Tohoku
J. exp.
Ultrasonic
Med.,
1977,
123, 337-341
Diagnosis
of Intrascrotal
Contents
MASAHITO SAITOH, HIROSHI OHE, SHIGEKI TANAKA, TERUO M ISHINA and HIROKI WATANABE
Department of Urology, Kyoto Prefectural University of Medicine, Kyoto 602 SAITOH,M., OBE, H., TANAKA,S., M1SHINA,T. and WATANABE,H. Ultrasonic Diagnosis of Intrascrotal Contents. Tohoku J. exp. Med., 1977, 123 (4), 337-341 -Our brief experience of the use of ultrasonography and the ultrasonic Doppler method for the diagnosis of intrascrotal contents were described. Five cases of testicular tumor, two cases of hydrocele and one case of epididymal tuberculosis were successfully diagnosed by ultrasonography. Only one case of chronic inflammation was misdiagnosed as a testicular tumor. Two cases of testicular torsion and two cases of acute epididymitis were easily differentiated by the ultrasonic Doppler method. We suggest that this is the most reliable technique for differentiation between these two diseases. ultrasonography; testicular tumor; hydrocele; ultrasonic Doppler method; testicular torsion
As a routine we have used ultrasound in the diagnosis of intrascrotal diseases as well as in the diagnosis of the diseases of the prostate (Watanabe et al. 1974, 1975), the urinary bladder (Watanabe 1976) and the kidney (Watanabe et al. 1976). In this report, some results of the diagnosis of intrascrotal diseases by means of ultrasonography or the ultrasonic Doppler method will be described. METHODS
Patients complaining of intrascrotal swelling were examined by ordinary contact compound scanning. The sonogram in patients with hydrocele showed no echo area inside the mass surrounded by a clear echo outline (Fig. 1), even when tested at high sensitivity levels. In patients with testicular tumor or orchitis, scattered echo patterns were obtained within the mass section (Fig. 2). Thus, hydrocele could easily be differentiated by this method from the other diseases with solid tumors. Patients with an acute scrotal condition were examined by the ultrasonic Doppler method. In these cases the affected testis was manually separated from the unaffected one. Jelly was used as a coupling medium. A transducer was placed on the scrotum, and its angle and position were adjusted until audible Doppler sound could be detected. Signals were recorded on tape and were later analyzed. In cases of testicular torsion no Doppler signal was obtained because of the interruption of the blood supply (Fig. 5). In patients with acute epididymitis the signal was easily audible and was augmented. The difference between the states could be distinguished simply. Ultrasonograms were recorded by using the SSD-60 system (Aloka Co.) with 2.25 MHz ultrasound. For the detection of Doppler signals either a Doppler flowmeter 1935 (San-ei Sokki Co., 5 MHz ultrasound) or a Doppler Fetus Detecter FD 100 (Toitu Co., 2.5 MHz ultrasound) was used. Received for publication, May 25, This work was supported by grants the Ministry of Education, Science and
1977. from the Ministry Culture, Japan. 337
of Health
and Welfare
and from
338
Fig.
M. Saitoh
1.
Ultrasonogram
Fig. 2. Ultrasonogram echo pattern.
of hydrocele.
of a neoplasm
et al.
No echo is recorded
of the testis.
Enlarged
from
the
testis
inside
of the
tumor.
showing
dense
internal
RESULTS
From May, 1976 to January, 1977, nine patients with scrotal swelling were studied ultrasonographically. Six of them were diagnosed as testicular tumor and two as hydrocele. In the remaining patient, epididymal tuberculosis was strongly suspected because the sonogram indicated a pattern of several cysts inside a solid tumor on the epididymis (Fig. 3). In each case, a pathological evaluation was performed after surgical exploration. Detailed pathological results on the six patients diagnosed as testicular tumor by ultrasonography were as follows: Three teratomas, one seminoma, one Hodgkin disease (Fig. 4) and one chronic in flammatory change. No marked difference between them could be recognized on the ultrasonograms. The ultrasonic diagnoses were confirmed correctly in the other three cases. During the same period, four patients were studied by the ultrasonic Doppler method. Two cases were diagnosed as testicular torsion and the others were
Ultrasonic
Fig.
