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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 14  |  Issue : 4  |  Page : 330-337

Role of sonography and color doppler in the evaluation of scrotal swellings


Department of Radiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India

Date of Submission27-Nov-2019
Date of Decision10-Dec-2019
Date of Acceptance22-Dec-2019
Date of Web Publication16-Jul-2020

Correspondence Address:
Dr. Rajasbala Dhande
Department of Radiodiagnosis, Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe), Wardha - 442 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_166_19

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  Abstract 


Background: Ultrasonography combined with color Doppler is the first modality for investigation of scrotal swellings. It is difficult for a clinician to differentiate a testicular pathology from an extratesticular one with presents as a scrotal swelling based on physical examination alone. Aims and Objectives: Early detection of pathology and establishing a surgical versus nonsurgical treatment for acute scrotal pain is important. Materials and Methods: This study included a total of 107 patients. Various scrotal pathologies were detected with ultrasound and Doppler with clinical correlation and found out that noninflammatory pathologies are more common than inflammatory pathologies. Conclusion: We concluded that high-resolution sonography and color Doppler can be used as a primary imaging modality in the diagnosis of scrotal pathologies.

Keywords: Color, Doppler, epididymis, scrotum, sonography, testis, ultrasound


How to cite this article:
Goje K, Dhande R. Role of sonography and color doppler in the evaluation of scrotal swellings. J Datta Meghe Inst Med Sci Univ 2019;14:330-7

How to cite this URL:
Goje K, Dhande R. Role of sonography and color doppler in the evaluation of scrotal swellings. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2020 Aug 4];14:330-7. Available from: http://www.journaldmims.com/text.asp?2019/14/4/330/289839




  Introduction Top


Ultrasonography combined with color Doppler is nowadays considered the first modality for investigation of scrotal swellings. It is difficult for a clinician to differentiate a testicular pathology from an extratesticular one with presents as a scrotal swelling based on physical examination alone, which includes inspection, palpation, and transillumination. Clinical presentation is often vague in such cases. Miskin and Bain and Martin et al.[1],[2] made the earliest publications regarding the use of ultrasound in the imaging of scrotal lesions.

The current modalities for the evaluation of scrotal pathologies include high-frequency gray-scale ultrasound combined with color Doppler, magnetic resonance imaging (MRI), testicular angiogram, computed tomography (CT), and radionuclide scans. There is a risk of excessive radiation exposure with CT scans, and MRI is not commonly available everywhere, especially in rural areas.

Ultrasonography has the advantage of being cheap and inexpensive without any danger of ionizing radiation, so it can be used for repeated examinations and follow-up of patients with inflammatory or neoplastic lesions for early detection of any further complications and identified the efficacy of treatment.

In adolescents, it is of the extreme importance of differentiating testicular torsion from other acute testicular pathologies such as acute epididymo-orchitis which can both present with similar clinical presentation. Clinical examination alone cannot differentiate these two conditions, so ultrasonography along with color Doppler has a momentous role in differentiating these two conditions and prevent any unnecessary surgical exploration. Prompt diagnosis is of utmost importance to plan the treatment.

Aim

The aim of the study is to assess the role of high-resolution sonography and color Doppler as a primary imaging modality in the diagnosis of scrotal lesions.

Objectives

  • Classify scrotal lesions into testicular and extratesticular
  • To study the clinico-radiological spectrum of scrotal lesions
  • To detect testicular ischemia with color flow and power mode Doppler.



  Materials and Methods Top


Research methodology

  1. In our study, we will include all male population with suspicious scrotal swelling who are advised ultrasound and Doppler study for the evaluation with their consent
  2. The procedure will be explained to the patients, and they will be made to lie down comfortably on the patient's bed
  3. Coupling gel will be applied, and probe will be placed on the scrotum. Images will be obtained from the device and studied for evaluation.


Study area – Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe).

Study subjects – Male population presenting with scrotal swelling to the surgery department of Acharya Vinoba Bhave rural hospital.

Research design – Cross-sectional study.

Duration of study – Period of 14 months (August 2018 to October 2019).

Sampling procedure – Male population with scrotal swelling referred to the Department of Radiology (Acharya Vinoba Bhave Rural Hospital, Datta Meghe Institute of medical sciences, Sawangi (Meghe), WARDHA with clinically suspected scrotal swellings will be subjected for the study. After giving informed consent and ethical clearance, patients will undergo history recording and ultrasonography and Doppler evaluation.

Sample size

Calculated by the formula:



Total patients in 2 years = N = 147.

