Role of ultrasonography in diagnosis of scrotal disorders: a review of 110 cases
1 Department of Radiology, Lampang Hospital, Lampang, Thailand
2 Department of Radiology, Chiang Mai University, Chiang Mai, Thailand
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
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. � 2009 Biomedical Imaging
and Intervention Journal. All rights reserved.
Keywords: Scrotal abnormalities; ultrasonography
A wide variety of disease processes involving the scrotum
may have similar clinical manifestation (eg, pain, swelling or presence of
mass). Differentiation of these processes is important for proper management. High-resolution
ultrasonography (US) combined with colour Doppler ultrasonography (CDUS) has
become the imaging modality of choice for evaluating scrotal diseases .
Scrotal abnormalities can be divided into two main complaints, which are
scrotal pain and mass. Causes of scrotal pain include inflammation
(epididymitis, epididymo-orchitis, abscess), testicular torsion, testicular
trauma, and testicular cancer [1-5]. Prompt diagnosis is required to
differentiate surgically correctable lesions from abnormalities that can be
adequately treated by medical therapy alone. Clinical symptoms and physical
examination are often not enough for definite diagnosis due to pain and
swelling that limit an accurate palpation of the scrotal contents [2, 4]. For
patients presenting with a scrotal mass, it is critical to determine whether
the mass is intra- or extratesticular. This is important because the majority
of intratesticular lesions are malignant, while extratesticular lesions are
usually benign. US is helpful in differentiating extra- from intratesticular
lesions [1, 2, 6, 7]. This study was undertaken to determine the role of US in
the diagnosis of scrotal disorders in adolescent and adult patients.
Materials and Methods
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 underwent US at Maharaj Nakorn Chiang Mai Hospital. The presenting symptoms were divided into three main
groups including scrotal pain, painless scrotal mass or swelling, and others
such as undescended testes. Medical records of these patients were reviewed to
determine the age, presenting symptoms, US results, treatment and pathological results.
Gray-scale and colour Doppler US were performed on all the patients using
either high-resolution US units 3000HDI or 5000 HDI (Advanced Technology
Laboratories, Bothell, Washington) with a 10-12 MHz linear transducer.
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 (Figs 1-4), 21 (19%) had painless scrotal mass or swelling (Figs 5-7) and
5 (4.5%) had other symptoms (Table 1). Of the 84 patients with scrotal pain, 52
had infection, 27 had non-infection, 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 (TBEO), one was non-Hodgkin�s lymphoma
(NHL), and one was metastasis from liposarcoma. Of the 5 patients who presented
with other symptoms, 4 had undescended testes (Fig 8), and 1 had gynaecomastia,
which finally proved to be liver cirrhosis (Table 2).
Testicular torsion was found in only 4 patients with a
mean age of 17.2 years. Two of these 4 patients presented early, between 1 and
4 hours after the onset of pain. US gave correct diagnosis leading to prompt
surgical correction and the testis was salvaged in both patients. The other 2
patients came late, between 4 and 7 days after their symptoms. Orchiectomy was
performed after diagnosis of missed torsion. US gave incorrect diagnosis in
only one patient with scrotal pain. This patient was a 23-year-old who
presented with scrotal pain. US showed mild enlargement of right epididymis and
testis with absent vascularity. He was diagnosed to have testicular torsion
(Fig 9). Orchiectomy was performed but pathology revealed epididymo-orchitis
with vasculitis in the spermatic cord.
In the 7 patients who had history of scrotal trauma, US
detected testicular rupture in 4 patients, scrotal haematomas in 2 patients and
no abnormality in 1 patient. All 4 patients with ruptured testes underwent
operation. Three had partial orchiectomy and one had total orhiectomy.
Common scrotal problems in adolescent and adult male
patients that require medical care are scrotal pain and painless scrotal mass
or swelling. Bacterial epididymitis or epididymo-orchitis are the most common
causes of scrotal pain in adults while torsion is more common in a younger age
group [1, 2, 4, 5]. Gray-scale US findings of these lesions, including enlarged
epididymis and/or testis with heterogeneous echogenicity, are overlapping but
CDUS findings are different. The inflamed epididymis and testis have increased
blood flow whereas testicular torsion has decreased blood flow [1-5, 8, 9].
In our study, scrotal pain is more common than painless
scrotal mass or swelling. The most common cause of scrotal pain is infection
(52/84), which was mostly found in middle-aged men (mean age 40.9 years).
Testicular torsion was found in only 4 patients with a mean age of 17.2 years.
Two of these 4 patients presented early, between 1 and 4 hours after the onset
of pain. US gave correct diagnosis leading to prompt surgical correction and
the testes were salvaged in both patients. The other 2 patients came late,
between 4 and 7 days after their symptoms appeared. Orchiectomy was performed
after diagnosis of missed torsion. The testicular salvage rate is 80% to 100%
if surgery is performed within 5 to 6 hours, but the rate decreases to
approximately 20% if detorsion is performed after 12 hours following the onset
of symptoms [1, 2, 4, 5]. US gave incorrect diagnosis of testicular torsion in
one case and surgery was performed but turned out to be epididymo-orchitis with
vasculitis in the spermatic cord. This vasculitis may cause testicular
ischaemia leading to incorrect diagnosis. However, treatment in this
compromised epididymo-orhitis with ischaemia is also surgery.
