|Year : 2018 | Volume
| Issue : 1 | Page : 60-65
A 10-Year review of ultrasonographic findings of scrotal diseases in Ibadan, South Western, Nigeria
Ademola Joseph Adekanmi1, Adenike Temitayo Adeniji-Sofoluwe1, Gbolahan Obajimi2, Ekwutosi Okafor3
1 Department of Radiology, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
2 Department of Obsterics and Gynecology, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
3 Department of Radiology, University College Hospital, Ibadan, Nigeria
|Date of Web Publication||2-Jul-2018|
Adenike Temitayo Adeniji-Sofoluwe
Department of Radiology, College of Medicine, University of Ibadan and University College Hospital, Ibadan
Source of Support: None, Conflict of Interest: None
Introduction: Despite the importance of a thorough clinical evaluation, ultrasonography has emerged as the mainstay of imaging of the scrotum and its contents. Differentiation of testicular lesions and that of adjacent scrotum and content is usually difficult clinically. Scrotal ultrasound (SUSS) is highly sensitive in the detection of intrascrotal abnormalities and in differentiating testicular from paratesticular lesions. SUSS accurately determines the location and nature of palpable lesions and reveals nonpalpable scrotal masses. The aim of this study is to report the various indications for SUSS in this setting and to describe the sonographic findings in these patients. Materials and Methods: A retrospective and descriptive study carried out to evaluate scrotal ultrasound scans performed on 442 patients referred for various clinical indications from the clinics and units of the University College Hospital, to the Radiology department of the same hospital which serves as referral center in Ibadan, and the South-Western Nigeria; over a 10 year period from January 2006 to December 2015, a tertiary health Institution. Results: The mean age of the study population was 36.13 years ± standard deviation 15.88 years. Most of the patients (57.1%) were within the age group of 30 and 49 years. The leading clinical indication for ultrasound referral was infertility/infertility related issues in 56.1% of the total patients. Testicular masses were clinically detected and required SUSS for confirmation in 4.5% of the study population. On USS, the average testicular volume in adults with normal study was 16.38 cm3 and 15.99 cm3 on the right and left side, respectively. The most common USS findings were varicocele (29.4%), this was bilateral in more than half of the cases. Hydrocele was the second most common finding in 18.78% and often bilateral. Testicular masses were seen in 11.1% and were cystic in nature in more than half of the study population. Conclusion: Infertility/infertility related diagnosis were the most frequent indications for testicular ultrasound in adults in our environment. We recommend SUSS as a routine investigation in suspected scrotal/testicular pathologies.
Keywords: Hydrocele, infertility, scrotum, testes, ultrasound, varicocele
|How to cite this article:|
Adekanmi AJ, Adeniji-Sofoluwe AT, Obajimi G, Okafor E. A 10-Year review of ultrasonographic findings of scrotal diseases in Ibadan, South Western, Nigeria. Afr J Med Health Sci 2018;17:60-5
|How to cite this URL:|
Adekanmi AJ, Adeniji-Sofoluwe AT, Obajimi G, Okafor E. A 10-Year review of ultrasonographic findings of scrotal diseases in Ibadan, South Western, Nigeria. Afr J Med Health Sci [serial online] 2018 [cited 2019 Apr 26];17:60-5. Available from: http://www.ajmhs.org/text.asp?2018/17/1/60/235744
| Introduction|| |
Ultrasonography is one of the safest imaging modality and is the mainstay of imaging of the scrotum and its content., Scrotal ultrasonography (SUSS) is efficient in the determination of the location and nature of palpable lesions and in the demonstration of clinically nonpalpable scrotal lesions. It has a high sensitivity in the detection of intrascrotal abnormalities, and it is an imaging modality of choice in differentiating testicular from paratesticular lesions in adults and children.,,
Several studies have shown that intrascrotal pathologies such as inflammatory conditions and other lesions that has been successfully imaged and diagnosed with ultrasound imaging.,,,
Scrotal ultrasonography is invaluable in the management of male infertility. It provides information for the diagnostic assessment of infertile men. Scrotal sonography also facilitates successful testicular sperm extraction and evaluates hematoma collection, intratesticular bleeding from the procedure.
