Ultrasound diagnosis of Mondor's disease involving the superficial scrotal veins: Unveiling a rare mimicker of acute scrotal emergencies.

We describe a rare case of Mondor disease of the superficial scrotal veins, which can clinically mimic acute testicular pathologies such as testicular torsion or epididymo-orchitis, and highlight the value of grayscale/Doppler ultrasound examination in distinguishing these entities, which have different management implications.

Outcomes of islanded scrotal raphe flap employment for skin shortage in complicated hypospadias repair.

BACKGROUND: Ventral skin deficiency in complicated hypospadias is a difficult problem to treat. The aim of our study is to report our technique and outcomes of vascularized islanded scrotal raphe flap for ventral skin deficiency in complicated hypospadias. METHODS: A retrospective review was conducted at Northwest General Hospital & Research Centre, Peshawar, from January 2012 to January 2019. Complicated hypospadias patients who underwent two-stage surgery employing islanded scrotal flap were identified. Patients underwent surgery in two stages: scar tissue removal, chordee correction and buccal mucosal graft in the first stage; neourethral tubularization, water proofing, and skin coverage with vascularized islanded scrotal raphe flap in the second stage. The primary outcome was 6-month flap survival rate. Secondary outcomes were 6-month complication rate (fistula, persistent chordee, distal stenosis) and end-of-follow-up patient self-reported satisfaction rate. RESULTS: A total of 1845 patients underwent hypospadias surgery, of which 380 patients had complications. Scrotal raphe flap was used in 45 patients. Mean age was 14.09 (±8.02) years. Mean follow-up was 29.78 (±12.18) months. Mean number of previous surgeries was 4.31 (±2.59). The flap survived in all cases. Nine patients (20%) developed complications. One patient (2.2%) developed distal stenosis. Eight patients (17.8%) developed fistulas, one of whom additionally had persistent chordee. Five fistulas closed spontaneously within 3 months, while the rest were repaired surgically after 6 months. All patients self-reported satisfaction with results at end-of-follow-up. CONCLUSIONS: Islanded Scrotal Raphé flap is a promising option for treating complicated hypospadias when there is significant ventral deficiency of skin, as it not only provides vascularized pliable skin but also fascia as a waterproofing layer.

Standing Ultrasound Adds Clinical Utility for the Diagnosis of Varicoceles.

PURPOSE: We assessed the role of standing vs supine scrotal ultrasound (SUS) for varicocele assessment by evaluating differences in clinical outcomes. MATERIALS AND METHODS: We retrospectively reviewed men from 2008-2020 diagnosed with varicocele who had documented SUS with both supine and standing assessments with and without Valsalva. Clinical outcomes (semen parameters, TUNEL and serum testosterone [T]) after microsurgical varicocelectomy were compared among men who had varicoceles diagnosed by standing SUS (vein size >2.5 mm, vein size >3.0 mm or reversal of flow) to those who would have been missed on supine SUS only. RESULTS: A total of 349 men underwent varicocelectomy (right: 5 [1.4%]; left: 118 [33.8%]; bilateral: 226 [64.8%]). Disagreement between those with abnormal standing vs normal supine for vein size >2.5 mm was: 56 men (16.1%) on the right and 31 men (8.9%) on the left, for vein size >3.0 mm was: 64 men (18.3%) on the right, and 56 men (16.1%) on the left, and for flow reversal was: 36 (14.0%) on the right and 40 (15.4%) on the left. For those >2.5 mm, only T had significant improvements on the left (p=0.05). For those >3.0 mm significant differences were seen for sperm motility on the right (p=0.04), and TUNEL (p=0.04) and T (p <0.01) on the left. For flow reversal, significant differences were seen for sperm concentration (p <0.01), morphology (p=0.03) and volume (p=0.05) on the right and TUNEL on the left (p=0.02). CONCLUSIONS: Standing SUS identifies a greater number of men who would have been missed using supine SUS only.

The Impact of Adjuvant Sirolimus Therapy in the Surgical Management of Scrotal Slow-Flow Vascular Malformations.

