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International journal of medical science & dental health Original Article Evaluation of clinical and radiological correlation in scrotal lesions in
patients at tertiary care teaching hospital
Krati S. Mundhra 1, ShashiKumar H. Mundhra 2
1Associate Professor, Department of Radiology, Smt. N.H.L. Municipal Medical College,Ahmedabad, Gujarat, India. 2 Associate Professor, Department of Medicine, G.M.E.R.S. Medical college, Gandhinagar, Gujarat, India. ABSTRACT
Introduction:
In the clinical evaluation of a scrotal abnormality, the physical examination
may be inadequate. Diagnostic ultrasonography with duplex imaging is exceptionally well
suited for studying the scrotum. Objective: to find out incidence in scrotal pathology
regarding age. Materials and Methods: This study was conducted at a tertiary care centre.
Fifty patients were enrolled in the study. Both testicles were scanned in transverse and
longitudinal planes and echogenicity; size of the two testicles were compared. The
epididymis (including head, body and tail) and the spermatic cord were scanned by
ultrasonography for abnormalities. Results: Scrotal swelling was most common presentation
among patients under study. Testicular lesions were 42%, while lesions with extra testicular
involvement were 58%. Benign lesions were 92%, while malignant lesions were only 8 %.
Thirteen patients were presented with enlarged epididymis and 7 patients with secondary
hydrocele. One of these 7 patients of secondary hydrocele, 1 was having abscess and 2 had
pyocele. Twenty two patients of hydrocele were found and out of these , 12 patients were of
primary hydrocele and 10 patients were of secondary hydrocele. There were 5, 3 and 3
patients of varicocele, epididymal cyst and scrotal hernia respectively in present study.
Conclusion: A variety of imaging modalities were utilized for diagnosis of scrotal pathology.
Diagnostic ultrasonography with duplex imaging is exceptionally well suited for studying the
scrotum. We tried to correlate clinical and radiological findings in fifty patients of scrotal
disease at a tertiary care centre.
Keywords: Ultrasonography, scrotal lesion

INTRODUCTION

The first description of scrotal
A variety of imaging modalities ultrasonography was published by Musken have been utilized to complement the and Bain in 1874-75 by using static B- clinical presentation and physical findings mode scanning. Until then examination of in the differential diagnosis of scrotal scrotal contents was limited to palpation trans-illumination. examination of scrotum for abnormality thermography, radionucleotide studies, cannot yield much information required to ultrasonography and duplex scanning, come to probable diagnosis owing to pain, computerised tomography scanning (CT tenderness, odema and discomfort to scan) and magnetic resonance imaging patients with scrotal lesion. Many a time (MRI) have been described as valuable clinical presentations are non specific, variable and commonly misleading. International Journal of Medical Science & Dental Health│2015│Vol 1│Issue 2 74
Mundhra et al. ; clinical and radiological correlation in scrotal lesions
Diagnostic ultrasonography with duplex imaging is exceptionally well differentiate between intra as well as extra suited for studying the scrotum. It is testicular lesions. We tried to find out simple to perform, causing not much clinic-pathological and radiological co- relation of scrotal lesions. noninvasive and relatively inexpensive with wide availability when the clinical MATERIALS AND METHODS
diagnosis is questionable. Ultrasonography This study was performed at is reliable in differentiating intra as well as tertiary care teaching hospital in western part of India. Fifty patients were enrolled for this study. High resolution real time etiologies of painful scrotum (spermatic ultrasound equipment appears to be the cord torsion vs. acute epididymoorchitis [3] best for optimal imaging of superficial and determining testicular integrity in small parts like scrotum. The present study cases of trauma. Ultrasonography (USG) is was done on Toshiba equipment using 9 also helpful in determining testicular size, and 11 MHz high resolution linear transducer for scrotum 3.5 MHz transducer demonstrating occult testicular neoplasm. USG is also helpful for follow up After explaining the procedure to patients in their vernacular language and orchidectomy for recurrent testicular obtaining consent from them, procedure