Role and added value of contrast enhanced ultrasound of the painful scrotum in the emergency setting.

Emergency imaging of the scrotum is part of routine medical practice. Indications include epididymitis/epididymo-orchitis, testicular torsion, trauma, tumors and infarction. Prompt diagnosis and management are needed to ensure optimal patient outcome. Ultrasound (US) is the initial, and often the only, imaging modality for testicular pathologies. Usually, B-mode and color Doppler US are adequate. In challenging cases, contrast-enhanced US (CEUS) facilitates final diagnosis or increases the examiner's confidence by confirming findings on non-enhanced US. This paper elaborates on the examination technique of CEUS for testicular pathologies, thereby showing its added value over baseline US techniques in the emergency setting.

How useful is a complete urinary tract ultrasound in orchiepididymitis?

Orchiepididymitis (OE) is a frequent cause of pediatric emergency department attendance in boys presenting with acute scrotum. The etiology of most episodes of OE remains unclear and there is no consensus regarding the correlation between OE and underlying genitourinary malformations. Whether imaging evaluation should comprise complete urinary tract ultrasonography (US) or voiding cystography is a subject of debate. The aim of this retrospective, single-center study was to analyze i) the number/type of urinary tract malformations detected by US following a first episode of OE in boys with no previously known malformation and ii) the frequency of associated urinary tract infection (UTI). We reviewed the records of 495 boys <16 years presenting to our pediatric emergency department with acute scrotum between January 2012 and December 2017. Patients with incomplete radiological data were excluded. Of 119 boys with a radiologically-confirmed first episode of OE, 99 had a complete urinary tract US and were included in the study. No genitourinary malformation was detected (0%). Urinary cultures showed UTI in 3/98 (3.1%) patients. Mean age at presentation was 9.7 years (standard deviation, 3.9) with a three-peak incidence of OE at 10-13 years, 4-5 years, and during infancy. Conclusion: Complete urinary tract US does not appear to be useful during a first episode of OE in countries with an antenatal US screening rate similar to Switzerland. The very low UTI rate suggests that a urinalysis is sufficient to investigate a first episode of OE and antibiotics should be reserved for positive urinalysis only.

The role of ultrasound in detecting renal tract abnormalities following a single episode of epididymitis.

AIM: The aim of the study was to establish the utility of ultrasound scan in detecting renal tract abnormalities following a single episode of epididymitis. METHODS: A single-centre retrospective review of all boys diagnosed with epididymitis between October 2012 and 2017 including review of follow up imaging and clinical course was completed. Primary outcome was new diagnosis of renal tract abnormality by ultrasound. MAIN RESULTS: Eighty-four boys with a first diagnosis of epididymitis were identified. Sixty-four cases (76%) were diagnosed at scrotal exploration, the remaining twenty clinically. Median age was 7.30 years (range 0.08-15.83 years), and five had a positive urine culture at presentation. Forty-eight boys (57%) had a follow-up ultrasound scan (at median 4.57 weeks [range 1-31 weeks]). Only two renal tract abnormalities were identified by ultrasound scan, both in boys aged < 6 months, and neither was clinically relevant. Recurrent epididymitis occurred in 4 cases at median 26 days after initial presentation, of whom 3 had been followed up by ultrasound after initial presentation, all of which were normal. Further investigation revealed posterior urethral valves in 1 boy (age 6.5 months at initial presentation). CONCLUSION: Following a single episode of epididymitis, ultrasound was not helpful at detecting clinically relevant renal tract abnormalities, and furthermore did not identify the only patient with a clinically relevant abnormality. Based on these data, we propose follow-up imaging only in boys ≤ 6 months of age with a positive urine culture or a recurrent episode with consideration given to micturating cystogram even if ultrasound normal. LEVEL OF EVIDENCE: IV.

[Scrotoscopy in the diagnosis and treatment of testicular and epididymal diseases: Analysis of 39 cases].

