Scrotal Pathology Research Articles

Is it possible to distinguish testicular torsion from other causes of acute scrotum in patients who underwent scrotal exploration? A multi-center clinical trial.

IntroductionTo assess the clinical presentation of patients who underwent surgical exploration for acute scrotum and to investigate the potentially related factors for differential dignosis.Material and methodsWe retrospectively analyzed the medical records of 97 patients who underwent surgical exploration for acute scrotum between May 2007 and July 2013. The patients were divided into two groups as follows: Group1 included patients with testicular torsion (TT) and Group 2 contained patients with acute scrotal pathologies other than TT, including torsion of the testicular appendage, epididymo-orchitis, trauma and Henoch-Schönlein purpura. The physical examination findings, colour Doppler ultrasound (CDUS) and laboratory findings for the groups were compared.ResultsIn total, 97 scrotal explorations were carried out for acute scrotum. Group 1 included 72 patients (74.2%) and Group 2 included 25 patients (25.8%). Group 2 was comprised of patients with torsion of the testicular appendage (n = 13), epididymo-orchitis (n = 8), testicular trauma (n = 2) and Henoch-Schönlein purpura (n = 2). In Group 1, 32 cases (44.4%) presented to a hospital less than 6 hours after onset of pain. More than half (64%) of Group 2's cases presented more than 24 hours after pain onset. Fever and pyuria appeared more frequently in Group 2 than in Group 1 and the results reached statistical significance (p = 0.001 and p = 0.044, respectively). Group 1 had more testicular tenderness than Group 2 (p <0.001). Our testicular salvage rate was 59.7%, and 40.3% of patients underwent orchiectomy.ConclusionsCDUS predicted the diagnosis of TT (sensitivity 98.6%). Furthermore, clinical findings may also play a substantial role in the differential diagnosis of acute scrotum.

Pattern of scrotal examination by physicians in the Eastern Province of Saudi Arabia

Introduction: A wide variety of pathological lesions affect the scrotal contents. They include both benign and malignant lesions. Missed or delayed diagnosis of such lesions can lead to compromised fertility, cosmetic deformities, testicular loss or even death. Early diagnosis of scrotal lesions can prevent the possible development of such complications. Objectives: The pattern of scrotal examination by physicians in the Eastern Province of Saudi Arabia was evaluated in this study to assess the extent of efficacy for early diagnosis. Materials and methods: In this cross-sectional study of scrotal pathology, self-administered questionnaires regarding scrotal evaluation were answered by physicians of different disciplines, including emergency care, internal medicine, paediatric surgery, family medicine and general practitioners. The questionnaires included direct questions on clinical examination of the scrotum as well as clinical scenario quizzes. Collected data were analysed with SPSS (Statistical Product and Service Solutions) version 17 (SPSS Inc., Chicago, IL, USA). The chi-squared test was used to analysis categorical variables, while the t -test was used for continuous variables. Factors affecting scrotal evaluation were assessed by logistic regression. Results: 257 questionnaires were analysed. Routine evaluation of the scrotum was performed by only 14% of respondents. Among the physicians who did not perform routine scrotal examination, 64.2% restricted it to cases with scrotal complaints and 16% considered the conservative cultural nature of their patients a hindering factor. Forty-five per cent did not perform scrotal examination in the standing position. Only 27.8% advised patients with high risk of testicular cancer to perform routine self-examination of their testicles. Conclusions: This study revealed a significant deficiency of early detection of scrotal disease by physicians in the Eastern Province of Saudi Arabia with a high probability of development of complications. We recommend that all physicians be advised to follow a well-structured protocol for scrotal examination during routine practice.

Prevention of Orchialgia After Left-Sided Laparoscopic Donor Nephrectomy-A Prospective Study.

