This is the current release of the guideline.

Abnormalities of the scrotum

Note: Refer to the "Indications" section of the "Major Recommendations" field for a detailed list of diseases and conditions.

Patients undergoing ultrasound examination of the scrotum

Not stated

The Medline literature search is based on keywords provided by the topic author. The two general classes of keywords are those related to the condition (e.g., ankle pain, fever) and those that describe the diagnostic or therapeutic intervention of interest (e.g., mammography, MRI).

The search terms and parameters are manipulated to produce the most relevant, current evidence to address the Practice Guideline or Technical Standard topic being reviewed or developed. Combining the clinical conditions and diagnostic modalities or therapeutic procedures narrows the search to be relevant to the topic. Exploding the term "diagnostic imaging" captures relevant results for diagnostic topics.

The following criteria/limits are used in the searches.

1. Articles that have abstracts available and are concerned with humans.
2. Restrict the search to the year prior to the last topic update or in some cases the author of the topic may specify which year range to use in the search. For new topics, the year range is restricted to the last 5 years unless the topic author provides other instructions.
3. May restrict the search to Adults only or Pediatrics only.
4. Articles consisting of only summaries or case reports are often excluded from final results.

The search strategy may be revised to improve the output as needed.

The total number of source documents identified as the result of the literature search is not known.

Not applicable

Not stated

Recommendations are formulated through iterative review by committee, collaborating societies, and membership. Suggested recommendations are reviewed by the committee and agreement is reached by consensus.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Each practice guideline and technical standard, representing a policy statement by the American College of Radiology (ACR), has undergone a thorough consensus process in which it has been subjected to extensive review, requiring the approval of the Commission on Quality and Safety as well as the ACR Board of Chancellors, the ACR Council Steering Committee, and the ACR Council.

These guidelines are intended to assist practitioners performing ultrasound studies of the scrotum. In some cases, additional and/or specialized examinations may be necessary. While it is not possible to detect every abnormality, adherence to the following guidelines will maximize the probability of detecting most of the abnormalities that occur in the scrotum.

Qualifications and Responsibilities of the Physician

Each organization addresses this requirement individually. American College of Radiology (ACR) language is as follows:

See the "ACR–SPR–SRU Practice Guideline for Performing and Interpreting Diagnostic Ultrasound Examinations" (see the ACR Web site  for this practice guideline and additional ones mentioned below).

Indications

Indications for scrotal ultrasound include, but are not limited to:

1. Evaluation of scrotal pain, including but not limited to testicular trauma, ischemia/torsion, and infectious or inflammatory scrotal disease
2. Evaluation of a palpable inguinal, scrotal, or scrotal mass
3. Evaluation of scrotal asymmetry, swelling, or enlargement
4. Evaluation of potential scrotal hernia
5. Detection/evaluation of varicoceles
6. Evaluation of male infertility
7. Follow-up of prior indeterminate scrotal ultrasound findings
8. Localization of undescended testes
9. Detection of an occult primary tumor in patients with metastatic germ cell tumor
10. Follow-up of patients with prior primary testicular neoplasms, leukemia, or lymphoma
11. Evaluation of abnormality noted on other imaging studies (including but not limited to computed tomography [CT], magnetic resonance imaging [MRI] and positron emission tomography [PET])
12. Evaluation of intersex conditions

Written Request for the Examination

Each organization addresses this requirement individually. ACR language is as follows:

The written or electronic request for a scrotal ultrasound examination should provide sufficient information to demonstrate the medical necessity of the examination and allow for its proper performance and interpretation.

Documentation that satisfies medical necessity includes 1) signs and symptoms and/or 2) relevant history (including known diagnoses). Additional information regarding the specific reason for the examination or a provisional diagnosis would be helpful and may at times be needed to allow for the proper performance and interpretation of the examination.

The request for the examination must be originated by a physician or other appropriately licensed health care provider. The accompanying clinical information should be provided by a physician or other appropriately licensed health care provider familiar with the patient's clinical problem or question and consistent with the state's scope of practice requirements. (ACR Resolution 35, adopted in 2006)

Specifications of the Examination

The testes should be evaluated in at least two planes, longitudinal and transverse. Transverse images should be obtained in the superior, mid, and inferior portions of the testes. Longitudinal views should be obtained centrally as well as medially and laterally. Each testis should be evaluated in its entirety, as should the epididymis (head, body and tail) when technically feasible. The size and echogenicity of each testis and epididymis should be compared to the contralateral side. Comparison of the testes, including grayscale and color Doppler imaging, is best accomplished with a side-by-side transverse image. Scrotal skin thickness should be evaluated. If a palpable abnormality is the indication for the sonogram, this area should be directly imaged.

