Scrotal Ultrasonography

Number: 0532

Table Of Contents

Policy Applicable CPT / HCPCS / ICD-10 Codes Background References

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Policy

Scope of Policy

This Clinical Policy Bulletin addresses scrotal ultrasonography.

1. Medical Necessity

   Aetna considers scrotal ultrasonography medically necessary for any of the following conditions:

   1. Detection and characterization of scrotal mass lesions/tumors; or
   2. Detection of undescended (cryptorchid) testes in either of the following:
      1. To look for gonads or a uterus in a phenotypically male infant with bilateral non-palpable testes (to evaluate the possibility of disorder of sexual development); and
      2. In obese boys, in whom intra-canalicular testes may be difficult to palpate and would change the surgical approach (from laparoscopic to inguinal); or
   3. Diagnosis of suspected testicular torsion; or
   4. Evaluation of hydroceles; or
   5. Evaluation of infertile men; or
   6. Evaluation of scrotal pain and/or swelling (acute scrotal symptoms); or
   7. Evaluation of scrotal injury/trauma; or
   8. Evaluation of varicoceles.

2. Experimental, Investigational, or Unproven

   1. Aetna considers scrotal ultrasonography experimental, investigational, or unproven for the initial evaluation for infertility unless physical examination of the scrotum is difficult or inadequate, or when a testicular mass is suspected.
   2. Aetna considers scrotal ultrasonography experimental, investigational, or unproven for surveillance of testicular microlithiasis in the absence of additional risk factors (e.g., a history of cryptorchidism or testicular atrophy (less than 12 ml), previous testicular cancer) and for all other indications because of insufficient evidence of its clinical value for other indications.

Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code Code Description

CPT codes covered if selection criteria are met:

76870 Ultrasound, scrotum and contents

ICD-10 codes covered if selection criteria are met:

C63.2 Malignant neoplasm of scrotum D29.4 Benign neoplasm of scrotum D40.10 – D40.12 Neoplasm of uncertain behavior of testis I86.1 Scrotal varices N43.0 – N43.42 Hydrocele and spermatocele N44.00 – N44.04 Torsion of testis N45.1 – N45.4 Orchitis and epididymitis N46.01 – N46.9 Male infetility N50.0 Atrophy of testis N50.811 – N50.819 Testicular pain N50.82 Scrotal pain [not covered for testicular microlithiasis] P83.5 Congenital hydrocele Q53.00 – Q53.9 Undescended and ectopic testicle Q55.22 Retractile testis Q55.23 Scrotal transposition R39.83 – R39.84 Non-palpable testicle S39.848+ Other specified injuries of external genitals [scrotal trauma] S39.94X+ Unspecified injury of external genitals

ICD-10 codes not covered if selection criteria are met:

Z31.41 Encounter for fertility testing [Initial evaluation for infertility unless physical examination of the scrotum is difficult or inadequate, or when a testicular mass is suspected] Z31.49 Encounter for other procreative investigation and testing [Initial evaluation for infertility unless physical examination of the scrotum is difficult or inadequate, or when a testicular mass is suspected]

Background

Scrotal ultrasonography has been demonstrated to have a clinically significant impact on urologists’ diagnoses of scrotal abnormalities and disorders. Scrotal ultrasound is characterized by high sensitivity in the detection of intra-scrotal abnormalities and is a very good mode for differentiating testicular from para-testicular lesions. The main indication for color Doppler ultrasound (which can reveal scrotal blood flow) is assessment of acute scrotal symptoms (pain or swelling), especially in the diagnosis of suspected testicular torsion. The vast majority of boys who exhibit acute scrotal symptoms have non-surgical conditions, usually epididymitis or torsion of the appendix testis. Since the clinical appearances of these conditions are often similar to that of testicular torsion, imaging is frequently performed to help with diagnosis. In fact, color Doppler ultrasound is the method of choice for imaging scrotal organs, and allows more objective and precise assessment of varicoceles. Varicoceles can be diagnosed by showing intra-scrotal veins larger than 2 mm. It has also been shown that color Doppler ultrasound is more accurate and reliable than physical examination in conjunction with gray-scale ultrasound (which is non-specific and can’t be used to diagnose testicular torsion) in the differential diagnosis of acute scrotum.