Etiology of orchialgia or testicular pain after laparoscopic donor nephrectomy (LDN) has been found to be related to injury of the spermatic plexus during gonadal (testicular) vein (GV) or ureteral ligation. This study aimed to evaluate and validate the impact of the level of ligation of GV and ureter in relation to the crossing of iliac vessels (CIV) on incidence of orchialgia. A prospective study was conducted on 70 males who underwent left LDN from January 2008 to December 2010 (group A) to determine the correlation between orchialgia and level of ligation of the GV and ureter with respect to CIV; this revealed that the ligation of the GV and/or ureter above the level of the CIV (level 1, n=40) is less likely to cause orchialgia than ligating them at or below (level 2, n=30). Subsequently, in 45 male patients (group B) for left LDN from January 2011 to June 2013, we ensured that clipping of the ureter and GV be performed above the CIV to validate the above findings. Patients with a history of scrotal pathology or surgical procedure were excluded. One-sided Z-test with pooled variance was used to calculate the sample size. In group A, orchialgia was seen in 10 (14.3%) patients. The clipping of the ureter and GV at level 2 (orchialgia, n=9) was associated with a significantly higher incidence of orchialgia than clipping them at level 1 (orchialgia, n=1) (P=0.001,95% confidence interval=0.0707 to 0.2471). In group B, 43 patients were finally analyzed, and none had orchialgia. The level of ligation of the GV and ureter has significant impact on the incidence of orchialgia. Ipsilateral testicular pain in patients with left-sided LDN is preventable, if the ureter and GV are ligated or clipped above the level of iliac vessels bifurcation.

Scrotal calculi in clinical practice and their role in scrotal pain: A prospective study.

Scrotal calculi are rare, and their clinical significance is uncertain. Scrotal pain is a frequent, hard-to-manage problem in urology clinics. Our purpose in this study was to determine the relationship between the presence of scrotal calculi and scrotal pain in a prospective manner. Sonography and color Doppler ultrasound of the scrotum were performed in 758 consecutive patients referred with scrotal pain. The pain was rated by using an 11-point numeric rating scale; scores were compared among patients with scrotal calculi with and without additional scrotal pathology. Scrotal calculi were detected in 73 of the 758 patients (9.6%). Scrotal pain (n = 50 [61%]) and a palpable mass in the scrotum (n = 25 [30.5%]) were the most common complaints in patients with scrotal calculi. Hydrocele (n = 17 [29.8%]) and varicocele (n = 15 [26.3%]) were the most commonly associated abnormalities; there was a statistically significant association between the presence of scrotal calculi and hydrocele (p < 0.01). Scrotal pain was present in 61 (83.5%) patients with scrotal calculi, and this association was significant (p < 0.001). The presence of scrotal pain and the correlation between location of calculi and pain in patients without additional scrotal abnormalities were also significant (p = 0.04 and p < 0.004, respectively). The prevalence of scrotal calculi was 9.6%, and hydrocele was found to be associated with scrotal calculi. We also found a significant relationship between the presence of calculi and scrotal pain. Because the etiology of scrotal pain is essential for appropriate treatment, scrotal calculi should be kept in mind when making a differential diagnosis of scrotal pain. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 43:406-411, 2015.

Testicular resistive index determined by Doppler ultrasonography in men with spinal cord injury - a case series

In this case series, the testicular resistive index was determined in men with spinal cord injury. In ten men participating in our fertility programme, the peak systolic and end-diastolic velocity of centripetal testicular arteries was measured in triplicates by Doppler ultrasonography to calculate the testicular resistive index. Furthermore, the right and left testicular volume was determined by ultrasonography, blood samples were obtained for hormonal evaluation, and sperm analysis was performed according to the WHO guidelines. The median testicular resistive index measured 0.69 and was significantly (P<0.001) greater than the reported cut-off value of 0.6. The spermiograms were characterised by normal sperm count but decreased sperm motility and plasma membrane integrity. The median right and left testicular volume was significantly (P<0.01) smaller compared to the volumes measured in able-bodied adult males without scrotal pathology and measured 8.4ml and 7.2ml respectively. There was a significant (P=0.005) correlation (rs =0.81) between testicular resistive index and sperm concentration. However, no correlations were observed between testicular resistive index and other variables. The testicular resistive index in men with spinal cord injury was significantly greater than 0.6. Measuring the testicular resistive index may represent a useful additional parameter in the assessment of infertility in spinal cord-injured men.

