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