OBJECTIVE: To describe the effects of oral sirolimus administered before and after surgical resection of slow-flow vascular malformations of the scrotum in pediatric patients. METHODS: Retrospective review of 3 patients presenting with complex lymphatic-venous malformations of the scrotum who received adjuvant oral sirolimus 3 months before and 3 months after surgical resection. Demographic data, clinical course, imaging findings, and management strategies were reviewed for each patient. RESULTS: In each of the 3 patients, there was a significant volume reduction of the lesion within the 3 months after initial dose of sirolimus. Scarce lymphatic leakage during and after surgery was reported, associated with an adequate wound healing. Two years after the last postsurgical dose of sirolimus, all patients remain asymptomatic without any lymphatic leakage or lesion recurrence. CONCLUSION: Combined lymphatic-venous vascular malformations of the male genitalia are rare but associated with high morbidity and challenging treatment options. Pre- and postsurgical adjuvant treatment with oral sirolimus seems to be a promising therapeutic option that provides reduction of the lesion size before surgery and improvement of postsurgical recovery and wound healing.

Left Spermatic Vein Thrombosis - An Uncommon Diagnosis: A Case Report.

Introduction: Spermatic vein thrombosis is a rare entity with poor clinical distinctive signs for the differential diagnosis, which raises numerous controversies about the appropriate management. Case report: A 55 years old man presents at the emergency room for left scrotal pain and swelling evolving for two weeks. The patient denied any recent local traumatic event. Physical examination revealed an approximately 15 to 20 cm length mass from the posterior scrotum to the external inguinal orifice. The other genitals had a healthy appearance at the moment of the examination. An incarcerated hernia couldn't be excluded. The Doppler ultrasound evaluation of the scrotum con firmed the suspicion of left testicular vein thrombosis with complete cessation of blood flow. Both testicles appeared to have regular blood flow. CT scan established that the thrombus extended up to the left external inguinal orifice. Surgical treatment was preferred to address an eventually incarcerated hernia. The left testicular vein was excised from the external orifice. Postoperative management consisted of apixaban for 30 days, and the cardiology department thus conducted the treatment. Conclusions: Doppler ultrasound evaluation of the scrotum represents the gold standard diagnostic test for spermatic vein thrombosis. There are still controversies about the management approach of this pathology, conservative or surgical.

Thrombosis of the posterior scrotal vein associated with essential thrombocytemia: Report of a case.

Mondor's disease is a rare superficial thrombophlebitis of subcutaneous vein and usually occurs in the anterior and lateral chest. Penile Mondor's disease is a rare condition characterized by superficial thrombophlebitis of the dorsal vein of the penis. We report a rare case of atypical penile Mondor's disease involved the right posterior scrotal vein, in a patient affected by essential thrombocythemia. A 50-years old man presented with thrombosis of right posterior scrotal vein. He presented with an indurated subcutaneous and painful cord, palpable along the length of the involved vein and located parallel to the urethra in the posterior aspect of the scrotum. It was treated with lowmolecular- weight heparin and resolves without sequelae. The scrotal vein thrombosis is a fairly rare disease.

Isolated Spermatic Vein Thrombosis.

Isolated spermatic vein thrombosis is an uncommon pathology, mostly involving left side. These patients present with acute scrotal symptoms, and can be misdiagnosed as testicular torsion or incarcerated inguinal hernia. At this point, Doppler ultrasound (US) plays critical role for the prompt and correct diagnosis of this rare clinical entity. Herein, a 54- year-old man having left sided testicular enlargement and tenderness with an unremarkable etiology was reported as a rare case of isolated spermatic vein thrombosis which could easily be diagnosed by colour Doppler US.

The correlation between mammalian target of rapamycin (mTOR) gene expression and sperm DNA damage among infertile patients with and without varicocele.

This study aimed to assess the possible correlation between mammalian target of rapamycin (mTOR) gene expression and sperm DNA damage among infertile patients with and without varicocele. The study included sixty infertile males and fifty fertile males as controls. The infertile group was subdivided into the following subgroups: thirty males with varicocele and thirty males without varicocele. All subjects underwent medical history collection, clinical examination, semen analysis, sperm DNA integrity assessment, mTOR gene expression assessment and scrotal colour Doppler ultrasound. The mean mTOR gene expression in infertile patients with varicocele (23.52 ± 14.65) was significantly higher than that in infertile patients without varicocele (12.24 ± 12.44) and fertile control subjects (3.92 ± 3.26; p = 0.003 and p < 0.001 respectively). In the infertile varicocele-positive group, mTOR gene expression showed a significant negative correlation with sperm count (p = 0.028, r = -0.400) and progressive sperm motility (p = 0.038, r = -0.381), as well as a significant positive correlation with the sperm DNA fragmentation index (DFI; p = 0.001, r = 0.578). In the infertile varicocele-negative group, mTOR gene expression showed a significant negative correlation with progressive sperm motility (p = 0.018, r = -0.429) and a significant positive correlation with sperm DFI (p < 0.001, r = 0.673). In conclusion, according to these results, there is a significant positive correlation between mTOR gene expression and sperm DFI among infertile patients with and without varicocele.