Relevant extratesticular structures should be evaluated. Additional techniques such as Valsalva maneuver or upright positioning can be used as needed. Any abnormality should be documented.

Doppler sonography (spectral and color/power Doppler imaging) should be used as necessary in all examinations of the scrotum, particularly in the setting of acute scrotal pain. If used, color and/or power Doppler sonography should include at least one side-by-side image comparing both testes and two images with identical Doppler settings to evaluate symmetry of flow. Low-flow detection settings should be used to document testicular blood flow, and the transducer frequency should be optimized for maximum Doppler sensitivity while maintaining adequate penetration. If flow cannot be demonstrated on color Doppler, power Doppler, if available, should be used to increase flow sensitivity.

Documentation

Each organization addresses this requirement individually. ACR language is as follows:

Adequate documentation is essential for high-quality patient care. There should be a permanent record of the ultrasound examination and its interpretation. Comparison with prior relevant imaging studies may prove helpful. Images of all appropriate areas, both normal and abnormal, should be recorded. Variations from normal size should generally be accompanied by measurements. Images should be labeled with the patient identification, facility identification, examination date, and image orientation. An official interpretation (final report) of the ultrasound examination should be included in the patient's medical record. Retention of the ultrasound examination images should be consistent both with clinical need and with relevant legal and local health care facility requirements.

Reporting should be in accordance with the "ACR Practice Guideline for Communication of Diagnostic Imaging Findings."

Equipment Specifications

See the original guideline document for information about equipment specifications.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

While it is not possible to detect every abnormality, adherence to the guidelines will maximize the probability of detecting most of the abnormalities that occur in the scrotum.

Not stated

Quality Control and Improvement, Safety, Infection Control, and Patient Education

Each organization addresses this requirement individually. American College of Radiologists (ACR) language is as follows:

Policies and procedures related to quality, patient education, infection control, and safety should be developed and implemented in accordance with the ACR Policy on Quality Control and Improvement, Safety, Infection Control, and Patient Education appearing under the heading Position Statement on QC & Improvement, Safety, Infection Control, and Patient Education on the ACR Web site .

Equipment performance monitoring should be in accordance with the "ACR Technical Standard for Diagnostic Medical Physics Performance Monitoring of Real Time Ultrasound Equipment" (see the ACR Web site ).

Not applicable: The guideline was not adapted from another source.

American College of Radiology

Guidelines and Standards Committee of the American College of Radiology (ACR) Commission on Ultrasound in collaboration with the American Institute of Ultrasound in Medicine (AIUM) and the Society of Radiologists in Ultrasound (SRU)

Collaborative Committee

American College of Radiology (ACR): Ruth B. Goldstein, MD (Chair); Nirvikar Dahiya, MD; Rick I. Feld, MD, FACR

American Institute of Ultrasound in Medicine (AIUM): Michael C. Hill, MB, FACR; William D. Middleton, MD, FACR; Thomas C. Winter, III, MD

Society of Radiologists in Ultrasound (SRU): Brian D. Coley, MD; Vikram S. Dogra, MD; Sharlene A. Teefey, MD

ACR Guidelines and Standards Committee – Ultrasound: Mary C. Frates, MD, FACR (Chair); Debra L. Acord, MD; Marcela Bohm-Velez, MD, FACR; Helena Gabriel, MD; Ruth B. Goldstein, MD; Robert D. Harris, MD, MPH, FACR; Beverly E. Hashimoto, MD, FACR; Leann E. Linam, MD; Laurence Needleman, MD, FACR; Maitray D. Patel, MD; Philip W. Ralls, MD, FACR; Michelle L. Robbin, MD, FACR; Robert M. Sinow, MD; Deborah Levine, MD, FACR (Chair, Commission)

Not stated

This is the current release of the guideline.

Electronic copies: Available in Portable Document Format (PDF) from the American College of Radiology (ACR) Web site.

Print copies: Available from the American College of Radiology, 1891 Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

The following are available:

• The process of developing ACR practice guidelines and technical standards. Reston (VA): American College of Radiology. Electronic copies: Available from the American College of Radiology (ACR) Web site .
• Purpose and intended use. Reston (VA): American College of Radiology. Electronic copies: Available from the ACR Web site .

None available

This NGC summary was completed by ECRI Institute on December 8, 2011.

Copyright © by the American College of Radiology, 1891 Preston White Dr., Reston, VA 20191-4397, 703-648-8900. All rights reserved. No reproduction of this material in any format, electronic or otherwise, is permitted except with prior written consent from the American College of Radiology.