Testicular ultrasound: an emergency medicine perspective

Abstract

Ultrasound of the scrotum plays a crucial role in assessing acute scrotal conditions in the Emergency Department. Although the Emergency Physician and Intensivist have shared responsibility for the care of the critically ill patient, the Emergency Physician typically uses Point-of-care Ultrasound in a broader range of applications than the intensivist to include advanced abdominal, obstetric, testicular, musculoskeletal, and ocular ultrasonography. Acute scrotum refers to the sudden onset of scrotal erythema, swelling, or pain, and it is not a rare condition in the Emergency Department. Prompt intervention is required in cases of testicular torsion or rupture, and ultrasound of the scrotum has high utility for emergency physicians seeing acute scrotal complaints with any frequency. However, the incidence of acute scrotum incidence is low compared to other disease states requiring ultrasound diagnosis. This presents a problem when considering ultrasound training of Emergency Physicians for ultrasound of the scrotum in a Point-of-care perspective. With this narrative review, we will attempt to raise the awareness of emergency medicine doctors to the importance of ultrasound of the scrotum in the Emergency Department. We will also discuss educational aspects in testicular ultrasound and the use of contrast-enhanced ultrasound. Finally, we propose an algorithm for action.

Keywords: Acute scrotum; Doppler; Testis; Torsion.

Fig. 1

A midline transverse image, including a portion of each testis, is essential in the comparison of echotexture and vascular flow. Here, the right testicle shows asymmetric flow in relation to the left testicle, using Color Doppler with a velocity scale in the order of 3.2 cm/s

Fig. 2

Absent flow and changes in echogenicity in the left testicle due to testicular torsion. Power Doppler was applied and a comparison with the right non-affected testicle is shown

Fig. 3

Seminoma is observed as a homogeneous hypoechoic lesion, with calcifications (open arrows) and intralesional anechoic areas corresponding to necrosis

Fig. 4

Testicular rupture with interruption of the tunica albuginea, extrusion of the testicular parenchyma (asterisk) through the point of disruption of the same, and a heterogeneous testicular parenchyma. The Power Doppler evaluation shows the absence of vascularization in the affected territory

Fig. 5

Epididymitis show an increase in the Color Doppler signal with respect to the head of the epididymis, due to the hyperemia associated with the infectious process

Fig. 6

Fournier’s gangrene: multiple hyperechoic foci with a "dirty shadow" and subsequent reverberation artifacts associated with the gas formed by the pathogens involved (arrow), which constitutes the pathognomonic sign in this entity