Cystic lesions and scrotal fluid collections in adults: Ultrasound findings.

The widespread use of scrotal ultrasonography (US) has led to increased detection of testicular and extratesticular pathologies. Cystic or encapsulated fluid collections are relatively common benign lesions that usually present as palpable testicular lumps. Most cysts arise in the epidydimis, but all anatomical structures of the scrotum can be the site of their origin. US may suggest a specific diagnosis for a wide variety of intrascrotal cystic and fluid lesions and appropriately guide therapeutic options. US should be used as an adjunctive diagnostic modality after clinical evaluation of a scrotal lesion associated or not with the presence of a lump.

Clinical uroradiology: the standardisation of terminology for lower urinary tract function and dysfunction.

A key problem in clinical practice and research regards effective communication and comparison of results. This is particularly difficult between different specialities that use different definitions and terms for lower urinary tract dysfunction. We therefore tried to adapt the document on the "Standardisation of Terminology of Lower Urinary Tract Function" prepared by the International Continence Society for radiologists who need to acquire some basic clinical experience in the interpretation of the symptoms and signs encountered during simple urodynamic studies in order to increase the effectiveness of imaging studies of the lower urinary tract in men and women.

Contrast-enhanced US evaluation in patients with blunt abdominal trauma().

INTRODUCTION: To evaluate the use of contrast-enhanced ultrasonography (CEUS) in patients with blunt abdominal trauma. MATERIALS AND METHODS: A total of 133 hemodynamically stable patients were evaluated using ultrasonography (US), CEUS and multislice Computer Tomography (CT) da eliminare. RESULTS: In 133 patients, CT identified 84 lesions: 48 cases of splenic injury, 21 of liver injury, 13 of kidney or adrenal gland injury and 2 of pancreatic injury. US identified free fluid or parenchymal abnormalities in 59/84 patients positive at CT and free fluid in 20/49 patients negative at CT. CEUS revealed 81/84 traumatic injuries identified at CT and ruled out traumatic injuries in 48/49 negative at CT. Sensitivity, specificity, positive and negative predictive values for US were 70.2%, 59.2%, 74.7% and 53.7%, respectively; for CEUS the values were 96.4%, 98%, 98.8% and 94.1%, respectively. CONCLUSIONS: The study showed that CEUS is more accurate than US and nearly as accurate as CT, and CEUS can therefore be proposed for the initial evaluation of patients with blunt abdominal trauma.

Contrast-enhanced ultrasonography in blunt abdominal trauma: considerations after 5 years of experience.

PURPOSE: The aim of the study was to evaluate the diagnostic capability of contrast-enhanced ultrasonography (CEUS) in a large series of patients with blunt abdominal trauma. MATERIALS AND METHODS: We studied 133 haemodynamically stable patients with blunt abdominal trauma. Patients were assessed by ultrasonography (US), CEUS and multislice computed tomography (MSCT) with and without administration of a contrast agent. The study was approved by our hospital ethics committee (clinical study no. 1/2004/O). RESULTS: In the 133 selected patients, CT identified 84 lesions; namely, 48 splenic, 21 hepatic, 13 renal or adrenal and two pancreatic. US identified free fluid or parenchymal alterations in 59/84 patients with positive CT and free fluid in 20/49 patients with negative CT. CEUS detected 81/84 traumatic lesions identified on CT and ruled out traumatic lesions in 48/49 patients with negative CT. The sensitivity, specificity and positive and negative predictive values of US were 70.2%, 59.2%, 74.7% and 53.7%, respectively, whereas those of CEUS were 96.4%, 98%, 98.8% and 94.1%, respectively. CONCLUSIONS: Our study showed that CEUS is an accurate technique for evaluating traumatic lesions of solid abdominal organs. The technique is able to detect active bleeding and vascular lesions, avoids exposure to ionising radiation and is useful for monitoring patients undergoing conservative treatment.

Contrast-enhanced US of the prostate with time/intensity curves: Preliminary results.

