Imaging findings in scrotal pain YunusaCopy (1).pptx

Ultrasound of the scrotum

1. DISCUSS THE RADIOLOGICAL INVESTIGATIONS AND FINDINGS IN A PATIENT WITH A SCROTAL SWELLING BY DR YUNUSA YAHAYA 10/12/2024 1

2. SCROTAL PAIN 2

3. OUTLINE Introduction Anatomy of the scrotum and its contents Differential diagnoses of scrotal pain Imaging modalities Radiological features of the causes of scrotal pain Summary References 3

4. INTRODUCTION. Scrotal swelling is an enlargement of the scrotum or scrotal sac that houses the testicles It arises from pathologies affecting any of the components of the scrotum These include the skin, muscles and fascia, tunica vaginalis , epididymis, testis and testicular vessels. The swelling can be very painful or it may be painless. If the swelling is painful then it is considered as an emergency 4

5. ANATOMY OF THE SCROTUM 5

6. ABDOMINAL WALL AND ITS CORRESPONDING SCROTAL WALL LAYERS ABDOMINAL WALL SCROTUM Skin Skin Scarpas fascia Dartos muscle External oblique muscle External spermatic fascia Internal oblique muscle Cremasteric fascia and muscle Transversus abdominus muscle Internal spermatic fascia Peritoneum Tunica vaginalis 6

7. ANATOMY OF THE TESTIS 7

8. THE SPERMATIC CORD The spermatic cord has three coverings and six constituents. The coverings are the internal spermatic fascia, cremasteric and the external spermatic fascia. The contents are: The vas deferens Arteries-testicular artery, artery to the vas, and the cremasteric artery Veins-the pampiniform plexus Lymphatics Nerves-genital branch of genitofemoral nerve The processus vaginalis . 8

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10. DIFFERENTIALS DIAGNOSES OF SCROTAL SWELLING Traumatic causes: Testicular torsion Torsion of the appendix testis Testicular haematoma Testicular rupture Infective causes: Epididymo-orchitis Scrotal cellulitis Fournier gangrene Neoplastic causes: Testicular neoplasms Scrotal cysts 10

11. DIFFERENTIAL DIAGNOSES OF SCROTAL SWELLING Congenital/others Inguinoscrotal hernia Vaginal hydrocele Varicocele Extra-scrotal cause Renal stone 11

12. IMAGING MODALITIES Ultrasonography-modality of choice: Affordable, available, accessible, non-ionizing Gray scale- linear high freq transducer Doppler ultrasound. Magnetic resonance imaging T1W sequence T2 W sequence Plain abdominal x-ray Nuclear medicine. Interventional radiology Image guided embolization in treatment of varicocele 12

13. TESTICULAR TORSION Occurs when a testicle twists on the spermatic cord resulting in the cutting off of its blood supply Epidemiology Torsion is classified into: 1 extra-vaginal (supra-vaginal) t orsion occurs at the level of external inguinal ring Seen in neonates 2 intra-vaginal Torsion occurs within the scrotum More common variety due to bell clapper deformity Typically occurs in adolescents and young adults 13

14. TESTICULAR TORSION Torsion can result from: direct trauma to the scrotum. Can be spontaneous Classic presentation is exactly as epididymo-orchitis : acute scrotal pain, swelling, redness or tenderness and vomiting in the absence of fever . Not relieved by elevation of the scrotum. No fever or urethral discharge. Pain may be intermittent (spontaneous detorsion ) Painless torsion is also a recognized entity 14

15. TESTICULAR TORSION Classification of testicular torsion based on time of presentation: Acute torsion=24hrs to 10 days Subacute /chronic torsion=beyond 10 days Testicular salvage rate depends on the time diagnosis is established and intervention carried out. <6 hours: ~100% salvage 6-12 hours: 50% 12-24 hours: 20% Also classified into incomplete(<360*) and complete(>360*) 15

16. TESTICULAR TORSION Ultrasound findings always comparing to the normal side: Twisting of the spermatic cord (whirlpool sign) most specific and sensitive sign. A spiral twist on grey scale ultrasound either in the external inguinal ring or in the scrotal sac. An enlarged heterogeneous testis and epididymis in the acute phase Multiple areas of infarction(hypoechoic) Scrotal oedema Reactive hydrocele Reactive thickening of the scrotal skin Decreased or no blood flow on Doppler interrogation Elevated resistive index >0.75 (normal=0.48-0.75) mean RI=0.62 Homogenous echotexture(early finding). Heterogenous echotexture(late finding greater than 24h) Nuclear medicine using Tc-99m pertechnetate: Photopenic area (area with no activity) 16

