Home Ahead of print Instructions
About us Current issue Subscribe
Editorial board Archives Contact us
Search Submit article Login 
Print this page Email this page

 Table of Contents  
Year : 2016  |  Volume : 13  |  Issue : 2  |  Page : 89-93

Scrotal doppler ultrasound evaluation in Zaria, Nigeria

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 Publication1-Aug-2016

Correspondence Address:
Muhammad Zaria Ibrahim
Department of Radiology, Ahmadu Bello University/Ahmadu Bello University Teaching Hospital, Zaria
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0331-8540.187356

Rights and Permissions

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 Top

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.[1] Scrotal ultrasound started with static B-mode imaging in 1974 by Miskin and Bain.[1] 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.[2]

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.[2] Information obtained from scrotal US studies has been shown to contribute significantly in the management of patients with scrotal pathologies.[2] 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 Top

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.[3]

The criterion for a thickened epididymis was a mean diameter of more than 12 mm in cross-section at the level of the caput [4] 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.[4] A suspicion of testicular tumour was diagnosed as the presence of focal hypoechoic mass lesion within the normally homogeneous testis.[4] The presence of multiple, diffuse, non-shadowing hyperechoic foci was diagnosed as microlithiasis.[4] The presence of echo-free (or faintly echoic) collection of fluid in the tunica vaginalis (or surrounding the testis) was diagnosed as hydrocele.[4]

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.[5]

The clinical diagnosis and final ultrasound diagnosis were compared to determine the sensitivity and specificity of the later.

  Results Top

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.
Table 1: Age distribution of the subjects

Click here to view

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 2: Frequency distribution of the Doppler findings of the subjects

Click here to view
Table 3: The sensitivity and specificity of colour Doppler ultrasonography in diagnosis of varicocele

Click here to view
Table 4: The sensitivity and specificity of colour Doppler ultrasonography in diagnosis of hydrocele

Click here to view

[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

Click here to view

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

Click here to view

  Discussion Top

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.[6] Furthermore, in painful scrotum, greyscale US cannot accurately differentiate testicular torsion from epididymo-orchitis.[7]

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.[7]

On US, varicoceles appear as serpiginous anechoic tubular structures with diameters larger than 2 mm.[8] They will often enlarge during the Valsalva manoeuver and will show reversal of blood flow.[6],[8] 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.[6] in India, [Figure 1]a and [Figure 1]b and Tijani et al.[9] 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.[8],[10] 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,[3], 10, [11],[12],[13] more recently, some authors have reported prevalence of 35–41% in men with primary infertility and 70–81% in men with secondary infertility.[12],[13] 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

Click here to view

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 [9] and Awad in Saudi Arabia.[10] However, contrary to Rizvi et al.,[5] 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 [3] were able to demonstrate that idiopathic hydrocele may cause testicular enlargement and increased vascular resistance in the intratesticular arteries, thereby adversely affecting testicular function.[14]
Figure 2: Low-level echo-rich right-sided intrascrotal collection (hydrocele)

Click here to view

The finding of epididymitis as the third most common diagnosed abnormality on CDUS in this study agrees with that of Tijani et al.[9] 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.[15] 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.[16],[17] Holden et al. previously documented that up to 68% of patients may have scrotal thickening in the setting of epididymitis.[18] 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

Click here to view

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.[5] 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

Click here to view

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.[18] This, however, cannot be proved with this study.
Figure 5: Clustered hyperechoic foci (microlithiasis) within the left testicular parenchyma

Click here to view

Other investigations such as MRI can be applied when US proves inconclusive. Its use in scrotal diseases is increasing;[19] 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.[20]

