Diagnosis of pediatric varicoceles by physical examination and ultrasonography and measurement of the testicular volume: using the prader orchidometer versus ultrasonography

INTRODUCTION: The differentiation of unilateral versus bilateral varicoceles and testicular volume measurements are important in determining the need for adolescent varicocele surgery and also in following patients after varicocelectomy. The aim of this study was to prospectively compare the findings of physical examination and color Doppler ultrasonography in the diagnosis of pediatric varicoceles and to compare the findings using the Prader orchidometer and scrotal ultrasonography in the measurement of testicular volumes. PATIENTS AND METHODS: This study included 68 boys with varicoceles, ranging in age from 8 to 19 years. Varicoceles were diagnosed using both physical examination and scrotal color Doppler ultrasonography. The testicular volumes of 136 testicles were measured using the Prader orchidometer and scrotal ultrasonography. A difference of more than 10% or 2 ml in each testicular volume was considered significant. RESULTS: The mean age of the boys was 13.5 +/- 2.3 years. On physical examination, a left unilateral varicocele was diagnosed in 46 boys (67.6%). The other 22 boys (32.4%) had bilateral varicoceles. Color Doppler ultrasonography detected bilateral varicoceles in 4 of the 46 boys (8.7%) who were diagnosed by physical examination as having only left unilateral varicoceles (grade 3 in 3 patients and grade 2 in 1 patient). A different of more than 10% or 2 ml in testicular volume using the Prader orchidometer versus scrotal ultrasonography was detected in 3 out of 136 testicles (2.2%). The correlation between ultrasonography and Prader orchidometer results in the measurement of testicular volumes was statistically highly significantly consistent using the intraclass correlation test (r = 0.997 and p < 0.001 for the left testis; r = 0.998 and p < 0.001 for the right testis). CONCLUSIONS: Although the management of subclinical varicoceles remains controversial, these data show that color Doppler ultrasonography may be necessary in the diagnosis of bilateral varicoceles, especially in boys with high-grade left varicoceles. In contrast, scrotal ultrasonography, if considered the gold standard, did not show superiority over the Prader orchidometer in measuring testicular volumes.     

Relationship between testicular volume and testicular function： comparison of the Prader orchidometric and ultrasonographic measurements in patients with infertility

Aim： To evaluate the relationship between testicular function and testicular volume measured by using Prader orchidometry and ultrasonography （US） to determine the critical testicular volume indicating normal testicular function by each method. Methods： Total testicular volume （right plus left testicular volume） was measured in 794 testes in 397 men with infertility （mean age, 35.6 years） using a Prader orchidometer and also by ultrasonography. Ultrasonographic testicular volumes were calculated as length x width x height x 0.71. To evaluate volume-function relationships, patients were divided into 10 groups representing 5-mL increments of total testicular volume by each method from below 10 mL to 50 mL or more. Results： Mean total testicular volume based on Prader orchidometry and US were 36.8 mL and 26.3 mL, respectively. Semen volume, sperm density, total sperm count, total motile sperm count, and serum FSH, LH, and testosterone all correlated significantly with total testicular volume measured by either method. Mean sperm density was in the oligozoospermic range in patients with total testicular volume below 35 mL by orchidometry or below 20 mL by ultrasonography. Mean total sperm count was subnormal in patients with total testicular volume below 30 mL by orchidometry or under 20 mL by ultrasonography. Conclusion： Testicular volume measured by either ultrasonography or Prader orchidometry correlated significantly with testicular function. However, critical total testicular volume indicating normal or nearly normal testicular function was 30 mL to 35 mL using Prader orchidometer and 20 mL using ultrasonography. Prader orchidometry morphometrically and functionally overestimated the testicular volume in comparison to US. （Asian JAndro12008 Mar; 10： 319-324）     

Usefulness and limitation of punched-out orchidometer in testicular volume measurement