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18. TESTICULAR TORSION 18

19. TESTICULAR INFARCTION FROM TORSION 19

20. TESTICULAR TORSION 20

21. TORSION OF THE APPENDIX TESTIS Appendix testis represent a developmental remnant of the paramesonephric ( mullerian ) duct situated in the upper pole of the testis Prevalence in children is about 83-92% Can be bilateral in 69% of the cases. It is made prominent when it coexists with hydrocele. It measures between 1-4mm in length, oval or pedunculated in shape. Torsion occurs when testicular appendix twists, cutting of its blood supply. Clinical presentation includes: Acute hemiscrotal pain in a child 21

22. TORSION OF THE APPENDIX TESTIS Small firm nodule palpated on the superior aspect of the testis with blueish discolouration of the overlying skin(blue dot sign) Ultrasound findings: Increase in the size of appendix testis Increase or decrease in echogenicity May be accompanying hydrocele and scrotal wall thickening Absent or reduced vascularity on Doppler scan of the appendix testis. The testis is normal 22

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24. INTRATESTICULAR HAEMATOMA Blood collection in the testis commonly secondary to trauma Can occur from direct impact of high velocity object against the testis or compression of the testis against the pubic arch and the impacting object. Usually difficult to clinically differentiate it from testicular rupture and torsion. Ultrasound appearance depends on the time between occurrence of the trauma and ultrasound evaluation. Acute intratesticular haematoma are typically hyper/ isoechoic to the normal testicular parenchyma and can be difficult to identify Becomes hypoechoic as it resolves 24

25. INTRATESTICULAR HAEMATOMA There is lack of colour Doppler flow to the affected region There should be a follow up ultrasound scan in 2-4weeks to exclude an underlying neoplasm 25

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27. TESTICULAR RUPTURE Tearing of the tunica albuginea with extrusion of the testicular parenchyma into the scrotal sac Associated with laceration, fragmentation, intratesticular haematoma and infarction Ultrasound reveals a poorly defined testicular margins with heterogenous echotexture . There is loss of/decreased Doppler flow on the part of the testis affected. 27

28. A 25yr old man who presented with acute scrotal pain. Was struck by a car at low speed, slid under car and was dragged a short distance 28

29. EPIDIDYMO-ORCHITIS Refers to inflammation of the epididymis and testis Usually affects the epididymis first then extends to the testis Caused by Neisseria gonorrhea, Chlamydia (STIs) Can also be caused by E.Coli , Pseudomonas, and Tuberculosis Systemic infections and trauma are uncommon causes of acute epididymo-orchitis . Orchitis alone occurs very rarely and may be due to viral infections such as mumps, where it can present with bilateral testicular swelling. 29

30. EPIDIDYMO-ORCHITIS Ultrasound may demonstrate the following: Enlarged epididymis/testis Hydrocele Heteroechoic / hypoechoic testis Increased flow on colour Doppler interrogation . PSV 15cm/sec RI of less than 0.5 30

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33. Tuberculous epididymo orchitis 33

34. SCROTAL CELLULITIS Painful bilateral swelling of the scrotum Caused mainly by a beta hemolytic streptococci Can also result from a clostridium infection Cellulitis of the scrotum is uncommon but clinically significant as it can progress to necrotizing fasciitis (Fournier`s gangrene) especially in the immunocompromized or diabetics. Ultrasound findings include: Increased scrotal wall thickness Increased flow on Doppler scan There may be hydrocele Subcutanous emphysema and hypoechoic collection(abscess) when complicated 34

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36. Fourniere’s Gangrene 36

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38. TESTICULAR NEOPLASM Abnormal masses arising from the testis. Masses arising from the testis can be malignant or benign They can also be primary testicular malignancies or metastatic deposits. Primary testicular malignancy: Germ cell tumour : seminoma and non seminomatous germ cell tumour Sex cord stromal tumor Miscellaneous tumour:Leukaemia ,lymphoma etc 38

39. CLASSIFICATION OF TESTICULAR TUMOURS Sex cord-stromal tumours Leydig cell tumour Sertoli cell tumour Granulosa cell tumour Thecoma -fibroma Miscellaneous tumours Lymphoma Leukaemia sarcoma 39

