Role of high frequency USG & color Doppler in scrotal diseases

ORIGINAL ARTICLE

Current role of high frequency ultrasonography & color Doppler in diagnosis of

scrotal diseases

Hemangi Patel1*, Neela Gandhi2, Falguni Shah3, Bhavana Shah4, Sudhir Singh4, Kaushal
Suthar4
1*
Associate professor, department ofradiology,GMERS Sola medical college and hospital,Sola Ahmedabad
2
Assistant professor,department of radiology,GMERS Sola medical college and hospital,Sola Ahmedabad
3
Professor and Head of radiology department GMERS Sola medical college and hospital,Sola Ahmedabad
4
Resident,department of radiology,GMERS Sola medical college and hospital,Sola Ahmedabad

ABSTRACT
BACKGROUND:High frequency linear ultrasonography and colour Doppler have become valuable diagnostic
modalities for the evaluation of scrotum lesions. The aim of study is to evaluate role of ultrasound with color
doppler in scrotal pathologies in patient with scrotal pain and /or scrotal swelling and to determine origin, extent
and location of lesion and evaluation of vascularity.MATERIALS AND METHODS:A prospective study of 600
patients was done. The study group consists of patient with scrotal swelling, scrotal pain or both. Patient with
normal USG scrotum, inguino scrotal hernia and penile pathologies are not included in our study.Detailed history
was taken before the sonographic examination during January 2014 to December2014.RESULTS:Out of 600
patients, 397 (66.1%) patients were between age group of 21 to 50years of age. Out of 600 patients, 206 patients
(34.3%) had scrotal inflammatory disease, 10 (1.66%) patients had malignant testicular tumor, 57 (9.5%) patients
had varicocele, 64, (10.6%) patients had torsion, 249 (41.5%) patients had epididymal cyst and 253 (42.1%)
patients had hydrocele. Out of 600patients of malignant testicular tumor 5(50%) had seminoma & all of them were
homogenously hypoechoic.CONCLUSION:Ultrasonography (USG) performed with a high-frequency linear
transducer and the use of pulsed and color Doppler mode is the imaging modality of choice for evaluating acute
and non-acute scrotal disease. Ultrasonography differentiates scrotal malignancy from other testicular lesions. It
easily differentiate solid from cystic scrotal masses. Color doppler is highly sensitive in differentiating testicular
ischemia & torsion from acute epididymo orchitis.

Keywords:High frequency ultrasonography, color Doppler, scrotum, USG

INTRODUCTION epididymo-orchitis and intratesticular tumor,

Ultrasonography is the primary imaging
modality for the evaluation of scrotum. With
Advent of high frequency probe in ultrasound
machine, clinical examination of scrotum has
become of limited use, especially in patients
with acute scrotal pain. Sonography of the
scrotum is easy, fast, noninvasive without any
radiation hazard, relatively inexpensive, widely
available. Portability and repeated examination
is also possible without patient discomfort.
B-mode gray scale sonography with use of high
frequency linear transducers allows excellent
visualization of morphologic parenchymal
changes associated with scrotal lesions. Many of
scrotal pathology, including testiculartorsion,
*Corresponding Author:
Hemangi kartik Patel
14, Asthamangal Bunglow,
Near parshwanath metrocity and Golden villa,
44-T.P.Scheme, Chandkheda
Ahmedabad- 382424
E-mail: Hemangi_63@yahoo.com
produce the common symptom of pain at
presentation and differentiation of these
conditions and disorders is important for
determining the appropriate treatment. Color
Doppler is the most useful and most rapid
technique to establish the diagnosis of testicular
torsion and to help distinguish torsion from
epididymo-orchitis1.High-frequency ultra-
sonography in its present state can help identify
certain benign intratesticular lesions so we can
preserve testis during surgery. Knowledge of
ultrasonographic characteristics appearance and
the examination pitfalls of scrotal sonography is
essential for correct diagnosis and management.
MATERIALS AND METHODS
In our study, 600 patients were scanned with the
convex probe ( 2 MHz 5 MHz) and linear
probe (4 MHz - 9 MHz ) on the ultrasound
machine Esaote My Lab series. Detailed history
and presenting symptoms was asked. Study was
done during January 2014 to December

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 Role of high frequency USG & color Doppler in scrotal diseases

2014.Ultrasound was performed on the patient in
the supine and in the standing position. Valsalva
maneuver was done when indicated. A direct
contact scanning technique with the use of the
acoustic coupling gel was used and scanning was
done in the sagittal, transverse, coronal and
oblique sections.
RESULTS AND DISCUSSION
In our study all patients were between the age of
infant to 80 years of age. And 316 out of 600
(52.6% ) patients were between age of 31 to 50
years followed by 149 out of 600 (24.6%)
patient were between 11-30 yrs.
Figure1: Acute epididymoorchitis
With secondary hydrocele
group. Majority of cases with inflammatory
pathology were generalized involving testes and
/ or epididymis while malignant mass lesion was
localized. Out of 206 patients Secondary
hydrocele was present in 98patients (48%). Out
of 206 patients, 5 had testicular abscess both
patients had multiple hypo echoic ill-defined
lesions in testes with heterogeneous epididymis
and 1 of them had foci of calcifications within it.
Only one patient had Fourniers gangrene. Color
Doppler differentiates testicular pathology,
Epididymo-orchitis as well as tumors >1.6 cm
are hypervascular and thus both entities show
increased Blood flow on color Doppler study.
The correlation of clinical history, physical
examination, ultrasound with color Doppler and
response to antibiotic therapy predicts the
diagnosis in all the cases. The hyper vascularity
of large neoplasm can't be differentiated from
that inflammatory lesion.

