European Journal of Cardiovascular Medicine

Scrotal swelling is a frequent issue faced in everyday medical practice among males of all ages. The range of potential causes for scrotal swellings includes simple hydrocele, varicocele, epididymal-orchitis, testicular torsion, trauma, and testicular cancer, among others. While thorough clinical examination is a vital initial step in evaluation, it often falls short of accurately identifying the precise underlying cause of scrotal swelling. Given that various underlying conditions can lead to the observed symptoms, correctly interpreting the findings is crucial for directing subsequent treatment and intervention. A swift and precise diagnosis is necessary to distinguish between conditions that require surgical intervention and those that can be managed with conservative treatment alone.1 Since pain and swelling may hinder the ability to palpate the scrotum effectively, a definitive diagnosis cannot be established solely through clinical symptoms and physical examination. When patients present with a scrotal mass, it is critical to determine whether it is intra-testicular or extra-testicular.

To assess scrotal swellings, high-resolution ultrasound (HRUS) with colour Doppler has become the preferred imaging modality. It is capable of distinguishing between extra testicular lesions and intratesticular lesions, as well as identifying other scrotal abnormalities, particularly scrotal injuries. Being non-invasive, it can be utilised to assess the contents of the scrotum, check the integrity of the testis, evaluate blood flow, and identify hematomas, fluid collections, or foreign bodies.2 In managing scrotal trauma, aside from cases of degloving injury that leads to the avulsion of the scrotal skin, ultrasound is often used to guide treatment. Blunt trauma is the most frequent cause of scrotal injury, followed by penetrating injuries, both of which can lead to hematomas, hydroceles, haematoceles, testicular fractures, or ruptures. In 80%-90% of rupture instances, it is possible to preserve the testis with emergency surgery if a timely diagnosis of the tunica albuginea discontinuity is established through ultrasound.

The blood flow to the testes can be evaluated by incorporating colour Doppler imaging with standard grey scale ultrasound. Besides grey scale and colour Doppler imaging, other diagnostic techniques that may be useful include radioisotope studies, testicular angiography, and MRI. While CT and MRI have a limited role in assessing scrotal conditions, they are primarily employed for staging testicular cancers and examining undescended testes that cannot be visualised with ultrasound.3 CT involves radiation exposure to the gonads, while MRI is costlier and less readily available, making it less suitable for routine imaging. Radioisotope studies have a restricted role and are typically used to complement uncertain imaging results. Ultrasound is favoured due to its easy accessibility, non-invasive nature, relatively low cost, and lack of gonadal radiation; it also offers excellent anatomical detail. When colour Doppler and power Doppler imaging are utilised, the perfusion of the testicles can be evaluated.4 Therefore, this study aims to investigate the "Role of colour Doppler ultrasonography in the assessment of scrotal swellings."

OBJECTIVES

1. To assess the accuracy of high-resolution sonography and colour Doppler in the diagnosis of scrotal swellings.
2. To evaluate the sonographic appearance of the spectrum of scrotal swellings.

Study Design:

A prospective hospital-based cross-sectional study.

Study area:

Department of Radio Diagnosis, M. V. J Medical College & Research Hospital, Hoskote, Bangalore.

Study Period:

1 year.

Study population:

 Patients referred to the Department of Radiology for ultrasonography for scrotal swellings.

Sample size:

 The study consisted of 100 subjects.

Sampling method:

Simple random technique.

Inclusion criteria:

All cases with clinical evidence of scrotal swelling.

Exclusion Criteria:

- All cases with scrotal wounds and discharging sinus.

- Medical conditions like nephritic syndrome, hypoproteinemia, angioneurotic oedema and Insect bite.

- Scrotal swellings extending into the inguinal region (hernias) were excluded from the study.

Ethical consideration: Institutional Ethical Committee permission was obtained before the commencement of the study.

Study tools and Data collection procedure:

Equipment: - In this study, High-resolution real-time gray scale ultrasonography and a Doppler study of the scrotum were carried out using a 5 to12 MHz linear transducer, abdominal ultrasonography was done using 1 to 5 MHz convex curved array transducer of PHILLIPS AFFINITI 70 machine and PHILLIPS HD7 XE.

