Scrotal Contrast-Enhanced Ultrasound (CEUS)

 

Scrotal Contrast-Enhanced Ultrasound (CEUS)

Contrast-enhanced ultrasound (CEUS) is an advanced imaging technique that improves the evaluation of scrotal pathology, particularly in differentiating testicular infarction, ischemia, tumors, and infection. It involves the use of microbubble contrast agents, which enhance vascular visualization without nephrotoxic effects.

 ➤Advantages of CEUS in Scrotal Imaging

✅ Higher Sensitivity for Blood Flow – Detects microcirculation changes that conventional Doppler cannot visualize.
✅ No Radiation or Nephrotoxicity – Safe for patients with kidney disease (unlike CT/MRI contrast).
✅ Real-Time Perfusion Imaging – Allows dynamic evaluation of testicular blood supply.
✅ Better Tumor Characterization – Helps differentiate benign vs. malignant lesions.
✅ More Accurate Trauma Assessment – Identifies testicular rupture and ischemic injury.

➤Indications for Scrotal CEUS

CEUS is particularly useful in assessing:

1. Testicular Torsion & Ischemia

   • Helps detect reduced or absent enhancement in cases of testicular torsion or infarction.
   • Can differentiate between viable and non-viable testicular tissue.

2. Epididymo-Orchitis & Abscess

   • Inflammatory changes show increased enhancement due to hyperemia.
   • Abscesses appear as non-enhancing areas within an inflamed region.

3. Testicular Trauma

   • Helps differentiate between viable testicular tissue and ruptured, infarcted areas.
   • Detects testicular hematomas (non-enhancing regions).

4. Testicular Tumors vs. Benign Lesions

   • Malignant tumors usually show rapid and intense enhancement with irregular vascularity.
   • Benign lesions (e.g., Leydig cell tumors) have more uniform enhancement patterns.

5. Varicocele and Microvascular Perfusion Defects

   • Evaluates testicular perfusion abnormalities that may impact fertility.

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➤Scrotal CEUS Scanning Protocol

A. Patient Preparation

• Position: Supine with scrotum supported.
• Transducer: High-frequency linear probe (7.5–15 MHz) with CEUS capability.
• Contrast Agent:
  • Microbubble agents (e.g., SonoVue, Lumason) administered intravenously.
  • Typical dose: 1–2.4 mL, followed by saline flush.

B-CEUS Imaging Patterns

1. No Enhancement → Suggests ischemia, infarction, or hematoma.
2. Hyperenhancement → Suggests inflammation, tumors, or hypervascular lesions.
3. Peripheral Rim Enhancement → Common in abscesses.
4. Heterogeneous Enhancement → Seen in trauma, tumors, or mixed pathology.

➤Clinical Applications of Scrotal CEUS

A. Testicular Trauma

✅ Testicular Rupture → No enhancement in devitalized areas (indicates necrosis).
✅ Contusion/Hematoma → Heterogeneous enhancement or non-enhancing areas within the testis.
✅ Intact Vascularity → Suggests the testis is salvageable.

CEUS helps determine the need for surgery by assessing viability.

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B. Testicular Torsion (Emergency 🚨)

✅ Early Torsion (<6 hrs) → Reduced but present perfusion.
✅ Late Torsion (>12 hrs, complete infarction) → No enhancement (ischemia/necrosis).
✅ Differentiation from Epididymo-Orchitis → Orchitis shows increased enhancement, whereas torsion has absent flow.

🔴 Key Benefit: CEUS detects perfusion changes earlier than Doppler, aiding in timely intervention.

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C. Testicular Tumors

✅ Benign Tumors (Leydig Cell, Epidermoid Cyst, Hemangioma, Fibrosis) → No enhancement or slow, homogeneous enhancement.
✅ Malignant Tumors (Seminomas, Non-Seminomas, Lymphoma) → Rapid enhancement with early washout.
✅ Tumor Vascularity Mapping – Helps differentiate tumor vs. infarcted areas, guiding biopsy or surgery.

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D. Epididymo-Orchitis & Abscess Formation

✅ Orchitis → Hyper-enhancement due to increased vascularity.
✅ Abscess → Non-enhancing necrotic center surrounded by hypervascular inflammatory tissue.
✅ Differentiation from Tumors – CEUS shows well-defined abscess cavities, whereas tumors have irregular vascular patterns.

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➤Summary of CEUS Findings in Scrotal Pathology

Condition	CEUS Enhancement Pattern
Normal Testis	Uniform enhancement
Testicular Torsion	Absent enhancement (necrosis)
Orchitis	Hyper-enhancement (increased vascularity)
Testicular Tumor	Rapid enhancement with early washout (malignancy)
Benign Cyst/Fibrosis	No enhancement
Hematoma	Non-enhancing region (avascular)
Abscess	Central non-enhancement with rim hypervascularity