Testicular Evaluation using Bedside Ultrasonography
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Testicular ultrasonography (also called scrotal ultrasonography) is the primary diagnostic modality for the evaluation of testicular and scrotal disease. [1, 2, 3, 4] Its nonionizing nature, along with continued advances in technology, render ultrasonography the imaging modality of choice.
Testicular ultrasonography is a useful noninvasive tool in both adult and pediatric patient groups. It serves as a good screening and diagnostic tool and helps dictate further management in the appropriate clinical setting. [5] Testicular ultrasonography has a wide range of applications, varying from acute scrotal pain to more chronic and nonspecific symptoms. [5, 6]
In the clinical setting of testicular torsion, ultrasonography should not delay manual or surgical reduction. [7]
Typically, scrotal and testicular ultrasonography are not associated with any complications. The patient may experience pain if the testis is acutely inflamed or torqued, particularly in the setting of trauma.
Guidelines on scrotal ultrasound examination have been published by the American Institute of Ultrasound in Medicine (in collaboration with the American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound). [8] Indications include the following:
Evaluation of scrotal pain, including but not limited to testicular trauma, ischemia/torsion, and infectious or inflammatory scrotal disease.
Evaluation of palpable inguinal, intrascrotal, or testicular masses.
Evaluation of scrotal asymmetry, swelling, or enlargement.
Evaluation of potential intrascrotal hernias.
Detection/evaluation of varicoceles.
Evaluation of male infertility.
Follow-up of prior indeterminate scrotal ultrasound findings.
Localization of nonpalpable testes.
Detection of occult primary tumors in patients with metastatic germ cell tumors or unexplained retroperitoneal adenopathy.
Follow-up of patients with prior primary testicular neoplasms, leukemia, or lymphoma.
Evaluation of abnormalities noted on other imaging studies (including but not limited to CT, MRI, and positron emission tomography [PET]).
Ultrasonography is often indicated in the work-up of acute scrotal pain. It is particularly valuable in cases that are challenging to diagnose clinically or in patients whose conditions fail to respond to initial treatment. Ultrasonography is also helpful in patients who present with chronic nonspecific symptoms, in whom a definitive diagnosis is not easily made. [9] Ultrasonography has been shown to decrease the number of emergency scrotal explorations and the length of hospital stay and, thus, reduce the cost of management of the acute scrotum. [10] In animal studies of acute testicular ischemia, pulse-wave spectral Doppler ultrasonography has been shown to assess perfusion better than conventional color flow Doppler or power Doppler methods. [11, 7]
Ultrasonography is also used for the following:
Evaluation of testicular swelling or masses [12, 1, 3, 4]
Testicular trauma
Infertility [13]
Undescended testis (vanishing testes or impalpable testis in children [14] )
Male hypogonadism [15]
Testicular interventions (eg, ultrasound-guided aspiration, biopsy, epididymal ablation)
Postvasectomy pain
Place the patient in a supine position. Take care to support the scrotum. Consider adducting the thighs or placing a towel or sheet under the scrotum. Propping the scrotum with a towel or sheet, however, can block inferior and coronal approaches to the testis. It may also redistribute physiologic amounts of fluid within the scrotal sac and make the imaging of small structures (eg, appendix testis) more challenging.
If the penis obstructs the scanning field, ask the patient to shift the penis superiorly toward the abdominal wall and then cover with a sheet.
In infants and young boys, the testes may need to be immobilized directly with the sonographer’s finger, since the testes are very small and mobile at this age. A towel can also be wrapped around the patient’s thighs to lend support and to relatively immobilize the scrotum. [16]
In terms of grading varicoceles, the diameter of the dominant vein in the upright position at the inguinal canal can be used. [17]
Ultrasonography of the scrotum should be performed with the patient’s symptoms and privacy in mind. Be sure the drape covers the patient appropriately. [18]
A focused history and clinical examination should be performed prior to scrotal ultrasonography. Ultrasonographic findings should always be interpreted in the context of the patient’s history and clinical examination. The history and clinical examination, however, are often not enough to discriminate between the possible etiologies for the patient’s symptoms.
Ask the patient to identify the area of maximum tenderness or the location of any palpable findings. Doing so saves time by decreasing the amount of time spent searching with ultrasound. The presence of inflammation or obvious signs of ischemia or injury dictate subsequent steps in assessment and management.
Wash hands and put on gloves.
Apply ultrasound gel.
Using direct contact, scan the scrotum and all of its contents as follows:
Begin with the asymptomatic side first and then proceed to the affected side. If possible, perform views that include both testes. Comparing both sides is essential to defining and characterizing any abnormalities (see image below).
Each part of the testis and epididymis are to be scanned in both longitudinal and transverse planes (see images below). The tail of the epididymis is often best visualized using a coronal view; obtaining such a view may require the patient to temporarily assume a frog-leg position.
