scrotal sonography - event.anobnic.ru · technical requirements linear-array transducer 12-18 mhz...
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ScrotalSonography
Julia Geiger
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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
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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
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11 yo boyscrotal pain for 4h, no swelling or redness
symmetric size13
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Doppler sonography:Asymmetric perfusion
testicular torsion!
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13 yo boyright scrotal pain since yesterday
Asymmetric testicular volume and echogenicity15
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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
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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
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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
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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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