3. Ultrasonogram small cavities.
Fig. 4. Ultrasonogram filtrated by the
Diagnosis
of epididymal
of the testis neoplasm.
of Intrascrotal
tuberculosis.
of Hodgkin
disease.
Contents
Destructive
Spermatic
339
intrascrotal
mass
cord was diffusely
with
in
340
M. Saitoh
et al.
Fig. 5. Upper tracing obtained from normal testis showed the presence of clear Doppler signals. Lower tracing was recorded from the distorted testis, which showed no Doppler signals.
TABLE 1.
Ultrasonic examination
in 4 patients suspected of testicular torsion
diagnosed as acute epididymitis (Table 1). One after
of the
the
revealing case.
first
patients
with
symptoms.
A
a recovery
The other
testicular week
of blood supply
patient
torsion
after
the
were obtained
had been treated
for about
underwent
surgery
surgery,
clear
from
the damaged
six months
two
Doppler testis
in a different
hours signals in this hospital
under a misdiagnosis of acute epididymitis. The ultrasonic Doppler method indicated testicular torsion, and testicular necrosis due to the distorted spermatic cord
was
by the
observed
ultrasonic
during Doppler
surgery. method
Two were
cases
treated
diagnosed
as acute
epididymitis
with
resulting
in complete
drugs
recovery. DISCUSSION
A few diagnostic means have been used for determining intrascrotal contents. Almost all diagnostic information has derived from the clinical history and palpa tion. Ultrasonic examinations can provide interpretable information on intrascrotal disorders in more detail and in a visible way (Miskin et al. 1976). Solid and cystic enlargements are easily and definitely differentiated by ultrasonography. The size, shape, and location of the abnormalities can be described.
Ultrasonic
Diagnosis
of Intrascrotal
Contents
341
It was difficult, however, to distinguish the histological differences in solid tumors. Differential diagnosis between testicular torsion and acute epididymitis has been one of the most difficult problems. These two clinical conditions are frequently misdiagnosed. Since 1974, several authors have stated that the ultrasonic Doppler method is useful for the differential diagnosis of these conditions (Milleret and Liaras 1974; Bertram 1975; Pedersen et al. 1975). The principle of the method is to detect the presence of the blood supply to the testis. In cases of testicular torsion, the blood supply is interrupted due to the distorted spermatic cord. Conversely, in cases of acute epididymitis the blood supply increases. Currently, the Doppler flowmeter or the Doppler stethoscope has been used for the purpose of differentiating the conditions, but we used the Foetal Heart Sound Detector which is more easily available in almost every gyne cological clinic, and we demonstrated that this simple instrument is sufficiently useful for the diagnosis of some acute scrotal conditions. References
1) Bertram, J.L. (1975) The diagnosis of torsion of the testicle using the Doppler ultrasonic stethoscope. J. Urol., 113, 63-65. 2) Milleret, R. & Liaras, H. (1974) L'auscultation a l'aide des ultra-sons dans les torsions du testide. (Interet diagnostique et therapeutique). J. Chir., 107, 35-38. 3) Miskin, M., Buckspan, M. & Bain, J. (1976) Ultrasonographic examination of scrotal masses. J. Urol., 117, 185-188. 4) Pedersen, J.F., Holm, H.H. & Hald, T. (1975) Torsion of the testis diagnosed by ultrasound. J. Urol., 113, 66-68. 5) Watanabe, H. (1976) Diagnostic ultrasound in urology. In: Present and Future of Diagnostic Ultrasound, edited by Ian Donald & Salvator Levi, Kooyker Scientific Publications, Rotterdam, pp. 189-200. 6) Watanabe, H., Igari, D., Tanahashi, Y., Harada, K. & Saitoh, M. (1974) Develop ment and application of new equipment for transrectal ultrasonography. J. clin. Ultrasound, 2, 91-98. 7) Watanabe, H., Igari, D., Tanahashi, Y., Harada, K. & Saitoh, M. (1975) Transrectal ultrasonotomography of the prostate. J. Urol., 114, 734-739. 8) Watanabe, H., Saitoh, M., Igari, D., Tanahashi, Y. & Harada, K. (1976) Non-invasive detection of ultrasonic Doppler signals from renal vessels. Tohoku J. exp. Med., 118, 393-394.