  • N2 = Chi-square value for 1° at some desired probability level. This is 3.84 at 5% level of significance
  • P = 50% proportion
  • Q = 100 − P = 50
  • C = Confidence interval of the one choice (95% CI) = 0.05.




Inclusion criteria

  • All patients presenting with scrotal swellings referred to the department of radiodiagnosis of all age groups.


Exclusion criteria

  • All patients unwilling to undergo the examination
  • All postoperative patients of scrotal surgeries
  • Post radiotherapy patients.


Investigation required for the study

Ultrasonography and Doppler study of patients referred from the Department of surgery, Department of Medicine and Pediatrics, Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe).

Equipment

The study will be conducted using Aloka Hitachi USG Machine Arietta 70 S with Linear high-frequency probe (12–18 MHz) with color Doppler.

Scope

Ultrasonography and color Doppler now play a central role for the evaluation of scrotal swellings due to its wide availability, good resolution, low cost, and lack of ionizing radiations. A detailed scan can help the clinician to prevent surgical procedure in some cases and prefer the surgical treatment in other cases.

Ethical clearance

Ethical clearance was obtained from the Institutional Ethical Committee of JNMC, Sawangi (Meghe), Wardha, on 18th Feb 2019. With ethical clearance no DMIMS(DU)/IEC/2019-20/308


  Observation and Results Top


Out of 107 patients included in the study group, the most common age of presentation was found to be between 31 and 40 years (26%) followed by 41 and 50 years (25%).

The most common presenting symptom was scrotal swelling 66 cases (62%) followed by a combination of symptoms such as pain and scrotal swelling 18 cases (17%) followed by pain in scrotum 17 cases (16%).

The most common pathology detected was hydrocoele (72 cases) followed by inflammatory disease of scrotum (18 cases).

In this study, of 107 cases, Unilateral scrotal pathologies were found in 69 cases (65%) and bilateral scrotal pathologies were found in 38 cases (35%).

Among the noninflammatory swellings of scrotum, the most common pathology was hydrocoele 72 cases (82%) followed by epididymal cyst 5 cases (6%). The incidence of noninflammatory scrotal pathologies was very much more than the inflammatory scrotal pathologies.

Among the total 17 intratesticular pathologies, the most common condition was acute epididymo-orchitis 6 cases (35%) followed by acute orchitis 4 cases (23%).

Among the total 90 extratesticular pathologies, the most common condition was hydrocoele 72 cases (80%) followed by epididymal cyst 5 cases (6%).


  Discussion Top


The contents of scrotum being superficial are ideal for ultrasonographical study. With the advancement in the technology of real-time high-frequency imaging, the diagnostic accuracy of scrotal sonographic examination. Scrotal high-frequency sonography is now considered the first line and the only imaging modality necessary for evaluation of scrotal contents.

In this study a total of 107 cases were examined.

The age distribution of the cases is described in [Table 1], our study included cases from 4 years age to 71 years of age. Most cases presented between 41 and 50 years (26%) followed by 31–40 (25%). Patients from 31 to 50 years of age constituted 51% of total number of cases. Least number of cases were in the 71–80 and 11–20 years age group (2% each).
Table 1: Age distribution

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The various clinical presentations are described in [Table 2]; the most common clinical presentation was scrotal swelling 66 cases (62%) followed by combination of symptoms such as pain and scrotal swelling 18 cases (17%) followed by pain in scrotum 17 cases (16%)
Table 2: Clinical presentation of patients

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The various pathologies detected are described in [Table 3]; in our study, the noninflammatory scrotal pathologies (83.1%) were more common than inflammatory scrotal pathologies (26.9%). Overall, the most common scrotal pathology detected was hydrocoele 72 cases (67.2%).[3],[4],[5]
Table 3: Types of pathologies detected

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The laterality of scrotal pathologies detected is described in [Table 4], among the total 107 cases unilateral pathology was detected in 69 cases (65%), and bilateral pathology was detected in 38 cases (35%).
Table 4: Laterality of detected scrotal pathologies

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The various inflammatory pathologies detected are described in [Table 5]; of the107 cases in this study, inflammatory scrotal conditions were detected in 18 patients (16.8%), and among them, the most common condition was acute epididymo-orchitis – 6 cases followed by acute orchitis – 4 cases.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19]
Table 5: Inflammatory scrotal pathology distribution

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Among the 6 cases of acute epididymo-orchitis, there was increased vascularity with hypoechoic appearance in 3 cases, heterogenous echotexture in 2 cases and normal echogenicity in 1 case. Diffusely increased vascularity was detected in 4 cases. All of the cases were of unilateral involvement. These findings of acute epididymo-orchitis correlate well with the studies conducted by Horstman et al.[32] and Farriol et al.[20]