OBJECTIVE: To investigate the efficiency, safety and clinical application value of scrotoscopy in the diagnosis and treatment of testicular and epididymal diseases. METHODS: A total of 39 patients with testicular or epididymal diseases underwent scrotoscopic surgery in our hospital from February 2015 to February 2018. We retrospectively analyzed the clinical data, results of surgery, and postoperative scrotal pain scores, complications and recurrence. RESULTS: Scrotoscopic surgery was successfully performed in all the 39 cases, without such severe complications as testis rupture and scrotal hematoma. Thirteen cases of epididymal tumor were treated by total excision of the tumors by laser ablation; 10 of the 12 patients complaining of chronic testicular pain were diagnosed with incomplete torsion of testicular or epididymal appendages and treated by holmium laser ablation; of the 11 cases of suspected testicular torsion, 8 were confirmed as testicular torsion and the other 3 as acute epididymitis; and 3 cases of scrotal trauma-induced old hematoma underwent surgical removal under the scrotoscope. No infection of scrotal incision occurred postoperatively. The visual analog pain scores of the patients averaged 3.4 ± 1.2 (2－5) and their hospital stay 3.2 ± 0.8 (3－6) days. Scrotal ultrasonography at 1 month after surgery revealed no abnormality in the testis, epididymis or spermatic cord. CONCLUSIONS: Scrotoscopy is safe and effective for the diagnosis and treatment of testicular and epididymal diseases and deserves a wide clinical application.

Tumor of the epididymis: an uncommon presentation of disseminated coccidioidomycosis.

Coccidioidomycosis is an endemic disease of arid regions in the Western hemisphere. Its clinical presentation varies from asymptomatic nodules on chest x-rays to disseminated disease. We present the case of a 48-year-old man with a hard and heterogeneous tumor in the posterior aspect of the right testis. Color flow doppler testicular ultrasonography was performed and two nodular masses in the tail of the right epididymis were identified. An epididymectomy was performed and histopathological examination revealed coccidioidomycosis. After diagnosis, the patient was successfully treated with fluconazol.

The role of multiparametric ultrasound in the diagnosis of paediatric scrotal pathology.

Multiparametric ultrasound (MPUS), combining conventional techniques (greyscale and colour Doppler ultrasound), ultrasound strain elastography, and contrast-enhanced ultrasound (CEUS), has been successfully used in the assessment of adult scrotal pathology. Contrast-enhanced ultrasound can confidently establish testicular tissue vascularity even in the small-volume paediatric testis. Elastography provides further assessment of tissue stiffness, potentially adding useful diagnostic information. In children, ultrasonography is particularly advantageous, being safe, radiation-free and negating the need for sedation or general anaesthesia during the imaging evaluation. In this review article, we aim to familiarise readers with the MPUS scanning protocol used for paediatric scrotal examination and provide an overview of scrotal MPUS features, with particular focus to clinical indications where MPUS may be advantageous over conventional ultrasonography.

Positron emission tomography and reframing vasculitis as a spectrum of disease when investigating a patient with a fever of unknown origin.

A retired businessman presented to the infectious diseases department with a history of ongoing fevers and myalgia and raised inflammatory markers. This continued despite adequate antibiotic treatment of an epididymo-orchitis. Extensive investigations, including bone marrow and liver biopsies and a positron emission tomography, did not reveal a cause but showed reactive change in the bone marrow. Later, he developed a vasculitic rash and vision loss due to non-arteritic anterior ischaemic optic neuropathy. High-dose steroids were immediately initiated. A temporal artery biopsy was performed, which confirmed a healing large vessel vasculitis, possibly giant cell arteritis. He has responded very well to therapy. We must better appreciate the limitations of positron emission tomography in investigating a fever of unknown origin. The case also encourages awareness of autoimmune disorders as the leading category of causative diseases for this in older age groups.

Is follow-up ultrasound necessary after acute epididymitis? A retrospective analysis from a large university hospital.

OBJECTIVES: To evaluate the role of scrotal ultrasound in the follow-up after epididymitis for underlying serious testicular pathologies, which could be overseen in the acute phase. METHODS: Retrospective chart reviews were performed for patients diagnosed with acute epididymitis at Herlev-Gentofte Hospital between 2006 and 2013. Patients were included if they had received the diagnosis after a clinical evaluation in the emergency department and had subsequently undergone antibiotic treatment and a follow-up scrotal ultrasound at a later date. RESULTS: Overall, 118 patients fulfilled the inclusion criteria. The median age was 45 years (range = 18-80). The follow-up ultrasound scans showed no signs of significant pathology in 92/118. Incidental findings of hydroceles, spermatoceles, and varicoceles were made in eight, five and five of the 118, respectively. One patient had testicular tuberculosis and one had neglected testicular torsion. Six patients were diagnosed with suspicious testicular lesions and underwent surgery. Cancer was confirmed in four men (27, 32, 40, and 45 years old). CONCLUSIONS: Epididymitis can be diagnosed and treated correctly without scrotal ultrasound in the majority of cases. However, the risk of underlying testicular cancer should be kept in mind. Patients below 50 years of age without bacteriuria and patients with persistent symptoms after antibiotic treatment should be referred to an urologist for a re-evaluation or for a follow-up ultrasound.