neoplasm, staging the malignant disease were started. The examination of patients and to evaluate metastasis, in nodes and was done in supine position. Although in liver and staging of malignant testicular patients who had suspected with varicocele or hernia both supine and standing B-mode study superimposed on positions were employed. The scrotum color flow mapping is helpful in cases of was elevated and supported by a folded acute scrotum [3] varicocele (sub fertility) towel held between the upper thighs. The [5] and testicular penis was retracted cephalad. Scrotum was gently palpated. The transducer was CT scan is particularly useful for applied directly to the scrotum with staging and follow-up of cases with aqueous coupling gel. testicular tumours because of its ability to Both testicles were scanned in evaluate liver and lung metastasis and transverse and longitudinal planes and abdominal and mediastinal lymph nodes. echogenicity and size of the two testicles MRI may detect the ectopic testis and were compared. The epididymis head was helpful in diagnosis of diffuse testicular scanned and if it is visible, its body and infiltration for example leukemia, owing to tail were also scanned. The spermatic cord its superior contrast resolution. was scanned from inguinal canal to the The aim of the study was to find characteristic echo-pattern of various In our study the commonest age scrotal pathologies. We studied the ability group was 21-30 years of age. In this study International Journal of Medical Science & Dental Health│2015│Vol 1│Issue 2
Mundhra et al. ; clinical and radiological correlation in scrotal lesions
youngest was of 1 year old baby while Table-2 Spectrum of scrotal lesions
eldest was of 69 years. (Table -1) Percentage
Table-1Age distribution of scrotal pathology
Age Group
Cases Percentage
Epididymoorchitis Testicular abscess Epididymal abcess Testicular tumor found the commonest scrotal lesion. Second commonest was inflammatory scrotal disease. In this study 22 patients of hydrocele, out of Testicular rupture which, 12 cases were primary and 10 cases were of secondary hydrocele. In diagnosed with inflammatory scrotal disease. Thirteen patients were showing enlarged epididymis out of which ten patients having hypoechoic epididymis and 3 having hyperechoic epididymis. One patient of epididymitis without orchitis was tuberculous in origin. (Table 2) There were 5 patients of varicocele in this study. Eighty percent cases had pathology in left side. International Journal of Medical Science & Dental Health│2015│Vol 1│Issue 2
Mundhra et al. ; clinical and radiological correlation in scrotal lesions
Varicocele was found common between 20 to 30 years age group (60%). Out of 3 Table-3 Location of lesions
patients presented with scrotal trauma and one of them having hematoma and two Location of
Cases Percentage
having haematocele. One case of testicular torsion was found. Three cases of epididymal cyst and same number of cases having scrotal hernia were also seen. Figure –1 Clinical presentation of scrotal lesion
As shown in figure -1 patient most commonly present with scrotal swelling (88%). Next common feature was pain and tenderness (48%). We shows testicular lesion were 42% while extra testicular involvement were 58%. Testis withot any extratesticular involvement were seen in 14% and with extratesticular involvement in 28%. Only extra testicular lesions are seen in Epididymis (26%), Tunica vaginaiis(20%), Pampiniform plexus(10%), Subcutaneous tissue(2%) of cases. (Table -3). We were able to differentiate Figure -2 Benign v/s malignant disease
benign (92%) from malignant lesion (8%). We saws that there is no difference in inhomogenisity, and 1 having calcification. regarding side of lesion (Figure -2). All of In follow-up for histology 2 having them having normal scrotal wall and seminoma while one each having teratoma epididymis. In three of the malignant and embryonal cell carcinoma. lesion testis is having hypoechoic area, 2 International Journal of Medical Science & Dental Health│2015│Vol 1│Issue 2
Mundhra et al. ; clinical and radiological correlation in scrotal lesions
Discussion
