 greetings for the day. This is Dr. Rajesh Kamble from Mumbai, Maharashtra, India. I am basically a radiologist practicing since last seven years, passed out from Nair Hospital and having my own center, Shobha Diagnostic Center. I am passionate a lot about ultrasound. For the last period of 17 years, I have developed a lot of interest in fetal ultrasound and small part ultrasound and one of them is scrotum which is one of my favorite subject. I have seen over a period of last 17 years that revolution in ultrasound has led us to high frequency transducers widely available with the use of which you can evaluate scrotum in a very, very good way. Also when I in this last 17 years I realized that there was very few literature found on the scrotal ultrasound. In fact, in residency I remember there was only one chapter in Rumac. In fact, whatever literature you try to search for scrotal pathology is mainly there on the Google or it is in this book or it we hear through the lectures. So here I am to share you my perspective for how to evaluate scrotum in day-to-day clinical practice and I want to give you approach how you are going to look up at these cases in day-to-day practice. Thank you. If you look at modalities to diagnose scrotal diseases in day-to-day practice, you know that you have ultrasound with color Doppler where you do a good B-mode ultrasound and if required you use color Doppler application to see scrotal diseases. But other than that there is CT, MR and radionuclide scans. In fact, you will be surprised in western countries in pediatric age group they still use radionuclide scans for any suspected cases of pediatric testicular torsion. So we have all these modalities but if you look at this American appropriated criteria for picking up and evaluating which modality would be best, you would see that a B-mode ultrasound with a Doppler has a rating of 9. So I think one of the best modality in today's era, one of the quickest, safest having no ionizing radiation and has a very high sensitivity and specificity to pick up scrotal pathologies. Of course, if at all you are stuck up with a certain pathology and you are unable to evaluate it, the other modality which is favorite is doing an MR. But in India, I think in any acute onset scrotum or any scrotal masses, ultrasound is the first modality of choice. Now where all you will use ultrasound in scrotal diseases. So the patient has come with a lump in the scrotum. You want to localize and know the characteristics of the scrotal mass and you are going to use ultrasound. Then sometimes you're doing an abdominal scanning and you see a mass in the retroperitodium. It's looking like a metastatic adenopathy and many a times you'll be surprised that there is a hidden primary tumor sometimes in the scrotum. So that is one excellent application of ultrasound. Then there are these diagnosed cases of testicular masses, leukemias, lymphomas, where you will use ultrasound as a technology to pick up whether the testes has got involved with this lympho proliferative process. Then one cannot forget the origin of the testes is one of the most acute emergencies which are present in the pediatric age group as well as the adult age group or especially the 17, 18 group and beyond out acute scrotums are best evaluated with ultrasound. Any kind of trauma to the scrotum patient is definitely going to use first modality of choices ultrasound. Beyond this, sometimes patients can feel lumps in the testes and any kind of legions in the cord, epidermis or even hydro seal which presents as a large lump in the scrotum can present to you and you can do ultrasound and do a great justice. Then one of the most beautiful modality today in pediatric age group is hidden testes there are the undistended testes and cryptorchidism can be picked up very well on ultrasound. Then today with so much infertility on rise and IVFs been going on in the total infertility workup varicoseal evaluation where you're going to use scoladoplar to make a primary diagnosis of varicoseal and hence in all infertility protocol, varicose evaluations are best done by a b-mode scrotum ultrasound. Now, how is the clinical presentation of the patient going to be? One is that any kind of pain discomfort or any kind of acute pain in the scrotum the patient is going to walk in your clinic to do an ultrasound or there could be a silently sitting mass which is palpable or it has both slow and suddenly increased in size patient has not made cognizance to it and suddenly the mass became big patient is definitely going to come to you for ultrasound. What is your job as a radiologist? You're going to do a first of good b-mode ultrasound and if necessary in all cases you're going to do color or powered-up evaluation. So what is your approach if a patient walks in your clinical suit to image the scrotum? Always, always a very important take home. Listen to the patient's history. There is always a diagnosis hidden in the patient's history. We immediately usually jump and start doing these scrotum ultrasound. Never do that. Take a short history since when is the onset of the pain in the scrotum or the lump feeling and that throws you in a different perspective when you do a ultrasound. Then regarding to technique, they say that you can support the scrotum with towels and tissue paper and that's one of the standard way to do it. They say avoid cold room. But what's more important is that you need to have a decent mid-range ultrasound machine which has a high frequency transducers. Now today most of the machines have frequencies in the range of 3 to 12 Megas. If you have that much you can make a decent diagnosis of scrotal pathologies in day to day practice. A very important take home year I want to give to all residents or even radiologists who scan in periphery is that when a ultrasound scrotum is referred to you by a clinician always, always make it a protocol that you will not just jump and start doing scrotal ultrasound. You know that the testes were lying in the lumbar area when it is in the womb. So always, always it was worthwhile to start scanning right from seeing the kidneys retroperitonium. Then coming to inguinal scan, it is just going to take you a minute to just screen these areas. Why I am trying to stress importance of this you will see that in many scrotal pathologies there are incidental findings seen in vast abnormalities, epidermal abnormalities. Sometimes you will see that on the same side the kidneys are absent and there are many such pathologies where there is an overlap. So it's worthwhile to take one minute scan both the kidneys then go down to the inguinal canal and then jump to the scrotum. Now in scrotum also you are not going to go haphazard about it. You are going to have a systematic approach. So how are you going to go about it is that you are going to go for screening from outside to inside. By what that I mean is that this is the scrotal wall. Then you see this hyper echoic area surrounding the testes