PURPOSE: To evaluate the diagnostic performance of ultrasonography using second-generation contrast agent in the study of patients with focal prostate lesions and increased serum prostate-specific antigen (PSA) level. MATERIALS AND METHODS: SIX CONSECUTIVE PATIENTS (AGE RANGE: 72-87 years) with increased PSA (≥4 ng/ml) underwent transrectal ultrasonography (TRUS) followed by contrast-enhanced ultrasonography (CEUS) with injection of second-generation contrast agent. All patients showed areas of abnormal echostructure suspicious for neoplastic lesions. On the basis of CEUS, a time/intensity curve of the suspected area was compared to that of a normal-appearing distant area of the gland and to the results of biopsy of the hypoechoic area. RESULTS: AT CEUS TWO DIFFERENT PATTERNS OF ENHANCEMENT WERE IDENTIFIED AND CONSIDERED TO BE SIGNIFICANT: pattern 1 characterized by a rapid rise in the time/intensity curve of the suspected area compared with the normal gland. Two out of six patients had this pattern and biopsy showed cancer in the biopsied area. Pattern 2 was characterized by a similar rise in the time/intensity curve of the suspected area compared with the normal gland. Four out of six patients had this pattern and biopsy showed prostatitis in the biopsied area. CONCLUSIONS: CEUS using second-generation contrast agent can on the basis of time/intensity curves show differences in vascularization in normal and pathological tissue. Evaluation of the two patterns seems to be useful for identifying areas requiring biopsy, particularly when peripheral hypoechoic areas are observed at TRUS. Our data need to be confirmed in a larger patient population.

Nonspecific granulomatous prostatitis.

Nonspecific granulomatous prostatitis (NSGP) is a relatively uncommon type of chronic inflammation of the prostate, frequently mistaken for carcinoma on digital rectal examination, trans-rectal ultrasound (TRUS) and serum PSA test. It is presently the most frequent variety of granulomatous prostatitis observed at histological examination. The present study reviews the trans-rectal US results and serum PSA levels of 20 patients with biopsy-proven NSGP. Physical findings, laboratory data and US indicated malignancy in all cases. Sonographically (TRUS), the lesions appeared as single or multiple hypoechoic nodules, mainly localised in the peripheral zone of the gland, mimicking carcinoma. Mean serum PSA values were 13.3 ng/ml (range from 3.5 to 34 ng/ml), and only one patient had a value lower than 4 ng/ml. A sufficiently long period of follow-up (mean 19 months; range from 7 to 48 months) with TRUS and PSA was only possible in 11/20 patients. In 8/11 cases, serum PSA returned within normal range, and in 5/11 patients the US features slowly resolved, the hypoechoic nodules disappearing. Final diagnosis can only be obtained by prostatic biopsy. Several questions remain unanswered regarding the relationship between chronic prostatitis and prostatic carcinoma, natural history, the need for specific therapy and also the follow-up of this disease.

Female paraurethral leiomyoma: ultrasonographic and magnetic resonance imaging findings.

Primary benign paraurethral tumors in females are observed only rarely. They may occasionally be detected at physical examination or present with symptoms of bladder outlet obstruction. A leiomyoma originating from the smooth muscle fibers of the urethra in a 43-year-old woman is reported. The benign nature of the lesion was suspected on the basis of transvaginal ultrasonography and magnetic resonance imaging. Surgical enucleation was performed and light microscopy showed a well-differentiated smooth muscle tumor.

New imaging of the anterior male urethra.

Retrograde urethrography is the method commonly employed in the detection of anterior male urethra pathology. Ultrasonography and magnetic resonance imaging have been proposed recently as new methods that can replace conventional radiography. Normal urethral anatomy can be easily studied after saline distention of the urethra, which creates high contrast relative to adjacent structures such as mucosa and corpus spongiosum. Sonourethrography with high-frequency probes has a high spatial resolution and has proved to be sensitive, specific, and accurate in the diagnosis of anterior urethral pathologies such as strictures, syringocele, tumors, and trauma. It has a major role in the selection of therapy in patients with bulbar strictures. Magnetic resonance imaging with a surface coil with a small field of view can detect penile and bulbar stenoses and tumor extension. After contrast administration, the activity of the inflammatory process in the spongiosum can be assessed and used to modify the urethroplasty technique. The clinical use of the new imaging modalities in the male anterior urethra is limited despite their demonstrated accuracy in diagnosis and presurgical staging of different diseases.

Distal extremity swelling with pitting edema in psoriatic arthritis: a case-control study.