USS has become the first choice of imaging in the evaluation of scrotal/testicular pathologies in acute, emergencies, and chronic cases due to its safety (noninvasiveness, simplicity of use, rapid, relatively inexpensive, and wide availability).,,,,
Despite the various uses and benefits of scrotal ultrasonography, there is a paucity of data on ultrasonographic evaluation of the scrotum in our environment. This study aims to document the demography of patients who had a scrotal scan done over a 10 year period. We also aim to report the various indications for SUSS in this setting and describe the sonographic findings in these patients.
| Materials and Methods|| |
This is a retrospective and descriptive study carried out at the Radiology Department of a tertiary hospital located in Oyo state, South-Western Nigeria spanning a 10-year period from January 2006 to December 2015. All patients referred for scrotal ultrasonography due to various clinical indications during the period were included in the study. A total of 442 patients were recruited into the study. These patients were previously scanned using two ultrasound scanners: An Aloka SSD-1700 (Dynoview, Japan Ultrasound machine) and a Logic-P5 (General Electric ultrasound unit). Sonographic images were acquired using a 7.5-10MHz linear transducer.
On ultrasonography, the normal testis is paired symmetric ovoid organs; showing homogenous intermediate echogenicity. The mediastinum of the testis is seen as an echogenic band in its long axis with fine strands radiating from it into the testicular tissue. The normal epididymis shows varying echogenicity, with the epididymal head slightly more echogenic than the testis, while the main length of the epididymis is less echogenic than the adjacent testis. Pathological findings were documented in line with established appearances in the literature.,
Each testicle was measured in its longitudinal (LS), anteroposterior (AP) and transverse (TS) dimensions in cm and the volume in cm 3 was calculated by multiplying the LS × AP × TS × 0.71. This was found to be more accurate in determining the testicular volume., The diameter of the dominant testicular vein in the upright position at the inguinal canal was also measured to assess for varicosity. The diagnostic criteria of varicosity include as follows: the largest plexus pampiniform vein measuring >2 mm in diameter in supine position (or) >3 mm in diameter in standing/semi-erect position (or) >1 mm increase in size of the largest vein during valsalva on gray-scale examination and >2 s retrograde flow during valsalva manoeuvre on color Doppler US., These findings were documented in the radiology report of each patient.
The radiology reports on SUSS performed during the period of the study were retrieved and relevant findings extracted from a structured data form. Ethical approval was not sought as secondary data were employed. However, patients' confidentiality was preserved by assigning numbers to each patient in place of real names. The collected data was entered into the statistical package for social sciences (SPSS) software version 20 (International Business Machines, IBM SPSS) spreadsheet and analyzed. Results are presented using frequency tables and percentages as appropriate. Chi-square tests were used for statistical analysis of categorical variables.
| Results|| |
Four-hundred and forty-two cases were evaluated in this study. Data on age were incomplete in a number of patients representing 7.1% of the study population. The age range of the patients was <1 year–92 years. The mean age was 36.13 years ± 15.88 years. Most of the patients (57.1%) in the study population were within the 30 and 49 years age group (38.5%) and 40–49 years age group (18.6%). The patients in the seventh to ninth decade were the least represented (3.25%) in the study population [Figure 1].
|Figure 1: Bar chart showing age group distribution of the study population|
Click here to view
The source of referral was indicated in 417 (94.34%) patients but not documented in 25 patients (5.7%). Majority of the patients were referred for scrotal ultrasonography from the surgery outpatient clinic (79.4%). While the accident and emergency unit, the general outpatient and the medical outpatient accounted for 7.2%, 6.3%, and 0.7%, respectively. There were only two referrals from the Children's emergency (0.5%) and only one case (0.2%) from the Medical ward.
Clinical indications for scrotal/testicular ultrasonography
Clinical indications were stated in 432 patients (97.7%), while 10 patients (2.3%) had no presenting complaint indicated on their request cards. The leading clinical indications for scrotal/testicular ultrasound examination were: Combination of infertility and varicocele (21.9%), varicocele (18.3%), infertility (17.7%), hydrocele (14.0%) and scrotal swelling (10.6%). Other less frequent clinical indications were small testicles (28/442, 6.3%), testicular torsion and inguinoscrotal hernia as listed in [Table 1]. Overall, infertility/infertility related diagnosis (56.1%) accounted for most of the reasons for referral of patients. The pediatric patients were 11.1% of the study population, 5.7% of which were referred for absent/undescended testes for SUSS.
