Scrotal Calculi in Clinical Practice and Their Role in Scrotal Pain: A Prospective Study ur D€ Ahmet Aslan, MD,1 Sinan Tan, MD,1 Halil Yıldırım, MD,2 Ug onmez, MD,2 Ali C¸am, MD,2 2 2 Mehmet Can Gezer, MD, Mehmet Akif Teber, MD, Halil Arslan, MD2 1 2
S¸evket Yılmaz Education and Research Hospital, Department of Radiology, Bursa, Turkey Atat€ urk Education and Research Hospital, Department of Radiology, Ankara, Turkey
Received 20 February 2014; accepted 6 September 2014
ABSTRACT: Purpose. Scrotal calculi are rare, and their clinical significance is uncertain. Scrotal pain is a frequent, hard-to-manage problem in urology clinics. Our purpose in this study was to determine the relationship between the presence of scrotal calculi and scrotal pain in a prospective manner. Methods. Sonography and color Doppler ultrasound of the scrotum were performed in 758 consecutive patients referred with scrotal pain. The pain was rated by using an 11-point numeric rating scale; scores were compared among patients with scrotal calculi with and without additional scrotal pathology. Results. Scrotal calculi were detected in 73 of the 758 patients (9.6%). Scrotal pain (n 5 50 [61%]) and a palpable mass in the scrotum (n 5 25 [30.5%]) were the most common complaints in patients with scrotal calculi. Hydrocele (n 5 17 [29.8%]) and varicocele (n 5 15 [26.3%]) were the most commonly associated abnormalities; there was a statistically significant association between the presence of scrotal calculi and hydrocele (p < 0.01). Scrotal pain was present in 61 (83.5%) patients with scrotal calculi, and this association was significant (p < 0.001). The presence of scrotal pain and the correlation between location of calculi and pain in patients without additional scrotal abnormalities were also significant (p 5 0.04 and p < 0.004, respectively). Conclusions. The prevalence of scrotal calculi was 9.6%, and hydrocele was found to be associated with scrotal calculi. We also found a significant relationship between the presence of calculi and scrotal pain. Because the etiology of scrotal pain is essential for appropriate treatment, scrotal calculi should be kept in mind when making a differential diagnosis of scroC 2014 Wiley Periodicals, Inc. J Clin Ultratal pain. V
Correspondence to: A. Aslan The authors have no conflicts of interest to disclose. C 2014 Wiley Periodicals, Inc. V
406
sound 43:406–411, 2015; Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/ jcu.22247 Keywords: scrotum; calculi; lithiasis; hydrocele; pain; ultrasonography
INTRODUCTION
S
crotal calculi are rare, but because they are well visualized on high-frequency ultrasound (US), their detection rate has increased. They are most commonly described as freely floating or fixed calcifications between the layers of the tunica vaginalis testis (TVT). They have been said to have no clinical significance in several studies.1–4 Scrotal pain has been an increasing cause of referrals to urology clinics.5 For many patients, the etiology of the scrotal pain remains uncertain, and its management is usually complex and controversial, with resulting anxiety that may well affect the patients’ quality of life. Published data concerning scrotal calculi mostly have been derived from case reports or retrospective studies, and the relationship between such calculi and scrotal pain has not been investigated prospectively.2,6,7 In this prospective study, we aimed to determine the prevalence of scrotal calculi and their association with scrotal pain and other scrotal pathology.