Patients with hydroceles large enough to prevent adequate palpation of the testes should undergo scrotal ultrasound. Sonographic identification of calculi in the hydroceles may prevent further imaging and unnecessary surgery. Color Doppler ultrasound is also used in the evaluation of traumatized scrotum. Testis rupture must be diagnosed rapidly and color Doppler ultrasound can be used to evaluate perfusion of the testis. The prediction of testicular viability following trauma is essential for proper treatment. Other indications for scrotal ultrasonography are detection of undescended (cryptorchid) testes, and evaluation of infertile men. It should be noted that intra-abdominal testes can not be located with ultrasound. Routine scrotal ultrasound has been reported to provide valuable information in the diagnostic evaluation of infertile men and substantially more pathological conditions are detected compared to clinical palpation. The high prevalence of testicular malignancies underscores the importance of routine scrotal ultrasonography in infertile men.

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Serter et al (2006) noted that testicular microlithiasis (TM) is a rare, usually asymptomatic finding of the testes associated with various genetic anomalies and infertility. It is believed that TM is strongly associated with testicular tumor. In a prospective study, these researchers determined the prevalence of TM in an asymptomatic population by means of ultrasound screening. Healthy male volunteers (17 to 42 years old) were recruited from the annual Army Reserve Officer Training Corps training camp at Manisa, Turkey. A screening genito-urinary history was obtained and a physical examination and screening scrotal ultrasound scan were performed. All men diagnosed with TM underwent complete clinical evaluations, physical examinations and determination of tumor markers. A total of 53 men with TM were identified from the 2,179 ultrasound scans, giving a prevalence of TM of 2.4 % in this asymptomatic population. The age (mean ± SD) of subjects with TM was 23.9 ± 4.2 years (range of 20 to 31 years). The authors concluded that these findings suggested that there is no significant association between TM and testicular cancer, although it is difficult to rule out such an association without further studies with a longer follow-up period.

DeCastro and colleagues (2007) stated that TM is an imaging entity of the testicle with questionable significance as a marker for testicular cancer. In 2001 these investigators reported on a large prospective screening study establishing the prevalence of TM to be 5.6 % in a healthy asymptomatic population of Army volunteers 18 to 35 years old. In contrast, testicular cancer develops in only 5 of 100,000 men. Two-year follow-up of 63 of the 84 patients with TM showed that none of these men had testicular cancer or scrotal masses. Here these researchers reported he 5-year follow-up in this cohort of men with TM at risk for testicular cancer. According to the original parameters of the screening study these investigators performed a history, genito-urinary examination and scrotal ultrasound on 1,504 healthy army volunteers 18 to 35 years old. Testicular microlithiasis was defined as greater than 6 echogenic signals found on ultrasound. They identified 84 patients with TM (5.6 %). These men were entered into the follow-up phase of the study and instructed regarding testicular self-examination and the need for follow-up. They were told to report any changes in their examination or a finding of testicular mass or cancer. Five years after the initial screening study, the authors attempted to contact all remaining 84 men by e-mail, standard mail and telephone. Of the original 84 men with TM identified in the original screening study, 63 have been contacted via e-mail and by telephone (75 %). Of the 63 subjects, a mixed germ cell tumor developed in 1 patient 64 months after the initial screening study. Compared to the incidence of testicular cancer in the general population the odds ratio of developing testicular cancer in this study population was 317 (95 % confidence interval [CI]: 36 to 2,756). The authors concluded that testicular cancer will not develop in the majority of men with TM (98.4 %) during a 5-year follow-up interval. They believed that an intensive screening program for men with TM is not cost-effective and would do little to improve outcomes associated with testicular cancer. These investigators continued to recommend testicular self-examination in men at risk.