The scrotum is studied with a linear, high-resolution, high-frequency (5–12 MHz) dedicated high-resolution small-parts transducer. Although many problems can be solved with grey-scale imaging alone, colour Doppler is extremely useful in selected patients. Colour Doppler settings are adjusted to detect slow flow: the highest colour gain setting allows an acceptable signal-to-noise ratio, the lowest wall filter, and the lowest velocity scale. Ultrasound of the scrotum is usually performed in the supine position. Sometimes, it is helpful to support the scrotum with a towel to gain easier access to comparative views. The patient may be asked to hold the penis suprapubically. Occasionally, additional scanning in the upright position is helpful. If there is a palpable abnormality on physical examination, it is often helpful to perform targeted scanning during palpation to correlate potential US abnormalities with physical examination.

Parameters to be measured:

During the ultrasound scan, on a routine basis, the following parameters will be evaluated.

1) Testis: Size: normal / increased / atrophic Shape: Normal/ Diffuse enlargement/ Focal enlargement, Echogenicity: Normal/ Hypoechoic / Hyperechoic / Hypoechoic / Heterogenous Color flow: Normal /absent / increased / reduced. Spectral study: Normal pattern / increased velocity/ absent flow.

2) Epididymis: Size: Normal / enlarged, Echogenicity: Hypoechoic / Hyperechoic / Heterogenous Color flow: Normal /absent / increased / reduce

3) Spermatic cord: Size: normal / thickened, Echo pattern: normal/Hypoechoic / Hyperechoic / Heterogenous. Colour flow: normal / increased/absent. Pampiniform plexus: normal / dilated.

4) Scrotal wall thickness – normal / thickened

5) Presence or absence of any collection in the scrotal sac

6) Presence of any other abnormalities in the scrotum.

Observations will be collected in a prescribed Proforma for analysis.

Statistical analysis:  In the present study, descriptive statistical analysis was done. Results for categorical measurements are reported in Number (%), whereas results for continuous measurements are reported as Mean ±SD(Min-Max). At a 5% level of significance, significance is evaluated.

Table 1: Distribution of cases among various age groups.

The age distribution of cases ranges from 2 Years to 88 Years. The highest number of cases presented were in the age group of 61 to 70 years (23 cases – 23%), followed by 41 to 50 years (20 cases – 20%). The age group of 21 to 40 years constituted about 26%.

TABLE-2 CLINICAL PRESENTATION FREQUENCY OF SYMPTOMS

Most of the cases presented clinically with a combination of more than one symptom. The commonest clinical presentation was a combination of Symptoms like pain and scrotal swelling, accounting for 51 cases (51%), and scrotal swelling alone was seen in 35 cases (35%). Out of 100 cases of scrotal swellings, 52% were inflammatory swellings, and 48% were non-inflammatory swellings.

TABLE 3: TYPES OF INFLAMMATORY PATHOLOGY DETECTED

In our study, out of 100 cases, 52 cases were detected to have inflammatory scrotal pathologies on high-resolution ultrasonography and colour Doppler study. Out of all the inflammatory pathologies, Chronic Epididymo-orchitis was the commonest, noted in 16 cases (30.7%). The next most frequent inflammatory pathology detected was acute Epididymo-orchitis, noted in 12 cases (23.0%). 

TABLE 4: HIGH-RESOLUTION US APPEARANCE OF INFLAMMATORY SCROTAL PATHOLOGIES

TABLE 6: COLOUR DOPPLER APPEARANCE OF INFLAMMATORY SCROTAL PATHOLOGIES

fig 1. Ultra sonographic image of Acute epididymo-orchitis

High-resolution ultra-sonographic imaging in right acute epididymal-orchitis showing diffuse enlargement of size, diffusely hypoechoic echotexture in epididymis and testis.

Fig 2. Doppler image of acute epididymo-orchitis

Doppler imaging in right acute epididymal-orchitis shows a diffuse increase in vascularity of both epididymis and testis

Fig 3. Doppler image of tuberculous orchitis

Doppler study in acute tuberculous orchitis showing a diffuse increase in vascularity

Fig 4. Doppler image of orchitis

Doppler imaging in left acute orchitis showing diffuse increase in vascularity of testis

     Fig 5. Doppler image of acute epididymitis

Doppler ultrasonographic imaging in acute epididymitis shows diffusely increased vascularity of epididymis.

Fig 6. Doppler image of tuberculous epididymitis

High-resolution ultrasonography with Doppler imaging in chronic tuberculous epididymitis showing diffuse enlargement of size, heterogeneously hyperechoic echotexture in the epididymis and focal decrease in vascularity.

Fig 7. Doppler image of funiculitis

Doppler imaging in funiculitis shows increased vascularity in the spermatic cord.