PATIENTS AND METHODS
This prospective observational study was approved by the Institutional Review Board, JOURNAL OF CLINICAL ULTRASOUND
SCROTAL CALCULI AND SCROTAL PAIN
and written informed consent was obtained from all patients. Consecutive patients referred to our radiology departments from the internal medicine, emergency, or urology outpatient clinics for scrotal US or color Doppler US (CDUS) examinations were enrolled in our study. All consecutive patients were planned to be included in the study, and all were questioned about the presence of scrotal pain at the time of the US examination. US and CDUS examinations were performed using US scanners equipped with a 9–14-MHz linear probe (Logic 9; GE Healthcare, Milwaukee, WI), an 8–14-MHz linear probe (Technos MPX; Esaote, Genoa, Italy), and a 4–12-MHz linear probe (Mindray DC7T; Shenzhen, P.R. China) by one of four radiologists who had 3–8 years of experience with conventional sonography and who were blinded to the patients’ clinical findings. All US and CDUS examinations were done while patients were in the supine position. The scrotum was elevated by placing a towel between the thighs, and the penis was placed by the patient on his abdomen with a second towel.8,9 Sonograms were obtained in at least two planes and along multiple oblique planes to inspect the entire scrotum. CDUS was used to document blood flow and measure Doppler indices in the spermatic cord to diagnose a varicocele and to evaluate the vascularization of the testis and epididymis for the diagnosis of torsion or inflammation. Round or oval echogenic foci floating or located between the layers of the TVT were assessed as scrotal calculi, whether they cast acoustic shadowing or not (Figure 1).2,3 The collected data included patient age, referring clinic, patient complaints, US findings of the testis and epididymis, the presence and side of hydrocele or varicocele, the presence of scrotal calculi, and the side and size of calculi. The size of a calculus was defined by its maximum dimension. Patients who had scrotal or lower abdominal pain were further questioned about the duration of the pain, which was categorized as having lasted less than 6 months or 6 months or longer (ie, chronic). The type of pain was categorized as constant or intermittent by one of four radiologists who had not performed the US and CDUS examinations.5,10 To interpret and measure the severity of the scrotal pain, the patients were asked to grade the intensity of the pain on an 11-point numeric rating scale (NRS): 0, no pain; 1–3, mild; 4–6, moderate; or 7–10, severe.11 VOL. 43, NO. 7, SEPTEMBER 2015
FIGURE 1. Sonogram of the scrotum of a 26-year-old man with hydrocele shows a scrotal calculus (arrow) with posterior acoustic shadowing (arrowheads). T, testis.
Statistical Analysis A descriptive analysis of the collected data was done for demographics and US and CDUS findings by using SPSS version 16 software (SPSS Inc., Chicago, IL). The numeric variables were expressed as either means 6 standard deviations (SD) or as numbers and percentages, as appropriate. Statistical analyses were made with the Mann-Whitney U test, the v2 test, or Fisher’s exact test, whichever was suitable. The correlations between the size of the scrotal calculi and the scrotal pain, the pain duration, and the pain intensity were analyzed by applying Spearman’s correlation analysis. Patients with bilateral scrotal pain or bilateral scrotal calculi were excluded from the agreement analysis, and the agreement between the localization of scrotal calculi and scrotal pain was analyzed by using j statistics in patients with no scrotal pathology aside from scrotal calculi and pain. Statistical significance was set as p < 0.05, and the tests used were two-sided.
RESULTS
Seven hundred fifty-eight patients were enrolled in the study. Eighty-nine scrotal calculi were detected in 73 patients (9.6%). Scrotal calculi in 32 patients were seen in the right hemiscrotum, in 30 patients in the left hemiscrotum, and bilaterally in 11 patients. The scrotal calculi were solitary in 53 patients and multiple in 20 patients. Sixty-eight (93.1%) patients were referred from the urology clinics and 5 (6.9%) patients were referred from the emergency clinics. Patients with scrotal calculi were referred for US examinations for a total of seven various 407
ASLAN ET AL TABLE 1 Complaints Among Patients with Scrotal Calculi* Patients with Pain (n 5 61) Complaint Scrotal pain Palpable mass Infertility Sexual dysfunction Urinary incontinence Dysuria Postherniorrhaphy control
Group 1† (n 5 28)
Group 2‡ (n 5 33)
Pain-Free Patients (n 5 12)
Total (n 5 73)
26 (83.8) 4 (12.9) 1 (3.3) 0 0 0 0
24 (60) 12 (30) 1 (2.5) 1 (2.5) 1 (2.5) 1 (2.5) 0
0 9 (75) 0 1 (8.3) 1 (8.3) 0 1 (8.3)
50 (61) 25 (30.5) 1 (1.2) 2 (2.4) 2 (2.4) 1 (1.2) 1 (1.2)
*Data are presented as number (%). Patients had no scrotal pathology except scrotal calculi. Patients had scrotal pathology in addition to scrotal calculi.