[Real-time transrectal ultrasonography in seminal vesiculoscopy].

OBJECTIVE: To compare three different pathways for transurethral seminal vesiculoscopy (SVS) and investigate the reliability and efficiency of transrectal ultrasonography (TRUS)-guided SVS (TRUS-SVS). METHODS: We retrospectively analyzed 90 cases of seminal vesiculoscopy conducted directly through the ejaculatory duct or prostatic utricle or under the guide of TRUS. We compared the success rate and complications among the three approaches. RESULTS: Operations were successfully performed in 87 (96.67%) of the 90 cases, 30 through the ejaculatory duct, 37 via the prostatic utricle, and 20 under the guide of TRUS, the operation time ranging from 25 to 75 minutes. Sperm was detected from the seminal vesicle fluid in (92.06%) of the azoospermia patients (58/63) during the surgery and in 77.78% of them (49/63) in semen analysis at 1 week postoperatively. Fifteen hematospermia and 12 spermatocystitis patients were cured. Postoperative follow-up found 20 cases of water-like semen and 3 cases of orchiepididymitis, but no such complications as retrograde ejaculation, incontinence, or rectourethral fistula. CONCLUSIONS: Transejaculatory duct and transprostatic utricle pathways are two common approaches to SVS, while TRUS-SVS may achieve a higher success rate and avoid injury of both the prostate and the rectum.

Acute Epididymo-orchitis-Related Global Testicular Infarction: Clinical and Ultrasound Findings With an Emphasis on the Juxta-epididymal String-of-Bead Sign.

Acute epididymo-orchitis (AEO)-related global testicular infarction (GTI) is rare. We report herein the clinical and ultrasound findings of 6 patients with AEO-related GTI. Seventeen patients with torsion-related GTI were also reviewed and compared. The echotexture of AEO-related GTI ranged from mildly inhomogeneous to diffuse heteroechoic, depending on the severity of testicular necrotic changes. All of the patients showed a juxta-epididymal string-of-bead pattern on color Doppler ultrasound, which was ascribed to patent arteries (5/6, 87%) and collateral vessels (1/6, 13%) in the tunica albuginea. There were no significant differences in age, laterality, leukocyte count, testicular volume ratio (infarcted/normal), frequencies of heteroechoic testicular parenchyma, scrotal skin thickening, and hydrocele between the 2 groups. However, the left testis was predominantly affected in both groups. Compared with torsion-related GTI, patients with AEO-related GTI had significantly longer duration from scrotal pain onset to surgery (13.5 ± 5.2 vs 2.6 ± 2.0 days, P < 0.001), a higher level of serum C-reactive protein (110.0 ± 82.0 vs 41.2 ± 35.9 mg/dL, P = 0.013), a higher frequency of the juxta-epididymal string-of-bead sign (100% vs 12%, P < 0.001), and a lower frequency of the whirlpool/knot sign (0% vs 88%, P = 0.002). Although the testis in AEO-related GTI may appear variable from mildly to extensively heteroechoic on gray-scale ultrasound, this unusual disease can be characterized by an avascular testis with a juxta-epididymal string-of-bead sign on color Doppler ultrasound.

A Minimally Invasive Method in Diagnosing Testicular Torsion: The Initial Experience of Scrotoscope.

PURPOSE: To introduce scrotoscopy in the diagnosis of testicular torsion and evaluate its value in clinical application. PATIENTS AND METHODS: From February 2010 to June 2013, 14 patients, aged 12 to 24 years, were included into this study due to acute onset of scrotal pain. On Doppler ultrasound imaging, the blood flow decreased in seven cases (including two "no flow" cases) and remained normal in the other seven. Following anesthesia, a 10F pediatric cystoscope employed as scrotoscope was inserted into the cavity of tunica vaginalis of the testis with continued saline washing to exam the testis and epididymis. RESULTS: The scrotoscope had a diagnostic accuracy of 100% (100% specificity and 100% sensitivity), and the color Doppler ultrasound had 77.8% specificity. Five cases were diagnosed with testicular torsion, among which four were corrected and one underwent orchiectomy. No complications were observed in these patients. Nine patients with epididymitis were given oral antibiotics, and the blood flow of the testis was normal in the testis-preserving patient. CONCLUSIONS: Our study showed that scrotoscopy could serve as a minimally invasive, safe, and effective approach in the early diagnosis of testicular torsion.

[Assessment of the validity of Doppler sonography in the diagnosis of acute scrotum in boys]. / Ocena wartosci badania ultrasonograficznego metoda Dopplera w diagnostyce ostrej moszny u chlópców.