OBJECTIVE: To evaluate the frequency and the clinical characteristics of distal extremity swelling with pitting edema in patients with psoriatic arthritis (PsA). METHODS: This was a case-control study of consecutive outpatients with PsA (old and new diagnosis) observed over a 3-month period in three secondary referral centers in Italy. As controls we used the two consecutive rheumatic outpatients, excluding those with spondylarthropathies, observed after a PsA patient. The demographic and clinical features were assessed by clinical examination and review of the medical records. RESULTS: A total of 183 patients with PsA and 366 controls were evaluated. Distal extremity swelling with pitting edema was recorded in 39/183 (21%) PsA patients and in 18/366 (4.9%) controls (p < 0.0001). In 8/39 (20%) patients this feature presented as a first, isolated manifestation of PsA, and in 8 others it was associated with other features of PsA at diagnosis. The upper and lower extremities were affected, predominantly asymmetrically, in 40% and 60% of the cases respectively. In patients with pitting edema compared to those without this feature, the frequency of Achilles enthesitis and plantar fasciitis, calculated together, was higher (p < 0.05) and the duration of arthritis was significantly lower (p = 0.02). In 7 patients the clinical evidence of a predominant involvement of tenosynovial structures was confirmed by MRI. CONCLUSION: Upper or lower distal extremity swelling with pitting edema due to tenosynovitis, usually unilateral, is a common feature in PsA patients and may represent the first, isolated manifestation of the disease.

Imaging of the acute scrotum.

The scrotum is a superficial structure and clinical examination is frequently not enough for making a specific diagnosis. In acute scrotal pain US can confirm the presumptive clinical diagnosis and provide additional relevant information. In testicular torsion, color-Doppler imaging has a central role since it has become possible to identify it at early stage by showing absence of perfusion in the affected testis before any gray-scale abnormality. Scintigraphy remains a satisfactory alternative in evaluating testicular torsion and should be used when color Doppler is inadequate, raising doubts about the suspected torsion. Diagnosis of torsion of testicular appendages is particularly difficult. Ischemic infarction shows a characteristic pattern at gray-scale and color Doppler imaging, whereas hemorrhagic ischemia may require MRI. Inflammatory diseases of the scrotum can be easily investigated by echo color Doppler and conventional radiography, and CT can be particularly useful in the detection of gas bubbles. In scrotal trauma, scrotal hematoma, hematocele, intratesticular hematoma, and testicular rupture can be identified using gray-scale US with very good reliability. Magnetic resonance imaging is indicated when a small tear of tunica albuginea is suspected but not visualized on US.

Magnetic resonance imaging in the diagnosis of PMR.

The cause of musculoskeletal symptoms in polymyalgia rheumatica (PMR) is not clearly defined because joint synovitis may only partially explain the diffuse discomfort. MRI imaging of the shoulders, hip and extremities of patients with PMR has been analyzed. MRI showed that subacromial and subdeltoid bursitis of the shoulders and iliopectineal bursitis and hip synovitis are the predominant and most frequently observed lesions in active PMR. The inflammation of the bursae associated with glenohumeral synovitis, bicipital tenosynovitis and hip synovitis may explain the diffuse discomfort and morning stiffness.

[Doppler color ultrasonography of the normal penis]. / Eco-color Doppler del pene normale.

The penile blood vessels arise from the internal pudendal artery. After the arcuate ligament the artery is usually called the main penile artery. Afterwards the vessel is divided into the dorsal penile artery, which is thin, and the cavernosal artery, which enter the corpus cavernosum on the supero-medial surface of the penis. The branches of this artery are called the arteriae helicinas that subsequently divide in smaller vessels that communicate with the lacunae of the corpus cavernosum. The venous blood flow is drained into the venous plexus beneath the tunica albuginea. The emissary veins perforate the albuginea and the blood is drained by the venae circumflexae into the deep dorsal vein. Color-Doppler sonography allows actually to depict all these vessels and to study the blood flow in these structures with the exclusion of the lacunar spaces. To detect slow flows the technical parameters are very important and the Doppler angle must be always less than 60 degrees. During pharmacologically induced erection the peak systolic velocity in the cavernosal artery shows different values, according to the time of measurements. Initially high systolic velocity is detected (over 35 cm/s) and high diastolic flow (8-15 cm/s) due to low intracavernosal resistance. After veno-occlusive mechanism activation, an increase of flow is normally observed with peak systolic velocity up to 80-120 cm/s associated to progressive decrease of diastolic flow. In the initial phase of the erection the venous flow is characterized with elevated blood velocity in the circumflex and deep dorsal veins. Afterwards with progressive erection the venous flow reduces to disappear completely with full rigidity. Three dimensional US allows a better visualization of the morphology, number and distribution of the vascular tree of the penis.

Remitting seronegative symmetrical synovitis with pitting oedema (RS3PE) syndrome: a prospective follow up and magnetic resonance imaging study.

