ScrotalSonography

Julia Geiger

Learning objectives

Technical basics: how to perform scrotal sonographyin children and adolescents

Most important scrotal pathologies in boys

Recognize and differentiate «acute scrotum»

No scrotal tumors and trauma

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Technical requirements

Linear-array transducer12-18 MHz (high-frequency)

• use gray-scale ultrasound first• always perform Color doppler and spectral doppler !• adjust settings

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Scrotal anatomy

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Standard documentation

Start with transverse-plane image to compare both testiclesSymmetry in location, size and echogenicity?

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Doppler: PRF (pulse repetition frequence adaption) low!

Standard documentation

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Standard documentation: sagittal and transversal

Continue withunaffected side,Volumetry of both testicles

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reliable Doppler evaluation of both testiclesrepeat, try to derive curve in the center!

Standard documentation

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Standard documentation

Focus on epididymis:compare size, echogenicity and perfusion

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Standard documentation

Do not forget spermatic cord!10

Acute scrotum

Testicular torsion Epididymitis

Acute idiopathicscrotal edema

Testicular appendagestorsion

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11 yo boyscrotal pain for 4h, no swelling or redness

No scrotal swelling, symmetric echogenicity12

11 yo boyscrotal pain for 4h, no swelling or redness

symmetric size13

Doppler sonography:Asymmetric perfusion

testicular torsion!

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13 yo boyright scrotal pain since yesterday

Asymmetric testicular volume and echogenicity15

Suspicion of epididymitis with associated orchitis

Perfusion of both testicles, almost symmetric flow curves!

Swelling andhyperperfusion ofepididymis

hydrocele

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Follow-up 4 days later…testicular torsion

Progressive swelling, no perfusion right testicle

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Follow-up 2 days later after exploration and detorsion

Asymmetric echogenicity, no perfusion,right testicle necrotic

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Testicular torsion

• ~25% of acute scrotum• Adolescents and newborns

• Acute pain, nausea, vomiting• Absent cremaster reflex, high-riding testicle

• Surgical emergency (testicular infarction)

• If clinically high suspicion, do not waste time with sonography«time is testicle» (max. 6 h for salvage)

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Testicular torsion

Sonography:

• Testicle may look normal in first hours

• May mimick epididymitis

• Reactive scrotal edema or hydroceles

• May visualize torsed spermatic cord

• Color doppler useful for abnormal/reduced blood flow, but can be false negative (early or partial torsion)!

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8 yo boyscrotal pain for 3 days, swelling, slight redness

Scrotal thickening, hydrocele

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Epididymitis, hydrocele and slight orchitis

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5 yo boyscrotal pain for 3 hours, swelling, flush

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Epididymitis with hydrocele, scrotal swellingmarked hyperperfusion!

IncreasedDoppler flow!

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Epididymitis

• ~30% of acute scrotum• Important: clinical history• Infectious inflammation (antibiotics)• In younger boys usually idiopathic,

in adolescents sexually transmitted• If recurrent, rule out urinary tract abnormalities

Sonography:

• Enlarged epididymis with hyperperfusion• Associated orchitis: testicle enlarged, hyperperfusion• Reactive hydrocele, scrotal wall thickening

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6 yo boyrecurrent pain for 2 days, swelling

thickening of scrotum26

AISE = Acute idiopathic scrotal edema

Normal testicular andepididymal perfusion

Hyperperfusionscrotum

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10 yo boyscrotal pain for about 18 h, no swelling or redness

thickening of scrotum

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AISE = Acute idiopathic scrotal edema

thickening and hyperperfusion of scrotum29

Acute idiopathic scrotal edema (AISE)

• <10% of acute scrotum• Scrotal swelling and erythema• 4-7 yo boys• Idiopathic, self-limiting disease

Sonography:

• Scrotal wall thickening• Scrotal hyperemia («fontain sign»)• Normal testicles and epididymides

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12 yo boyleft scrotal pain

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Torsion of testicular appendage

Hydrocele, calcified structurefloating in hydrocele

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Torsion of testicular or epididymal appendage(Hydatid torsion)

• Frequently in prepubertal boys• Torsion/Twisting of testicular appendage more frequent• Focal scrotal pain• Palpable nodule, bluish skin («blue dot sign»)

Sonography:

• Often no finding!• Oval avascular mass/nodule with variable echogenicity• Location frequently between testicle and epididymis• Associated scrotal edema and reactive hydrocele• Color Doppler may show surrounding hyperemia

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What else to consider?

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13 yo boyleft scrotal swelling for some years

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VaricoceleValsalva enforces the dilation

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Varicocele

symmetric volume?

(shunt or stop type?)

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13 yo boyright scrotal pain for 3 h

Cyst or spermatocele epididymis38

1 yo boyswelling right inguinal region

Fluid collection in tunica vaginalis = hydrocele

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2 yo boyswelling in right inguinal region

Funiculocele =Funicular hydrocele

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6 yo boypainless swelling left scrotum for weeks

Lymphatic malformation

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6 month old boyCryptorchism right

Retractile testiswith microlithiasis

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Take home messages

Consider clinical information and history

Standardized sonography and documentation helpsto avoid errors

Side-by-side transverse view important

Recognize acute pathologies: testicular torsion = emergency vs. epididymitis vs. AISE and torsion of testicular appendages

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