AIM: To determine the limitations of a punched-out orchidometer in practical use, we compared with a scrotal ultrasound (USG). METHODS: A total of 281 testes from 142 males were examined using both a punched-out orchidometer and a USG. The volume differential between both methods was calculated and expressed as orchidometer/USG volume (O/U ratio). Distribution of the O/U ratio was determined and subdivided by clinical or pathological diagnosis. The correlations between the O/U ratio and patient age or orchidometer results were assessed. RESULTS: There was a significant linear relationship between the results of orchidometer and USG (r=0.94, P <0.0001). The relationship between the O/U ratio and age or testicular volumes showed significant inverse correlations (r=0.22, P=0.0002, r=0.45, P <0.0001, respectively). Klinefelter's syndrome, ipsilateral detorted testes and hypogonadotropic hypogonadism comparatively showed a high O/U ratio. No incidental lesion was detected by USG necessitating treatment. CONCLUSION: The punched-out orchidometer gives estimates that correlated well with the USG measurements and provides enough information for routine andrological evaluation. We should be aware that the orchidometer often overestimates the testicular volume, especially for the patients with small testis or adolescents.     

Measurement of testicular volume by ultrasonography

To measure testicular volume accurately, an ultrasonographic method was developed and the results obtained from this compared with those obtained by conventional measurements, namely (1) comparison with testis models, (2) an orchidometer, and (3) measurement of testicular volume by calipers through the scrotal skin. Data from these methods were compared with the actual volume measured at operation by slide calipers placed directly on the testis. The volume obtained by comparison with testis models or with an orchidometer tended to over-estimate the actual volume. The volume measured by slide calipers on scrotal skin was also found to be incorrect. On the other hand, the volume measured by ultrasonography proved to be closer to, and to correlate well with, the actual volume, and was considered to be the best method.     

Objective measurement of testicular volume by ultrasonography: evaluation of the technique and comparison with orchidometer estimates

Ultrasonography of the scrotum is a valid and safe method for differentiating testicular and extratesticular disease. In the present study the accuracy and reproducibility of ultrasonographic estimation of testicular volume was evaluated. A high correlation (r = 0.992) between actual testicular volume (measured by weighing and water displacement) and the volume determined by ultrasonography was found on examination of 14 tests from patients at autopsy without any systematic under- or over-estimation. The ultrasound method proved to be highly reproducible with a coefficient of variation of 7.0 +/- 0.7%. Using different ultrasound scanners did not significantly influence the results obtained. The comparison of Prader orchidometer measurements, performed by four different clinical investigators, and ultrasonography in 256 patients revealed a significant correlation of 0.91, but the degree of correlation was dependent on the investigator's clinical experience. Volume estimates by comparative palpation appear to be valuable in most clinical settings. Ultrasonography provides an excellent tool for determining testicular volume when objective, accurate and reproducible measurements of testicular volume are required.     

Use of ultrasound and surgery in adults with acute scrotal pain

Background: The epidemiology of patients with acute scrotal pain presenting to the emergency department (ED) is largely unknown. Urgent surgical referral is recommended for patients presenting with suspected testicular torsion. However, we have noted an increasing use of Doppler ultrasound (US) as an adjunctive tool in the evaluation of patients with acute scrotal pain. This study aimed to retrospectively review the presentation of patients with acute scrotal pain to a tertiary ED and the use of ultrasound in the assessment of acute scrotal pain. Methods: An explicit chart review was performed including all patients presenting to an adult tertiary ED between 2003 and 2008 with acute scrotal pain. The timing of presentation, initial assessment, review by the Urology team and the use of US were recorded. The diagnosis recorded at hospital discharge was the primary end point, while follow‐up at outpatient clinic or private urologist rooms was used as a secondary end point. Results: There were 329 patients with acute scrotal pain during the study period, with 294 patients included in the study. Of these, 173 (58.8%) had a US scan performed in the ED. There were 44 (15.0%) patients who underwent scrotal exploration, with 19 having a prior US. There was a significant increase in the use of US over the study period. Conclusions: Colour‐flow duplex Doppler ultrasonography appeared to play an increasing role in the assessment for patients presenting with acute testicular pain. Rapid and more reliable assessments of these patients may be possible through greater education of emergency personnel in ultrasonography techniques.     

