Article

Scrotal ultrasound and Doppler

Scrotal ultrasound with Doppler: technique, testes and epididymes, acute pain (torsion vs epididymitis), varicocele, masses and hydrocele, normal report.

What it is and when to indicate it

Scrotal ultrasound with Doppler assesses the testes, epididymes and scrotal content. It is the exam of choice for acute scrotal pain, swelling, evaluation of a testicular mass, varicocele, infertility and trauma.

This page organizes the protocol in clear language and does not replace the original guidelines (AIUM, ACR, CBR), supervised training or clinical correlation.

Preparation and technique

• No preparation required; high-frequency linear transducer (7 to 15 MHz)
• Assess each testis in two planes, comparing sides (size, echotexture, vascularization)
• Color and spectral Doppler with low PRF to capture normal testicular flow
• Valsalva maneuver and standing position for varicocele
• Document the epididymes, tunica vaginalis (hydrocele) and scrotal wall

Acute scrotal pain: torsion vs epididymitis

The priority is to differentiate torsion (a surgical emergency) from epididymitis/orchitis. Doppler is decisive.

• Torsion: absent or reduced testicular flow compared with the normal side; enlarged, heterogeneous testis in later phases
• Epididymitis/orchitis: enlarged epididymis/testis with hyperemia on Doppler
• Always compare with the contralateral side and adjust PRF for slow flow
• Partial/intermittent torsion may have flow present — correlate with the clinical picture
• An emergency finding requires immediate communication to the requester

Varicocele, hydrocele and masses

• Varicocele: dilated pampiniform plexus veins (above about 2 to 3 mm) with reflux on Valsalva
• Hydrocele: anechoic collection between the layers of the tunica vaginalis
• A solid intratesticular mass is suspicious for malignancy until proven otherwise — describe and refer
• Epididymal cysts and testicular microlithiasis described when present
• Trauma: hematoma, fracture and albuginea rupture are findings to value

Normal report template

• Testes in topical position, of homogeneous dimensions and echotexture, symmetric
• Symmetric and preserved testicular vascularization on Doppler
• Epididymes of usual appearance, without inflammatory signs
• Absence of significant hydrocele, varicocele or masses
• Scrotal wall without alterations

Limitations and pitfalls

• High PRF masking normal testicular flow and simulating torsion
• Intermittent torsion with flow present at the time of the exam
• Extratesticular mass (usually benign) vs intratesticular (suspicious): define the topography
• Microlithiasis overvalued outside the clinical context
• Report limitations and the urgency of communication when torsion is suspected

Do not overdiagnose

In acute pain, the decision is clinical-surgical; ultrasound supports it, but a strong suspicion of torsion should not be delayed by a doubtful exam. For masses, describe topography and features and refer, without asserting histology.

Sources

Educational content; it does not replace original guidelines, medical evaluation or supervised training. Main references:

• AIUM-ACR-SPR-SRU. Practice Parameter for the Performance of Scrotal Ultrasound Examinations.
• ESUR/EAU. Recommendations on scrotal ultrasound (didactic support).
• Brazilian College of Radiology (CBR). Standardization and technical guidelines for ultrasound.
• Rumack CM, Levine D. Diagnostic Ultrasound (scrotum).
• Radiopaedia. Scrotal ultrasound (didactic support, not copied).

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