† ‡
TABLE 2 Additional Sonographic Abnormalities in Patients with Scrotal Calculi Abnormality on Sonography Hydrocele Varicocele Testicular microlithiasis Testicular cyst Testicular mass Testicular atrophy Orchitis Testicular heterogeneity Epididymal cyst Epididymitis Totals, n (%)
Location of Abnormality (n) Ipsilateral
Contralateral
Bilateral
Total, n (%)
10 7 0 2 1 0 1 0 8 1 30
3 7 1 0 1 1 1 1 4 1 20
4 1 2 0 0 0 0 0 0 0 7
17 (29.8) 15 (26.3) 3 (5.2) 2 (3.5) 2 (3.5) 1 (1.7) 2 (3.5) 1 (1.7) 12 (21) 2 (3.5) 57 (100)
complaints: scrotal pain (n 5 50 [61%]) and a palpable mass in the scrotum (n 5 25 [30.5%]) were the most common (Table 1). The size of detected calculi ranged from 1 to 9 mm (mean [6SD] size, 3.6 6 1.5 mm). The patients with scrotal calculi were between 14 and 80 years old (mean age, 39 6 17 years). There was no correlation between age and the size of scrotal calculi (p 5 0.80). The mean age of patients without scrotal calculi (35 6 17 years) was less than the age of those with scrotal calculi, but the difference was not statistically significant (p 5 0.09). There was also no correlation between age and the size of scrotal calculi (r 5 –0.03, p 5 0.80). In the 73 patients with scrotal calculi, US revealed no other abnormality in 29 (39.7%) patients. In the remaining 44 (60.3%) patients, US showed a total of 57 scrotal lesions, of which hydroceles and varicoceles were the most common (Table 2). Hydrocele was seen at a rate of 23.2% (n 5 17) in patients with scrotal calculi and was unilateral in 13 patients and bilateral in 4 patients; it was painless in 3 patients. 408
A hydrocele was detected in 100 of the 758 patients. The incidence of scrotal calculi in patients with hydrocele was 17%, compared with 8.5% in patients without hydrocele (p < 0.01). According to our data, the presence of a hydrocele increases the risk of scrotal calculi (odds ratio, 2.2; 95% confidence interval, 1.22–3.97). Varicocele was diagnosed on US and CDUS examinations in 222 patients. The incidence of varicocele was 20.5% in patients with scrotal calculi. Scrotal calculi were detected in 6.8% of the patients with varicocele and in 10.8% of the patients without varicocele (p 5 0.08). Among the 73 patients with scrotal calculi, scrotal pain was present in 61 (83.5%; p < 0.001). The mean size of the calculi was 3.9 6 1.2 mm (range, 2.4–6.5 mm) in pain-free patients and 3.5 6 1.6 mm (range, 1–9 mm) in patients with scrotal pain. Although the size of the calculi was larger in pain-free patients, the difference was not significant (p 5 0.5). A palpable mass in the scrotum was the most common complaint in this group (n 5 8 [61.5%]). JOURNAL OF CLINICAL ULTRASOUND
SCROTAL CALCULI AND SCROTAL PAIN TABLE 3 Characteristics of Scrotal Pain in Patients with and Without Scrotal Calculi* Characteristic of Pain Intensity Mild Moderate Severe Duration
S¸evket Yılmaz Education and Research Hospital, Department of Radiology, Bursa, Turkey Atat€ urk Education and Research Hospital, Department of Radiology, Ankara, Turkey
Received 20 February 2014; accepted 6 September 2014
ABSTRACT: Purpose. Scrotal calculi are rare, and their clinical significance is uncertain. Scrotal pain is a frequent, hard-to-manage problem in urology clinics. Our purpose in this study was to determine the relationship between the presence of scrotal calculi and scrotal pain in a prospective manner. Methods. Sonography and color Doppler ultrasound of the scrotum were performed in 758 consecutive patients referred with scrotal pain. The pain was rated by using an 11-point numeric rating scale; scores were compared among patients with scrotal calculi with and without additional scrotal pathology. Results. Scrotal calculi were detected in 73 of the 758 patients (9.6%). Scrotal pain (n 5 50 [61%]) and a palpable mass in the scrotum (n 5 25 [30.5%]) were the most common complaints in patients with scrotal calculi. Hydrocele (n 5 17 [29.8%]) and varicocele (n 5 15 [26.3%]) were the most commonly associated abnormalities; there was a statistically significant association between the presence of scrotal calculi and hydrocele (p < 0.01). Scrotal pain was present in 61 (83.5%) patients with scrotal calculi, and this association was significant (p < 0.001). The presence of scrotal pain and the correlation between location of calculi and pain in patients without additional scrotal abnormalities were also significant (p 5 0.04 and p < 0.004, respectively). Conclusions. The prevalence of scrotal calculi was 9.6%, and hydrocele was found to be associated with scrotal calculi. We also found a significant relationship between the presence of calculi and scrotal pain. Because the etiology of scrotal pain is essential for appropriate treatment, scrotal calculi should be kept in mind when making a differential diagnosis of scroC 2014 Wiley Periodicals, Inc. J Clin Ultratal pain. V
Correspondence to: A. Aslan The authors have no conflicts of interest to disclose. C 2014 Wiley Periodicals, Inc. V
406
sound 43:406–411, 2015; Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/ jcu.22247 Keywords: scrotum; calculi; lithiasis; hydrocele; pain; ultrasonography
INTRODUCTION
S
crotal calculi are rare, but because they are well visualized on high-frequency ultrasound (US), their detection rate has increased. They are most commonly described as freely floating or fixed calcifications between the layers of the tunica vaginalis testis (TVT). They have been said to have no clinical significance in several studies.1–4 Scrotal pain has been an increasing cause of referrals to urology clinics.5 For many patients, the etiology of the scrotal pain remains uncertain, and its management is usually complex and controversial, with resulting anxiety that may well affect the patients’ quality of life. Published data concerning scrotal calculi mostly have been derived from case reports or retrospective studies, and the relationship between such calculi and scrotal pain has not been investigated prospectively.2,6,7 In this prospective study, we aimed to determine the prevalence of scrotal calculi and their association with scrotal pain and other scrotal pathology.