Table 1: Age of patients

Age group No of patients %
Infants to 10 yrs 32 5.3
11 to 20yrs 68 11.3
Figure 2: Left sided varicocele 21 to 30 yrs 81 13.5
31 to 40 yrs 174 29
41 to 50yrs 142 23.6
51 to 60 yrs 64 10.6
61 to 70 yrs 22 3.6
71 to 80yrs 17 2.8
Total 600 100.0

Figure 3: Testicular abscess Table 2: Clinical presentation

Symptoms and clinical No of
%
presentations patients
scrotal swelling 357 59.5
pain / tenderness 304 50.6
fever 180 30
Trauma 9 1.5
empty scrotal sac 36 6
burning micturition 14 2.3
Infertility 43 7.16

Scrotal inflammatory disease: In our study

inflammatory disease was of 34.3% of total
cases. Acute epididymo orchitis was the most
common and presenting in 21 to 40 years of age

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 Role of high frequency USG & color Doppler in scrotal diseases

Table 4: Incidence of site of scrotal lesions

Table 3: Distribution of scrotal lesions Site of lesion Number of
Total %
No patients
Scrotal Number
of % Isolated Within
lesions of 153 25.5
pts testis
patient
Epididymal Isolated Within
249 41.5 264 44
cyst epididymis
Hydrocele 253 42.1 Both in testis and
110 18.3
Epidermoid epididymis
1 0.1
cyst Localized within
8 1.33 tunica vaginalis sac 261 43.5
Seminoma 5 only
Primary Non Lesion involving
malignancy seminomatous 121 51.6
3 spermatic cord
germ cell
Lesion involving
tumour 10 1.6
2 0.33
scrotal wall
Lymphoma 1
Secondary Table 5: Ultrasonography pattern of
Leukemia 0
malignancy
Other
1
testicular tumor
metastasis Homogenous
206 34.3 Hypoechoic Hetrogenenous
Acute
54
epididymitis
Seminoma 5 -
Acute
epididymo- 79
Non
orhcitis seminomatous
- 3
Chronic germ cell
epididymo- 31 tumors
inflammation orchitis
Acute orchitis 23 Table 6: Ultrasound appearance of
Testicular inflammatory scrotal pathology:
5
abscess Echopattern
Fourniers & colour
Acute Chronic Abscess
1 presentation presentation
gangrene
Scrotal wall Clear cyst - - -
9
abscess hypo echoic 70 10 1
Pyocele 4 Hyper echoic 14 5
Torsion 64 10.6 Heterogeneous 72 23 1
hematocele + Collection with
floating - - 11
testicular 9 1.5
internal echos
contusion Testicular
Varicocele 57 9.5 - 1 -
calcification
Undescended Increase
36 6 124 4 3
or absent vascularity
testis diffuse
Testicular decrease in 4 11 5
4 0.6 vascularity
infarct
Normal
- - 1
vascularity
Absent
1 - -
vascularity.
Air trapping - - 17
Calcification 1