Inter/intra investigator variation in orchidometric measurements of testicular volume by ten investigators from five institutions

Aim： To perform quality control studies on testicular volume measurements for a multi-center epidemiological study of male reproductive function. Methods： We constructed a data matrix with a balanced assignment for 2 consecutive days by ten investigators （andrological career： 4-21 years） from five institutions and 12 male volunteers aged 20-26 years. Testicular volume was measured by Prader＇s orchidometer. A skilled technician also performed an ultrasound estimate of testicular volume. Results： A statistically significant inter-investigator variation was found for both testes （P 〈 0.05）. In addition, there was a statistically significant investigator-by-volunteer interaction in testicular volume measurement （P 〈 0.01）. However, there was no statistically significant difference in the two measurements performed on consecutive days for either testis. The testicular volumes for both the right and left testes as estimated by ultrasonography were smaller than results using the orchidometer. However, there was no statistical significance （P 〉 0.05）. The difference in experiences of the investigators did not significantly correlate with accuracy of measurements in either testis. Conclusion： The present study revealed significant differences in the results of estimation of testicular volume among the ten investigators, but intra-investigator variation was not considerable. Improved training and proper standardization of the measurement will be necessary before starting a multi-center study based on an andrological examination.     

十位来自五个不同机构的调查者进行睾丸体积测量的组间和组内差异

目的:对多单位男性生殖功能流行病学研究中的睾丸体积测量进行质量控制研究。方法:我们构建了一个平衡分配数据矩阵,由10位来自5个不同研究所的调查者(从事男科学工作4到21年)在连续的两天内用 Prader 睾丸测量器测量12个男性志愿者(20—26岁)的睾丸体积。睾丸体积超声估计由一个经验丰富的技术人员完成。结果:10个调查者测量双侧睾丸体积的结果存在显著的组间统计差异(P<0.05)。睾丸体积测量结果显示调查者和志愿者之间存在显著的统计意义上的相互作用(P<0.01)。但是连续两天通过2种测量方法测得的双侧睾丸体积结果之间无显著差异。用超声波检查法测得的左右睾丸体积小于用睾丸测量器测得的值,但无显著差异(P>0.05)。调查者的工作经验没有显著影响睾丸体积测量结果的精确度。结论:研究表明10个调查者对睾丸体积的估计结果之间有显著差异,但组内差异不明显。因此,有必要在多单位男科学调研之前进行良好的培训和确定适当的测量标准。     

睾丸微结石的超声诊断及与男性不育的关系

目的:探讨睾丸微结石(TM)的超声声像图表现及其与男性不育症的相关性。方法:应用高分辨率二维超声常规检查1198例阴囊疾病患者。结果:其中男性不育患者379例,TM检出21例(5.54%),阴囊内其他疾病患者819例,TM检出12例(1.47%)。TM与男性不育相关(r=0.115,P<0.01),TM在男性不育中发病率显著高于阴囊内其他疾病患者(P<0.05)。TM超声声像图表现为于睾丸实质内可见稀疏?散在或密集分布的强光点,直径在1mm左右,不伴有声影。结论:TM超声声像图特征明显,易于明确诊断;TM与男性不育存在一定相关性。     

