Pitfalls in Imaging for Acute Scrotal Pathology

Abstract

Differentiation among the many clinical situations that can present with acute scrotal pain is a significant diagnostic problem in clinical practice. A firm diagnosis is often difficult based on clinical history and physical examinations alone, and imaging is usually requested for this purpose. However, imaging findings alone may not clarify the diagnosis as imaging studies have to be interpreted in close correlation with clinical information and with knowledge of the possible pathologic situations underlying the clinical presentation of the specific patient.\ud \ud In this article we describe and discuss the most common problems encountered when performing diagnostic studies for acute scrotal symptoms and the solutions for, possibly, avoiding them

The EFSUMB Guidelines and Recommendations for the Clinical Practice of Contrast-Enhanced Ultrasound (CEUS) in Non-Hepatic Applications: Update 2017 (Long Version)

“…Testicular hematoma can rarely present with acute scrotal pain in a patient with no history of trauma. US demonstrates an intratesticular mass suggesting malignancy, but the lack of enhancement is a good marker for the absence of vascularity and for a benign lesion, leading to a presumptive diagnosis and conservative management [82,94,95].…”

Nonscrotal Causes of Acute Scrotum

“…In acute renal colic, passage of the calculus may result in inflammation and edema of the ureteral walls, which stimulate the autonomic innervation of both the ureter and the kidney, as well as the genitofemoral nerve, eventually causing acute scrotal pain (Figure 3). 1 …”

“…These patients are first referred for a scrotal ultrasound (US) examination because the scrotum appears to be the area of concern clinically. This could be detrimental, in particular, for a number of life‐threatening conditions for which the correct diagnosis may be delayed or even missed if a nonscrotal origin of the pain is not considered 1 …”

Multiparametric US for scrotal diseases

“…Experimental studies in rabbit show that evaluation of time-intensity curves after microbubble injection could perform better than conventional Doppler modes [29,31]. In the clinical practice, however, diagnosis of low-degree torsion is obtained combining detection on the symptomatic side of monophasic waveforms, increased resistance index with decreased diastolic flow velocities, diastolic flow reversal, or post-stenotic flows associated with the ''whirlpool sign,'' i.e., demonstration of the funicular vessels wrapping around the central axis of the twisted spermatic cord [37].…”

“…Regardless of gray-scale appearance, segmental testicular infarction is invariably hypovascular or avascular at color Doppler interrogation. The differential diagnosis from a hypovascular tumor may be problematic in rounded lesions and when vascularity is not completely absent [37]. CEUS proved effective in differentiating segmental tes-ticular infarction from hypovascular tumors when appearance at conventional Doppler modes is equivocal.…”