Findings on scrotal ultrasonography
Ultrasonography of the scrotum performed during the 10 years period, was normal in 151 (34.2%) patients while the remaining 289 (65.8%) studies had various abnormalities as shown in [Table 1] and [Figure 2].
|Figure 2: Sonographic images of some scrotal abnormalities. (a) Sonographic images of the right testes with hydrocele. (b) Sonographic image of dilated venous plexuses in varicocoele|
Click here to view
Among the adult patients (18 years and above) with normal findings, the mean sonographic measurements of the right testicle were; 3.72 cm ± 0.62; 2.23 cm ± 0.57; 2.77 cm ± 0.59 in LS × AP × TS with a mean volume of 16.38 cm 3 ± 6.09 on the right. On the left recorded measurement was 3.76 cm ± 0.58 in its LS, 2.34 cm ± 0.54 in AP and 2.77 cm ± 0.59 in its TS dimension with a volume of 15.99 cm 3 ± 5.49. The right testicles were slightly larger than the left, but no statistically significant difference was noted (P = 0.433).
The echogenicity of the testes was recorded in 413/93.4% of the study population. Most of the patients evaluated (88.86%; 367/413) showed normal testicular echogenicity. Increased echogenicity was recorded in 20 cases (4.84%), while 22 (5.33%) showed decreased echogenicity and 4 (0.94%) had testicular microlithiasis.
The most common ultrasonographic findings among the study population were a varicocele, seen in 131 cases (29.64%). Majority of the varicocele were bilateral (50.38%), while 46/131 (35.11%) were diagnosed on the left. Only 19/131 (28.79%) were documented on the right side.
Hydrocele was the second most common diagnosis and was reported in 83 patients (18.78%). Bilateral hydrocele was the most common form and was recorded in 35/83 (42.16%) of this category of patients. Comparing the sides in this study, hydroceles were more common on the left with 27/83 (32. 53%) than the right side 21/83 (25.30%).
Testicular masses were found in 49 patients (11.1%) of the study population. This was significantly (2.5 times) more than the number suspected by clinical palpation. Cystic masses were reported in more than half of this group with testicular masses (26/49; 53.06%). Solid mases were seen in 21/49 patients (42.86%) and only 2 (4.08%) cases had mixed masses (cystic with solid parts) as represented in [Figure 3].
In the 23 cases with traumatic injury, intrascrotal hematoma was found in 12 patients, a testicular rupture in 3 and 7 cases of testicular torsion was reported in the group.
Inflammatory conditions reported in this study were epididymo-orchitis; which was the leading cause documented in eleven (11/442) patients. Fewer cases of orchitis (4/442) were seen among the study population. Inflammation of the soft tissue of the scrotum was seen in (20/442) 4.52%. Other relatively uncommon findings were; epididymal cysts, spermatocele and Fournier's gangrene of the scrotum [Table 1].
Correlation of the major clinical diagnosis and scrotal ultrasound findings
The sensitivity, specificity, and the predictive values of scrotal ultrasonography as the goal standard were compared with clinical evaluation. Clinical evaluation showed sensitivity and specificity of 47.1% and 68%, respectively, in identifying varicocele and positive predictive and negative predictive values of 60% and 67.8%, respectively. Regarding the clinical detection of hydroceles, 52.4% and 71.2% sensitivity and specificity were recorded respectively with low-positive predictive value (PPV) of about 40%.
The sensitivity and PPV of clinical evaluation of testicular masses were very low (sensitivity = 49%; PPV = 11.4%). While clinical diagnosis had a high specificity and negative predictive value in excluding testicular torsion, its specificity and PPV was also low as shown in [Table 2].
|Table 2: Comparison of the major clinical diagnosis and scrotal ultrasound findings|
Click here to view
| Discussion|| |
Testicular ultrasonography has emerged as a noninvasive tool for the evaluation of scrotal and testicular lesions in both adult and pediatric age group. Due to its excellent screening and diagnostic capability, it can accurately confirm or exclude the clinical diagnosis, as well as detect nonpalpable lesions. It is widely employed in the evaluation of acute, chronic and symptomatic scrotal/testicular pathologies thus contributing greatly to patients' management.,
Data were retrospectively gathered with only a few missing data recorded, especially with regards to patients' age (7.1% of the cases), referring clinic (5.7%) and clinical indication for scrotal USS (2.3%). This figure is low and within the limit of what is allowed for in literature. Moreover, this will in no way affect the outcome of this study.