Among the 4 cases of acute orchitis, 3 cases showed diffusely increased vascularity with increase in scrotal size and hypoechoic echotexture. One case showed focal involvement appearing hypoechoic in a localized area.[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31]

The various noninflammatory pathologies detected are described in [Table 6]. Of the 107 cases in this study, noninflammatory scrotal conditions were found in 89 (83.1%) cases. The most common pathology was hydrocoele 72 cases (82%) followed by epididymal cyst 5 cases (6%). The incidence of noninflammatory scrotal pathologies was very much more than the inflammatory scrotal pathologies.
Table 6: Noninflammatory swellings of scrotum

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Arger et al.[6] conducted a study of 62 patients and found that inflammatory diseases (16 cases = 26%) were less common than noninflammatory disease in (45 cases = 67%).

Willscher et al.[74] performed a study of 43 patients, concluded that inflammatory diseases (12 cases) were less common than noninflammatory diseases (28 cases).[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60],[61],[62],[63],[64],[65],[66],[67],[68],[69],[70],[71],[72],[73]

Richie et al.[75] conducted a study by ultrasound evaluation of 124 patients, also concluded that inflammatory conditions of scrotum (31 patients) were far less common than noninflammatory conditions of scrotum (75 patients).

In the present study, noninflammatory scrotal pathologies were more than the inflammatory scrotal pathologies which correlates well with the above-mentioned studies.

The various intratesticular pathologies are described in [Table 7]; among the total 17 intratesticular pathologies, the most common condition was acute epididymo-orchitis 6 cases (35%) followed by acute orchitis 4 cases (23%).
Table 7: Intratesticular pathology distribution

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The various extratesticular pathologies are described in [Table 8]; among the total 90 extratesticular pathologies, the most common condition was hydrocoele 72 cases (80%) followed by epididymal cyst 5 cases (6%) [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10].[76],[77],[78],[79],[80],[81]
Table 8: Extratesticular pathology distribution

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Figure 1: Case of chronic torsion: Epididymis appears heterogeneously hyperechoic and twisted giving the characteristic swirl appearance of torsion knot. The testis appear hypoechoic with few areas of necrosis within showing no vascularity on Doppler

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Figure 2: Case of acute epididymitis: epididymis appears thickened and heterogeneous with increased vascularity on Doppler

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Figure 3: Case of acute orchitis: Testis appears heterogeneously hypoechoic with increased vascularity of Doppler

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Figure 4: Case of acute epididymo-orchitis: Testis appears heterogeneously hypoechoic with thickened and heterogeneous epididymis showing increased vascularity on Doppler

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Figure 5: Case of varicocele: Prominent pampiniform plexus of veins at the upper pole of testis which show reflux of flow on Valsalva

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Figure 6: Case of epididymal cyst: Large cystic lesion in the head of epididymis with internal debris and echoes

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Figure 7: Case of hydrocele: Anechoic fluid collection in the right hemiscrotum

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Figure 8: Case of seminoma of testis: Heterogeneously hypoechoic mass in the left testis showing increased vascularity on Doppler

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Figure 9: Case of scrotal hernia: Multiple bowel loops seen reaching up to scrotum with anechoic fluid collection in the scrotum

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Figure 10: Case of tubular ectasia of epididymis: Mildly bulky epididymis with anechoic dilated cystic structures in head, body and tail of right epididymis posterior to testis. No color flow detected on color Doppler

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  Conclusion Top


One hundred and seven cases of scrotal swellings were included in this study and the most common presenting manifestation was scrotal swelling in the presence or absence pain and fever. Any architectural abnormality can be detected on gray-scale sonography and comparison with the normal side aids in diagnosing the subtle abnormalities.

In this study, noninflammatory pathologies were more common than inflammatory pathologies, and the most common noninflammatory pathology was found to be hydrocoele. Gray-scale sonography can help differentiate between cystic and solid lesions.

Among the inflammatory scrotal pathologies, the most common condition was acute epididymo-orchitis, followed by orchitis. With the use of color Doppler, we were able to differentiate between testicular ischemia and other inflammatory pathologies of testis in acute scrotal pain. Follow-up scans are necessary in cases of inflammatory pathologies for early identification of any complications.

With the help high-resolution ultrasound combined with color Doppler, we can help reduce the rate of unnecessary surgical exploration in patients of acute scrotal pain. The high-frequency US and color Doppler has the advantage of the absence of hazardous ionizing radiation, repeatability, easy availability, cheap, and affordable.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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