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

To determine whether asymmetric spermatic cord vessel enhancement (ASE) on contrast-enhanced computed tomography (CECT) indicates scrotal pathology. Sixty-one male patients with scrotal symptoms who underwent both scrotal ultrasound (US) and CECT within 24h 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. 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). 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.

Apparent diffusion coefficient values of normal testis and variations with age

The usefulness of diffusion-weighted magnetic resonance imaging (DWI) in the evaluation of scrotal pathology has recently been reported. A standard reference of normal testicular apparent diffusion coefficient (ADC) values and their variations with age is necessary when interpreting normal testicular anatomy and pathology. We evaluated 147 normal testes using DWI, including 71 testes from 53 men aged 20–39 years (group 1), 67 testes from 42 men aged 40–69 years (group 2) and nine testes from six men older than 70 years (group 3). DWI was performed along the axial plane, using a single shot, multislice spin-echo planar diffusion pulse sequence and b-values of 0 and 900 s mm−2. The mean and standard deviation of the ADC values of normal testicular parenchyma were calculated for each age group separately. Analysis of variance (ANOVA) followed by post hoc analysis (Dunnett T3) was used for statistical purposes. The ADC values (× 10−3 mm2 s−1) of normal testicular tissue were different among age groups (group 1: 1.08 ± 0.13; group 2: 1.15 ± 0.15 and group 3: 1.31 ± 0.22). ANOVA revealed differences in mean ADC among age groups (F = 11.391, P < 0.001). Post hoc analysis showed differences between groups 1 and 2 (P = 0.008) and between groups 1 and 3 (P = 0.043), but not between groups 2 and 3 (P = 0.197). Our findings suggest that ADC values of normal testicular tissue increase with advancing age.

A review of ultrasound imaging in scrotal emergencies

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.

Ultrasound of the Pediatric Scrotum

Clinical evaluation of pediatric scrotal pathologies can be challenging. Different pathologies have similar presentations, and scrotal tenderness may limit physical examination. Ultrasound (US) is the imaging modality of choice for the pediatric scrotum. It provides excellent anatomical detail and assessment of testicular perfusion by color Doppler without ionizing radiation. Scrotal US examination should also include the inguinal area; inguinal canal pathology can extend into the scrotum. In the pediatric acute scrotum, US can differentiate between testicular torsion requiring scrotal exploration and other pathologies with conservative management. This article will review scrotal US anatomy and demonstrate how US can guide management in a variety of scrotal abnormalities including trauma, masses, varicocele, and cryptochydism.

Scrotal Ultrasound in Adults

Scrotal ultrasound (US) is the technique of choice for imaging the scrotal contents. US is widely used in the characterization of scrotal pathologies as a supplement to the clinical examination. Modern US equipment, precise technical performance, and knowledge of sonographic anatomy and pathology, as in any US examination, are the basis for a correct diagnosis. New techniques, including elastography and contrast-enhanced US, may have an added value to the diagnosis.

Scrotal pathology

Scrotal pathology

Clinico-radiological and pathological evaluation of extra testicular scrotal lesions