A comparative study of different methods of orchidometry in a canine model

Purpose An investigation was carried out to compare the testicular volumes obtained by different methods of assessment in a series of dogs. Method After obtaining ethical approval for the study, ten dogs were identified which were scheduled for castration, either at the owner’s request or prior to being placed in suitable homes. A Prader orchidometer, which consists of a series of ovoid model testes inscribed with corresponding equivalent volumes, was used as an indirect method of assessing the volume of each testis. Percutaneous measurements of length and width of each testis were also carried out prior to surgery under general anaesthesia, using both a sliding and a pinch type caliper. After each testis was removed it was isolated and submerged in a beaker containing water in order to get a direct estimate of its volume by fluid displacement. Using the formula for deriving the volume of an ellipsoid from length and weight measurements, the volumes derived from the caliper measurements were estimated and compared with the orchidometer and fluid displacement values. Pearson correlation coefficients were calculated to obtain the correlations between the values produced by the four methods. Results The Prader orchidometer and the pinch type caliper both showed significant correlations, of 0.64 and 0.62 respectively, with the definitive values obtained by fluid displacement. The correlation obtained with the sliding caliper (0.4) was not significant. Despite the significant correlations, all the indirect methods consistently overestimated the real volumes obtained by fluid displacement. Conclusion Estimates of testicular volumes obtained by orchidometer and pinch type caliper are useful for situations where a qualitative rather than quantitative assessment of testicular volume is required.     

The reliability of ultrasonographic measurements for testicular volume assessment: comparison of three common formulas with true testicular volume

The aim of this study was to determine the correlation of ultrasonographic estimates of testicular volume with true testicular volume and to compare the accuracy and precision of the three most commonly utilized formulas. A total of 15 patients underwent high-resolution ultrasonography (US) analysis for testicular volume before orchiectomy. Testicular volume was calculated using three common formulas: (1) length (L) × width (W) × height (H) × 0.52; (2) the empirical formula of Lambert: L × W × H × 0.71; and (3) L × W² × 0.52. The actual volume of each removed testis was estimated directly by a water displacement method. Thus, four volume measurements were obtained for each of the 30 testes. The obtained data were analyzed by paired t-test and linear regression analysis. All three US formula measurements significantly underestimated the true testicular volume. The largest mean biases were observed with US formula 1, which underestimated the true volume by 3.3 mL (31%). US formula 2 had a smaller mean difference from the true volume, with an underestimation of only 0.6 mL (6%). Regression analysis showed that formulas 1 and 2 had better R² values than formula 3. However, all three US formulas displayed a strong linear relationship with the true volume (R²= 0.872−0.977; P < 0.001). Among the commonly used US formulas, the empirical formula of Lambert (L × W × H × 0.71) provided better accuracy than the other two formulas evaluated, and better precision than formula 3. Therefore, the formula of Lambert is the optimal choice in clinical practice.     

Scrotal ultrasound: pearls, patterns and pitfalls

We present a review of the scrotal ultrasound findings showing normal anatomic variants that may simulate scrotal pathology (rete testis dilatation, normal testicle and epididymis appendages). US patterns of the scrotal pathology may be classified as: calcified (scrotal and albuginea calcifications, microcalcifications, epididymis calcifications, testicular tumors with calcium), cystic appereance (intratesticular and echogenic varicocele, epididymis cysts, albuginea cysts, haematoma, abscess), solid nodular testicular lesions (infarct, neoplasm) and diffuse lesions (orchitis, lymphoid hyperplasia lymphoma, leukemia). Testicular ultrasound may be helpful in detecting extraescrotal pathologies. There is a known relationship between right varicocele and extratesticular neoplasms. We also show some cases of Burn-out testicular tumor and their MR, CT and PET findings. The knowledge of normal US scrotal anatomy, US patterns of the scrotal lesions and scrotal findings that suggest extratesticular pathologies are crucial in the management of testicular pathology and if unnecessary orchiectomies want to be avoided.     