PATIENTS AND METHODS
This prospective observational study was approved by the Institutional Review Board, JOURNAL OF CLINICAL ULTRASOUND
SCROTAL CALCULI AND SCROTAL PAIN
and written informed consent was obtained from all patients. Consecutive patients referred to our radiology departments from the internal medicine, emergency, or urology outpatient clinics for scrotal US or color Doppler US (CDUS) examinations were enrolled in our study. All consecutive patients were planned to be included in the study, and all were questioned about the presence of scrotal pain at the time of the US examination. US and CDUS examinations were performed using US scanners equipped with a 9–14-MHz linear probe (Logic 9; GE Healthcare, Milwaukee, WI), an 8–14-MHz linear probe (Technos MPX; Esaote, Genoa, Italy), and a 4–12-MHz linear probe (Mindray DC7T; Shenzhen, P.R. China) by one of four radiologists who had 3–8 years of experience with conventional sonography and who were blinded to the patients’ clinical findings. All US and CDUS examinations were done while patients were in the supine position. The scrotum was elevated by placing a towel between the thighs, and the penis was placed by the patient on his abdomen with a second towel.8,9 Sonograms were obtained in at least two planes and along multiple oblique planes to inspect the entire scrotum. CDUS was used to document blood flow and measure Doppler indices in the spermatic cord to diagnose a varicocele and to evaluate the vascularization of the testis and epididymis for the diagnosis of torsion or inflammation. Round or oval echogenic foci floating or located between the layers of the TVT were assessed as scrotal calculi, whether they cast acoustic shadowing or not (Figure 1).2,3 The collected data included patient age, referring clinic, patient complaints, US findings of the testis and epididymis, the presence and side of hydrocele or varicocele, the presence of scrotal calculi, and the side and size of calculi. The size of a calculus was defined by its maximum dimension. Patients who had scrotal or lower abdominal pain were further questioned about the duration of the pain, which was categorized as having lasted less than 6 months or 6 months or longer (ie, chronic). The type of pain was categorized as constant or intermittent by one of four radiologists who had not performed the US and CDUS examinations.5,10 To interpret and measure the severity of the scrotal pain, the patients were asked to grade the intensity of the pain on an 11-point numeric rating scale (NRS): 0, no pain; 1–3, mild; 4–6, moderate; or 7–10, severe.11 VOL. 43, NO. 7, SEPTEMBER 2015
FIGURE 1. Sonogram of the scrotum of a 26-year-old man with hydrocele shows a scrotal calculus (arrow) with posterior acoustic shadowing (arrowheads). T, testis.
Statistical Analysis A descriptive analysis of the collected data was done for demographics and US and CDUS findings by using SPSS version 16 software (SPSS Inc., Chicago, IL). The numeric variables were expressed as either means 6 standard deviations (SD) or as numbers and percentages, as appropriate. Statistical analyses were made with the Mann-Whitney U test, the v2 test, or Fisher’s exact test, whichever was suitable. The correlations between the size of the scrotal calculi and the scrotal pain, the pain duration, and the pain intensity were analyzed by applying Spearman’s correlation analysis. Patients with bilateral scrotal pain or bilateral scrotal calculi were excluded from the agreement analysis, and the agreement between the localization of scrotal calculi and scrotal pain was analyzed by using j statistics in patients with no scrotal pathology aside from scrotal calculi and pain. Statistical significance was set as p < 0.05, and the tests used were two-sided.