Fig 8. Ultra sonographic image of the epidydimal cyst

High-resolution ultrasonographic imaging showing anechoic fluid-filled lesion in the head of the epididymis with posterior acoustic enhancement suggestive of epididymal cyst.

Table 1: Distribution of cases among various age groups.

The age distribution of cases ranges from 2 Years to 88 Years. The highest number of cases presented were in the age group of 61 to 70 years (23 cases – 23%), followed by 41 to 50 years (20 cases – 20%). The age group of 21 to 40 years constituted about 26%.

TABLE-2 CLINICAL PRESENTATION FREQUENCY OF SYMPTOMS

Most of the cases presented clinically with a combination of more than one symptom. The commonest clinical presentation was a combination of Symptoms like pain and scrotal swelling, accounting for 51 cases (51%), and scrotal swelling alone was seen in 35 cases (35%). Out of 100 cases of scrotal swellings, 52% were inflammatory swellings, and 48% were non-inflammatory swellings.

TABLE 3: TYPES OF INFLAMMATORY PATHOLOGY DETECTED

In our study, out of 100 cases, 52 cases were detected to have inflammatory scrotal pathologies on high-resolution ultrasonography and colour Doppler study. Out of all the inflammatory pathologies, Chronic Epididymo-orchitis was the commonest, noted in 16 cases (30.7%). The next most frequent inflammatory pathology detected was acute Epididymo-orchitis, noted in 12 cases (23.0%). 

TABLE 4: HIGH-RESOLUTION US APPEARANCE OF INFLAMMATORY SCROTAL PATHOLOGIES

TABLE 6: COLOUR DOPPLER APPEARANCE OF INFLAMMATORY SCROTAL PATHOLOGIES

fig 1. Ultra sonographic image of Acute epididymo-orchitis

High-resolution ultra-sonographic imaging in right acute epididymal-orchitis showing diffuse enlargement of size, diffusely hypoechoic echotexture in epididymis and testis.

Fig 2. Doppler image of acute epididymo-orchitis

Doppler imaging in right acute epididymal-orchitis shows a diffuse increase in vascularity of both epididymis and testis

Fig 3. Doppler image of tuberculous orchitis

Doppler study in acute tuberculous orchitis showing a diffuse increase in vascularity

Fig 4. Doppler image of orchitis

Doppler imaging in left acute orchitis showing diffuse increase in vascularity of testis

     Fig 5. Doppler image of acute epididymitis

Doppler ultrasonographic imaging in acute epididymitis shows diffusely increased vascularity of epididymis.

Fig 6. Doppler image of tuberculous epididymitis

High-resolution ultrasonography with Doppler imaging in chronic tuberculous epididymitis showing diffuse enlargement of size, heterogeneously hyperechoic echotexture in the epididymis and focal decrease in vascularity.

Fig 7. Doppler image of funiculitis

Doppler imaging in funiculitis shows increased vascularity in the spermatic cord.

Fig 8. Ultra sonographic image of the epidydimal cyst

High-resolution ultrasonographic imaging showing anechoic fluid-filled lesion in the head of the epididymis with posterior acoustic enhancement suggestive of epididymal cyst.

The scrotum is positioned superficially, which makes it ideal for sonographic evaluation. The development of a high-frequency real-time scanner improves the accuracy of scrotal sonographic diagnostic tests. In this study, we examined 100 patients using high-frequency ultrasound and colour Doppler examination for the diagnosis of scrotal swellings.

Clinical Background: The cases have been referred from the Department of Urology and the Department of Surgery, with suspicion of scrotal pathology. The highest number of patients were in the age range of 61-70 years (23 cases - 23%), followed by 41-50 years (20 cases - 20%).

Symptomatology: The most common clinical presentation was a combination of symptoms such as pain and swelling of the scrotum in 40 cases (40%) and pain, swelling and fever in 10 cases (10%).

Swelling: 30 cases presented with complaints of swelling (30%). There were nine patients (30%) with acute presentation of swelling [duration of 2 days to 10 days]. There were 21 patients with chronic presentation of swelling (70%) [Duration of 15 days to 6 months].

Pain: 11 cases presented exclusively only with pain in the scrotum (8%). Out of these, 5 cases presented with acute onset (45%) [Duration few hours to 5 days] and 6 cases presented with chronic pain (55%) [Duration15 days to 6 months].

