Scrotum Protocol
Patient Prep
Avoid the "rolled towel between the legs" method. Use a single blanket, when placed underneath the scrotum and over the legs, both supports the scrotum as well as covers the patient. As an added benefit, you can easily pull on one side of the blanket to reposition any internal scrotal structures e.g. epididymis. Steps outlined below:- The patient is supine, unclothed from the waist down, draped with a gown open to the back, and covered with a blanket over the legs and lower torso.
- Tell the patient to pull his gown up to the groin such that it is still covering the penis, but the scrotum is exposed.
- Uncover the blanket down to the groin, and have him elevate the scrotum or place the scrotum over the blanket.
- Ask the patient to keep his legs close together. The scrotum should now mostly be immobile. Scanning Duration: 20 minutes, including standing varicocele evaluation.
Normal Bilateral Testes Comparison Source: https://doi.org/10.1007/s00247-018-4093-0
Authors: Anjum Bandarkar, Anna Blask
CC BY 4.0 / No changes made
Testes B/L Trans
- Take an image showing both testes with similar texture and echogenicity when normal.
- This can be challenging when there is a large hydrocele. Switch to a curvilinear probe and try to obtain both testes in one image. When this is not possible, use dual screen. Color image: One image showing similar perfusion in both testes.
Right Testis Sag
- Show the midline testis in an oblong shape, using light pressure so as not to deform the testis. Measurement image: One image with A/P and length measurements.
Right Testis Trans
- Show the midline testis in a circular shape, using light pressure so as not to deform the testis. Measurement image: One image with transverse measurement.
Normal Arterial Flow within Testis Source: https://doi.org/10.1007/s00247-018-4093-0
Authors: Anjum Bandarkar, Anna Blask
CC BY 4.0 / No changes made
Right Testis Sag Med/Mid/Lat
- Obtain stills at the medial, mid, and lateral testis.
- When normal, take color and Doppler at the mid testis only.
- Doppler any intratesticular varicoceles (and with Valsalva by the patient) to demonstrate venous waveform. Color image: One image at midline testis with perfusion in the upper through lower poles.
Doppler image: Sample the center of the testis and show the arterial waveform.
Cine: Medial to lateral, or lateral to medial.
Right Testis Trans Sup/Mid/Inf
- Obtain stills at the superior, mid, and inferior testis. Color image: One image at midline testis.
Cine: Superior to inferior.
Right Epididymis Sag Head/Body/Tail
- Take grayscale images of the epididymal head, body, and tail with the ductus deferens.
- You should attempt to reposition the epididymis to be anterior to the testis. This can be achieved by slowly applying more pressure to the side of the scrotum. Alternatively, pull on the blanket supporting the scrotum to make scrotal contents move.
- Color images are used to compare the vascularity between the epididymis and the adjacent testis.
- No need to measure the epididymis. Color image: One image each at the head, body, and tail.
Cine: One clip showing the entire length of the epididymis.
Right Epididymis Trans Sup-Inf
- No still images needed when it is normal. Cine: Superior to inferior, showing the entire epididymis from head to tail with the ductus deferens.
Hemiscrotum with Large Hydrocele Source: https://commons.wikimedia.org/wiki/File:Ultrasonography_of_hydrocele.jpg
Author: Mikael Haggstrom
Right Hydrocele Sag/Trans
- No need to document small or trace hydroceles.
- Be aware of your gain, noting when a hydrocele contains echogenic debris.
- Document any incidental scrotoliths. Do not measure them unless they are an area of concern. Measurement image: Measure the hydrocele in three dimensions (sagittal and transverse).
Positive Reflux with Valsalva Source: https://doi.org/10.1007/s40477-020-00509-z
Authors: M. Bertolotto, S. Freeman, J. Richenberg, et al.
CC BY 4.0 / No changes made
Right Supine Spermatic Cord W/ Valsalva
- Scan supero-laterally from the testis to identify the pampiniform plexus veins. Align the probe to be sagittal to or parallel with the veins.
- Steer the color box, and ask the patient to perform a light Valsalva maneuver by slowly bearing down as if starting a bowel movement. Or sometimes, taking deep breaths in and out is sufficient to elicit a flow reversal (reflux).
- The normal color filling of the vein with Valsalva will be the same color at rest. In other words, the normal Valsalva waveform will not cross the baseline (will show no reflux). Presence of reflux indicates a varicocele, or a developing varicocele. Cine with Color: Limit one cine clip showing good color filling with Valsalva.
Doppler image: Doppler the vein of interest, confirming presence or absence of reflux.
Correct A/P Measurement of VaricoceleSource: https://doi.org/10.1038/s41598-018-24890-2
Authors: S.M. Bagheri, F. Khajehasani, H. Iraji, et al.
CC BY 4.0 / No changes made
Right Supine Spermatic Cord (Rest and W/ Valsalva)
- Measure the A/P diameter of the largest pampiniform plexus vein in the sagittal view, with the patient at rest and again with Valsalva.
- The ductus deferens is a singular, hypoechoic and tubular structure which normally runs within the spermatic cord. It is found next to the pampiniform plexus but will have no color filling, and is not to be confused for a vein.
- Varicocele ≥0.25 cm.
- Varicoceles are common on the left (85%) or bilaterally (15%), and rare on the right side only. Dual screen image: Take the A/P measurement of the pampiniform plexus vein before and after Valsalva.
(Repeat the protocol including supine varicocele evaluation for the left side)
Standing Varicocele?
- If this study is for infertility, hypogonadism, or r/o varicoceles, then perform additional standing varicocele evaluation for both sides.
- If reflux is seen supine, then no need to repeat color and Doppler of the pampiniform plexus on that side. Obtain the standing varicocele measurements.
Worksheet
- Print the worksheet containing measurements.