Testicular hypotrophy does not correlate with grade of adolescent varicocele

PURPOSE: Testicular hypotrophy is the most widely accepted indication for correcting adolescent varicocele. Previous studies in adolescents have shown a relationship between increasing grade of varicocele and the likelihood of testicular hypotrophy. As this relationship has significant clinical implications, we studied the correlation between grade and testicular volume disproportion in our adolescent varicocele population. MATERIALS AND METHODS: We reviewed the adolescent varicocele database at our institution. A total of 168 patients 8 to 21 years old were studied. We routinely calculated testis volumes using scrotal ultrasound. Testicular disproportion was calculated using the equation [(size of unaffected testis) - (size of affected testis)]/(size of unaffected testis) x 100%. Disproportion was categorized as less than 10%, 10% to 20% and more than 20%. Varicoceles were graded by an attending urologist with the patient standing, using the system of Dubin and Amelar. Analysis of variance and Pearson chi-square indicated no significant differences in volume differential between varicocele grades. RESULTS: Mean +/- SD volume differential was 18% +/- 15% for grade I, 25% +/- 20% for grade II and 19% +/- 14% for grade III. ANOVA revealed no significant difference in mean volume differential between the 3 varicocele grades (p = 0.10). When categorizing patients into 3 levels of volume differential (less than 10%, 10% to 20%, more than 20%) no significant correlation was observed between varicocele and volume differential (p = 0.48, chi-square test). CONCLUSIONS: Grade of varicocele does not correlate with presence or severity of testicular disproportion in adolescent boys with varicocele as measured by scrotal ultrasound.     

Testicular microlithiasis: analysis of prevalence and associated testicular cancer in central-eastern Sicilian andrological patients

The aim of this retrospective study was to determine the prevalence of testicular microlithiasis (TM) in central-eastern Sicilian men and to evaluate the association between TM and testicular tumour or infertility. A total of 1056 Sicilian patients underwent scrotal US between 2005 and 2010. TM was found in 106 men with an overall prevalence of 10%; roughly about four times the median prevalence reported in the previous studies (0.6-18.1%). Forty men (3.8%) had a classic TM, whereas 66 (6.2%) had a limited TM. The prevalence of testicular tumour in this cohort was 2.4% (25/1056). At the moment when the testicular tumour was diagnosed, 15 patients (60%) had TM. There was a significant difference (P < 0.01) between the rate of malignancy in men with TM (15/106; 14.2%) and that in men without TM (10/950; 1.1%) with an odds ratio = 16. The prevalence of TM among infertile patients was 18.8%. These data may relate to an increased awareness towards scrotal US examination and/or to the use of more sensitive equipments. The elevated rate of testicular malignancy in men with TM suggests that this US feature may be regarded as a risk factor for testicular tumour.     

Effect of adult microsurgical varicocelectomy on testicular volume

OBJECTIVES: To re-examine the potential influence of varicocelectomy on testicular volume using scrotal ultrasonography, because it has been reported that total testicular volume (assessed by physical examination) increases after adult varicocele ligation. METHODS: A retrospective review of the testicular volume and semen parameters of 61 men who underwent microsurgical varicocelectomy between 1996 and 1998 was performed. Ultrasound-derived testicular volumes and total motile sperm counts were compared before varicocelectomy and at a mean of 7.2 months postoperatively. RESULTS: Bilateral varicocelectomy was performed in 22 men; 39 men underwent a left-sided procedure only. Overall, no significant change was found in the mean total testicular volume after varicocelectomy compared with preoperatively (24.0 versus 23.9 mL, respectively; P = 0.74). Similarly, the testicular volumes did not change significantly after left or bilateral varicocelectomy (P >0.05). Overall, the mean total motile sperm count increased significantly after varicocelectomy (17. 9 to 25.4, P = 0.05). CONCLUSIONS: This was the first study to examine the effect of adult varicocelectomy on testicular volume using ultrasound-derived measurements of volume. Unlike previous findings, our data suggest that although adult varicocelectomy improves semen quality in most infertile men, it does not result in a significant increase in testicular volume.     

Neonatal scrotal haematoma: mimicker of neonatal testicular torsion

OBJECTIVE: To describe the clinical features of neonatal scrotal haematoma and distinguish them from those of neonatal testicular torsion. PATIENTS AND METHODS: Five neonates presenting with an acute scrotum and initial diagnosis of neonatal testicular torsion were found to have neonatal scrotal haematoma. In one case the diagnosis was surgical and in four subsequent cases the diagnosis was by colour Doppler ultrasonography, and surgery was avoided. Four of the five children had risk factors associated with neonatal scrotal haematoma, including bleeding diathesis, birth trauma and high birth weight. CONCLUSIONS: The importance of including haematoma in the differential diagnosis of the acute neonatal scrotum is emphasized, as is the value of contemporary Doppler ultrasonography in making this diagnosis.     