Scrotal pain varied from dull aching to very severe pain. Most cases of acute onset of scrotal pain, particularly those associated with fever, had severe pain, whereas those with insidious onset and not associated with fever had dull, aching scrotal pain.

Types of scrotal swellings detected: The largest number of cases (52 cases) showed inflammatory pathology, 8 cases showed Congenital lesions and neoplastic lesions were noted in 2 cases.

Arger et al. ⁵, in a series of 62 patients, detected Inflammatory diseases in 12 cases (29.84%) and non-inflammatory swellings in 45 cases (67%). Willscheret al⁶, in a study conducted on 43 patients, noted Inflammatory pathology in 15 cases and Non-inflammatory diseases in 30 cases. Richie et al. ⁷, in their study on 124 patients by ultrasonography of the scrotum, found inflammatory lesions in 31 cases and non-inflammatory swellings in 75 cases. In our study, inflammatory conditions constitute the largest number of detected pathology.

In our study, out of the 100 cases of scrotal swelling, 52 were detected to have inflammatory scrotal pathology on high-frequency ultrasonography and colour Doppler study. The commonest inflammatory pathology detected was Chronic Epididymo-orchitis, which was noted in 16 cases (30.7%), followed by acute Epididymo-orchitis, noted in 12 cases (23%). Other detected inflammatory pathologies include scrotal filariasis seen in 4 cases (7.6%), acute orchitis in 6 cases (11.5%), chronic epididymitis in 4 cases (7.6%), scrotal wall inflammation in 4 cases (7.6%), acute epididymitis in 5 cases (9.6%) and Funiculitis in 1 case (1.7%).

Horstman, Middleton, and Nelson, in their study of 45 patients, found acute epididymitis in 25 cases (56%), acute Epididymo-orchitis in 19cases (42%) and acute orchitis in 1 case (2 %)12. No case of chronic epididymoorchitis was reported. Lerner et al. ⁸, in their limited series of 5 cases of acute inflammatory diseases of the scrotum, found acute epididymitis in 3 patients (60%) and acute Epididymoorchitis in 2 patients (40%).

Farriol et al. ⁹, using high-resolution grey scale and power Doppler sonographic imaging, studied 25 cases of acute inflammatory diseases of the scrotum and found epididymitis in 11 cases (44%), Epididymo-orchitis in 10 cases (40%), orchitis in 2 cases (8%) and funiculitis in 2 cases (8%).

There is an increased incidence of chronic Epididymo-orchitis in our study, mainly due to the large incidence of tubercular Epididymo-orchitis, the incidence of which is less in the Western population. In our study, where there were 52 cases of inflammatory scrotal pathology, the High-resolution US appearance findings are depicted, and colour Doppler findings are depicted. Of the five cases of acute epididymitis, diffuse hypoechogenicity was observed in all five cases, a diffuse increase in vascularity was observed in five cases, and the size of epididymis was increased in five cases. These findings are similar to the findings of Horstman et al.¹⁰, where in their study of 45 cases (51 hemiscrotum) and Farriol et al.⁹, in their study of 11 cases, documented similar findings of comparison with other series (acute epididymitis).

Of the 12 cases of acute Epididymo-orchitis, diffuse hypoechogenicity was noted in 8 cases, 1 case showed heterogenous echotexture and 3 cases showed normal echotexture; 9 cases showed a diffuse increase in vascularity, and 3 cases showed a focal increase in vascularity. The size of the epididymis was increased in 7 cases. These findings are similar to the findings of Horstman et al.^10, who, in their study of 45 cases, and Farriol et al. ⁹, in their study of 11 cases17, demonstrated similar findings. Comparison with other series (epididymal-orchitis) is depicted.

Of the six cases of acute orchitis, all six cases were seen to be unilateral. Focal involvement was noted in 3 cases, while the other 3 cases showed diffuse involvement. On high-frequency ultrasonography, focal involvement was seen as a focal area of hypoechogenicity, while the other 3 cases that had diffuse involvement showed diffuse enlargement with diffuse hypoechogenicity. On colour Doppler sonography, three cases showed focal increased vascularity in the areas of hypoechogenicity, and three showed diffuse increase in vascularity. These findings are similar to the findings of Farriol et al.⁹ study of 11 cases. Comparison with other series (Acute orchitis) is depicted.