The video below is a demonstration of a scrotal ultrasonographic examination.
The videos below depict normal findings.
The mnemonic TESTIC(K)AL is a practical sequence and useful guide to the scrotal and testicular ultrasound examination:
T estis
E pididymis
S kin and soft tissues of scrotum
T unicae (vaginalis, albuginea)
I nternal blood supply
C ompare with the other testis
K idney
A ppendages
Don’t L eave examination of both pampiniform plexus
Thoroughly interrogate each testis in both longitudinal and transverse planes. Be sure to compare with the contralateral side.
Decreased echogenicity
Orchitis, epididymo-orchitis: Diffuse decreased echogenicity suggests orchitis; the addition of epididymal findings suggests a diagnosis of epididymo-orchitis; early in infection, however, the echogenicity may be isoechoic. See images below.
Testicular tumors: Focal low echogenicity masses or nodules should raise suspicion; a complex cystic lesion within the testis may represent necrosis resulting from tumor. [1]
Scrotal injury or hematoma: Hematomas may resemble tumors. See images below.
Tunica albuginea: Irregular masses, in the context of trauma, may be associated with rupture of the tunica albuginea; prompt diagnosis followed by emergent surgery results in salvage of the testis in 80-90% of cases. [19]
Torsion: In the subacute stage of testicular torsion, the testis may demonstrate low echogenicity. [7]
Increased echogenicity
Testicular microlithiasis: Multiple small echogenic grainlike calcifications throughout the testicle are important to appreciate, as they may be associated with an increased risk of cancer.
Chronic atrophy: In the chronic stage of torsion, the testis may be small, atrophic, and echogenic.
Decreased vascularity
Torsion: Decreased perfusion of the testis on Doppler imaging is the single most important finding to suggest the diagnosis of testicular torsion. [7]
Increased vascularity
Infection: Acute infection results in inflammatory hyperemia and increased vascularity within the testis.
Comparison
Directly comparing both testes may be the only manner in which a subtle abnormal finding (eg, mild decrease in echogenicity) can be appreciated.
The shape of the epididymis varies from straight to C-shaped. Scan the epididymal head, body, and tail on both sides. Be sure to scan the epididymis in multiple planes (longitudinal, transverse, and coronal). The epididymis is usually isoechoic to the testis. Look carefully for the following:
Cysts: Cysts are a common finding in the epididymal head; when found, measure the size in both longitudinal and transverse directions.
Increased size: An enlarged and swollen epididymis is a finding seen in epididymo-orchitis.
Increased vascularity: Hyperemia and increased vascularity of the epididymis may be another finding of epididymo-orchitis.
Imaging the tail of the epididymis is important because infection is often most apparent at this location.
The scrotum is a cutaneous pouch with 2 lateral compartments divided by the median raphe. It is lined by the tunica vaginalis, which reflects over the exterior surface of each testicle.
Assess for swelling of the skin and soft tissues; edema and hyperemia within the skin and subcutaneous tissues of the scrotal sac may be seen in infection (scrotal cellulitis) and trauma. In scrotal cellulitis, the skin and subcutaneous tissues are affected, but the contents of the scrotum inside the tunica vaginalis are spared. Scrotal abscesses may result when testicular abscesses rupture through the tunica albuginea and into the scrotal sac.
Rupture, discontinuity, or irregular disruption of the tunica albuginea (the exterior capsule of the testicle) all suggest testicular rupture in the appropriate clinical setting; associated hematoma may exist within the testis or subcutaneous tissues; testicular fracture requires prompt surgical evaluation.
Hydrocele: Fluid located between the visceral and parietal layers of the tunica vaginalis is called a hydrocele. It may be idiopathic and asymptomatic. Reactive hydroceles are seen in association with infection, torsion, and trauma; infective processes can lead to complex hydroceles or pyoceles.
Fournier gangrene: This is a serious and life-threatening form of necrotizing scrotal cellulitis and also involves the tissues of the perineum and base of the penis. Unlike simple scrotal cellulitis, Fournier gangrene causes ischemia, so involved tissue does not have demonstrable inflammatory hyperemia, and may also produce gas, which results in bright echoes with dirty shadowing on ultrasound.
Vestigial appendages are normal variants in the testis and epididymis and are usually of little significance. They typically have a thin, elongated, vermiform shape.
Torsion of the appendix testis or appendix epididymis can present similar to spermatic cord torsion.
The torsed appendix appears enlarged and often with an altered echotexture due to infarction with or without hemorrhage. The testis appears normal, and a reactive hydrocele may be present.
Typically, blood flow is not demonstrated in the normal appendix testis or appendix epididymis. As such, the absence of flow in a suspected torsed appendix has little diagnostic value.