  Conclusion Top

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.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Naveed I, Nadeemullah A, Mohammad U, Tahira N. The role of high resolution grey scale (B-Scan) and Doppler ultrasound in detection of scrotal masses. J Med Sci 2013;21:93-8.  Back to cited text no. 1
Prajapati N, Madhok R, Tapasvi C, Prasad U, Rastogi S. High frequency and color Doppler ultrasound evaluation of scrotal and testicular pathologies. Int J Res Health Sci 2014;2:153-61.  Back to cited text no. 2
Mihmanli I, Kantarci F. Sonography of scrotal abnormalities in adults: An update. Diagn Interv Radiol 2009;15:64-73.  Back to cited text no. 3
Nicholson A, Rait G, Murray-Thomas T, Hughes G, Mercer CH, Cassell J. Management of epididymo-orchitis in primary care: Results from a large UK primary care database. Br J Gen Pract 2010;60:e407-22.  Back to cited text no. 4
Rizvi SA, Ahmad I, Siddiqui MA, Zaheer S, Ahmad K. Role of color Doppler ultrasonography in evaluation of scrotal swellings: Pattern of disease in 120 patients with review of literature. Urol J 2011;8:60-5.  Back to cited text no. 5
Qublan HS, Al-Okoor K, Al-Ghoweri AS, Abu-Qamar A. Sonographic spectrum of scrotal abnormalities in infertile men. J Clin Ultrasound 2007;35:437-41.  Back to cited text no. 6
Yasser AM, Said AA. Acute torsion of the testis in children and young adults: Role of high resolution and color Doppler ultrasonography. Egypt J Radiol Nucl Med 2015;46:151-7.  Back to cited text no. 7
Kwak N, Siegel D. Imaging and interventional therapy for varicoceles. Curr Urol Rep 2014;15:399.  Back to cited text no. 8
Tijani KH, Oyende BO, Awosanya GO, Ojewola RW, Lawal AO, Yusuf AO. Scrotal abnormalities and infertility in West African men: A comparison of fertile and sub-fertile men using scrotal ultrasonography. Afr J Urol 2014;20:180-3.  Back to cited text no. 9
Awad ME. Ultrasonography diagnosis of scrotal pathologies. J Pharm 2015;5:1-4.  Back to cited text no. 10
Agarwal A, Deepinder F, Cocuzza M, Agarwal R, Short RA, Sabanegh E, et al. Efficacy of varicocelectomy in improving semen parameters: New meta-analytical approach. Urology 2007;70:532-8.  Back to cited text no. 11
Chen SS. Differences in the clinical characteristics between young and elderly men with varicocoele. Int J Androl 2012;35:695-9.  Back to cited text no. 12
Gat Y, Bachar GN, Zukerman Z, Belenky A, Gornish M. Varicocele: A bilateral disease. Fertil Steril 2004;81:424-9.  Back to cited text no. 13
Okorie CO, Pisters LL, Liu P. Longstanding hydrocele in adult Black Africans: Is preoperative scrotal ultrasound justified? Niger Med J 2011;52:173-6.  Back to cited text no. 14
[PUBMED]  Medknow Journal  
Chanc Walters R, Marguet CG, Crain DS. Lower prevalence of varicoceles in obese patients found on routine scrotal ultrasound. J Urol 2012;187:599-601.  Back to cited text no. 15
Mihmanli I, Kantarci F, Kulaksizoglu H, Gurses B, Ogut G, Unluer E, et al. Testicular size and vascular resistance before and after hydrocelectomy. AJR Am J Roentgenol 2004;183:1379-85.  Back to cited text no. 16
Yang DM, Kim SH, Kim HN, Kang JH, Seo TS, Hwang HY, et al. Differential diagnosis of focal epididymal lesions with gray scale sonographic, color Doppler sonographic, and clinical features. J Ultrasound Med 2003;22:135-42.  Back to cited text no. 17
Holden A, List A. Extratesticular lesions: A radiological and pathological correlation. Australas Radiol 1994;38:99-105.  Back to cited text no. 18
Mohrs OK, Thoms H, Egner T, Brunier A, Eiers M, Kauczor HU, et al. MRI of patients with suspected scrotal or testicular lesions: Diagnostic value in daily practice. AJR Am J Roentgenol 2012;199:609-15.  Back to cited text no. 19
Saleh O, El-Sharkawi MS, Imran MB. Scrotal scintigraphy in testicular torsion: An experience at a tertiary care centre. Int Med J Malays 2012;11:1-8.  Back to cited text no. 20


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded360    
    Comments [Add]    

Recommend this journal