The mean age of the patients was 36.13 ± 15.65 years in this study. Most of the patients were in their second and the third decades of life in agreement with the work of Aubaid et al. These age groups accounted for 57.1% of the studied population, this is higher than the 44% recorded by Aubaid et al. However, the higher percentage in our study population may be due to the smaller sample size and study duration of other studies. Elkhadir documented that those in the second to the fourth decades represented 44% of their study population. We presume that this is due to men in this age bracket being the most active reproductive age group and are more likely to be investigated for infertility/infertility-related cases., The malefactor is responsible for 40%–50% of infertility cases in Nigeria, though with slight variations in percentages depending on the region of the country. Various studies have attested to a rising rate of abnormal semen quality of male partners in Nigeria; necessitating a greater focus on preventive strategies for male infertility. The need for men to accept responsibility for their contributions cannot be overemphasized.
Most of the cases in this study were due to infertility alone or in association with other pathologies/infertility related cases. This was at variance with the work of Narra et al. in India that recognized inflammatory lesions as the leading cause of scrotal pathology in their population. Although, there is a paucity of data and publication on this subject in our environment for comparison. The small sample size employed by Narra et al. and the differences in the studied population dynamics might be responsible for this difference.
In this study, the most common ultrasonographic findings among the study population were varicocele (29.64%), followed by hydrocele (18.78%), similar to the pattern of findings by Elkhadir  Testicular varicosity in this study, were more common in the second decade, in agreement with the findings of Aubaid et al.
Overall, the majority of varicocele in this study were bilateral similar to results of Alsaikhan et al. Comparing the two sides in this study, however, testicular varicose veins occurred more on the left, in consonance with the findings of Elkhadir, Aubaid et al. and Minayoshi et al.,, This is presumably due to the different course of the left veins compared to the right. We suppose that differences in geographic location of the patients studied, environmental peculiarities, and study design might be responsible for this observed differences.
Hydroceles were reported in the fifth decade, which appears to agree with most previous studies that documented hydroceles among adults over 40 years of age., Etiology of hydrocele has been reported to be due to congenital, trauma, filariasis infestation, epididymitis, testicular torsion, and testicular neoplasms., The high number documented in this study may be due to traumatic injuries, epididymitis, testicular torsion, and neoplasm in the study population.
Aubaid et al., however documented hydrocele as the most common ultrasound finding (33.1%), subsequently varicocele (20.3%). We presume that the population dynamics and varied scrotal aetiologies in the settings involved might be responsible for this disparity.
Concerning inflammatory lesions on SUSS, the present study is in tandem with previous studies. These studies showed that epididymitis and epididymo-orchitis might be unilateral or bilateral in agreement with the work of Narra et al. and Chhetri et al.,
Previous researchers had documented that cystic masses were most commonly found in the very young children and middle-aged adults. The present study showed that cystic testicular masses were the most common testicular masses presumably due to more middle-aged adults in the study population. This study also showed a right-sided predilection for testicular masses (56.25%).
Scrotal ultrasound has been established as highly sensitive in the detection of intrascrotal abnormalities, differentiating testicular from paratesticular lesions and accurately determining the location and nature of palpable lesions and nonpalpable scrotal masses. The low sensitivity of the clinical palpation compared to SUSS in detecting scrotal abnormalities in this study agrees with findings of other researchers ,,, and therefore underscores the important role of ultrasonography as baseline investigation in scrotal pathologies.
| Conclusion|| |
Ultrasound is the preferred imaging modality in the evaluation of scrotal pathologies due to its availability, low cost of the examination and nonusage of ionizing radiation as well as its real-time scanning capability. In this study, most of the patients had a scrotal/testicular ultrasound for infertility/infertility related problems. The leading findings on scrotal ultrasound were varicocele and hydrocele. Varicoceles were more common in the young and frequently bilateral. Hydroceles were more common in the fifth decade. Testicular masses were more common in the fifth decade and were also more common on the left side. SUSS is more sensitive than clinical examination in the detection of testicular masses.
Scrotal ultrasonography should be a routine workup for patients with scrotal/testicular pathologies, given its high sensitivity and specificity in the detection of scrotal abnormalities. We also propose training of competent personnel in scrotal ultrasonography, particularly at the secondary health institution level. These will make scrotal ultrasonography more accessible to our vast population that may need it. This will aid early detection of scrotal lesions and guide appropriate management.
