Multiparametric Ultrasound Strengthens Scrotal Imaging

Multiparametric ultrasound combines B-mode, Doppler techniques, microvascular imaging, contrast-enhanced ultrasound and elastography to improve scrotal imaging. It supports assessment of conditions including pain, trauma, infertility, focal lesions, cryptorchidism and incidental findings. The superficial position of the scrotum allows high-resolution imaging of anatomy and blood flow, while the multiparametric approach adds information on microcirculation and tissue stiffness. Guidance from the European Federation of Societies for Ultrasound in Medicine and Biology identifies contrast-enhanced ultrasound as the reference method for vascular assessment and elastography as a complementary tool for tissue characterisation.

Combined Techniques Improve Assessment

Ultrasound is the main imaging method for assessing the scrotum because it provides high-resolution views and allows vascular assessment during the same examination. B-mode imaging shows anatomy and tissue structure, while colour Doppler techniques assess blood flow. Multiparametric ultrasound adds microvascular imaging, contrast-enhanced ultrasound and elastography, creating a broader examination of scrotal disease.

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Contrast-enhanced ultrasound gives a detailed view of perfusion and serves as the reference method for vascular assessment. It helps distinguish perfused tissue from non-perfused tissue and can reveal vascular patterns that are not visible on conventional Doppler imaging. Microvascular imaging also improves sensitivity, especially in small lesions or difficult cases. Elastography adds information on tissue stiffness and supports assessment of both the testicular parenchyma and focal abnormalities.

Together, these techniques improve diagnostic confidence in situations where conventional ultrasound findings are uncertain. They help identify vascular compromise, assess tissue viability and support distinction between benign and malignant conditions. The result is a more complete and still non-invasive examination that can support diagnosis and management in a wide range of scrotal pathologies.

Value in Acute Pain, Trauma and Infertility

Multiparametric ultrasound has an important role in acute scrotal pain, where fast distinction between surgical and non-surgical causes is essential. In testicular torsion, contrast-enhanced ultrasound shows absent vascularisation in complete torsion and shows reduced enhancement on the affected side in low-degree torsion. Microvascular imaging can reveal asymmetrical vascularisation when conventional Doppler findings are unclear. Elastography shows increased stiffness in the twisted spermatic cord and testis, although its value for routine use remains limited.

In epididymo-orchitis, the testis and epididymis show increased vascularity. When inflammation causes impaired venous outflow, tissue ischaemia may follow. Contrast-enhanced ultrasound helps separate viable tissue from necrotic tissue and can identify segmental ischaemic areas. It also helps distinguish benign inflammatory complications such as infarctions and abscesses from tumours by showing absence of vascularity in benign lesions. This is also useful during follow-up, where restoration of vascularisation or progression to infarction can be seen.

In scrotal trauma, contrast-enhanced ultrasound improves evaluation when standard ultrasound findings are unclear. It can show disruption of the tunica vasculosa, which supports the diagnosis of testicular rupture. It also helps define viable and non-viable parenchyma, which is important for surgical planning. Intratesticular haematomas may resemble tumours on B-mode imaging, but lack of enhancement supports the diagnosis of haematoma and may support conservative management.

In infertility, multiparametric ultrasound provides further information on perfusion and parenchymal change. Evidence suggests that contrast-enhanced ultrasound and elastography may help predict the likelihood of surgical sperm retrieval, although practical clinical use remains limited.

Better Lesion Characterisation and Risk Stratification

Multiparametric ultrasound improves the characterisation of focal testicular lesions by combining vascular and stiffness information. Contrast-enhanced ultrasound improves visualisation of microvessels and helps distinguish neoplastic from non-neoplastic lesions, especially when lesions are small and non-palpable. Avascularity on contrast-enhanced ultrasound is strongly associated with benignity. Enhancement, however, is seen in both benign and malignant tumours, which means vascularity alone does not resolve every diagnostic question.

Elastography cannot be used alone for lesion characterisation, but it adds useful information when combined with B-mode imaging, colour Doppler and contrast-enhanced ultrasound. Malignant lesions are often stiffer than non-neoplastic lesions but overlap remains substantial. Benign lesions can also appear hard, while some malignant lesions can appear soft. Even so, elastography can increase diagnostic confidence when it is interpreted alongside the other ultrasound findings.

In extratesticular masses, ultrasound accurately localises lesions and can confirm cystic nature. Contrast-enhanced ultrasound is useful for showing absence of vascularity and for identifying necrotic tissue, which helps establish the diagnosis of abscess. Findings are often non-specific in solid extratesticular tumours, so reliable distinction between benign and malignant lesions remains difficult. Elastography may support assessment of inflammatory change and response to treatment.

Multiparametric ultrasound also supports the assessment of testicular incidentalomas. Many of these lesions are small, non-palpable and benign. Doppler findings, contrast enhancement and elastography can all contribute to risk stratification. Absent flow on contrast-enhanced ultrasound strongly supports benignity. Although multiparametric ultrasound cannot definitively separate benign from malignant small lesions, it helps support decisions between surveillance and surgery. This is especially relevant because radical orchidectomy would represent overtreatment for many men with incidentalomas.

Multiparametric ultrasound strengthens scrotal imaging by combining structural, vascular and stiffness information in one approach. It improves assessment in acute scrotal pain, trauma, infertility and focal lesions. Contrast-enhanced ultrasound is central for perfusion assessment, while elastography adds supportive information on tissue properties. The combined approach improves lesion characterisation, supports risk stratification and helps guide management. Standardised use of these techniques supports more consistent practice and reinforces the role of ultrasound as a comprehensive tool in scrotal imaging.

Source: European Journal of Ultrasound