testicular ultrasound scan. Non-significant findings accounting for 1% of scans or less have been grouped together as ‘‘other’’.
The use of testicular ultrasound: is it always necessary
107
Fig. 3 Indications for ultrasound leading to a diagnosis of testicular cancer.
Fig. 4 Findings at ultrasound performed for ‘‘mass adjacent but separate from the testis’’.
Fig. 5 Findings at ultrasound performed for ‘‘painful testicle’’.
Fig. 6 Ultrasound diagnoses associated with testicular microlithiasis.
mon finding (637/2475 or 26%), but not necessarily relevant to the indication for investigation. 24% of cysts were 5 mm or less in diameter, and 27% were 10 mm or less. A large number of these cysts are likely to be of little clinical relevance. A total of 54 scans (2%) yielded a testicular tumour.
Discussion The ultrasound findings for each indication were not dependent on the referring physician (i.e., urologist or otherwise). The majority of ultrasound findings in this study were of doubtful clinical significance, which raises the possibility that many tests could
108 be avoided if appropriate clinical indications for ultrasound could be defined. Most testicular pathologies and complaints are amenable to diagnosis by clinical examination alone [2] and testicular ultrasound should only be necessary in those cases where the physical findings are equivocal or when ultrasound diagnosis is required before definitive management (e.g., testicular cancer).
Testicular cancer The indications for those ultrasounds that diagnosed testicular cancer in this series are shown in Fig. 3. The two patients scanned for ‘‘lump adjacent to the testis’’ and two for ‘‘hydrocele’’ were probably misclassified due to inaccurate clinical evaluation, and were actually found to be ‘‘mass in the body of the testis’’ and ‘‘swollen testis’’ respectively when evaluated by a urologist. ‘‘Search for cancer’’ refers to investigation for the clinical suspicion of cancer due to non-scrotal signs (e.g., raised markers, abdominal lymphadenopathy, gynaecomastia, etc.). In this case, the patient had a raised hCG tumour marker and an abdominal mass. Non-palpable testicular tumours are very uncommon. Intratesticular masses found on ultrasound in the context of normal clinical examination are benign in at least 80% of cases in historical series [3]. Rare instances of non-palpable tumours in men with infertility have been reported. Pierik et al. [4] found 7 testicular tumours among 1,372 infertile men (0.5%), six of which were impalpable. Carmignani et al. [5] also advocated ultrasound scanning in this group, although only 2 malignant tumours were detected in 462 patients, and both were palpable. Raman et al. [6] investigated 3,847 infertile men with abnormal sperm parameters and detected 10 testicular tumours (0.26%), 6 of which were impalpable (0.16%). The prevalence of atrophy in this group was not reported, however. The detection rate of serious pathology is thus very low in this group and the merit of routine ultrasonography is therefore dubious. It is not recommended as a routine investigation by either the EAU [7] or the WHO [8].
Mass adjacent but separate from the testis The most common indication for ultrasound in this series was for a ‘‘mass adjacent but separate from the testis’’ with 748 scans (see Fig. 4). Predictably, the most common findings were either an epididy-
R.J. Parkinson et al. mal cyst or a normal testicle. In 2 cases (0.3%) a testicular tumour was diagnosed. The original clinical diagnosis by the referring GP was an epididymal cyst in both cases, but when assessed in the urology clinic, the tumour was in fact palpable as a mass within the body of the testis. This is most likely to be indicative of unfamiliarity with testicular examination amongst some physicians as the diagnosis of testicular cancer is inconsistent with the clinical findings originally described. A possible epididymal tumour was reported in one instance in this group (representing 0.1%). Such tumours are rare and almost always benign. A firm, irregular, expanding epididymal mass might arouse suspicion, but the majority of scans can be avoided in the knowledge that the probability of missing a significant diagnosis is remote in the extreme. Thus, ‘‘mass adjacent but separate from the testis’’ should not be an indication for testicular ultrasound provided the examining physician is confident in their clinical findings. However, the two testicular cancers detected in this group would justify scrotal ultrasound when the clinician is uncertain of the physical signs.
Testicular pain Scrotal or testicular pain is a common condition, accounting for almost 1% of male urology clinic attendances [9], and most are idiopathic. Testicular pain affects approximately 20% of men following vasectomy and is longstanding in 5% [10—14]. Many will also have lumps adjacent to the testis due to sperm granulomata or general epididymal congestion. Where infection is the cause, the symptoms are usually acute and associated with other features of epididymitis. The majority of testicular cancers are painless and non-tender, and it is very rare for pain to be the only presenting feature. In one series 23.5% of patients with testicular cancer presented with pain [15], although only 10% had pain as their only symptom. As the authors did not report on clinical findings it is unclear whether any had impalpable tumours. The most common finding amongst the 482 ultrasound scans performed for this indication in the current series was a completely normal scan (60%), and the second most common was an abnormality of no clinical significance such as a small epididymal cyst (see Fig. 5). Varicocele was evident in 11%, but when clinically undetectable, the significance of this is moot. Smaller or sub-clinical varicoceles are frequently an incidental finding and not responsible for the symptoms described: the use of ultrasound
The use of testicular ultrasound: is it always necessary to try to detect impalpable varicoceles is therefore of doubtful value. It may be concluded that testicular pain alone does not merit testicular ultrasound, and that potentially treatable causes, such as a significant varicocele or epididymitis, can be detected by examination alone. No testicular cancers were detected in this series where testicular pain was the only indication for scan.