Background:Scrotal ultrasound, though reliable in distinguishing between intratesticular and extratesticular lesions and characterizing them as cystic and solid, cannot distinguish benign from malignant pathology. Although fine needle aspiration cytology (FNAC) has proved to be of great diagnostic importance in testicular lesions, its scope in extratesticular lesions is largely unexplored.Aim:To evaluate extratesticular scrotal lesions cytologically and compare it with their clinical, radiological, and histological findings.Materials and Methods:Sixty five patients with extratesticular scrotal lesions were assessed clinically, radiologically, and cytologically. Histopathology was done in 45 cases where surgical exploration was undertaken. All the data were then analyzed and correlated.Results:Extratesticular lesions accounted for 72.2% of the scrotal swellings. Of these, the epididymis is most commonly involved (61.5% cases) with the commonest type of lesion being cystic (49.3% cases). Ultrasonography preferably with color doppler is highly useful for the evaluation of the scrotum. Apart from distinguishing extratesticular from testicular and cystic from solid lesions, it has an important role in identifying individual lesions, thus reducing the list of differential diagnosis. Fine needle aspiration cytology contributed to a definitive diagnosis in 47.7% cases. It helps classify cystic masses on the basis of their contents and defines the etiology of chronic inflammatory lesions, apart from corroborating with the clinico-radiological diagnosis. Histological evaluation was possible only in cases where surgery was performed and helps further define the diagnosis.Conclusion:Fine needle aspiration cytology is essentially non-traumatic and easy to carry out and should be a technique of choice for the study of scrotal pathology, main advantage being avoidance of delays in diagnosis.

Scrotal ultrasound: anatomy and pathological findings

Ultrasonography (US) is the imaging modality of choice for the evaluation of scrotal disease. It provides high anatomical detail and in most cases, it is essential to enable a correct diagnosis and to obtain the right management of the patient. Color Doppler ultrasonography is a non invasive technique that aids important information about testicular perfusion, necessary in reaching a specific diagnosis in many pathologic conditions; moreover contrast-enhanced ultrasonography (CEUS), recently introduced in the clinical practice, may be considered an additional tool in the classification and differentiation of testicular pathology. The purpose of this review, is to provide the state of the art on the role of ultrasonography in the evaluation of different scrotal pathologies including vaginal process' disorders, acute scrotum, varicocele, hydrocele, chronic inflammatory diseases and testicular tumours.

Inhibition of Adhesion and Fibrosis Improves the Outcome of Epididymectomy as a Treatment for Chronic Epididymitis: a Multicenter, Randomized Controlled, Single-Blind Study

We measured the effectiveness of inhibition of adhesion and fibrosis on patient outcomes after epididymectomy as a treatment for chronic epididymitis. An initial cohort of 152 patients was treated conservatively for chronic epididymitis. Of these patients 43 did not respond to conservative treatment and following informed consent they were enrolled in the clinical trial. The patients were randomized into 2 groups so that 22 underwent epididymectomy with concurrent administration of the inhibitors of adhesion and fibrosis hyaluronic acid and carboxymethylcellulose (group 1), and 21 underwent epididymectomy only (group 2). Visual analog pain scores and patient satisfaction scores were obtained at postoperative weeks 4, 12 and 24. There were no postoperative complications such as wound infection or hematoma in either group. One patient was lost to followup from group 1 and 2 were lost from group 2. At postoperative week 24, 12 patients (57.1%) from group 1 and 3 (15.8%) from group 2 were pain-free, 6 (28.6%) from group 1 and 6 (31.6%) from group 2 exhibited limited pain relief, 2 (9.5%) from group 1 and 7 (36.8%) from group 2 exhibited no pain relief, and 1 (4.8%) from group 1 and 3 (15.8%) from group 2 exhibited recurrence of pain after initial resolution at earlier followup intervals (p = 0.028). Inhibition of adhesion and fibrosis after epididymectomy as a treatment for chronic epididymitis improves pain relief and patient satisfaction.

Scrotal Pearls and Pitfalls

Scrotal symptoms including palpable mass or pain often bring men to medical attention. Ultrasound serves as an extension of the physical examination in these patients and, in most cases, allows definitive diagnosis. Although the diagnosis of malignancy is of greatest concern both to the patient and clinician, a number of benign scrotal pathologies exist and most have characteristic imaging features. Knowledge of these imaging findings can help the radiologist to confidently identify common benign scrotal conditions. Location and imaging characteristics of uncommon lesions help to establish a rational differential diagnosis and appropriate recommendations for patient management.