is nothing but tunica albujulia. So pathologies are going to be from these these areas and therefore you are going to go systematic about it and approach the case. Then testes is one thing which we never forget to scan but once you finish seeing the testes you should extend your scan, look for epidermis, look at chord structures and tunica vaginalis. Mind you if you follow this protocol you will be able to successfully evaluate most of the scrotal pathologies very confidently in day to day practice. So keep that approach. Then the best part of all the soft tissue imaging or symmetrical organs given in human body is that there is always going to be a symptomatic and asymptomatic side. So always when the patient gives a history of pain on the right side you always have an asymptomatic side to scan with. So always divide your screen into half. Look at that pathology at asymptomatic and symptomatic side. You can evaluate many legions that way and you should make it a protocol to compare an asymptomatic versus symptomatic side. Then in day to day practice how are you doing your ultrasound is after you have seen the scrotal wall you have seen the tunica albu junia you're going to evaluate the testes. You know these are these ovoid homogenous organs, iso-equic kind of structures. You know when you do the scan anything and everything in ultrasound we see in two planes. So you're going to take AP measurements and longitudinal measurements and this is the way you go in day to day practice where you measure the testes in all the three planes. Now you're now over a period of time where we have said protocols in the clinic. In all infertility patients we are also taking volume of the testes. So we have realized that doing these studies help us to pick up testicular hypoplasia or all hypovolemic testes and they have good correlation with infertility men. So always make it an habit to take a volume of the testes especially in infertility protocol evaluation. Following this you're going to go up till the upper pole of the testes and look at the epidermis which is also going to be a hypoto-iso-equic organ. So how in day to day practice is basically this is the scrotal wall, this is the ovoid homogenous testes. You're seeing it in transverse plane, longitudinal plane, making measurements. Easy to evaluate that. Once you have done that you know that this is a homogenous looking organ, no pathology in it and once you have done that whatever's telling you was the importance of this. This is the central median rafae. See contralateral symptomatic versus asymptomatic side. You should be able to give a very good justice especially to the pathological side. Once you have done that, now the next thing is that you need to image the epidermis. What is your approach? Go to the upper pole of the testes. The structure which is lying most at the top end is nothing but the head of the epidermis. From that point you rotate your transducer completely 90 degrees and you will see complete epidermis in terms of its head, body and tail. So pathologies involving that are completely different like an epidermis or a mask and they are separate from testes and you will be able to pick it up very confidently. Once you have done that, usually now most of the machines we have have color droplets available with it. So always make it a practice to switch on color, look at the color flow within the testes, epidermis and depending upon what the indication is, you go on and extend the study. This slide is also of paramount importance to see that again organs of importance in human bodies have got blood supply in dual in nature. So if you look at this slide it tells us that the wall of the scrotum is supplied completely by a climastic artery, separates blood supply, testes by testicular artery and epidermis with differential artery. Now this is also an important aspect for you to analyze especially when you get these overlapping flows especially when you see cases of torsion and sometimes you see peritesticular flow but no intertesticular flow and you are confused. So if you remember that there is differential flow in the testes you'll be able to confidently evaluate the blood flow of different things. Whenever you're doing Doppler, you want to pick up the most minutest flow in the testes. In fact, testes has continuous flow during the diastole of the cycle because again an organ of importance to the human body. So your aim is mainly to pick up all these low volume low velocity flow. Now how are you going to set your color Doppler unit? What I'm trying to tell you is that always go to asymptomatic side first. Set your machine on the asymptomatic side and apply the same color Doppler settings to the symptomatic side. How are you going to achieve that? Even if you minimize your PRF to the lowest Doppler scale, you're going to pick up very good flow. Also one of the tricks is increase the color game almost till you get background noise and then slowly decrease the color and that is the best way to set the machine. If required, you can minimize the wall filter settings. Now most of these machines, our Philips team or others companies set it so beautifully that you don't have to take efforts of setting up a color Doppler unit. But yes, especially in cases of torgen, if you're unsure, then only you need to play along with these settings and use the color Doppler unit. Then in spite of taking all these efforts and you're still not seeing colored Doppler or a color flow within the testes, you have a powerful setting called as Power Doppler, which can pick up the most minute test flow within the testes switch on the power Doppler, it can pick up my new test flow in any part of the testes, one of the best modality if you get stuck up, especially in cases of torgen of the testes. Once you've done that most of us complete our study and leave the patient. So again important take home is that in any and every case of testicular evaluation, I would request everyone to at least take one spectrum within the testes. Now, as you can see in this slide, it can depicts that it's a typical seesaw kind of pattern which we see in umbilical arteries. So again, testes also is an important organ to the male body to see that there is continuous low resistance kind of pattern in the continuous diastolic phase of the cycle. If you see this, you should document it in every case. Then if you look at the schematic card, it will not give you this kind of pattern, it will show some kind of high resistant pattern because of the surrounding tissues, which have sharp systoles, some amount of good diastolic flow. And this is the kind of pattern you need to see and remember in schematic card. Then this is the video which tells us that in certain cases, you switch on power Doppler, how beautifully it is telling you that yes, there is flow within this testes. Having said that, I think most of you by now have understood this is the way you're going to approach evaluating the testes and the epidermis.