conducte by Subramanian BR et al. [8] and In our study, the commonest age group Chung J J et al. [9] was 21-30 years of age and such a finding is consistent with studies of Rifkin et al. [4] epididymis with scrotum wall thickening is the most reliable sign of a benign involvement was more common than inflammatory disease. This finding was testicular involvement. Ultrasonography seen in 4 patients of present study. These can differentiate between testicular and findings are consistent with Fowler et al. extra testicular lesion in all patients. These and Rifkin M.D. [4] observations were consistent with study Increased vascularity on doppler conducted by Caroll et al. series. [2] study was seen in 11 patients of present study. These findings were with study differentiate benign from malignant lesion. done by Vikram S Dogra, MD et al. [10] Benign lesion was more common than and it stated that most of the case of malignant. These finding were consistent epididymoorchitis show increased blood with study carried by Rifkin et al. [4] Our analysis shows that lesions almost equally Hydrocele was most common involved both sides. presentation in scrotal disease. In 75% of Inflammatory scrotal disease was patients having hydrocele presented with second most common disease in scrotal painless scrotal swelling. This study was lesions. Hypoechoic epididymis was more consistent with study done by W.D. common than hyperechoic epididymis. Middletone et al. [11] Seven patients had enlarged testis and out On ultrasound primary hydrocele them, 6 patients had hypoechoic testis. had anechoic fluid surrounding testis and These findings were similar to those epididymis with no echoes or septation. observed with study done by Eugenio O. These findings are consistent with study Gerscovich M.D. [1] Among secondary done by Caroll B et al. [2] Causes of hydrocele one of them showed abscess and secondary hydrocele were epididymitis, two of them were having pyocele. epididymo-orchitis, torsion, trauma and One patient of epididymitis without orchitis was of tuberculous in origin. consistent with study done by Goldberg These findings were correlated with study B.B. et al. [12] done by Nickel W.R. [7] and it is frequently Varicocele was found in 10% cases observed that epididymitis without orchitis in this study and left side more common. can be seen in tuberculosis and sometime Varicocele was common in young age viral diseases, like mumps. One patient group between 20 to 30 years. These showed enlarged hypoechoic testis and findings were consistent with study done epididymis with anechoic areas of necrosis by Goldberg B.B. et al. [12] 60% patients and few areas of calcification and an were sub fertile due to varicocele and this organized hydrocele. The histopathological finding was similar to observed with study report of tuberculous epididymo orchitis done by Belker AM et al. [13] and Gonda was similar to observed with study R.L. et al. [14] On ultrasound varicocele appeared as serpiginous echo poor lesions in International Journal of Medical Science & Dental Health│2015│Vol 1│Issue 2
Mundhra et al. ; clinical and radiological correlation in scrotal lesions
spermatic cord which became prominent consistent with study done by Cohen H.L. on standing and valsalva maneuver. et al. [6] and Jeffrey et al. [19] patient with Doppler study revealed venous flow in age of 22 years, presented with acute these vessels. These findings were history of vomiting and severe pain in consistent with study done by Middleton groin. On USG examination of testis was Present study showing 4 patients of hydrocele. Color doppler study showed primary testicular tumors. Compare with absent blood flow in testis and reduced study of Carmignani L et al. [15] 80 percent blood flow in epididymis. These findings of nonpalpable testicular lesions are were consistent with study done by Margin benign. Two of them were seminoma, one B et al. [3] and it stated that color Doppler was teratoma and one was embryonal cell carcinoma. These findings are consistent epididymoorchitis. with study done by Peter M. et al. [16] There are two case of undescended According to them, incidence of seminoma testis. One had empty scrotum and both was 40-50%, 10-20% of embryonal cell testis found at deep inguinal ring. The carcinoma, 10%teratoma 10% and 20-35% other had unilateral undescended testis. of choriocarcinoma. Peak incidence of The testis found in inguinal canal. The tumor occurs between 20 to 35 years of incidence and sites of ectopic testis are group. These findings were consistent with agreed upon by Caroll B et al. [2] study done by Oyem RH [17] In this study In this study there were three cases all patients having germ cell tumor out of of epididymal cyst. One patient had which teratoma was commonest, also bilateral and multiple epididymal cyst. The agreed by Goldfinger SS et al.