Reasoning in Radiology
Evaluation of a scrotal mass By Cathy R. Kessenich, DSN, ARNP, and Kathryn Bacher, BSN
TK is a 21-year-old White male who presented to the University Health Center with complaints of moderate pain in his left testicle. He described the pain as intermittent and a 4 on a pain intensity rating scale of 0 to 10, with 0 being no pain and 10 being the worst pain. He stated that the pain has been a problem for the past 6 months, and he finally decided he should come in for an evaluation. He denied any recent trauma, sports activities, or episodes of heavy lifting. He described his health as generally good with no problems meeting the demands of his busy school, work, and social schedule. His family history is negative for breast, ovarian, or testicular cancer. He is currently in a monogamous relationship with his girlfriend of 1 year and denies any difficulty with sexual performance. His girlfriend is taking an oral contraceptive, as they do not wish to become parents at this time. TK’s physical exam was normal with the exception of a 1.5 × 2 cm, nonfixed tender mass on the lateral aspect of his left testicle. The nurse practitioner explained to TK that the mass needed to be evaluated further with an ultrasound. She also explained that the mass could be a varicocele, a hydrocele, a spermatocele, a malignancy, or an inguinal hernia. The test was scheduled for later that week. ■ Scrotal abnormalities Scrotal abnormalities can vary from the benign and painless to the malignant and debilitating. Three www.tnpj.com
common abnormalities seen using ultrasonography include varicocele, hydrocele, and spermatocele. A varicocele is an atypical dilation of the pampiniform plexus and the testicular vein within the scrotum.1 The varicocele can typically be illustrated as a “bag of worms” seen in the spermatic cord.1 The pampiniform plexus veins generally range from 0.5 to 2.0 mm in diameter, and an internal diameter of 3 mm or larger is considered abnormal.2 Most occur on the left side due to discrepancies in the valves of the
fertility is not an issue, treatment of a painful but mild varicocele includes scrotal support, limiting activity, and anti-inflammatory medication.1,3 Surgical repair of a varicocele is generally performed when the male has a grade II or III varicocele and an abnormal semen analysis while the female partner has no known infertility problems. It may also be done if the varicocele becomes bothersome and has not responded to conventional treatment.1,3 Although a varicocele is considered the most treatable cause
Scrotal abnormalities can vary from the benign and painless to the malignant and debilitating. left testicular vein, which is longer and has a more vertical position.1,2 A varicocele on the right side is rare and may result from obstruction or compression of the inferior vena cava via a thrombus or tumor.1 The prevalence of varicocele in males is 15% to 20%, and in infertile men, the prevalence ranges from 30% to 40%.2 An alteration in folliclestimulating hormone levels and testosterone cause oxidative stress, affect sperm quality, and decrease sperm count. Varicoceles may diminish blood flow through the testis, impeding spermatogenesis and causing infertility.1 Patients with a varicocele may present with scrotal pain and/or scrotal heaviness or dragging that worsens with straining or exercise.3 Varicoceles may also be discovered when a patient is being evaluated for infertility.3 When
of infertility, surgical treatment is still controversial.3 A hydrocele, the most common cause of scrotal swelling, is an abnormal collection of fluid between the visceral and parietal layers of the tunica vaginalis.1,2 Normally, a few mLs of serous fluid is present between these layers, but when an abnormal amount is seen, the type of fluid can help determine the etiology.2 The hydrocele may be idiopathic or may be secondary to a testicular neoplasm that might contain serous fluid (simple hydrocele), blood (hematocele), pus (pyocele), recent scrotal surgery, trauma, infection, or torsion.1,2 Congenital hydroceles occur in 6% of newborn males and are a result of a patent processus vaginalis that permits access of peritoneal fluid in the scrotal sac.1,2 These usually resolve themselves within the first year of life.1 The Nurse Practitioner • May 2014 13