Testicular torsion: time is the enemy

BACKGROUND: The acute scrotum is a diagnostic dilemma, and testicular torsion is of primary interest because of its fertility problems for the patient and medico-legal issues for the surgeon. The present study aimed to correlate operative findings of patients with suspected testicular torsion with certain clinical variables and investigations to see if diagnosis and outcome could be improved. METHODS: A total of 99 patients underwent scrotal exploration for suspected testicular torsion at the Royal Brisbane Hospital between 1990 and 1995. Colour Doppler ultrasound, white blood count and urine microscopy results were documented, along with the patient's age and duration of testicular pain. RESULTS: Fifty-six patients were found to have torsion, and the testicular loss rate was 23%. Patients who experienced testicular pain for longer than 12 h had a testicular loss rate of 67%. A negative urine microscopy was suggestive of testicular torsion, but was not diagnostic. The white blood count did not aid in the diagnosis. Colour Doppler ultrasound of the scrotum was used on nine occasions with three false negative results and a sensitivity of only 57%. CONCLUSIONS: Time is the enemy when managing the acute scrotum. No investigation substantially improves clinical diagnosis enough to warrant any delay in definitive surgical intervention.     

睾丸肿瘤的彩色多普勒超声特征

目的 :探讨睾丸肿瘤的彩色多普勒超声表现及其特征。　方法 :应用彩色多普勒超声诊断仪 ,对 4 6例经手术病理证实为睾丸肿瘤病人的睾丸声像图和彩色多普勒血流图进行分析和比较。　结果 :4 6例睾丸肿瘤中除 4例为转移性恶性淋巴瘤和 6例睾丸间质瘤外 ,其余均为睾丸生殖细胞瘤。　结论 :彩色多普勒超声诊断睾丸肿瘤具有较高的准确性和特异性 ,是睾丸肿瘤的首选影像学检查方法。     

男性不育与阴囊彩色多普勒超声异常

目的评价彩色多普勒超声对男性不育患阴囊检查的临床意义。方法对486例男性不育患行阴囊彩色多普勒超声检查,并将异常发现同临床体格检查进行比较。结果发现阴囊异常192例(39．5％)。其中精索静脉曲张141例(29．0％),附皋囊肿39例(8．0％),皋丸囊肿5例(1．0％),睾丸微小结石4例(0．8％),睾丸肿瘤3例(0．6％),该3例皋丸肿瘤在体格检查时均未触及。结论阴囊超声检查常能发现触诊触不到的阴囊异常,是诊断不育男性阴囊异常有价值的方法。     

Testicular resistive index determined by Doppler ultrasonography in men with spinal cord injury – a case series

In this case series, the testicular resistive index was determined in men with spinal cord injury. In ten men participating in our fertility programme, the peak systolic and end‐diastolic velocity of centripetal testicular arteries was measured in triplicates by Doppler ultrasonography to calculate the testicular resistive index. Furthermore, the right and left testicular volume was determined by ultrasonography, blood samples were obtained for hormonal evaluation, and sperm analysis was performed according to the WHO guidelines. The median testicular resistive index measured 0.69 and was significantly (P < 0.001) greater than the reported cut‐off value of 0.6. The spermiograms were characterised by normal sperm count but decreased sperm motility and plasma membrane integrity. The median right and left testicular volume was significantly (P < 0.01) smaller compared to the volumes measured in able‐bodied adult males without scrotal pathology and measured 8.4 ml and 7.2 ml respectively. There was a significant (P = 0.005) correlation (r_s = 0.81) between testicular resistive index and sperm concentration. However, no correlations were observed between testicular resistive index and other variables. The testicular resistive index in men with spinal cord injury was significantly greater than 0.6. Measuring the testicular resistive index may represent a useful additional parameter in the assessment of infertility in spinal cord‐injured men.