Reference Values for Testicular Volume, Epididymal Head Size and Peak Systolic Velocity of the Testicular Artery in Adult Males Measured by Ultrasonography

To obtain ultrasonography-based reference values for testicular volume, epididymal head size and peak systolic velocity (PSV) of the testicular artery in adult males of all ages. Between 2009 and 2011, 306 Caucasian adult males (median age: 51 years; range: 18-88 years) without scrotal pathology underwent prospective scrotal ultrasonography. The testicular volume was calculated from the length (L), width (W), and height (H) using three formulas: a) 0.52 × L × W × H, b) 0.52 × L × W², and c) 0.71 × L × W × H. Thickness and height of the epididymal head and PSV of the testicular artery were measured. The median testicular volumes on the right (left) side were 13.9 (12.7) ml, 18.1 (16.5) ml, and 18.9 (17.3) ml for formula a), b), and c) respectively, and thus significantly different (p < 0.01 for all). The left testes were significantly smaller than the right testes (p < 0.01). The thickness and height of the right (left) epididymal head measured 7.5 (7.7) mm and 11.6 (11.3) mm, respectively. Median PSV of the right (left) testicular artery was 8.7 (8.6) cm/sec. No significant side-specific differences were documented with respect to epididymal size and PSV. It was possible to obtain virtually age-independent reference values for testicular volume, epididymal head size and PSV of the testicular artery in adults. With regard to testicular volumetry, it is essential to consider which formula has been used, since the calculated volumes differ significantly from formula to formula.

Aspiration and Sclerotherapy: a Nonsurgical Treatment Option for Hydroceles

We demonstrated that hydrocele aspiration and sclerotherapy with doxycycline is an effective and safe nonsurgical treatment option for hydrocele correction. The medical records of patients who underwent hydrocele aspiration and sclerotherapy were analyzed in a retrospective cohort study for success rates as well as improvement in scrotal size and discomfort after a single hydrocele aspiration and sclerotherapy treatment. Patients who reported decreased scrotal size, improved physical symptoms and satisfaction with the procedure were considered as having success with hydrocele aspiration and sclerotherapy. A total of 29 patients (mean age 52.8 years) presenting with 32 nonseptated hydroceles underwent hydrocele aspiration and sclerotherapy with doxycycline between 2005 and 2012. Of the hydroceles 27 (84%) were successfully treated with a single aspiration and sclerotherapy procedure. Overall mean followup was 20.8 months. Three patients reported moderate pain which resolved in 2 to 3 days. Of those patients in whom hydrocele aspiration and sclerotherapy failed, 1 had hydrocele successfully resolved with a second aspiration and sclerotherapy treatment, 3 did not have success with a second procedure and underwent hydrocelectomy, and 1 wanted immediate surgical correction. Hydrocele aspiration and sclerotherapy was successful in correcting 84% of simple nonseptated hydroceles with a single treatment. This result is an increase from previously reported success rates involving a single hydrocele aspiration and sclerotherapy procedure with tetracycline (75%). The success rate of a single hydrocele aspiration and sclerotherapy procedure is similar to the reported success rates involving hydrocelectomy while avoiding the hospital expense and many other complications. We conclude that the hydrocele aspiration and sclerotherapy procedure is a reasonable, nonsurgical and underused treatment option for nonseptated simple hydroceles.