40. Leiomyoma Vascular tumours Fibroma Neurofibroma . 40

41. CLASSIFICATION OF TESTICULAR TUMOURS Germ cell tumours (GCT): 95% of testicular cancers in young men. Seminoma-50% of GCT Mixed germ cell tumours - 33% of GCT Embryonal carcinoma-10% Teratoma-4% Yolk sac tumours-1% Choriocarcinoma-0.3% 41

42. TESTICULAR NEOPLASM Risk factors include: Cryptochidism (most common) Mumps orchitis Previous testicular tumor in the contralateral testis Family history of infertility Testicular microlithiasis Clinical presentation: Commonly painless unilateral scrotal mass Approximately 10% present with acute pain thought to be due to haemorrhage . 42

43. SEMINOMA Peak incidence is in the 4 th and 5 th decades Rare in children Less agrasive Extremely radiosensitive Ultrasound features include: Well defined lesion Hypoechoic May be multifocal Reactive hydrocele It is confined within tunica vaginalis Normal colour flow by Doppler interogation 43

44. SEMINOMA 44

45. Embryonal cell carcinoma It is a non seminomatous germ cell tumour It is the second commonest testicular tumour apart from seminoma It is seen younger adult population around 30yrs of age It is usually more aggressive than seminoma Usually associated with a rise of alpha feto protein And has a poor prognosis ULTRASOUND APPEARANCES Heterogenous hypoechic mass with irregular margin It may extends beyond the tunica albuginea Ill define areas of necrosis haemorrhage and calcification may be seen MRI Heterogenous signal intensity lesion with areas of haemorrhage and calcification 45

46. EMBRYONAL CELL CARCINOMA OF THE TESTIS 46

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48. TESTICULAR TERATOMA Testicular teratoma unlilke ovarian teratoma is often agrassive in its biological nature and some time exist as testicular mixed germ cell tumour Pure testicular teratoma is found in children less than 2 years while mixed testicular germ cell tumour is found in adult 48

49. TESTICULAR TERATOMA 49

50. METASTATIC TESTICULAR TUMOURS Non-primary testicular malignancies are very rare because of location of testes in the body It is seen in men above 57years Most metastasis to the testes are from leukaemia ,followed by lymphoma Rare p rimary sites include the prostate, kidneys, bronchus, pancreas, urinary bladder and thyroid. Metastasis are bilateral in 8-15% of cases Overt clinical involvement of the testis is common in leukaemia , and over 50% of men with acute leukaemia and 25% with chronic leukaemia have testicular involvement. 50

51. TESTICULAR METASTASIS The testis is also a common site for leukaemia relapse after treatment (due to poor penetration by chemotherapeutic agents). Ultrasound feature: Diffused multifocal hyperechoic lesions ( leukaemic infiltrates ) LYMPHOMA Non- hodgkins lymphoma involves the testis in up to 20% of men Testis may be the primary site and may be bilateral Testicular involvement is rare in hodgkins lymphoma. Typical ultrasound feature is that of multifocal discrete heteroechoic lesions. 51

52. TESTICULAR LEUKAEMIA (SECONDARY INVOLVEMENT) 52

53. TESTICULAR LYMPHOMA (SECONDARY INVOLVEMENT) 53

54. EPIDIDYMAL/TESTICULAR CYST Simple cysts are common in the scrotum Results in scrotal pain when infected, haemorrhagic or when it twists Most common in the elderly, though they may be seen at any age Commonest site- upper pole of the epididymis They may be single or multiple Ultrasound features: Classical features of cysts elsewhere in the body(anechoic, thin-walled, well marginated , with distal acoustic enhancement) May have some echoes with/without fluid level if infected or contains blood 54

55. TESTICULAR CYST 55

56. EPIDIDYMAL HEAD CYST 56

57. INGUINOSCROTAL HERNIA Refers to protrusion of abdominal contents into the scrotal sac Can be direct or indirect D irect hernia emerges medial to the inferior epigastric vessels Usually compresses and displaces inguinal canal laterally. Direct hernias usually do not extend into the scrotum Indirect hernia arises lateral and superior to the course of inferior epigastric vessels, and then protrude through the deep inquinal ring into the inquinal canal. 57