Scrotal trauma results in contusion, haematoma, fracture
or rupture of the testis. Prompt diagnosis of testicular rupture is important
because the surgical testicular salvage rate drops from approximately 90% to
45% after 72 hours of onset [1, 2, 4, 5]. This study had 7 patients with
scrotal trauma and correct diagnosis was provided, leading to proper management
Other causes of scrotal pain include varicocele,
hydrocele, epididymal cyst, and metastases to scrotum and groin in case of
supraglottic squamous cell carcinoma. These patients presented with scrotal
pain, so they were initially classified in the scrotal pain presenting group,
although clinical examination later revealed scrotal mass. They were treated
according to their findings. In 5 patients who presented with scrotal pain, and
no detectable abnormality on US, this could have been due to prior antibiotic
treatment before the US study.
In patients with painless scrotal mass or swelling in this
study, extratesticular lesions were much more common than intratesticular
lesions. All extratesticular lesions were benign. In the 3 patients with
intratesticular lesion, one was TBEO, one was NHL, and one was metastasis from
liposarcoma at thigh. There was no primary testicular tumour during the study
period. TBEO may present with painless scrotal swelling and can mimic
carcinoma. US is helpful in differentiating TBEO from carcinoma. Epididymal
enlargement and skin thickening almost always occur in infection but carcinoma
rarely involves skin and epididymis [6, 7, 10]. Testicular lymphomas constitute
1-9% of all testicular neoplasms and are the most common testicular neoplasm in
men 60 years of age and older . Secondary testicular lymphoma is more
common than primary testicular lymphoma. Gray-scale US of testicular lymphoma
shows focal or diffuse areas of homogeneous hypoechogenicity which cannot be
differentiated from other primary testicular cancers . Testicular metastases
are uncommon, and the most common primary sites are prostate carcinoma (35%),
lung tumours (19%), colon tumours (9%), and kidneys (7%) .
The other presenting symptoms were undescended testes and
gynaecomastia. US is the initial imaging modality to detect the location of
undescended testes, which most commonly occurs at the inguinal region. The US appearance of undescended testes is similar to one lying within the scrotum, although it
is frequently atrophic and small [1, 2]. In this study, undescended testes at
the inguinal region could be localised in 3 patients but could not be
identified in one patient, who finally proved to be anorchia. US was performed
to exclude testicular tumour in one patient with gynaecomastia, which showed no
abnormality in the testes. This patient was finally found to have liver
cirrchosis, which could be the cause of gynaecomastia.
The most common cause of scrotal pain is infection. The
most common cause of scrotal mass or swelling is an extratesticular lesion. US
plays an important role in the diagnosis and proper management planning of the
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.
Table 1 Clinical data of 110 patients.
Table 2 Causes of scrotal abnormalities.
Dogra VS, Gottlieb RH, Oka M et al. Sonography of the scrotum. Radiology 2003; 227(1):18-36.
Muttarak M. Anatomy and disease of the scrotum. In: Peh WCG, Hiramatsu Y, eds. The Asian-Oceanian Textbook of Radiology. Singapore: TTG Asia Media, 2003: 809-21.
Blaivas M, Brannam L. Testicular ultrasound. Emerg Med Clin North Am 2004; 22(3):723-48, ix.
Muttarak M, Lojanapiwat B. The painful scrotum: an ultrasonographical approach to diagnosis. Singapore Med J 2005; 46(7):352-7; quiz 358.
Dogra V, Bhatt S. Acute painful scrotum. Radiol Clin North Am 2004; 42(2):349-63.
Muttarak M, Chaiwun B. Painless scrotal swelling: ultrasonographical features with pathological correlation. Singapore Med J 2005; 46(4):196-201; quiz 202.
Woodward PJ, Sohaey R, O'Donoghue MJ et al. From the archives of the AFIP: tumors and tumorlike lesions of the testis: radiologic-pathologic correlation. Radiographics 2002; 22(1):189-216.
Horstman WG, Middleton WD, Melson GL et al. Color Doppler US of the scrotum. Radiographics 1991; 11(6):941-57; discussion 958.
Howlett DC, Marchbank ND, Sallomi DF. Pictorial review. Ultrasound of the testis. Clin Radiol 2000; 55(8):595-601.
Muttarak M, Peh WC, Lojanapiwat B et al. Tuberculous epididymitis and epididymo-orchitis: sonographic appearances. AJR Am J Roentgenol 2001; 176(6):1459-66.
Shahab N, Doll DC. Testicular lymphoma. Semin Oncol 1999; 26(3):259-69.
|Received 16 October 2008; accepted 25 November 2008
Correspondence: Department of Radiology, Chiang Mai University, Chiang Mai, Thailand. Tel.: +66 53945450; Fax: +66 53946136; E-mail: firstname.lastname@example.org (Malai Muttarak).
Please cite as: Thinyu S, Muttarak M,
Role of ultrasonography in diagnosis of scrotal disorders: a review of 110 cases, Biomed Imaging Interv J 2009; 5(1):e2