USG in evaluation of patients with scrotal pain

Based on physical examination alone it is often difficult to accurately make a clinical diagnosis and decide whether a palpable scrotal pathology arises from the testis itself or from extratesticular elements within the scrotum. Clinical examination of the testis is especially difficult due to pain, tenderness or when obscured by a large hydrocele. The aim of the study was thus undertaken to evaluate the role of ultrasonography (USG) in patients presenting with scrotal pain. 50 patients who presented to the surgical department with scrotal pain were subjected to USG. The commonest cause for scrotal pain was epididymitis with or without orchitis (40 %), followed in descending order by cystic lesions of the epididymis (18 %), varicocele (12 %), trauma (8 %), torsion (4 %) and tumour (2 %). No abnormality was seen on USG in 7 patients ( 14 %). This study concludes that USG is a sensitive and specific examination in patients with scrotal pain. Besides differentiating testicular from extratesticular origin it can also differentiate solid from cystic masses. Colour flow imaging is especially helpful in varicocele and testicular torsion. Torsion of the testis remains the most urgent and important entity dependent on USG for diagnosis. Journal of College of Medical Sciences-Nepal,2012,Vol-8,No-1, 18-22 DOI: http://dx.doi.org/10.3126/jcmsn.v8i1.6821

Ultrasonography of tubular ectasia of the rete testis with associated scrotal findings.

Tubular ectasia of the rete testis (TERT) is a rare disorder that can be seen on ultrasonography (US) during a routine examination. In this study, we aim to discuss 15 cases of TERT and concomitant scrotal pathologies. A total of 405 patients who were admitted to our department between March 2009 and December 2011 for scrotal US with different complaints such as scrotal pain, palpable mass, infertility, varicocele, or hydrocele were evaluated. Presence or absence of TERT and associated scrotal anomalies if TERT was present were considered on gray-scale US and color Doppler US. Tubular ectasia of the rete testis was detected in 15 patients (3.7%). It was unilateral in eleven patients (73.3%) and bilateral in four patients (26.7%). The mean age of the patients with TERT in this study was 43.7years (range 24-85years). Five patients (33.3%) with TERT presented with infertility, four of them (26.7%) presented with palpable mass, and six of them (40%) were admitted with scrotal pain. In 14 patients (93.3%), at least oneof the following disorders associated with TERT was seen: epididymal cyst, spermatocele, hydrocele, and varicocele. Tubular ectasia of the rete testis shows characteristic appearances on gray-scale and Doppler US evaluation, and no other modality is necessary for diagnosis. TERT is usually associated with epididymal pathologies such as epididymal cyst or spermatocele located on the same side. Testicular neoplasms, intratesticular varicocele, and cystic dysplasia of the testis should be considered in the differential diagnosis of TERT.

Scrotal Liposarcoma - A Rare Extratesticular Tumour

Scrotal and inguinal masses are common patient complaints that prove diagnostically challenging due to the multiple anatomic structures found in the confined space of the scrotum.1 History and adequate examination is the cornerstone in diagnosing scrotal pathology. Ultrasonography is the principle radiologic study used to evaluate scrotal masses. This can locate the site of a mass, and differentiate between solid and cystic lesions. The Doppler feature can also be used to evaluate blood flow. Occasionally CT or MRI is used if ultrasound is inconclusive, and usually precedes scrotal exploration.1 Scrotal masses can be testicular or paratesticular. Paratesticular masses are usually benign, with adenomatoid tumours being the most common, representing 30% of paratesticular masses and 77% of benign tumours arising from the epididymis.2 They usually occur in the 20–40-year age group but can present at any age, are 0.5–5 cm in size, and slow-growing. Papillary cystadenomas and leiomyomas account for most of the other benign solid tumours.2 Primary malignancies of the epididymis or paratesticular structures are extremely rare in adults. These are adenocarcinomas, and sarcomas including rhabdomyosarcoma, leiomyosarcomas and liposarcomas.3 Liposarcoma is the second most common soft tissue tumour in adults, with an incidence ranging from 9.8–16.0%.4 According to the 2002 World Health Organization (WHO) histological classification of tumours, liposarcoma can be divided into five categories: atypical lipomatous tumour/well-differentiated; dedifferentiated; myxoid; pleomorphic; and mixed-type liposarcoma. Liposarcoma of the spermatic cord is however a rare condition, representing about 7% of paratesticular sarcomas.5