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 Role of high frequency USG & color Doppler in scrotal diseases
Table 7: Comparison for testicular size
No of No of
patients patients with
Idiopathic
with undescended
varicocele testis
Normal
sized 51 29 - and remaining 20%
testes
Small
sized 6 4 1 bilateral in 20% because right testis descends
testes
Hydrocele: In our study hydrocele is the most
common scrotal lesion as we includes both
primary as well as secondary hydrocele. Out of
total 253 cases of hydrocele, 90 patients had
isolated hydrocele in the present study which
comes to 35% cases of all hydrocele. Secondary
hydrocele was associated in 163 cases;
inflammatory secondary hydrocele was
maximum 55%. Hydrocele was easily
diagnosed by sonography as an anechoic
collection in the tunica vaginalis sac. Hydrocele
is the most common cause of painless scrotal
swelling and may be congenital or acquired2.
There was 5 patient of pyocoele in the present
study. Testicular torsion: There were 64 cases
of testicular torsion in our study Presented with
acute attack of pain, commonly sudden onset at
night, which was followed swelling and redness
on the affected Side. 56 patients had
enlargement of testis while 8 patients had normal
Size testis. 54 patients showed hypo echoic testis
while 6 patients had heterogeneous & 4 patients
had hyper echoic testis. 61 patients had reactive
hydrocele. 46 patients had characteristic torsion
knot diagnosed on ultrasonography. 31 patients
had absent arterial and venous flow on color
Doppler study while 22 patients had Decreased
color flow. 11 patients had increased color flow
on color Doppler study. 5 patient of torsion had
associated infarct in testis. Pitfalls to be aware of
when color Doppler in incomplete torsion in
which there will be Presence of normal
vascularity. In cases of detorsion increase
vascularity is also seen which mimics
epididymorchitis3. Pediatrics patient because
there are smaller vessels, making it difficult to
detect blood flow. In such cases history along
with examination helps in arriving diagnosis.
Undescended testis: In the study there were 36
patient of undescended Testis. 29 cases were
4 Int J Int Med Res. 2015; 2(1):1-5
seen up to 10 years of age and all of them
showed normal size testis. Remaining 4 cases
with late diagnosis due to delayed presentation,
all showed small size of testis. 3 cases showed
absent testis. About 80% of non-palpable
undescended testis are located in inguinal canal
are intra-abdominal3.
Undescended testis is more common on the right
side (58%) than in the left side (30%) And
later than Left testis normally4.Testicular
trauma: In present study there were 9 cases of
testicular trauma. Hematocele and Abnormal
altered echo texture were present in all of the
cases while abnormal contour is seen in only one
patient.Hematocele is the result of the venous
bleeding from the Testicle or the pampiniform
plexus into tunica vaginalis, which appears on
ultrasound as an extra testicular collection with
echoes within it. Clinical diagnosis is often
impossible because of marked scrotal pain and
swelling, and sonography can be valuable in the
assessment of tunica albugenia integrity and
extent of testicular hematoma1.Varicocele:
There were 57 patients of varicocele. They
showed dilated serpiginous tubular structures
more than 2 mm in Diameter and increase in size
by Valsalva maneuver and Upright position.
Reversal of color flow on valsalva adds to the
diagnosis. Varicocele is considered if the veins
in the pampiniform plexus are more than 2 mm,
which increases in size in Upright position or
during valsalva maneuver5,6. Out of 57 cases of
varicocele 6 patients (10%) had small sized testis
with grade 3 varicosity. 1 patient had small size
testis which was in normal position and did not
show varicosity.Epididymal cyst: In our study
epididymal cysts and spermatocele is the second
most common scrotal lesion.There were 249
patients (41.5%) of epididymal cyst and
spermatocele in the present Study while in Oyen
RH study epididymal cyst in most common
scrotal lesion and encountered up to 70% of
patients7.They appeared as well defined
anechoic cystic Lesions in the epididymis. Cyst
sizes ranges from 0.1cm to 5cm. Differentiation
from spermatocele are difficult on sonography
so spermatocele is not counted separately
elsewhere in our study. Testicular malignancy:
Testicular tumors represent 1% of all cancers in
men and Seminomas are the most common type
of testicular tumor account for 50% of all germ
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 Role of high frequency USG & color Doppler in scrotal diseases
cell tumors6,8. Malignant testicular tumors in our
study Constitutes about less than 2 % of total
cases. Testicular malignancy presented as
gradual painless hard swelling and a sensation of
testicular heaviness1. In present study,
seminoma was the most common of all testicular
tumors (50%), followed by mixed germ cell
tumors (30%). In our study 3 out of 10 testicular
tumors were heterogeneous which all turned out
to be non seminomatous malignancy, while rests
of 7 tumors were homogenously hypo echoic.
Out of all hypo echoic testicular malignancy 5
were seminomas, 1 lymphoma and metastasis
was also 1. In contrast to seminomas, other germ
cell tumors were heterogeneous. So from the
present study prediction of non seminomatous
malignancy can be done on basis of focal
heterogeneous echo texture. Lymph node was
seen in one case of non seminomatous germ cell
tumour and all cases with secondary malignancy.
Lymph node in case of non seminomatous germ
cell tumour was of 10 mm size in retro
peritoneum anterior to mid abdominal aorta. In
our study no patient showed secondary visceral
metastasis. Visceral metastases are seen in
advanced disease1. In our study Secondary
hydrocele was present in 4 out of 10 cases
(40%). It has mentioned that large hydroceles
occur uncommonly with neoplasms but small
hydroceles occur in 60% of patients with
testicular tumors1.
CONCLUSION
High resolution ultrasonography and colour
Doppler is excellent non-invasive imaging
modality of choice in the imaging of the scrotal
pathologies. It helps in the detection of the
lesions and to determine whether the lesion is
intratesticular or Extratesticular and also detect
the changes in the size, echogenicity &
vascularity of testis and epididymis and
associated findings i.e. Hydrocele and skin
Thickening. Color Doppler is the most useful
and most rapid technique to establish the
diagnosis of testicular torsion and to help
distinguish torsion from epididymo-orchitis.
Primary as well as secondary Hydrocele is the
most common scrotal lesions followed by
epididymal cyst. Seminoma is the most common
malignancy among all testicular malignancy.
Acute epididymo-orchitis is the most common
inflammatory conditions among all
5 Int J Int Med Res. 2015; 2(1):1-5
inflammatory scrotal pathology. High-frequency
US provides information essential to reaching a
specific diagnosis in patients with scrotal
pathology.
ACKNOWLEDGMENT
We thankful to our surgery department for
referring patients to us for sonography. We also
thankful to patients because without them we
could not complete our study.
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