Haematospermia Extensive investigations have been recommended by some for the evaluation of haematospermia. Although occasionally positive, the results of these investigations are almost always of no clinical importance. There is no evidence that haematospermia is associated with an increased prevalence of testicular cancer, and all of the 22 scans performed in this series for haematospermia were either normal (14), or detected insignificant incidental findings such as small hydroceles or cysts.
Epididymitis The diagnosis of epididymitis is usually possible by clinical evaluation alone. Routine ultrasound for the follow-up of epididymitis is not required as resolution is best assessed by clinical evaluation. There is no evidence that epididymitis is attended by a higher incidence of other significant testicular pathologies than in the general population. In this series, the 120 scans performed for epididymitis yielded no significant abnormalities.
Hydrocele Many practitioners advocate ultrasound for the assessment of a hydrocele that prevents palpation of the underlying testis. Testicular cancer is a rare but well recognised cause of hydrocele and cystic tumours masquerading as hydrocele have been described. Ultrasound evaluation may be particularly important in young patients, when the hydrocele is of sudden onset or if it does not transilluminate. In the current series, ultrasound performed to investigate hydroceles diagnosed an occult tumour in 3/71 (4%), one of which had been originally assessed by a urologist and transilluminated. This tumour was seen to be cystic in nature on ultrasound. The other 2 exhibited no cystic features and no hydrocele was detected on ultrasound, suggesting inaccurate clinical evaluation. Although the
109 most common finding by far was a normal underlying testis (86%), the possibility of an underlying tumour should always be considered in this group, particularly in younger patients with a short history.
Monitoring of known ultrasound abnormalities 109 scans were repeated at the suggestion of the ultrasonographer to confirm the resolution of a nonspecific finding where a tumour could not be ruled out, or for surveillance of testicular microlithiasis (TM). In 30%, the lesion resolved, in 59% there was no change and in 10% a diagnosis of a benign condition was made. One lesion was ultimately diagnosed as a tumour (a metastatic gastric cancer). None of the 15 patients undergoing surveillance for TM developed a tumour. Historically, TM has been a common indication for ultrasound surveillance. There are numerous reports of the association between testicular cancer, carcinoma in-situ (CIS) and TM in symptomatic men undergoing ultrasound, yet none that show a longitudinal risk of the development of testicular cancer in those with TM alone. In the current cohort, TM was found in 81 (3.3%) patients. Testicular cancer was found in 54 (2.2%) patients. 7% of patients with TM had an associated tumour. 11% of patients with testicular cancer had associated TM. TM was also associated with a number of other conditions (Fig. 6). A large study of a screened population of asymptomatic men with testicular ultrasound confirmed that TM is common and testicular cancer is rare [16], although no systematic follow-up of these patients was reported. There is no evidence that TM is an independent risk factor for the development of testicular cancer, and ultrasound surveillance is therefore not recommended. Physical examination alone would provide adequate surveillance of this group as there is no evidence that ultrasound screening is superior to physical examination and impalpable tumours are very rare. Teaching selfexamination is a simple and cost effective means of follow-up for such patients.
Good indications for testicular ultrasound The principle purpose of most testicular ultrasound scans is to diagnose or rule out a suspected testicular tumour. Occasionally, other indications will arise, such as suspected abscesses, TB or epididymal tumours.
110
R.J. Parkinson et al.
The argument that scans are frequently performed for patient reassurance is not compatible with our practice in other disciplines: not all patients with back pain are investigated with MRI; not all patients with hypertension are investigated with renal ultrasound. And nor should they be. If significant pathology can be excluded without diagnostic imaging, then none is necessary. Such practice also begs the question ‘‘do patients find investigation reassuring?’’ Immediate reassurance after clinical evaluation might be preferable to a period of uncertainty whilst the patient awaits the scan and its results, particularly as the patient might well infer that the need for a further test is indicative of a suspected serious diagnosis [2].
Conclusions The majority of scans requested in this series were for indications that were inconsistent with testicular cancer or any other significant finding. This may represent a deficiency in general medical training with respect to the eliciting of physical signs or their interpretation, but may also be, in part, attributable to habit. It is acknowledged that some scans are requested at the patient’s behest. It is not proposed that access to testicular ultrasound should be restricted; this would most likely precipitate an increase in urology outpatient referrals. Where the clinician is in doubt or lacks confidence then ultrasound is entirely appropriate: providing an accurate diagnosis without the need for referral in most cases. However these data should reassure clinicians that, provided they feel confident in their interpretation of the clinical signs, the majority of patients can be reassured without need for ultrasound or urology referral. At around £80 per scan, the cost of ultrasounds performed over an 18-month period at Nottingham City Hospital was almost £200,000, of which at least £130,000 might have been avoidable. Such figures should give some pause for thought by both urologists and others when requesting testicular ultrasound.
Conflict of interests
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