The pampiniform plexus (venous drainage of the testicle) should be assessed in both planes and with Doppler ultrasonography. The caliber of the vessels before and after the Valsalva maneuver is the mainstay of the diagnosis of varicocele.
A grading system categorizes varicoceles as small, medium, or large. The caliber of the largest vessel is measured at the groin while the patient is standing.
Varicoceles generally occur in the left scrotum because of the anatomic venous connection of the left testicular vein draining into the left renal vein.
Varicoceles are often asymptomatic but can present as a chronic ache or heaviness. They generally do not cause acute pain; due to slow flow, however, thrombosis can occur, and this may result in acute pain.
Depending upon the symptoms and the size of the varicocele, further ultrasound examinations may be needed. Varicoceles are associated with decreased fertility and require appropriate follow-up.
If a varicocele is present, the kidneys must be assessed to rule out a renal mass as the cause for the varicocele. Renal lesions can impair drainage of the testicular veins into the renal vein or inferior vena cava; some advocate for the routine assessment of both kidneys in every testicular ultrasound examination.
Testicular symptoms can be referred from the urinary tract (eg, kidney stones often cause pain that radiates down into the groin and testicles).
Multiple views (longitudinal, transverse, and coronal) of the structure of interest should be obtained and compared to the contralateral side. Each structure should be interrogated in terms of echogenicity and vascularity.
In the acute setting, an unremarkable ultrasound with the presence of central testicular blood flow does not always exclude testicular torsion. Testicular torsion is based on a critical deficiency in testicular blood flow and not on the absence of blood flow. [7]
When torsion is highly suspected, ultrasonography should not delay definitive treatment such as manual reduction or surgical exploration.
Doppler ultrasonography should be performed in all patients with an acute scrotum. Optimize Doppler settings on the asymptomatic side first, prior to evaluating the symptomatic side. [7]
Color flow Doppler and power Doppler imaging are valuable tools; they are the mainstays in the diagnosis of emergent conditions such as testicular torsion. [7]
Ultrasonography can also be used to facilitate a testis-sparing procedure. The amount of normal residual parenchyma visible on ultrasound is difficult to determine, as tissue is compressed during evaluation; thus, its true presence can be underestimated. [20]
Three-dimensional (3D) ultrasonography offers an improved way to depict anatomy and to assess for abnormalities. More studies are needed to establish its role and added utility. [21]
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Badar Bin Bilal Shafi, MBBS, MRCP, FRCR, CCT, EBIR Consultant Interventional Radiologist, South Mersey Vascular Centre and Countess of Chester Hospital, UK
Badar Bin Bilal Shafi, MBBS, MRCP, FRCR, CCT, EBIR is a member of the following medical societies: Radiological Society of North America, Royal College of Physicians, Royal College of Radiologists, Society of Interventional Radiology, Cardiovascular and Interventional Radiological Society of Europe, British Society of Interventional Radiology
Disclosure: Nothing to disclose.
John M Curtis, MB, ChB, FRCP, FRCR, DMRD Consultant Radiologist, University Hospital Aintree
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Laurie Scudder, DNP, NP Nurse Planner, Medscape; Senior Clinical Professor of Nursing, George Washington University
Disclosure: Nothing to disclose.
Mahan Mathur, MD Assistant Professor of Radiology and Biomedical Imaging, Yale University School of Medicine; Director, Medical Student Education, Associate Director, Diagnostic Radiology Residency Program, Yale-New Haven Hospital
Mahan Mathur, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Radiological Society of North America
Disclosure: Nothing to disclose.
James Quan-Yu Hwang, MD, RDMS, RDCS, FACEP Staff Physician, Emergency Department, Kaiser Permanente
James Quan-Yu Hwang, MD, RDMS, RDCS, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Institute of Ultrasound in Medicine, Society for Academic Emergency Medicine
Disclosure: Received salary from 3rd Rock Ultrasound, LLC for speaking and teaching; Received consulting fee from Schlesinger Associates for consulting; Received consulting fee from Philips Ultrasound for consulting.
Gowthaman Gunabushanam, MD, FRCR Assistant Professor, Department of Diagnostic Radiology, Yale University School of Medicine
Gowthaman Gunabushanam, MD, FRCR is a member of the following medical societies: American Roentgen Ray Society, Connecticut State Medical Society
Disclosure: Nothing to disclose.
The authors thank Mrs. Lynne Poll, Senior Radiographer, for her help in acquiring the images from PACS into their present form.
Medscape Reference thanks Meghan Kelly Herbst, MD, Emergency Ultrasound Director, Department of Emergency Medicine, Hartford Hospital, for assistance with the video contribution to this article. Medscape Reference also thanks Yale School of Medicine, Emergency Medicine for assistance with the video contribution to this article.
Testicular Evaluation using Bedside Ultrasonography
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