We acknowledge the roles played by Professor Millicent Obajimi, resident doctors and staff of the ultrasound and medical records units in the Department of Radiology, University College Hospital, Ibadan, Oyo State, Nigeria for facilitating the retrieval of medical records of scrotal ultrasound scans performed during the 10 year period evaluated.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Elkhadir AM. Ultrasonography diagnosis of scrotal pathologies. Iosrphr Org 2015;5:1-4.
Diamond DA, Paltiel HJ, DiCanzio J, Zurakowski D, Bauer SB, Atala A, et al.
Comparative assessment of pediatric testicular volume: Orchidometer versus ultrasound. J Urol 2000;164:1111-4.
Hamm B. Differential diagnosis of scrotal masses by ultrasound. Eur Radiol 1997;7:668-79.
Dewbury KC. Scrotal ultrasonography: An update. BJU Int 2000;86 Suppl 1:143-52.
Jeffrey RB, Laing FC, Hricak H, McAninch JW. Sonography of testicular trauma. AJR Am J Roentgenol 1983;141:993-5.
Stage KH, Schoenvogel R, Lewis S. Testicular scanning: Clinical experience with 72 patients. J Urol 1981;125:334-7.
Subramanyam BR, Balthazar EJ, Raghavendra BN, Horii SC, Hilton S. Sonographic diagnosis of scrotal hernia. AJR Am J Roentgenol 1982;139:535-8.
Pierik FH, Dohle GR, van Muiswinkel JM, Vreeburg JT, Weber RF. Is routine scrotal ultrasound advantageous in infertile men? J Urol 1999;162:1618-20.
O'Mara EM, Rifkin MD. Scrotum and contents. In: Resnick MI, Rifkin MD, editors. Ultrasound of the Urinary Tract. 3rd
ed. Baltimore: Williams & Wilkins; 2006. p. 386-435.
Blaivas M, Sierzenski P, Lambert M. Emergency evaluation of patients presenting with acute scrotum using bedside ultrasonography. Acad Emerg Med 2001;8:90-3.
Schurich M, Aigner F, Frauscher F, Pallwein L. The role of ultrasound in assessment of male fertility. Eur J Obstet Gynecol Reprod Biol 2009;144 Suppl 1:S192-8.
Dahnert W. Radiology Review Manual. 5th
ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003. p. 983.
Mbaeri TU, Orakwe JC, Nwofor AM, Oranusi CK, Mbonu OO. Ultrasound measurements of testicular volume: Comparing the three common formulas with the true testicular volume determined by water displacement. Afr J Urol 2013;19:69-73.
Carkaci S, Ozkan E, Lane D, Yang WT. Scrotal sonography revisited. J Clin Ultrasound 2010;38:21-37.
Narra R, Pasupuleti B, Kamaraju SK, Jukuri N. Sonological evaluation of scrotal pathology by high resolution ultrasound and color Doppler. Int J Med Res Rev 2015;3:90-6.
Aubaid HN, Al-Garawyet R, Hammed MH. Sonographic findings in scrotal swellings. J Kerbala Univ 2014;12:93-105.
Uadia PO, Emokpae AM. Male infertility in Nigeria: A neglected reproductive health issue requiring attention. J Basic Med Sci 2015;4:45-53.
Owolabi AT, Fasubaa OB, Ogunniyi SO. Semen quality of male partners of infertile couples in Ile-Ife, Nigeria. Niger J Clin Pract 2013;16:37-40.
] [Full text]
Alsaikhan B, Alrabeeah K, Delouya G, Zini A. Epidemiology of varicocele. Asian J Androl 2016;18:179-81.
] [Full text]
Minayoshi K, Okada H, Fujisawa M, Yamasaki K, Kamidono S. Hemodynamic evaluation of left testicular varicocele by scrotal scintigraphy. Eur Urol 2001;39:30-5.
Evers JH, Collins J, Clarke J. Surgery or embolisation for varicoceles in subfertile men. Cochrane Database Syst Rev 2008;3:CD000479.
Fearne Ch, Abela M, Aquilina D. Scrotal approach for inguinal hernia and hydrocele repair in boys. Eur J Pediatr Surg 2002;12:116-7.
Chhetri PK, Tayal A, Deka PK. Ultrasonography in evaluation of patients with scrotal pain. J Coll Med Sci Nepal 2012;8:18-22.
Feld R, Middleton WD. Recent advances in sonography of the testis and scrotum. Radiol Clin North Am 1992;30:1033-51.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]