J. exp.
Ultrasonic
Med.,
1977,
123, 337-341
Diagnosis
of Intrascrotal
Contents
MASAHITO SAITOH, HIROSHI OHE, SHIGEKI TANAKA, TERUO M ISHINA and HIROKI WATANABE
Department of Urology, Kyoto Prefectural University of Medicine, Kyoto 602 SAITOH,M., OBE, H., TANAKA,S., M1SHINA,T. and WATANABE,H. Ultrasonic Diagnosis of Intrascrotal Contents. Tohoku J. exp. Med., 1977, 123 (4), 337-341 -Our brief experience of the use of ultrasonography and the ultrasonic Doppler method for the diagnosis of intrascrotal contents were described. Five cases of testicular tumor, two cases of hydrocele and one case of epididymal tuberculosis were successfully diagnosed by ultrasonography. Only one case of chronic inflammation was misdiagnosed as a testicular tumor. Two cases of testicular torsion and two cases of acute epididymitis were easily differentiated by the ultrasonic Doppler method. We suggest that this is the most reliable technique for differentiation between these two diseases. ultrasonography; testicular tumor; hydrocele; ultrasonic Doppler method; testicular torsion
As a routine we have used ultrasound in the diagnosis of intrascrotal diseases as well as in the diagnosis of the diseases of the prostate (Watanabe et al. 1974, 1975), the urinary bladder (Watanabe 1976) and the kidney (Watanabe et al. 1976). In this report, some results of the diagnosis of intrascrotal diseases by means of ultrasonography or the ultrasonic Doppler method will be described. METHODS
Patients complaining of intrascrotal swelling were examined by ordinary contact compound scanning. The sonogram in patients with hydrocele showed no echo area inside the mass surrounded by a clear echo outline (Fig. 1), even when tested at high sensitivity levels. In patients with testicular tumor or orchitis, scattered echo patterns were obtained within the mass section (Fig. 2). Thus, hydrocele could easily be differentiated by this method from the other diseases with solid tumors. Patients with an acute scrotal condition were examined by the ultrasonic Doppler method. In these cases the affected testis was manually separated from the unaffected one. Jelly was used as a coupling medium. A transducer was placed on the scrotum, and its angle and position were adjusted until audible Doppler sound could be detected. Signals were recorded on tape and were later analyzed. In cases of testicular torsion no Doppler signal was obtained because of the interruption of the blood supply (Fig. 5). In patients with acute epididymitis the signal was easily audible and was augmented. The difference between the states could be distinguished simply. Ultrasonograms were recorded by using the SSD-60 system (Aloka Co.) with 2.25 MHz ultrasound. For the detection of Doppler signals either a Doppler flowmeter 1935 (San-ei Sokki Co., 5 MHz ultrasound) or a Doppler Fetus Detecter FD 100 (Toitu Co., 2.5 MHz ultrasound) was used. Received for publication, May 25, This work was supported by grants the Ministry of Education, Science and
1977. from the Ministry Culture, Japan. 337
of Health
and Welfare
and from
338
Fig.
M. Saitoh
1.
Ultrasonogram
Fig. 2. Ultrasonogram echo pattern.
of hydrocele.
of a neoplasm
et al.
No echo is recorded
of the testis.
Enlarged
from
the
testis
inside
of the
tumor.
showing
dense
internal
RESULTS
From May, 1976 to January, 1977, nine patients with scrotal swelling were studied ultrasonographically. Six of them were diagnosed as testicular tumor and two as hydrocele. In the remaining patient, epididymal tuberculosis was strongly suspected because the sonogram indicated a pattern of several cysts inside a solid tumor on the epididymis (Fig. 3). In each case, a pathological evaluation was performed after surgical exploration. Detailed pathological results on the six patients diagnosed as testicular tumor by ultrasonography were as follows: Three teratomas, one seminoma, one Hodgkin disease (Fig. 4) and one chronic in flammatory change. No marked difference between them could be recognized on the ultrasonograms. The ultrasonic diagnoses were confirmed correctly in the other three cases. During the same period, four patients were studied by the ultrasonic Doppler method. Two cases were diagnosed as testicular torsion and the others were
Ultrasonic
Fig.
