The Drs. Decio Prando and Osmar Saito gave presentations at the webinar on Hot Topics in Testicular Pouch Ultrasound
The National Ultrasonography Commission of the Brazilian College of Radiology and Image Diagnosis (CBR) promoted, on September 27, a webinar on Hot Topics in Testicular Bag Ultrasound. Available in full on the official CBR YouTube channel, the online seminar had lectures by doctors Decio Prando, graduated from the Faculty of Medicine of USP, with a postgraduate degree from the Escola Paulista de Medicina (Unifesp), radiologist at Clínica Prando-US Especializado ; and Osmar Saito, technical supervisor at Hospital das Clínicas at USP, radiologist at CBR and RSNA. They spoke, respectively, on the topics Torsion of the Spermatic Cord and Varicocele: How to Examine.
This Ultrasound Webinar was coordinated by Dr. Luis Ronan Marquez Ferreira de Souza, director of ABCDI and associate professor at the Federal University of Triângulo Mineiro (UFTM). “It was a unique moment, meeting great professors, who are very renowned in the area of Testicular Bag Ultrasound, and discussing new approaches to these pathologies”, highlighted Ronan. General coordination was provided by Dr. Harley de Nicola, coordinator of the National Commission on Ultrasound at CBR.
Torsion of the Spermatic Cord
Dr. Decio Prando spoke about Spermatic Cord Torsion and Doppler Ultrasound. “In torsion of the spermatic cord – this term is more appropriate than torsion of the testicle – it rotates on its longitudinal axis, and it can make half a turn or even three turns. It goes from 180° to 720° or more. But what twists is not the testicle, it is the cord”, he defended.
In cases of torsion, “in the first few hours there is a blockage of venous drainage, which leads to diffuse swelling of the entire gonad”, explained Dr. Decius Prado. “A rotation greater than 360°, even if it occurs only an hour or two later, will already cause arterial blockage. And this arterial blockage will cause hemorrhage, ischemia and necrosis. The reason is that there are no anastomoses, or they are rare, in this supra testicular territory”, he continued.
Still according to him, clinically there are two peaks for torsion: the pubertal and neonatal periods. “The pubertal period, generically, would range from 12 to 18 years, with a peak from 13 to 14; and neonatal goes from the moment the child is born to 6 months, 1 year.”
The Doctor. Decio Prado also defended the recommendation that, when the doctor does not see signs of torsion on the ultrasound, he should wait a while. “It is convenient to wait two to three hours, because there may be an important change and you start making the diagnosis, which until then was not evident, by Doppler.”
He presented 25 ultrasound signs of spermatic cord torsion, including increased testicle dimensions, position of the testicle in the pouch, identification of testicular architecture, spherical morphology, diffuse hyperechogenicity and scrotal wall thickening – check out the full version on the official channel from CBR on YouTube.
Varicocele: how to examine
The Doctor. Osmar Saito presented a lecture with the theme Varicocele: how to examine. He explained that varicocele is the dilation of the pampiniform plexus of the pampiniform plexus veins, a network of many small veins found in the male spermatic cord. It is the most frequently encountered mass of the spermatic cord.
The speaker also presented data that indicate that varicocele affects from 10% to 20% of the male population in the world; from 35% to 40% of patients with varicocele have the disease as the cause of primary infertility; and more than 80% have in varicocele the cause of secondary infertility.
“When I associate ultrasound with Doppler, the diagnosis of subclinical varicocele, the one that we do not identify clinically, increases to more than 91%. So, see the importance of ultrasound associated with Doppler”, highlighted Dr. Osmar Saito.
Regarding the physiology of varicocele, he explained: “it is a reflux, as we have in the leg veins, when we have varicose veins, related to the weight of the hydrostatic column, which often ends up leading to blood stasis and, secondarily, a hypoxia”. Still according to the speaker, “the main action of varicocele is due to the fact that this retained blood, in that place, ends up increasing the temperature in the scrotum. Then, the temperature increases and this leads to impaired spermatogenesis, generating oligospermia or azoospermia”.
The Doctor. Osmar Saito also presented details on the dynamics of varicocele, such as being more common on the left side; and symptoms of the disease such as pain in the testicle(s), heaviness in the scrotum, discomfort in the testicle and smaller testicle where the dilated veins are (due to the difference in blood flow).
The clinical classification of varicocele is: Grade I) palpated only during the Valsalva maneuver; Grade II) palpated without the Valsalva maneuver; and Grade III) visible distention of the pampiniform plexus.
On how to diagnose varicocele, Dr. Osmar Saito recommended: “The main point is the physical examination, questioning the patient about what is going on; Spermogram; ultrasound with Doppler, which has more than 91% of sensitivity in detecting varicocele”. Other tests cited, however with reservations, are: “scintigraphy, which is interesting, but very expensive, difficult to access in several centers; MRI is also a good test, but it is also expensive and often difficult to access; and venography of the spermatic vein, even more difficult”.
About the ultrasound exam, Dr. Osmar Saito stated that he often receives questions about how to do it and gave recommendations on the method, such as:
– Evaluation of the testes and epididymis with the patient in the supine position
– Calculation of testicular parenchyma volume and Doppler
– Heated room and gel to avoid contraction of the cremaster muscle
– Pampiniform plexus: Doppler in orthostasis with Valsalva maneuver (in the final moments of the exam)
After the presentations, speakers answered questions from physicians who participated live in the webinar.
Check out the Hot Topics Webinar on Testicular Pouch Ultrasound in full at official channel of CBR on YouTube.