Retroperitoneal high ligation versus subinguinal varicocelectomy: Effectiveness of two different varicocelectomy techniques on the treatment of painful varicocele.

In the present study, we compared the retroperitoneal high ligation with subinguinal varicocelectomy on the treatment of painful varicocele. A total of 90 patients who underwent retroperitoneal high ligation (n = 45) and subinguinal varicocelectomy (n = 45) for painful varicocele were included in this prospective study. Varicocele in all patients was diagnosed with by physical examination and coloured Doppler ultrasonography. All the patients underwent a conservative treatment for pain for 4 weeks. Patient ages, varicocele grades, preoperative pain scores, postoperative pain scores at 6 months, duration of surgeries, complications and recurrences were recorded. Complete success rate for chronic scrotal pain was found to be 80% in retroperitoneal varicocelectomy group and 71% in subinguinal varicocelectomy group. Partial success rate was 11% for retroperitoneal varicocelectomy group and 18% for subinguinal ligation group. There was no significant difference between two groups in terms of pain and complications. However, the operation time was significantly lower in the Palomo group. Although microsurgical subinguinal varicocelectomy is the current approach for the treatment of varicocele, retroperitoneal high ligation can achieve the same pain resolution with shorter operative duration compared to loupe-assisted subinguinal varicocelectomy.

Rare complication of varicocelectomy: Suture granuloma.

After varicocelectomy, complications such as hydrocele, testicular atrophy and recurrence can be seen. Our case was a 29-year-old male patient who had a fistula mouth laterally on the left scrotum. In the examination and scrotal ultrasonography (USG), a foreign body was detected under the skin. The patient had a history of varicocelectomy, suggesting suture reaction. Our case is interesting because it is the first reported suture granuloma case after varicocelectomy.

Scrotal necrosis and no Fournier's in sight: a rare case of juvenile gangrenous vasculitis.

Juvenile gangrenous vasculitis of the scrotum is a rare entity, of which to our knowledge we describe the first documented case in the UK. It follows a typical disease course, demonstrated by an 18-year-old male who presented with three necrotic scrotal lesions; proceeded by 3 days of fever, pharyngitis and lethargy. Previous cases have been managed successfully with systemic steroids. On this occasion, surgical debridement was made of the necrotic areas under antibiotic cover and complete resolution was achieved with excellent wound healing and no evidence of recurrence. This case report discusses the importance of disease recognition and the merits of surgical management. We also add to the debate as to whether this disease is a variation of pyoderma gangrenosum or a distinct entity itself within the pantheon of scrotal gangrene.

Testicular Volume Changes in Laparoscopic Staged Fowler-Stephens Orchiopexy: Studying the Impact of Testicular Vessel Division.

OBJECTIVE: To study the effect of testicular vessel division on testicular volume during laparoscopic staged Fowler Stephens orchiopexy (LSFSO). METHODS: Testicular dimensions were prospectively measured intraoperatively at both first (S1) and second stages (S2) of LSFSO, and with scrotal ultrasound 3-12 months postoperatively. Testicular volumes were compared to reference ranges. Volume changes were tracked with a change of >20% considered clinically significant. RESULTS: A total of 52 nonpalpable testes treated with LSFSO between 2008 and 2018 were included in the study. After a median follow-up of 6.8 (3-91.3) months, 46 (88.5%) testes were palpable in a scrotal location without adjunctive procedures and 39 (75%) maintained vascular flow on duplex ultrasound. One testis retracted to an inguinal position and was successfully treated with inguinal orchiopexy for an overall success of 90.4% (47/52). Of 36 testes with intra- and postoperative testicular volume documentation, only 2 (5.6%) had significant volume loss after S1. Both testes had catch-up growth after S2. Eight (22.2%) testes had significant volume loss after S2. At follow-up, 24 (66.7%) testes were smaller than the mean for age, of which 20 (83.3%) were small at baseline. Only 41.7% of testes larger than mean for age at follow-up, were small at baseline (P = .02). CONCLUSION: Significant testicular volume loss does not occur after testicular vessel division at S1, but expected in approximately 1 quarter of testes after S2. We propose that testicular atrophy after LSFSO is primarily due to defective testicular development and rarely due to vascular compromise during S2.