In a retrospective study, Chen and colleagues (2010) determined the incidence of TM in Taiwanese males who were referred for scrotal ultrasonography (US) and evaluated the association between TM and cancer, with state-of-the-art equipment. A total of 513 males who underwent scrotal US in a period of 7 months were included in this study. The US images and charts of each patient were reviewed to determine the presence of TM and note relevant clinical information. The data for all 513 patients were analyzed. Their age was 0 to 91 years (mean of 54.3 years). The overall incidence of TM was 14.4 % (74/513); 6.2 % (32/513) had classic TM, and 8.2 % had limited TM. The incidence of testicular cancer in this population was 1.6 % (8/513). Six of 8 (75 %) patients who had testicular cancer at presentation had classic TM or limited TM. There was a significant difference (p < 0.01) between the rate of malignancy in subjects with TM (6/74) and that in subjects without TM (2/439). The authors concluded that the incidence of TM in Taiwanese people may be higher than previously reported, which may be due to the difference in methodology and increased awareness of the US findings. Moreover, they stated that although there was a significant difference in the rate of malignancy in males with TM compared with those without TM, the question remains whether TM independently increases the risk of testicular malignancy.

Dutra et al (2011) evaluated the prevalence of TM among pediatric patients with inguino-scrotal affections. Between January 2005 and January 2010, these investigators evaluated, prospectively 1,504 children ranging from 1 to 15 years with inguino-scrotal affections with a high-frequency ultrasound system, which employs a 10-MHz transducer. Testicular microlithiasis was identified in 20 testes of 11 children (0.71 % of 1,504 patients evaluated), through an ultrasound scan. Testicular microlithiasis was found in 5 children with cryptorchidism (3.93 % of 127 patients), 4 children with retractile testes (14.8 % of 27 patients), 1 child with a hypotrophic testis (100 % of 1 patient), and 1 child with inguinal hernia (0.07 % of 1,349 patients). The children with TM were submitted to annual physical examinations and ultrasound evaluations. The authors concluded that TM was a rare condition and occurred in 0.7 % of the subjects studied. The association with cryptorchidism, retractile and hypotrophic testis was significant.

Richenberg et al (2012) stated that ultrasound surveillance of patients with TM has been advocated following the reported association with testicular cancer. These researchers evaluated the evidence supporting such surveillance. Formal literature review identified cohort studies comprising at least 15 patients followed-up for at least 24 months. Combining an institutional audit with the identified studies in a pooled analysis the incidence of new cancers during the surveillance period was evaluated. Literature review identified 8 studies. The authors’ institutional audit comprised 2,656 men referred for scrotal ultrasound. Fifty-one men (1.92 %) with TM were identified, none of whom developed testicular cancer (mean follow-up: 33.3 months). In a combined population of 389 men testicular cancer developed in 4. Excluding 3 who had additional risk factors, only 1 of 386 developed testicular cancer during follow-up (95 % confidence interval: 0.05 5 to 1.45 %). The authors concluded that ultrasound surveillance is unlikely to benefit patients with TM in the absence of other risk factors. In the presence of additional risk factors (a history of cryptorchidism or testicular atrophy, previous testicular cancer) patients are likely to be under surveillance; nonetheless monthly self-examination should be encouraged, and open access to ultrasound and formal annual surveillance should be offered.

An UpToDate review on “Screening for testicular cancer” (Lin, 2014) states that “Testicular microlithiasis is a common finding during infertility evaluations, but its association with testicular cancer is controversial. Microlithiasis has been detected with scrotal ultrasonography in up to 5 percent of healthy adolescents and young men”.