PURPOSE: Comparison of preoperative scrotal Doppler sonography and final diagnosis of subsequent exploration in patients with acute scrotum. MATERIAL AND METHODS: Retrospective analysis of the medical history of 61 patients operated on in The Department of Paediatric and Oncological Surgery in Szczecin in 2008-2014. RESULTS: Mean patient age (years) with testicular torsion was 12.7 ± 4.0, with torsion of a testicular appendage was 8.6 ± 4.5, and with orchitis or epididymitis was 7.2 ± 8.5. During operation we diagnosed testicular torsion in 28 (45%) patients, torsion of the testicular appendage in 26 (43%), and orchitis or epididymitis in 7 (12%). The specificity of Doppler sonography for testicular torsion was 46%, for torsion testicular appendage 20%, and for orchitis/epididymitis 57%. CONCLUSIONS: Doppler sonography of the scrotum shows limited specificity in the diagnosis of acute scrotum in boys. Surgical exploration is recommended even with apparently normal Doppler sonography examinations.

Ultrasonographic features of uterus masculinus in six dogs.

Uterus masculinus (persistent Mullerian duct) is a vestigial embryological remnant of the paramesonephric duct system in males and has been associated with clinical signs such as dysuria, incontinence, tenesmus and urethral obstruction in dogs. The radiological appearance of cystic uterus masculinus in dogs has been described previously with the aid of retrograde positive or negative contrast cystography. The purpose of this retrospective study was to describe ultrasonographic features of confirmed or presumed uterus masculinus in a group of dogs with confirmed or presumed disease. Ultrasonographic findings were recorded based on a consensus opinion of two readers. A uterus masculinus was defined as cylindrical when no lumen was observed and tubular when it had lumen that was filled with anechoic fluid. Six dogs met the inclusion criterion with a mean age of 8 years and 9 months. Uterus masculinus appeared as single (four dogs) or two (two dogs) horn-like, tubular (four dogs) or cylindrical (two dogs) structures, originating from the craniodorsal aspect of the prostate gland and extending cranially. The walls of the uterus masculinus were isoechoic to the urinary bladder wall. The diameter of the observed uterus masculinus varied from 0.3 cm to 1 cm. The length of the uterus masculinus varied from 2 cm to 6.5 cm but the cranial terminal end was not identified in two dogs. Concomitant prostatomegaly was seen in five dogs (83.3%) and urinary tract infection was noted in three dogs (50%). Findings indicated that uterus masculinus should be included as a differential diagnosis for male dogs with these ultrasonographic characteristics.

Asymmetric spermatic cord vessel enhancement on CT: a sign of epididymitis or testicular neoplasm.

PURPOSE: To determine whether asymmetric spermatic cord vessel enhancement (ASE) on contrast-enhanced computed tomography (CECT) indicates scrotal pathology. METHODS: Sixty-one male patients with scrotal symptoms who underwent both scrotal ultrasound (US) and CECT within 24 h were identified through a radiology information system. Twenty-eight emergency department patients who underwent CECT only for unrelated symptoms were included for comparison. Two blinded radiologists independently reviewed each CECT scan for qualitative ASE. These data were compared with US diagnoses, when present. A third blinded radiologist reviewed each CECT scan for quantitative ASE by measuring Hounsfield unit (HU) density ratios. McNemar, Kappa, Student's t test, and ANOVA were used for analysis. RESULTS: Eighty-nine total patients included 28 with CECT only and 61 with CECT and US, of which 41 had abnormal US: 15 acute epididymitis and/or orchitis, 7 testicular neoplasms, 11 varicoceles, and 8 with other pathologies. Twenty patients with normal US and 28 patients with CECT only served as control groups. Identification of ASE agreed with US diagnosis of epididymitis (and/or orchitis) or testicular neoplasm (reader 1: κ = 0.79, reader 2: κ = 0.75) with average 95.5% sensitivity and 88.8% specificity, and no significant difference between readers (p = 0.58). For epididymitis (and/or orchitis) or testicular neoplasm patients, the average ratio of spermatic cord HU density (ipsilateral:contralateral) was significantly different from other patients (4.01 vs. 1.26, p = 0.0025). CONCLUSION: ASE on CECT shows stronger correlation with epididymitis (and/or orchitis) and testicular neoplasm compared with other scrotal pathologies. If discovered on CECT, this should prompt further clinical and/or imaging workup.

Chronic epididymitis with scrotal vasocutaneous urinary fistula.