OBJECTIVE: To determine the clinical characteristics of patients with "pure" remitting seronegative symmetrical synovitis with pitting oedema (RS3PE) syndrome, and to investigate its relation with polymyalgia rheumatica (PMR). Magnetic resonance imaging (MRI) was used to describe the anatomical structures affected by inflammation in pure RS3PE syndrome. METHODS: A prospective follow up study of 23 consecutive patients with pure RS3PE syndrome and 177 consecutive patients with PMR diagnosed over a five year period in two Italian secondary referral centres of rheumatology. Hands or feet MRI, or both, was performed at diagnosis in 7 of 23 patients. RESULTS: At inspection evidence of hand and/or foot tenosynovitis was present in all the 23 patients with pure RS3PE syndrome. Twenty one (12%) patients with PMR associated distal extremity swelling with pitting oedema. No significant differences in the sex, age at onset of disease, acute phase reactant values at diagnosis, frequency of peripheral synovitis and carpal tunnel syndrome and frequency of HLA-B7 antigen were present between patients with pure RS3PE and PMR. In both conditions no patient under 50 was observed, the disease frequency increased significantly with age and the highest frequency was present in the age group 70-79 years. Clinical symptoms for both conditions responded promptly to corticosteroids and no patient developed rheumatoid arthritis during the follow up. However, the patients with pure RS3PE syndrome were characterised by shorter duration of treatment, lower cumulative corticosteroid dose and lower frequency of systemic signs/symptoms and relapse/recurrence. Hands and feet MRI showed evidence of tenosynovitis in five patients and joint synovitis in three patients. CONCLUSION: The similarities of demographic, clinical, and MRI findings between RS3PE syndrome and PMR and the concurrence of the two syndromes suggest that these conditions may be part of the same disease and that the diagnostic labels of PMR and RS3PE syndrome may not indicate a real difference. The presence of distal oedema seems to indicate a better prognosis.

Isolated tenosynovitis associated with psoriasis triggered by physical injury.

A 60-year-old man who had been suffering from psoriasis for 20 years developed finger dactylitis and inflammatory swelling with pitting edema over the dorsum of the hand one week after a contusive trauma to the left hand. These were not followed by any other clinical manifestations of PsA.

Retrocalcaneal bursitis in spondyloarthropathy: assessment by ultrasonography and magnetic resonance imaging.

OBJECTIVE: To establish by magnetic resonance imaging (MRI) and ultrasonography (US) the frequency of retrocalcaneal bursa involvement in Achilles enthesitis of spondyloarthropathy (SpA) and to compare the results of the 2 examinations. METHODS: Nineteen Achilles tendons with severe enthesitis and 9 normal tendons of 14 patients meeting the Amor criteria for SpA were examined by MRI and US. RESULTS: Both MRI and US showed a significant increase in the mean Achilles tendon thickness in the pathologic legs compared to the normal legs both at the superior calcaneal surface and 3 cm above. MRI showed retrocalcaneal bursitis in 14 (73.7%) of 19 pathologic legs and superficial bursitis in 2 (10.5%). US showed fluid collection only in 7 of 14 retrocalcaneal bursae positive on MRI, and failed to show fluid in the 2 superficial bursae involved. Using MRI as the gold standard, US showed 50% sensitivity and 100% specificity for retrocalcaneal bursa involvement and lacked sensitivity for superficial bursitis. CONCLUSION: Achilles tendon involvement in SpA is not only a disease of the enthesis but also of the adjacent bursae.

Clinical manifestations of seronegative spondylarthropathies.

Seronegative spondylarthropathies include ankylosing spondylitis, Reiter's syndrome and reactive arthritis, psoriatic arthritis, arthritis associated with ulcerative colitis and Crohn's disease, plus other forms which do not meet the criteria for definite categories and are called undifferentiated. Recently two sets of classification criteria have been proposed for the entire group including undifferentiated forms: the European Spondylarthropathy Study Group and the Amor criteria. The prevalence of spondylarthropathies is directly correlated with the prevalence of the HLA-B27 antigen in the population. The highest prevalence of ankylosing spondylitis (4.5%) has been found in Canadian Haida Indians, where 50% of the population is B27 positive. Among Europeans the frequency of the B27 antigen in the general population ranges from 3 to 13% and the prevalence of ankylosing spondylitis is estimated to be 0.1-0.23%. Seronegative spondylarthropathies have common clinical and radiologic manifestations: inflammatory spinal pain, sacroiliitis, chest wall pain, peripheral arthritis, peripheral enthesitis, dactylitis, lesions of the lung apices, conjunctivitis, uveitis and aortic incompetence together with conduction disturbances. All of these may also occur in isolation.