|Year : 2016 | Volume
| Issue : 2 | Page : 89-93
Scrotal doppler ultrasound evaluation in Zaria, Nigeria
Muhammad Zaria Ibrahim1, Abdulkadir Musa Tabari2, Joseph Bako Igashi1, Suleiman Lawal1, Mohammed Ahmed3
1 Department of Radiology, Ahmadu Bello University/Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Radiology, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Surgery, Urology Unit, Ahmadu Bello University/Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
|Date of Web Publication||1-Aug-2016|
Muhammad Zaria Ibrahim
Department of Radiology, Ahmadu Bello University/Ahmadu Bello University Teaching Hospital, Zaria
Source of Support: None, Conflict of Interest: None
Introduction: The superficial location of the scrotal contents makes them ideally suited for sonographic examination. The development of high-frequency, real-time greyscale scanners along with Doppler facility has enhanced the diagnostic accuracy of scrotal sonographic examinations. Objectives: To determine the pattern and utility of Doppler ultrasound in the assessment of patients with scrotal pathologies in Zaria, Nigeria. Methodology: This retrospective study was carried out over a period of 36 months (February 2012 to January 2015) at the Radiology Department of Ahmadu Bello University Teaching Hospital, Zaria, Nigeria, on patients who presented for scrotal sonography on account of scrotal pathology. After a brief examination, colour Doppler ultrasound scan (CDUS) was performed. The clinical diagnosis and final ultrasound diagnosis were compared to determine the sensitivity and specificity of the later. Results: A total of 115 patients were scanned. Nearly 55.6% presented on account of primary infertility. Varicocele (45), hydrocele (31), epididymo-orchitis (8), epididymal cyst (6), microlithiasis (6) and others (6) were frequent Doppler findings. Only 12 cases were normal scan. Overall sensitivity of CDUS in diagnosing varicocele and hydrocele was 100% each, respectively. Conclusion: Doppler ultrasonography is an excellent, safe and reliable method for evaluating patients with scrotal diseases. It is especially important in conditions such as varicocele and hydrocele where accurate diagnosis is required in the management of infertility.
Keywords: Doppler ultrasound scan, scrotal pathologies, Zaria
|How to cite this article:|
Ibrahim MZ, Tabari AM, Igashi JB, Lawal S, Ahmed M. Scrotal doppler ultrasound evaluation in Zaria, Nigeria. Niger J Basic Clin Sci 2016;13:89-93
|How to cite this URL:|
Ibrahim MZ, Tabari AM, Igashi JB, Lawal S, Ahmed M. Scrotal doppler ultrasound evaluation in Zaria, Nigeria. Niger J Basic Clin Sci [serial online] 2016 [cited 2021 Dec 2];13:89-93. Available from: https://www.njbcs.net/text.asp?2016/13/2/89/187356
| Introduction|| |
The desire to explore the living human anatomy goes back to many centuries. A great achievement was the discovery of X-rays in 1895 AD. The first ultrasound image was taken by Australian Bussik brothers in 1937. Scrotal ultrasound started with static B-mode imaging in 1974 by Miskin and Bain. Now, the availability of real-time high-frequency transducers and colour Doppler has made sonography as the primary diagnostic tool for diagnosing disorders of scrotum.
Other imaging modalities occasionally used to evaluate the scrotal pathologies include computed tomographic scan, magnetic resonance imaging (MRI) and angiography. However, the limitations of the hazards of ionising radiation, high-cost and unavailability make them inaccessible in most developing countries whereas ultrasonography (US) being readily available, cheap and uses no ionizing radiation makes it more acceptable in imaging the scrotum and its radiation sensitive gonadal tissue content.
Scrotal pathologies are seen routinely globally across all age groups on US with reported high sensitivity and specificity for specific pathologies. Information obtained from scrotal US studies has been shown to contribute significantly in the management of patients with scrotal pathologies. There is, however, paucity of data from these authors area of practice on the utility of greyscale and duplex Doppler US in the evaluation of scrotum and its content. This study is, therefore, designed to determine the pattern and utility of colour Doppler ultrasound (CDUS) in the assessment of patients with scrotal pathologies in Zaria, Nigeria.
| Methodology|| |
This retrospective study was carried out over a period of 36 months (from February 2012 to January 2015) at the Radiology Department of Ahmadu Bello University Teaching Hospital, Zaria, Nigeria, on patients presented for scrotal sonography on account of painful and non-painful scrotal complaints. The inclusion criterion was patients with complete records of scrotal Doppler ultrasound for suspected scrotal pathology. We retrieved documented Doppler ultrasound scan results of all patients who met the inclusion criteria. For all patients, scrotal Doppler ultrasound scan was performed with 7.5–11 MHz linear transducer on Mindray DC-6 scanner in supine position and erect postures when needed with the help of Valsalva manoeuvre. Greyscale ultrasound was first conducted to determine the size, location and echogenicity of the testis. CDUS was done to assess and document blood flow, spectral waveform pattern and velocity of flow and indices in the testes, epididymis, intra- and extra-testicular blood vessels and scrotal skin. All the scans were done by different radiologists (authors) using standard departmental CDUS protocols.
