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Imaging of the Scrotum
Technical Aspects
Scrotal imaging has been one of the undeniable success stories of modern radiology. The scrotum is predominantly imaged for two clinical indications: the painless scrotal mass and the acute scrotum. Both conditions predominantly affect young men in the second through fourth decades of life. Rapid and accurate diagnosis is the goal of all imaging. Among several imaging modalities available, ultrasonography and magnetic resonance imaging (MRI) are used predominantly, whereas computed tomography (CT), angiography, and nuclear medicine studies are rarely used as primary imaging modalities for disorders of the scrotum.
Ultrasonography
Ultrasonography is undoubtedly the mainstay and is invariably the first and often the only imaging modality necessary. However, MRI can be useful as a problem-solving tool when ultrasonographic findings are equivocal or suboptimal.
Scrotal ultrasonography is performed with the patient in the supine position and the scrotum supported by a rolled towel placed between the thighs. Optimal results are obtained with a high-frequency (7- to 10-MHz) linear-array transducer. Scanning is performed most often with the transducer in direct contact with the skin, but, if necessary, a stand-off pad can be used for evaluation of superficial lesions.
The testes are examined in at least two planes, along transverse and long axes. The size and echogenicity of each testis and epididymis are compared with those of the opposite side. Color Doppler and pulsed-wave Doppler imaging parameters are optimized to display low-flow velocities to demonstrate blood flow in the testes and surrounding scrotal structures. Power Doppler imaging also may be used to demonstrate intratesticular flow in patients with an acute scrotum. In patients being evaluated for an acute scrotum, the asymptomatic side should be scanned initially to set the gray-scale and color Doppler gain settings to allow comparison with the affected side. Transverse images with portions of each testis on the same image should be acquired in gray-scale and color Doppler modes. Scrotal skin thickness is evaluated. The structures within the scrotal sac are examined to detect extratesticular masses or other abnormalities. In patients with small palpable nodules, scans should include the area of clinical concern. A finger should be placed beneath the nodule and the transducer placed directly over the nodule for scanning. Alternatively, a finger can be placed on the nodule and the transducer opposite to allow visualization of the lesion. Additional techniques such as use of the Valsalva maneuver or upright positioning can be used as needed for venous evaluation.
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