58. INGUINOSCROTAL HERNIA It emerges via the superficial ring and, if large enough, extend into the scrotum These herniated abdominal contents can get twisted, cutting off its vascular supply and cause scrotal pain or can compress the testicular artery resulting in ischaemic pain Indirect hernia is 5x more common than direct hernia It`s 7x more frequent in male than female due the persistence of processus vaginalis Contents of a hernia sac include(s) Mesenteric fat(most common ). 58

59. INGUINOSCROTAL HERNIA Peritoneal fluid Small bowel loop Mobile colon segment (sigmoid, caecum, appendix) Pathophysiology of incarcerated hernia. A hernia sac contains the neck and body When the neck is narrow, the content of the sac becomes trapped (incarcerated) This condition predisposes it to strangulation, ischaemia and perforation resulting in severe scrotal/inguinal pain. 59

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62. TESTICULAR HYDROCELE Accumulation of fluid between the visceral and parietal layers of tunica vaginalis surrounding the testis Pain occurs when there is a superinfection of preexisting hydrocele The cause is unknown in most cases It however can develop in a background of Non-obliteration of processus vaginalis Infection ( epididymo-orchitis ) Trauma Malignant testicular tumour or Infarction (including torsion) 62

63. TESTICULAR HYDROCELE Radiological findings depends on the cause Infective causes: common infective organisms are usually bowel related gram-bacilli Probe tenderness Echo-rich fluid in the tunica vaginalis Clinical and radiological features of epididymitis Frank pus( pyocele ) in severe cases Calcifications of the tunica( tuberculous cause) Non-infective cause Echo-free fluid in the tunica vaginalis Echogenic collection with septation in the tunical vaginalis ( haematocele ) 63

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66. VARICOCELE Dilatation of the network of veins draining the testicles. Seen in up to 8-16% of the male population Most frequent between the ages of 15-25 years Commonly left-sided Usually asymptomatic, discovered incidentally in most cases When symptomatic, presents with scrotal aching and/or left scrotal mass These symptoms classically worsen during the day when the patient is upright 66

67. VARICOCELE They can present acutely as a manifestation of a renal carcinoma A ssociated with subfertility, reported in 21-39% of males being investigated for subfertility. Can be classified as primary or secondary varicocele Primary varicocele are due to developmental abnormalities of the valves and/or the veins themselves. They constitute the majority of the varicoceles . Secondary varicoceles are due to lesions compressing or occluding the testicular vein, eg left-sided renal cell carcinoma. 67

68. Ultrasound features of varicocele A leash of predominantly echo-free serpinginous structures measuring >2mm maximum diameter May show flow on Doppler interrogation ( ie large varicocele ) Increased prominence in the upright position and with the valsalva manouever . Treatments by: Percutanous embolization surgery 68

69. 30yr old man with oligospermia , left testicular pain, with feeling of heaviness, clinically small left testis. 69

70. CONCLUSION Scrotal swelling is caused by a variety of conditions. A good clinical history, physical examination as well as ultrasound interrogation are enough to establish diagnoses in most of these conditions. Furthermore, a prompt scrotal ultrasonography and surgical intervention is necessary to avert irreversible testicular changes in some cases presenting as scrotal pain. 70

71. REFERENCES Sutton D. Textbook of Radiology and Imaging. Vol. 2. 2003. Adam A, Dixon AK, Gillard JH, Schaefer- Prokop CM. GRAINGER & ALLISON’S DIAGNOSTIC RADIOLOGY A Textbook of Medical Imaging [Internet]. Vol. 5. 2015. 487-492 p. Available from: http://ir.obihiro.ac.jp/dspace/handle/10322/3933 3. Ryan S, McNicholas M, Eustace S. Anatomy for Diagnostic Imaging. 2004. 71

72. REFERENCES Patel MS. Testicular torsion | Radiology Case | Radiopaedia.org [Internet]. [cited 2019 Mar 19]. Available from: https:// radiopaedia.org/cases/testicular-torsion-7?lang=us Kühn AL, Scortegagna E, Nowitzki KM, Kim YH. Ultrasonography of the scrotum in adults. Ultrason (Seoul, Korea) [Internet]. 2016 Jul [cited 2019 Mar 19];35(3):180–97. Available from: http:// www.ncbi.nlm.nih.gov/pubmed/26983766 6 . Dogra VS, Gottlieb RH, Oka M, Rubens DJ. Sonography of the Scrotum . Radiology [Internet]. 2003 Apr 1 [cited 2019 Mar 19 ];227(1):18–36. Available from: http ://pubs.rsna.org/doi/10.1148/radiol.2271001744 72

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