In our study of 52 cases of inflammatory pathologies of the scrotum, 9 cases of complications of acute scrotal pathology were noted, out of which 4 cases were noted to be scrotal wall Cellulitis, 4 cases were found to be scrotal wall filariasis, and one case was noted to be funiculitis. In Cellulitis of the scrotal wall, High-frequency US sonography showed loss of normal uniform hypoechoic appearance of the scrotal wall, thickening of the scrotal wall and presence of normal testis, epididymis and tunica sac. These findings are similar to the studies of Luker and Siegel¹¹.

In our study, we have noted 48 cases of non-inflammatory scrotal pathologies (48%). In all the cases of non-inflammatory scrotal pathologies associated with pain, the pain was of low intensity and mild dragging in character, which helped to differentiate them from inflammatory swellings. Of the 48 cases of non-inflammatory scrotal pathologies, 2 cases were found to be neoplastic lesions, and the remaining 46 cases were non-neoplastic swellings. The 2 cases of neoplastic swellings were histopathologically confirmed to be seminoma. These findings are similar to previous studies by Grantham et al. ¹² and Schwerk et al. ¹³. Of the remaining. In forty-six cases, pathology was seen in both hemiscrotum in 10 cases on one side in 36 cases. 

Among non-inflammatory scrotal swellings, hydrocele was the most common pathology noted in 32 cases (66.7%). Out of the 32 cases, 22 cases were primary vaginal hydroceles (68.75%), and 10 were encysted hydroceles of cord (31.25%). Out of the 32 cases, hydrocele was seen on one side in 24 cases and bilateral in 8 cases. These findings are similar to previous studies of Arger et al. ^five and Willscher et al. ¹⁴. All cases of hydroceles appeared as collections of clear fluid between two layers of tunica vaginalis. In encysted hydroceles of the cord, collections of clear anechoic fluid were noted along the spermatic cord with repulsion on gentle traction to the cord.

In conclusion, high-resolution ultrasound (USG) and colour Doppler sonography are highly effective, non-invasive tools for evaluating scrotal swellings. They provide excellent sensitivity in diagnosing acute inflammatory conditions (e.g., epididymal-orchitis), differentiating testicular from extra-testicular pathologies, and identifying cystic versus solid lesions. Tubercular pathologies were the most common chronic inflammatory conditions, while hydrocele was the most frequent non-inflammatory swelling. Seminoma was the most common testicular tumour, with most intra-testicular masses being malignant. Doppler USG was particularly useful in detecting varicocele and monitoring traumatic or inflammatory cases. These methods are cost-effective, widely available, and radiation-free, making them ideal for diagnosing and managing scrotal pathologies.

1. Miskin M and Bain J: B-mode ultrasonic examination of the testes. Journal of Clinical Ultrasound, 1974; 2: 30
2. Murray Miskin, Martin Buckspan and Jerald Bain. Ultrasonographic examination of scrotal masses. The Journal of Urology, 1977; 117:185- 188
3. Thomas H Shawker B-mode ultrasonic examination of scrotal swellings Radiology 1976; 118:417- 419
4. Sample W F, Gottesman JE, Skinner DG, et al., Grayscale ultrasound of the scrotum.
5. Peter H Arger et al., Prospective analysis of the value of Scrotal Ultrasound. Radiology1981; 141: 763-766
6. Willscher M, Conway J, Daly K, DiGiacinto T, Patten D. Scrotal Ultrasonography. The Journal of Urology. 1983;130(5):931-932.
7. Ultrasonography as a diagnostic adjunct for the evaluation of masses in the scrotum.Richie JP, Birnholz J, Garnick MB.Surg Gynecol Obstet. 1982 May;154(5):695-8.
8. Robert M Lerner et al., Color Doppler US in the evaluation of Acute Scrotal Disease, Radiology, 1990; 176:355-358.
9. Victoria Garriga Farriol, et al., Gray-scale and power Doppler sonographic appearances of acute inflammatory diseases of the scrotum, J of Clin Ultrasound a 2000;28: 67-72.
10. Horstman W, Middleton W, Melson G, Siegel B. Color Doppler US of the scrotum. RadioGraphics. 1991;11(6):941-957.
11. Luker G, Siegel M. Color Doppler sonography of the scrotum in children. American Journal of Roentgenology. 1994;163(3):649-655.
12. Grantham G, Testicular neoplasms. Radiology, 1985; 157:775-780.
13. Wolf B Schwerk, et al., Testicular tumours: Prospective analysis of real-time US patterns and abdominal staging, Radiology; 164: 369-374.
14. Bhatt S, Dogra V. Role of US in Testicular and Scrotal Trauma. RadioGraphics. 2008;28(6):1617-1629.