A review of ultrasound imaging in scrotal emergencies

Abstract

Scrotal emergencies represent a small proportion of admissions to the emergency department; however, the intimate nature and potential for serious outcome often cause great anxiety. Rapid assessment is required to exclude fertility-threatening conditions and expedite surgical management. Ultrasound is an essential tool in acute scrotal assessment as it allows rapid, radiation-free, high-resolution imaging and, importantly, assessment of vascularity with colour Doppler imaging. In the presentation of the acute scrotum, the "on-call" practitioner will frequently be asked to exclude pathology requiring surgical management, in particular torsion of the spermatic cord. To provide an accurate evaluation the individual is required to have an understanding of scrotal anatomy, sonographic technique and recognition of pathology. This review article will familiarise the reader with the sonographic findings of common acute scrotal pathology.

Keywords: Doppler; Infection; Testis; Torsion; Trauma; Ultrasound.

Fig. 1

Grey-scale longitudinal ultrasound image of the testis in a patient with torsion of the spermatic cord. The testis is heterogeneous and enlarged (star) suggesting ischaemia. Lying at the upper aspect is an ill-defined circular mass representing the thickened, oedematous torted spermatic cord (arrow). The scrotal wall is also thickened

Fig. 2

CEUS transverse image of the testis in a patient with torsion of the spermatic cord (using a 4 MHz transducer). There is absence of vascularity within the left testicular parenchyma indicating infarction (long arrow). There is intra-testicular enhancement present in the right testis (short arrow)

Fig. 3

Grey-scale ultrasound image of a patient with acute scrotal pain showing a cystic heterogeneous pedunculated structure arising from the testis, representing an enlarged appendix testis which has undergone torsion (arrow). A small surrounding hydrocele is also present

Fig. 4

A longitudinal power Doppler image of the testis demonstrating no increased Doppler signal within the testis, but hyperaemia and thickening of the epididymis. A focal avascular area within the epididymis represents an area of abscess formation (arrow)

Fig. 5

Ultrasound grey-scale image showing thickening of the scrotal wall and two focal hyper-echoic regions casting posterior acoustic shadowing (arrows), representing air; a finding seen in Fournier’s gangrene

Fig. 6

A longitudinal grey-scale ultrasound image in a patient following testicular blunt trauma. There is a linear hypo-echoic line traversing the testis (arrow) with mild heterogeneity of the surrounding parenchyma. There is also a small hydrocele and mild thickening of the scrotal wall

Fig. 7

Split screen, dual CEUS and adjacent grey-scale image demonstrating a well-defined anechoic lesion within the testis (arrow) which shows no vascularity on CEUS: a haematoma following blunt trauma to the scrotal sac

Fig. 8

A grey-scale longitudinal ultrasound image of the testis following blunt trauma. There is a large septated, anechoic, extra-testicular abnormality (long arrow), which displaces the testis in a superior direction: a haematocele. In addition there is a hypo-echoic area in the testis likely an isolated haematoma (short arrow)