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Reasoning in Radiology Hydroceles are generally asymptomatic and fluctuate in size. On physical exam, the most important feature is a smooth, tense scrotal mass that transluminates easily.1 Men presenting with a hydrocele in their 30s or 40s need to be evaluated carefully for testicular cancer. 1 Treatment for a hydrocele includes watchful waiting and communicating or symptomatic hydroceles require treatment. 1 Treatment includes surgical aspiration, resection, or sclerotherapy to remove the tunica vaginalis. 1 Spermatoceles are benign, cystic collections located between the testis and the head of the epididymis that contain milky, fluid-containing sperm and are usually painless.1 Spermatoceles present as masses that are firm, move freely, are usually discrete, and can be transilluminated.1 Treatment includes scrotal support when asymptomatic or when mild discomfort is present.1 Spermatoceles that cause significant discomfort are removed.1 ■ Scrotal ultrasound Ultrasonography is the overall best imaging modality used to evaluate for scrotal disease, as it is simple to execute, is less expensive than other imaging options, does not contain ionizing radiation, and is transportable.2 Precise diagnosis using clinical evaluation alone may be inadequate, as a variety of scrotal abnormalities have similar clinical manifestations.2 A precise interpretation of the findings is vital in directing additional intervention and treatment.4 Scrotal ultrasonography is completed with the patient in a supine position with a rolled towel placed between the legs to support the scrotum; the patient is asked to hold his penis away from the imaging area (or positioned superolaterally or superiorly) and covered with a towel.2,4
In order to supply sufficient acoustic contact between the scrotal skin and the transducer, a moderate amount of gel should be used.2 Scrotal imaging is best performed using an 8-MHz to 15-MHz transducer with sequential transverse and sagittal images.4 In the presence of a hydrocele or an edematous scrotum, a lower frequency transducer should be used for deeper penetration to have optimum visualization of the underlying epididymis and testis.2,4 When comparing the echogenicity, flow symmetry, scrotal wall thickness, and size of each testis, three transverse (upper pole, middle pole, and lower pole) and three longitudinal (lateral, medial, and midline) images of each testis should be acquired.2,4 Power Doppler and color ultrasound are used to identify perfusion and to confirm abnormal flow patterns.4 Evaluation of nonpalpable and palpable scrotal masses using ultrasonography provides information that helps determine the differential diagnosis.2 Once a mass has been detected, the internal vascularity should be examined.2 To detect an extratesticular abnormality or varicocele, examining the structures inside the scrotal sac should begin at the level of the spermatic cord and should move inferiorly to the level of the pampiniform plexus.2 A vessel diameter greater than 3 mm in supine position and greater than 1 mm of reflux during valsalva maneuver can indicate varicocele.4 An important component of the ultrasound is use of the Valsalva maneuver, as this causes an enlargement in vessel size.5 Color doppler ultrasound (CDUS) is the gold standard technique for the evaluation of varicoceles.6 Varicoceles can lead to unpleasant symptoms and may be associated with fertility issues.6 Clinical and radiologic diagnoses are important, as
correct treatment may lead to improvement in fertility and resolution of symptoms.2 Ultrasonography is the imaging choice for evaluation of scrotal abnormalities thanks to its low cost, lack of adverse effects, widespread accessibility, and high repeatability.6 ■ Moving forward The result of TK’s ultrasound revealed a small varicocele in the lateral aspect of his left testicle. He was advised that mild, over-the-counter analgesics were the only treatment for now. Additionally, he was informed that if he experienced difficulty with fertility in the future, he might require surgical repair of the abnormality. Finally, TK was instructed on the importance and technique of regular testicular self-examination. He was relieved to discover that the pain and lump in his testicle was not testicular cancer and promised that he would return to the clinic if his pain exacerbated. REFERENCES 1. Huether SE, McCance KL, Brashers VL, Rote NS. Understanding Pathophysiology. 5th ed. St. Louis, MO: Mosby Elsevier; 2012:822-823. 2. Pearl MS, Hill MC. Ultrasound of the scrotum. Semin Ultrasound CT MR. 2007;28(4):225-248. 3. Chen SS. Factors predicting symptomatic relief by varicocelectomy in patients with normospermia and painful varicocele nonresponsive to conservative treatment. Urology. 2012;80(3):585-589. 4. Hebert SC, Chong WK, Deurdulian C. Essentials of scrotal ultrasound: a review of frequently encountered abnormalities. Appl Radiol. 2012;42(9):7-15. 5. Dudea SM, Ciurea A, Chiorean A, Botar-Jid C. Doppler applications in testicular and scrotal disease. Med Ultrason. 2010;12(1):43-51. 6. Pauroso S, Di Leo N, Fulle I, Di Segni M, Alessi S, Maggini E. Varicocele: Ultrasonographic assessment in daily clinical practice. J Ultrasound. 2011;14(4):199-204. Cathy R. Kessenich is a professor of nursing and MSN program director and Kathryn Bacher is a graduate assistant at the University of Tampa, Fla. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NPR.0000441920.64428.9a
14 The Nurse Practitioner • Vol. 39, No. 5
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.tnpj.com
