Role of ultrasonography in diagnosis of scrotal disorders: a review of 110 cases

Abstract

Objective: To determine the role of ultrasonography in diagnosis of scrotal disorders.

Materials and methods: This study was carried out after institutional review board approval was granted, and informed consent was waived. Between January 2005 and January 2007, 144 patients aged 12 years and older with scrotal symptoms, who underwent scrotal ultrasonography (US), were retrospectively reviewed. The clinical presentation, outcome, and US results were analysed. The presentation symptoms were divided into three groups including scrotal pain, painless scrotal mass or swelling, and others. Surgery was performed in 32 patients.

Results: Of 144 patients, 110 had clinical follow-up and constituted the material of this study. The patients ranged in age from 13 to 82 years (mean 38.6 years). Of 110 patients, 84 (76.4%) presented with scrotal pain, 21 (19%) had painless scrotal mass or swelling and 5 (4.5%) had other symptoms. Of the 84 patients with scrotal pain, 52 had infection, 4 had testicular torsion, 7 had testicular trauma, 10 had varicocele, 4 had hydrocele, 1 had epididymal cyst, 1 had scrotal sac and groin metastases, and 5 had unremarkable results. Of the 21 patients who presented with painless scrotal mass or swelling, 18 had extratesticular lesions and 3 had intratesticular lesions. All the extratesticular lesions were benign. Of the 3 intratesticular lesions, one was due to tuberculous epididymo-orchitis, one was non-Hodgkin's lymphoma, and one was metastasis from liposarcoma. Of the 5 patients who presented with other symptoms, 4 had undescended testes, and 1 had gynaecomastia. US gave incorrect diagnosis in only one patient with scrotal pain.

Conclusion: The most common cause of scrotal pain was infection. The most common cause of scrotal mass or swelling was extratesticular lesion. US plays an important role in the diagnosis of scrotal disorders and in planning for proper management.

Keywords: Scrotal abnormalities; ultrasonography.

Figure 1

Epididymo-orchitis in a 45-year-old man presenting with painful swelling of the right hemiscrotum for 3 days. (a) Transverse US image of the scrotum shows an enlarged hypoechoic right testis (RT) and a normal left testis (LT). The overlying right scrotal skin is thickened(*). (b) Longitudinal CDUS image of the right hemiscrotum shows increased vascular flow in the right epididymis and testis.

Figure 2

Right necrotising epididymo-orchitis with scrotal wall abscess in a 32-year-old man presenting with painful scrotal swelling and fever for 2 weeks. (a) Transverse US image of the scrotum shows an enlarged heterogeneously hypoechoic right testis (RT) and an heterogeneously hypoechoic tract (arrows) protruding from the right testicular abscess to form a scrotal wall abscess (*). The right testis has lost its well-defined margin. The normal left testis (LT) is partially seen. (b) CDUS image of the right hemiscrotum shows increased vascular flow surrounding the right testis and scrotal wall abscess.

Figure 3

Acute testicular torsion in a 23-year-old man presented with sudden right scrotal pain for 1 hour. (a) Transverse US image shows enlarged, hypoechoic right testis (RT) with thickened scrotal skin (*). (b) CDUS shows no vascularity in the right testis. Note that gray-scale US cannot differentiate between acute testicular tortion and infection. CDUS is helpful to show vascularity in the testis. However, complicated epididymo-orchitis may compromise blood supply.

Figure 4

Ruptured testis in a 20-year-old man presenting with a painful swelling of his right hemiscrotum for 1 day after he experienced trauma in the right scrotum while playing football. (a) Longitudinal US shows an indistinct testicular contour (arrows), acute hyperechoic intratesticular haematoma (H) and haematocele (*). (b) CDUS shows no vascularity in the intratesticular haematoma.

Figure 5

Bilateral hydrocele in a 58-year-old man with history of progressive painless swelling of bilateral hemiscrotum for 2 years. (a&b) Oblique CDUS images show anechoic fluid surrounding bilateral testes, left more than right. There is normal vascular flow in both right (RT) and left (LT) testes.

Figure 6

Tuberculous epididymo-orchitis in a 39-year-old man with history of pulmonary tuberculosis, presenting with chronic painless left testicular swelling for 3 years. Composite US images of the left hemiscrotum show nodularly enlarged heterogeneously hypoechoic epidididymal head (HE) and tail (TE), and heterogeneously echoic testis (T).

Figure 7

Non-Hodgkin’s lymphoma, diffused large B cell. (a) Longitudinal US image of the right hemiscrotum shows enlarged testis with intratesticular hypoechoic mass (arrows). The right epididymis (E) is normal. (b) CDUS shows marked increased vascularity in the mass. (c) Section of part of testis reveals diffuse infiltration of atypical lymphoid cells that bear large round to oval nuclei, hyperchromatic nuclear chromatin. Prominent nucleoli are noted. These cells individually infiltrate around seminiferous tubules and are densely packed in testicular stroma (H&E stain, x400). (d) The tumour cells are immunoreactive with CD20 (B cell marker staining, x400). (Courtesy of Assistant Professor Charin Ya-in, Department of Pathology, Chiang Mai University, Thailand).

Figure 8

Bilateral undescended testes at inguinal regions in a 19-year-old man with nonpalpable testes in the scrotal sac. (a &b) CDUS images at both inguinal regions show small right (RT) and left (LT) testes.

Figure 9

Right epididymo-orchitis with vasculitis in a 24-year-old man with acute right testicular pain for 1 week. (a,b) Longitudinal US images show enlarged heterogeneously hypoechoic right testis (RT) and a normal left testis (LT). (c) Transverse CDUS image of the scrotum shows normal vascular flow of the left testis, but absent vascular flow of the right testis. He was diagnosed with right testicular torsion. Right orchiectomy was performed but pathology turned out to be epididymo-orchitis with vasculitis.