The criteria used for the diagnosis of varicocele were: (1) The largest plexus pampiniformis vein measured more than 2 mm in diameter in supine position or >3 mm in the standing position; (2) more than 1 mm increase in size of the largest vein during Valsalva on greyscale examination and (3) more than 2 s retrograde flow during Valsalva manoeuvre on colour Doppler US. A combination of 1 and 2 above or 1 and 3 above was regarded as diagnostic of varicocele.
The criterion for a thickened epididymis was a mean diameter of more than 12 mm in cross-section at the level of the caput  while an epididymal cyst was diagnosed by the presence of cysts (on the epididymis) that were anechoic and circumscribed with good through transmission and posterior wall acoustic enhancement. A suspicion of testicular tumour was diagnosed as the presence of focal hypoechoic mass lesion within the normally homogeneous testis. The presence of multiple, diffuse, non-shadowing hyperechoic foci was diagnosed as microlithiasis. The presence of echo-free (or faintly echoic) collection of fluid in the tunica vaginalis (or surrounding the testis) was diagnosed as hydrocele.
Patients who presented clinically with acute painful scrotum were diagnosed to have testicular torsion when there was absent of intratesticular blood flow on colour Doppler US.
The clinical diagnosis and final ultrasound diagnosis were compared to determine the sensitivity and specificity of the later.
| Results|| |
We retrieved the records of a total of 115 male patients with different scrotal pathologies (both painful and painless) who were examined sonographically in this study period. Their mean age was 39.12 ± 11.89 years (range 17–66 years). A majority of 64 (55.6%) patients were in the age range between 25 and 44 years [Table 1]. Sixty-three (54.8%) presented on account of primary infertility, 25 (21.7%) with complaint of scrotal pain, 21 (18.3%) with scrotal swelling while 6 (5.2%) had secondary infertility.
The most frequent findings on CDUS are varicocele and hydrocele occurring in 45 (39.15%) and 31 (26.97%) of patients, respectively. Other findings such as intrascrotal haematoma, testicular mass, orchitis, post-operative pyocele and scrotal wall oedema are as shown in [Table 2]. Of the 45 patients diagnosed with varicocele on CDUS, 38 (95%) were left-sided while only 7 (5%) were bilateral. No isolated right-sided varicocele was diagnosed. The sensitivity of CDUS to diagnose varicocele and hydrocele was 100% each, respectively [Table 3] and [Table 4].
|Table 3: The sensitivity and specificity of colour Doppler ultrasonography in diagnosis of varicocele|
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|Table 4: The sensitivity and specificity of colour Doppler ultrasonography in diagnosis of hydrocele|
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[Table 5] shows the distribution of CDUS findings in relation to the indication for the scan where varicocele was the most common diagnosis seen in 63% (40) in those presenting with primary infertility while epididymitis accounted for 40% and less frequently testicular torsion in 16% among those with complaint of scrotal pain.
|Table 5: Distribution of colour Doppler ultrasound findings among different scan indication groups|
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However, 25 patients presented with scrotal pain, of which 10 patients had clinical diagnosis of epididymitis, only eight were found to have the disease on Doppler scan which accounted for sensitivity of 80% and specificity of 100% as demonstrated in [Table 6].
|Table 6: The sensitivity and specificity of colour Doppler ultrasonography in diagnosis of epididymitis|
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| Discussion|| |
Greyscale US is a well-established modality for the diagnosis of scrotal diseases; however, the major limitation of conventional greyscale US is lack of specificity for parenchymal changes. Indeed, scrotal abnormalities have been found on greyscale US in 38–72% of infertile men only. Furthermore, in painful scrotum, greyscale US cannot accurately differentiate testicular torsion from epididymo-orchitis.
Colour Doppler US is currently the most important imaging modality available for the diagnosis of scrotal pathologies, especially varicocele, torsion, and orchitis. Hence, CDUS allows accurate evaluation of scrotal conditions as well as normal anatomy.