Evaluation of a scrotal mass By Cathy R. Kessenich, DSN, ARNP, and Kathryn Bacher, BSN
TK is a 21-year-old White male who presented to the University Health Center with complaints of moderate pain in his left testicle. He described the pain as intermittent and a 4 on a pain intensity rating scale of 0 to 10, with 0 being no pain and 10 being the worst pain. He stated that the pain has been a problem for the past 6 months, and he finally decided he should come in for an evaluation. He denied any recent trauma, sports activities, or episodes of heavy lifting. He described his health as generally good with no problems meeting the demands of his busy school, work, and social schedule. His family history is negative for breast, ovarian, or testicular cancer. He is currently in a monogamous relationship with his girlfriend of 1 year and denies any difficulty with sexual performance. His girlfriend is taking an oral contraceptive, as they do not wish to become parents at this time. TK’s physical exam was normal with the exception of a 1.5 × 2 cm, nonfixed tender mass on the lateral aspect of his left testicle. The nurse practitioner explained to TK that the mass needed to be evaluated further with an ultrasound. She also explained that the mass could be a varicocele, a hydrocele, a spermatocele, a malignancy, or an inguinal hernia. The test was scheduled for later that week. ■ Scrotal abnormalities Scrotal abnormalities can vary from the benign and painless to the malignant and debilitating. Three www.tnpj.com
common abnormalities seen using ultrasonography include varicocele, hydrocele, and spermatocele. A varicocele is an atypical dilation of the pampiniform plexus and the testicular vein within the scrotum.1 The varicocele can typically be illustrated as a “bag of worms” seen in the spermatic cord.1 The pampiniform plexus veins generally range from 0.5 to 2.0 mm in diameter, and an internal diameter of 3 mm or larger is considered abnormal.2 Most occur on the left side due to discrepancies in the valves of the
fertility is not an issue, treatment of a painful but mild varicocele includes scrotal support, limiting activity, and anti-inflammatory medication.1,3 Surgical repair of a varicocele is generally performed when the male has a grade II or III varicocele and an abnormal semen analysis while the female partner has no known infertility problems. It may also be done if the varicocele becomes bothersome and has not responded to conventional treatment.1,3 Although a varicocele is considered the most treatable cause
Scrotal abnormalities can vary from the benign and painless to the malignant and debilitating. left testicular vein, which is longer and has a more vertical position.1,2 A varicocele on the right side is rare and may result from obstruction or compression of the inferior vena cava via a thrombus or tumor.1 The prevalence of varicocele in males is 15% to 20%, and in infertile men, the prevalence ranges from 30% to 40%.2 An alteration in folliclestimulating hormone levels and testosterone cause oxidative stress, affect sperm quality, and decrease sperm count. Varicoceles may diminish blood flow through the testis, impeding spermatogenesis and causing infertility.1 Patients with a varicocele may present with scrotal pain and/or scrotal heaviness or dragging that worsens with straining or exercise.3 Varicoceles may also be discovered when a patient is being evaluated for infertility.3 When
of infertility, surgical treatment is still controversial.3 A hydrocele, the most common cause of scrotal swelling, is an abnormal collection of fluid between the visceral and parietal layers of the tunica vaginalis.1,2 Normally, a few mLs of serous fluid is present between these layers, but when an abnormal amount is seen, the type of fluid can help determine the etiology.2 The hydrocele may be idiopathic or may be secondary to a testicular neoplasm that might contain serous fluid (simple hydrocele), blood (hematocele), pus (pyocele), recent scrotal surgery, trauma, infection, or torsion.1,2 Congenital hydroceles occur in 6% of newborn males and are a result of a patent processus vaginalis that permits access of peritoneal fluid in the scrotal sac.1,2 These usually resolve themselves within the first year of life.1 The Nurse Practitioner • May 2014 13