RESULTS
Seven hundred fifty-eight patients were enrolled in the study. Eighty-nine scrotal calculi were detected in 73 patients (9.6%). Scrotal calculi in 32 patients were seen in the right hemiscrotum, in 30 patients in the left hemiscrotum, and bilaterally in 11 patients. The scrotal calculi were solitary in 53 patients and multiple in 20 patients. Sixty-eight (93.1%) patients were referred from the urology clinics and 5 (6.9%) patients were referred from the emergency clinics. Patients with scrotal calculi were referred for US examinations for a total of seven various 407
ASLAN ET AL TABLE 1 Complaints Among Patients with Scrotal Calculi* Patients with Pain (n 5 61) Complaint Scrotal pain Palpable mass Infertility Sexual dysfunction Urinary incontinence Dysuria Postherniorrhaphy control
Group 1† (n 5 28)
Group 2‡ (n 5 33)
Pain-Free Patients (n 5 12)
Total (n 5 73)
26 (83.8) 4 (12.9) 1 (3.3) 0 0 0 0
24 (60) 12 (30) 1 (2.5) 1 (2.5) 1 (2.5) 1 (2.5) 0
0 9 (75) 0 1 (8.3) 1 (8.3) 0 1 (8.3)
50 (61) 25 (30.5) 1 (1.2) 2 (2.4) 2 (2.4) 1 (1.2) 1 (1.2)
*Data are presented as number (%). Patients had no scrotal pathology except scrotal calculi. Patients had scrotal pathology in addition to scrotal calculi.
† ‡
TABLE 2 Additional Sonographic Abnormalities in Patients with Scrotal Calculi Abnormality on Sonography Hydrocele Varicocele Testicular microlithiasis Testicular cyst Testicular mass Testicular atrophy Orchitis Testicular heterogeneity Epididymal cyst Epididymitis Totals, n (%)
Location of Abnormality (n) Ipsilateral
Contralateral
Bilateral
Total, n (%)
10 7 0 2 1 0 1 0 8 1 30
3 7 1 0 1 1 1 1 4 1 20
4 1 2 0 0 0 0 0 0 0 7
17 (29.8) 15 (26.3) 3 (5.2) 2 (3.5) 2 (3.5) 1 (1.7) 2 (3.5) 1 (1.7) 12 (21) 2 (3.5) 57 (100)
complaints: scrotal pain (n 5 50 [61%]) and a palpable mass in the scrotum (n 5 25 [30.5%]) were the most common (Table 1). The size of detected calculi ranged from 1 to 9 mm (mean [6SD] size, 3.6 6 1.5 mm). The patients with scrotal calculi were between 14 and 80 years old (mean age, 39 6 17 years). There was no correlation between age and the size of scrotal calculi (p 5 0.80). The mean age of patients without scrotal calculi (35 6 17 years) was less than the age of those with scrotal calculi, but the difference was not statistically significant (p 5 0.09). There was also no correlation between age and the size of scrotal calculi (r 5 –0.03, p 5 0.80). In the 73 patients with scrotal calculi, US revealed no other abnormality in 29 (39.7%) patients. In the remaining 44 (60.3%) patients, US showed a total of 57 scrotal lesions, of which hydroceles and varicoceles were the most common (Table 2). Hydrocele was seen at a rate of 23.2% (n 5 17) in patients with scrotal calculi and was unilateral in 13 patients and bilateral in 4 patients; it was painless in 3 patients. 408
A hydrocele was detected in 100 of the 758 patients. The incidence of scrotal calculi in patients with hydrocele was 17%, compared with 8.5% in patients without hydrocele (p < 0.01). According to our data, the presence of a hydrocele increases the risk of scrotal calculi (odds ratio, 2.2; 95% confidence interval, 1.22–3.97). Varicocele was diagnosed on US and CDUS examinations in 222 patients. The incidence of varicocele was 20.5% in patients with scrotal calculi. Scrotal calculi were detected in 6.8% of the patients with varicocele and in 10.8% of the patients without varicocele (p 5 0.08). Among the 73 patients with scrotal calculi, scrotal pain was present in 61 (83.5%; p < 0.001). The mean size of the calculi was 3.9 6 1.2 mm (range, 2.4–6.5 mm) in pain-free patients and 3.5 6 1.6 mm (range, 1–9 mm) in patients with scrotal pain. Although the size of the calculi was larger in pain-free patients, the difference was not significant (p 5 0.5). A palpable mass in the scrotum was the most common complaint in this group (n 5 8 [61.5%]). JOURNAL OF CLINICAL ULTRASOUND
SCROTAL CALCULI AND SCROTAL PAIN TABLE 3 Characteristics of Scrotal Pain in Patients with and Without Scrotal Calculi* Characteristic of Pain Intensity Mild Moderate Severe Duration