Chronic Epididymitis is a relatively rare problem in boys and is often enigmatic in its etiology. It is often associated with urinary tract abnormalities in infants and prepubertal children. This report describes a rare and unusual case of a chronic epididymitis with acquired scrotal vasocutaneous urinary fistula in an 8-mo-old boy who was found to have a large prostatic utricular cyst and ectopic vas insertion. The authors discuss embryology, pathophysiology, diagnostic dilemma and different treatment options.

Isolated tuberculous epididymitis presenting as a painless scrotal tumor.

Genitourinary tuberculosis, the second most common extrapulmonary tuberculosis (TB), is very difficult to diagnose unless one maintains a high index of suspicion. Isolated tuberculous epididymitis (ITE), defined as tuberculous epididymitis without clinical evidence of either renal or prostate involvement, is a rare entity among genitourinary tuberculosis. When diagnosed correctly, ITE can be cured with anti-TB medications. However, patients with poor response to medical treatment may require surgery. Here, we report a 20-year-old man who presented with a slow-growing painless scrotal tumor for 2 months, with the initial workup suspicious for a right paratesticular tumor. Surgical resection of the tumor was therefore scheduled. However, severe pain and redness over the patient's right hemi-scrotum were noted on the day of surgery. A repeat scrotal ultrasound was performed that revealed findings suggesting a chronic inflammatory process rather than a malignancy. Frozen section of the lesion confirmed the ultrasonographic findings, and the pathology established the diagnosis of ITE. The patient remained on anti-TB therapy postoperatively for 6 months and had an excellent outcome.

Varicocele and epididymitis in Behcet disease.

OBJECTIVE: Behçet disease is a systemic disease with protean manifestations. Vasculitis is a hallmark of the disease and may involve arteries, veins, and capillaries. Varicocele is dilatation of the pampiniform plexus veins. We aimed to investigate the incidence of varicocele in patients with Behçet disease. METHODS: The study included 47 male patients with Behçet disease and 31 healthy control participants. All underwent a clinical evaluation including a medical history and systemic and scrotal examinations. Subsequently, 2 investigators blinded to the clinical data performed sonographic examinations and measured pampiniform plexus vein diameters. RESULTS: The mean age of the patients ± SD was 23.4 ± 3.2 years; disease durations ranged from 3 to 120 months (46 ± 31 months). Scrotal pain or a palpable mass was detected by clinical examination in 24 patients with Behçet disease (51.1%) and 5 healthy participants (16.1%; P = .002). By color Doppler examination, left varicocele was diagnosed in 26 patients with Behçet disease (55.3%) and 9 healthy participants (29%; P = .02). All patients with right varicocele also had left varicocele; that condition was detected in 10.6% (5 patients) of the Behçet disease group and 6.4% (2 patients) of the control group (P > .05). Eight patients with Behçet disease (17%) had epididymitis, whereas none of the healthy participants did (P = .019, Fisher exact test). Genital ulcers and erythema nodosum lesions were more common among patients with varicocele (P = .034 and .058, respectively). There were no differences in smoking, epididymitis, arthritis, uveitis, or other clinical parameters for distinguishing varicocele in patients with Behçet disease. CONCLUSIONS: The incidence of varicocele was increased in Behçet disease. Whether varicocele confers fertility problems in patients with Behçet disease and the underlying mechanism for a possible association are yet to be determined.

Role of contrast enhanced ultrasound in acute scrotal diseases.

OBJECTIVE: To evaluate the efficacy of contrast-enhanced ultrasound (CEUS) in patients with acute scrotal pain not defined at ultrasound (US) with colour Doppler . METHODS: CEUS was carried out in 50 patients with acute scrotal pain or scrotal trauma showing testicular lesion of undefined nature at US. The accuracy of US and CEUS findings versus definitive diagnosis (surgery or follow-up) was calculated. RESULTS: Twenty-three patients had a final diagnosis of testicular tumour, three abscess, eight focal infarction, seven trauma, three testicular torsion, one haematoma. Five patients were negative. Thirty-five patients were operated (23 testicular tumours, six trauma, three testicular torsion, one abscess, one focal infarction, and one haematoma) and 15 underwent medical treatment or were discharged. US provided a definitive diagnosis in 34/50 as compared to the 48/50 patients diagnosed at CEUS. Sensitivity and specificity were 76% and 45% for US and 96% and 100% for CEUS respectively. CONCLUSIONS: CEUS was more accurate in the final diagnosis compared to US, potentially reducing the need for further imaging. In particular CEUS can be proposed in emergency in cases where US diagnosis remains inconclusive, namely in infarction, and trauma, when testicular torsion cannot be ruled out, and in identifying testicular mass.