3. Ultrasonogram small cavities.
Fig. 4. Ultrasonogram filtrated by the
Diagnosis
of epididymal
of the testis neoplasm.
of Intrascrotal
tuberculosis.
of Hodgkin
disease.
Contents
Destructive
Spermatic
339
intrascrotal
mass
cord was diffusely
with
in
340
M. Saitoh
et al.
Fig. 5. Upper tracing obtained from normal testis showed the presence of clear Doppler signals. Lower tracing was recorded from the distorted testis, which showed no Doppler signals.
TABLE 1.
Ultrasonic examination
in 4 patients suspected of testicular torsion
diagnosed as acute epididymitis (Table 1). One after
of the
the
revealing case.
first
patients
with
symptoms.
A
a recovery
The other
testicular week
of blood supply
patient
torsion
after
the
were obtained
had been treated
for about
underwent
surgery
surgery,
clear
from
the damaged
six months
two
Doppler testis
in a different
hours signals in this hospital
under a misdiagnosis of acute epididymitis. The ultrasonic Doppler method indicated testicular torsion, and testicular necrosis due to the distorted spermatic cord
was
by the
observed
ultrasonic
during Doppler
surgery. method
Two were
cases
treated
diagnosed
as acute
epididymitis
with
resulting
in complete
drugs
recovery. DISCUSSION
A few diagnostic means have been used for determining intrascrotal contents. Almost all diagnostic information has derived from the clinical history and palpa tion. Ultrasonic examinations can provide interpretable information on intrascrotal disorders in more detail and in a visible way (Miskin et al. 1976). Solid and cystic enlargements are easily and definitely differentiated by ultrasonography. The size, shape, and location of the abnormalities can be described.
Ultrasonic
Diagnosis
of Intrascrotal
Contents
341
It was difficult, however, to distinguish the histological differences in solid tumors. Differential diagnosis between testicular torsion and acute epididymitis has been one of the most difficult problems. These two clinical conditions are frequently misdiagnosed. Since 1974, several authors have stated that the ultrasonic Doppler method is useful for the differential diagnosis of these conditions (Milleret and Liaras 1974; Bertram 1975; Pedersen et al. 1975). The principle of the method is to detect the presence of the blood supply to the testis. In cases of testicular torsion, the blood supply is interrupted due to the distorted spermatic cord. Conversely, in cases of acute epididymitis the blood supply increases. Currently, the Doppler flowmeter or the Doppler stethoscope has been used for the purpose of differentiating the conditions, but we used the Foetal Heart Sound Detector which is more easily available in almost every gyne cological clinic, and we demonstrated that this simple instrument is sufficiently useful for the diagnosis of some acute scrotal conditions. References
1) Bertram, J.L. (1975) The diagnosis of torsion of the testicle using the Doppler ultrasonic stethoscope. J. Urol., 113, 63-65. 2) Milleret, R. & Liaras, H. (1974) L'auscultation a l'aide des ultra-sons dans les torsions du testide. (Interet diagnostique et therapeutique). J. Chir., 107, 35-38. 3) Miskin, M., Buckspan, M. & Bain, J. (1976) Ultrasonographic examination of scrotal masses. J. Urol., 117, 185-188. 4) Pedersen, J.F., Holm, H.H. & Hald, T. (1975) Torsion of the testis diagnosed by ultrasound. J. Urol., 113, 66-68. 5) Watanabe, H. (1976) Diagnostic ultrasound in urology. In: Present and Future of Diagnostic Ultrasound, edited by Ian Donald & Salvator Levi, Kooyker Scientific Publications, Rotterdam, pp. 189-200. 6) Watanabe, H., Igari, D., Tanahashi, Y., Harada, K. & Saitoh, M. (1974) Develop ment and application of new equipment for transrectal ultrasonography. J. clin. Ultrasound, 2, 91-98. 7) Watanabe, H., Igari, D., Tanahashi, Y., Harada, K. & Saitoh, M. (1975) Transrectal ultrasonotomography of the prostate. J. Urol., 114, 734-739. 8) Watanabe, H., Saitoh, M., Igari, D., Tanahashi, Y. & Harada, K. (1976) Non-invasive detection of ultrasonic Doppler signals from renal vessels. Tohoku J. exp. Med., 118, 393-394.