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Reasoning in Radiology Hydroceles are generally asymptomatic and fluctuate in size. On physical exam, the most important feature is a smooth, tense scrotal mass that transluminates easily.1 Men presenting with a hydrocele in their 30s or 40s need to be evaluated carefully for testicular cancer. 1 Treatment for a hydrocele includes watchful waiting and communicating or symptomatic hydroceles require treatment. 1 Treatment includes surgical aspiration, resection, or sclerotherapy to remove the tunica vaginalis. 1 Spermatoceles are benign, cystic collections located between the testis and the head of the epididymis that contain milky, fluid-containing sperm and are usually painless.1 Spermatoceles present as masses that are firm, move freely, are usually discrete, and can be transilluminated.1 Treatment includes scrotal support when asymptomatic or when mild discomfort is present.1 Spermatoceles that cause significant discomfort are removed.1 ■ Scrotal ultrasound Ultrasonography is the overall best imaging modality used to evaluate for scrotal disease, as it is simple to execute, is less expensive than other imaging options, does not contain ionizing radiation, and is transportable.2 Precise diagnosis using clinical evaluation alone may be inadequate, as a variety of scrotal abnormalities have similar clinical manifestations.2 A precise interpretation of the findings is vital in directing additional intervention and treatment.4 Scrotal ultrasonography is completed with the patient in a supine position with a rolled towel placed between the legs to support the scrotum; the patient is asked to hold his penis away from the imaging area (or positioned superolaterally or superiorly) and covered with a towel.2,4
In order to supply sufficient acoustic contact between the scrotal skin and the transducer, a moderate amount of gel should be used.2 Scrotal imaging is best performed using an 8-MHz to 15-MHz transducer with sequential transverse and sagittal images.4 In the presence of a hydrocele or an edematous scrotum, a lower frequency transducer should be used for deeper penetration to have optimum visualization of the underlying epididymis and testis.2,4 When comparing the echogenicity, flow symmetry, scrotal wall thickness, and size of each testis, three transverse (upper pole, middle pole, and lower pole) and three longitudinal (lateral, medial, and midline) images of each testis should be acquired.2,4 Power Doppler and color ultrasound are used to identify perfusion and to confirm abnormal flow patterns.4 Evaluation of nonpalpable and palpable scrotal masses using ultrasonography provides information that helps determine the differential diagnosis.2 Once a mass has been detected, the internal vascularity should be examined.2 To detect an extratesticular abnormality or varicocele, examining the structures inside the scrotal sac should begin at the level of the spermatic cord and should move inferiorly to the level of the pampiniform plexus.2 A vessel diameter greater than 3 mm in supine position and greater than 1 mm of reflux during valsalva maneuver can indicate varicocele.4 An important component of the ultrasound is use of the Valsalva maneuver, as this causes an enlargement in vessel size.5 Color doppler ultrasound (CDUS) is the gold standard technique for the evaluation of varicoceles.6 Varicoceles can lead to unpleasant symptoms and may be associated with fertility issues.6 Clinical and radiologic diagnoses are important, as
correct treatment may lead to improvement in fertility and resolution of symptoms.2 Ultrasonography is the imaging choice for evaluation of scrotal abnormalities thanks to its low cost, lack of adverse effects, widespread accessibility, and high repeatability.6 ■ Moving forward The result of TK’s ultrasound revealed a small varicocele in the lateral aspect of his left testicle. He was advised that mild, over-the-counter analgesics were the only treatment for now. Additionally, he was informed that if he experienced difficulty with fertility in the future, he might require surgical repair of the abnormality. Finally, TK was instructed on the importance and technique of regular testicular self-examination. He was relieved to discover that the pain and lump in his testicle was not testicular cancer and promised that he would return to the clinic if his pain exacerbated. REFERENCES 1. Huether SE, McCance KL, Brashers VL, Rote NS. Understanding Pathophysiology. 5th ed. St. Louis, MO: Mosby Elsevier; 2012:822-823. 2. Pearl MS, Hill MC. Ultrasound of the scrotum. Semin Ultrasound CT MR. 2007;28(4):225-248. 3. Chen SS. Factors predicting symptomatic relief by varicocelectomy in patients with normospermia and painful varicocele nonresponsive to conservative treatment. Urology. 2012;80(3):585-589. 4. Hebert SC, Chong WK, Deurdulian C. Essentials of scrotal ultrasound: a review of frequently encountered abnormalities. Appl Radiol. 2012;42(9):7-15. 5. Dudea SM, Ciurea A, Chiorean A, Botar-Jid C. Doppler applications in testicular and scrotal disease. Med Ultrason. 2010;12(1):43-51. 6. Pauroso S, Di Leo N, Fulle I, Di Segni M, Alessi S, Maggini E. Varicocele: Ultrasonographic assessment in daily clinical practice. J Ultrasound. 2011;14(4):199-204. Cathy R. Kessenich is a professor of nursing and MSN program director and Kathryn Bacher is a graduate assistant at the University of Tampa, Fla. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NPR.0000441920.64428.9a
14 The Nurse Practitioner • Vol. 39, No. 5
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.tnpj.com