[18] and findings were of an anechoic lesion with which is common primary testicular tumor posterior enhancement consistent with that of germ cell origin. In study done by of Caroll B et al. [2]. In one case of Barbera Caroll et al. [2] 80-95% tumor epididymal cyst, intra-testicular cyst was were germ cell origins. In this study seminomas was There were three cases of scrotal hernia in present series. Ultrasound masses. Teratoma produced bizarre echo findings were that of a complex intra scrotal mass separate from the testis and embryonal cell carcinoma showed mixed showed peristalsis. Testis was normal in echo-pattern with areas of necrosis and appearance. These findings are consistent with that of Bala Subramanyam et al. [8] consistent with study done by Peter M. et al. [16] CONCLUSION
Among scrotal trauma one of them Ultrasound was the mainstay of the is subcapsular haematoma, confined by diagnosis because it was found to be a safe, no expensive, easily available, less deforming the underlying testicular tissue. time consuming modality not involving Two cases having hypoechoic fluid in radiation and intervention. USG has a high tunica with echoes and septa suggest intratesticular from testicular lesions. This International Journal of Medical Science & Dental Health│2015│Vol 1│Issue 2
Mundhra et al. ; clinical and radiological correlation in scrotal lesions
intratesticular lesions can be potentially Pediatr Radiol 1992 ; 22 : 296-7. malignant. When testis could not be 7. Nickle WR, Plumb RT. Cutaneous evaluated clinically due to hydrocele, ultrasound was helpful in excluding Cambell's Urology edition 5, 1986: Philadelphia: WB Saunders; 956-82. epididymoorchitis or testicular tumour. 8. Subramanyam BR, Horii SC, Hilton S. Ultrasonography was helpful in Diffuse testicular disease. Am J Roentgenol 1985;145: 1221-4. disease. It thus not only facilitated early 9. Chung JJ, Kim MJ, Lee T,Yoo HS,Lee diagnosis in patients of testicular tumor, JT. Sonographic finding in tuberculous but also reduced need of surgical epididymitis and epididymoorchitis. J exploration in unwanted cases. In case of Clin Ultrasound 1997; 25: 390-4. testicular trauma, scrotal USG was useful 10. Vikram S Dogra, Eugene C Lin. to exclude/confirm testicular affection, allowing a more rationale choice between surgery and conservative management. 9-overview Sep 24, 2013 USG had high diagnostic accuracy 11. Middleton WD, Thorne DA, Melson and was found the investigation of choice GL. Color Doppler Ultrasound of the for scrotal lesions. normal testis. Am J Roentgenol 1989; REFERENCES
12. Goldberg BB, Fay PM, Rifkin MD. ultrasonography in the diagnosis of characteristics of the normal testis and scrotal pathology: I. normal scrotum and benign disease. J Clin Ultrasound. Resolution Superficial scanners. Med. Ultrasound 1984; 8 : 91-97. 2. Barbara A, Caroll, Kenneth, Krone D. 13. Belker AM. The varicocele and male Symposium on ultrasonography of infertility. Urol Clin North Am 1981; 3. Margin B, Conte J. Ultrasonography of RA,O'Donnell KT. Diagnosis of the acute Scrotum: J Clin Ultrasound subclinical varicocele in infertility. 1987; 15: 37-44. Am J Roentgenol 1987; 48: 71-5. 4. Refkin MD. Scrotal ultrasound. Urol 15. Carmignani L, Gadda F, Gazzano G, Radiol 1987; 9: 119-26. 5. Stephen Vick, William Middleton, High incidence of benign testicular Steven Fitzerald. Kenneth Taylor. neoplasms diagnosed by ultrasound. J Color Doppler imaging of scrotum and Urol 2003; 170:1783–6. 16. Carol B. Benson, Peter M. Doubilet 6. Cohen HL, Shapiro ML, Haller JO, Jerome P. Richie. Sonography of Male genital tract. Am J Roentgenol 1989; International Journal of Medical Science & Dental Health│2015│Vol 1│Issue 2
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Mundhra
18. Stoll S, Goldfinger M, Rothberg R, Buckspan MB Fernandes BJ ,Bain J. Date of submission- 09/07/2015
Incidental detection of impalpable Date of acceptance-16/07/2015
testicular neoplasm by sonography. Am J Roentgenol 1986; 146: 349- 50. How to cite this article: Mundhra K,
testicular trauma. Am J Roentgenol Mundhra S. Evaluation of clinical and 1983; 141: 993-5. radiological correlation in scrotal lesions in patients at tertiary care teaching hospital. Int J Med Sci Den Health
2015;1: 74-81.
Source of support: Nil, Conflict of
interest: None declared
Acknowledgement:None declared International Journal of Medical Science & Dental Health│2015│Vol 1│Issue 2

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