Late-Onset Vitamin K Deficiency Presenting as Scrotal Bruising and Mediastinal Mass.

Although there are several reports of intracranial hemorrhage associated with vitamin K deficient bleeding, there are few reported cases of extracranial manifestations, specifically involving the thymus. Here, we discuss the unique case of a 4-week-old infant presenting with scrotal discoloration, respiratory distress, and widened mediastinum, found to have thymic hemorrhage related to confirmed coagulopathy secondary to late-onset vitamin K deficiency bleeding of the newborn.

Testicular Torsion Pain Honeymoons.

A subset of testicular torsion patients report resolution of their initial severe pain that is followed by variable periods of hours to days of reduced or absent pain. Other patients report only mild pain that is described as gradual in onset. Because of delayed initial presentations or less than timely returns for secondary evaluation, these pain honeymoons may be partially responsible for poor clinical outcomes of the torsed spermatic cords and ischemic testicles.

Changes in testicular size, echotexture, and arterial blood flow associated with the attainment of puberty in Dorper rams raised in a subtropical climate.

There is a paucity of information on the relationships of testicular morphology, echotextural attributes, and blood flow dynamics with pubertal development of rams raised in a subtropical climate. Forty-five Dorper rams (24 rams aged 8-11 months and 21 rams aged 12-24 months) were examined using a portable ultrasound scanner connected to a 7.5-MHz transducer. Computer-assisted analyses of testicular ultrasonograms utilized commercially available Image ProPlus® analytical software. Spectral Doppler scans of testicular arteries were performed immediately after scrotal (B-mode) ultrasonography to determine peak systolic velocity (PSV), end-diastolic velocity (EDV), resistive index (RI = [PSV-EDV]/PSV), and pulsatility index (PI = [SPV-EDV]/mean velocity) of the blood vessels. The length of the testes (9.7 ± 0.3 compared with 9.0 ± 0.2 cm) and scrotal circumference (33.3 ± 0.5 compared with 31.8 ± 0.4 cm) were greater (p < 0.05) but testicular depth (4.5 ± 0.1  compared with 4.9 ± 0.08 cm) was less (p < 0.05) in sexually mature compared with peripubertal rams. [Corrections added on 9 Jan 2019 after initial online publication: The testicular size values in the sentence were corrected.] There were no differences (p > 0.05) between the two age groups of Dorper rams in blood flow indices of testicular arteries. Mean numerical pixel values (100.5 ± 4.1 compared with 89.2 ± 4.8) and pixel heterogeneity (25.6 ± 0.6 compared with 23.6 ± 0.5) of testicular parenchyma were greater (p < 0.05) in peripubertal than in postpubertal rams. Semen volume was negatively correlated with PI of testicular arteries (r = -0.57, p = 0.04). In summary, the attainment of sexual maturity in the rams of the present study was associated with significant changes in testicular length and depth, scrotal circumference, and parenchymal echogenicity/hetrogeneity but not in testicular volume and blood perfusion rates. Testicular artery PI can be used to predict the volume of ejaculate in rams.

The heritability of pampiniform plexus vessel size and varicocoele in boars.

Ultrasonography was used to capture a coronal-sagittal image of the veins of the pampiniform plexus (PP) and the testicular artery of 327 maternal-line boars at approximately 6 months of age at the University of Nebraska-Lincoln. Varicocoele was diagnosed by two methods. Method 1 diagnosed varicocoele when the average vessel area on one side of the scrotum was 1.5 times larger than the average vessel area on the other side of the scrotum. Method 2 diagnosed varicocoele when the average vessel area on one side of the scrotum of a boar was 1.5 times larger than the average vessel on the same side of the scrotum of the boar's cohorts (same population and year). Varicocoele was diagnosed in 23.17% and 15.1% of boars measured using method 1 and method 2, respectively. Ultrasonography showed to be an effective means to measure PP vessel size in boars and may even allow for earlier detection of varicocoele than by using palpation. Animal models were employed to estimate the heritability for: average area of right PP vessels (0.52), average area of the left PP vessels (0.46), varicocoele presence using method 1 (0.26) and varicocoele presence using method 2 (0.25). These heritability estimates suggest that vessel size and varicocoele could be selected against in breeding programmes to potentially improve boar semen quality.