On US, varicoceles appear as serpiginous anechoic tubular structures with diameters larger than 2 mm. They will often enlarge during the Valsalva manoeuver and will show reversal of blood flow., Varicocele is the most common Doppler ultrasound finding in those that presented with infertility in this study which is similar to the study by Qublan et al. in India, [Figure 1]a and [Figure 1]b and Tijani et al. in Lagos, Nigeria. Most studies have reported varicoceles to be more common on the left in subfertile men, a finding attributed to the drainage pattern of the more tortuous left internal spermatic vein into the left renal vein., Findings from this study were consistent with these reports. Other reports in the literature have also described varicocele as the most common identifiable abnormality detected in infertile men on scrotal US. While varicocele has traditionally been reported to have an overall prevalence of 29–40% in all infertile men,, 10, ,, more recently, some authors have reported prevalence of 35–41% in men with primary infertility and 70–81% in men with secondary infertility., These findings are consistent with this study where prevalence of 63%.
|Figure 1: (a) Dilated left pampiniformis veins with colour flow reversal and increased vascular diameter on Valsalva manoeuvre. (b) Pulsed Doppler spectral trace of left scrotal venous flow, with and without Valsalva manoeuvre, showing evidence of flow reversal|
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Hydrocele is the second most common finding in this study which could be reactive following inflammatory process or idiopathic [Figure 2]. This is similar to the findings of Tijani et al. in Lagos  and Awad in Saudi Arabia. However, contrary to Rizvi et al., in a study of 120 patients in India where epididymitis was found to be the most common scrotal Doppler findings probably due to ascending infections. Until recently, the effect of idiopathic hydrocele on the testis was poorly understood as it was thought to be completely harmless to testicular health; however, Mihmanli and Kantarci  were able to demonstrate that idiopathic hydrocele may cause testicular enlargement and increased vascular resistance in the intratesticular arteries, thereby adversely affecting testicular function.
|Figure 2: Low-level echo-rich right-sided intrascrotal collection (hydrocele)|
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The finding of epididymitis as the third most common diagnosed abnormality on CDUS in this study agrees with that of Tijani et al. in a study of 119 Nigerian patients. In CDUS performed for epididymitis, the most commonly reported ultrasound characteristics are epididymal enlargement, hypoechogenicity, reactive hydrocele and scrotal skin thickening. While our findings confirmed the presence of epididymal hypervascularity, testicular hypervascularity was also present in 91% of patients with primary epididymal pathology [Figure 3]. Therefore, epididymal inflammation may spread locally to the testis even in the absence of clinical orchitis., Holden et al. previously documented that up to 68% of patients may have scrotal thickening in the setting of epididymitis. In our study, however, only one in eight men with diagnosis of epididymitis had scrotal wall thickening, suggesting that this abnormality is far less common than previously reported.
|Figure 3: Enlarged epididymis with decreased echoes and increased vascularity on colour Doppler interrogation with thickened scrotal skin|
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Testicular torsion was found to be the sixth CDUS finding in our study with generalised predominantly decreased intratesticular parenchymal echogenicity and absent flow on Doppler interrogation [Figure 4]. This is inconsistent with findings of Rizvi et al. who studied 122 patients, of which four were found to have testicular torsion.
|Figure 4: Global decreased echogenicity of the testicular parenchyma with absent of colour flow on Doppler interrogation|
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Other abnormalities such as epididymal cysts and microlithiasis have also been reported to be associated with infertility [Figure 5]. Epididymal cysts are thought to cause obstruction while microlithiasis is thought to impair testicular function via an immunological mechanism. This, however, cannot be proved with this study.
|Figure 5: Clustered hyperechoic foci (microlithiasis) within the left testicular parenchyma|
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Other investigations such as MRI can be applied when US proves inconclusive. Its use in scrotal diseases is increasing; however, it is more expensive and not always available. Nuclear scintigraphy, which has high sensitivity and specificity in differentiating ischaemia from infarction, cannot accurately distinguish ischaemia from conditions such as hydrocele, spermatocele and inguinal hernia and it is not commonly performed due to high accuracy of CDUS.
| Conclusion|| |
Colour Doppler US of the scrotum is an excellent, safe, reliable method and valuable tool in the evaluation of patients with scrotal diseases and infertility, with varicoceles and hydroceles being the major findings. There is a need for a standard protocol for the CDUS diagnosis of scrotal abnormalities in the authors' environment.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]