Shetty et al (2014) examined if there is a consensus regarding the significance of TM and a strategy for managing patients with this condition, among ultrasound practitioners in the United Kingdom (U.K.). An electronic questionnaire was distributed to 1,482 members of the British Medical Ultrasound Society (BMUS), requesting information from ultrasound practitioners involved in scrotal ultrasound about their interpretation of the risk associated with TM and their departmental or personal recommendations for managing patients with this condition. Responses were obtained from 221 BMUS members. Analysis demonstrated a wide variation in the significance attributed to the discovery of TM and the risk of subsequent development of testicular germ cell tumors. There was also great variation in strategies for management of patients with TM, including the need for surveillance ultrasound, among ultrasound practitioners regardless of their job description. The authors concluded that lack of consensus shown by this study highlights significant differences across the U.K. in managing patients with TM and validates the importance of guidance currently being formulated by the European Society of Urogenital Radiology. These researchers believe that this is the first survey conducted among imaging specialists in the U.K. regarding TM and demonstrates that there is currently no uniform practice in managing patients with this condition.

Furthermore, the European Association of Urology’s clinical practice guidelines on “Testicular cancer” (Albers et al, 2011) stated that “In the absence of other risk factors (less than 12 ml (atrophy), maldescent testis), testicular microlithiasis is not an indication for biopsy or further (ultrasound) screening”.

Volokhina and colleagues (2014) noted that there is suggestion that testicular microlithiasis predicts risk of testicular malignancy, especially testicular germ cell tumors. This association remains uncertain. These investigators retrospectively reviewed testicular germ cell tumor occurrence in patients with testicular microlithiasis to assess this association and determined the prevalence of testicular microlithiasis in symptomatic boys. This study was IRB and HIPAA compliant. A total of 2,625 testicular US exams performed on 2,266 children (younger than 19 years of age) in the authors’ institution from 2000 through 2011 were reviewed for presence of testicular microlithiasis and masses. Testicular microlithiasis was defined as presence of 5 or more testicular microcalcifications on a single US image. Incidence of testicular germ cell tumors was calculated in a group of patients with testicular microlithiasis and in a control group without testicular microlithiasis. Relative risk, odds ratio, 90 % and 95 % CI were calculated. A total of 87 patients out of 2,266 had testicular microlithiasis. One child was found to have both testicular germ cell tumor and testicular microlithiasis. In 2,179 children without testicular microlithiasis, 8 had testicular germ cell tumors. Incidence of testicular microlithiasis was 3.8 %. Incidence of testicular germ cell tumors in testicular microlithiasis patients was 1.2 %, and 0.38 % in non-testicular microlithiasis patients. Relative risk of testicular germ cell tumors in testicular microlithiasis patients versus non-testicular microlithiasis patients was 3.13 (90 % CI: 0.55 to 17.76; 95 % CI: 0.40 to 24.76), odds ratio (OR) 3.16 (90 %CI: 0.55 to 18.32; 95 % CI: 0.39 to 25.5). The authors concluded that there is no association between testicular microlithiasis and testicular germ cell tumors. These investigators had hoped to do a meta-analysis, but only 2 studies had a sufficient case control group of non-testicular microlithiasis patients.

Testicular Microlithiasis

Richenberg et al (2015) stated that the subcommittee on scrotal imaging, appointed by the board of the European Society of Urogenital Radiology (ESUR), have produced guidelines on imaging and follow-up in testicular micro-lithiasis (TML). The authors and a superintendent university librarian independently performed a computer-assisted literature search of medical databases: MEDLINE and EMBASE. A further parallel literature search was made for the genetic conditions Klinefelter’s syndrome and McCune-Albright syndrome. Proposed guidelines were: follow-up is not advised in patients with isolated TML in the absence of risk factors; annual US is advised for patients with risk factors, up to the age of 55; if TML is found with a testicular mass, urgent referral to a specialist center is advised. The authors concluded that consensus opinion of the scrotal subcommittee of the ESUR is that the presence of TML alone in the absence of other risk factors is not an indication for regular scrotal US, further US screening or biopsy. Ultrasonography is recommended in the follow-up of patients at risk, where risk factors other than microlithiasis are present.

Undescended (Cryptorchid) Testes

Kanaroglou et al (2015) stated that there is a limited role for ultrasound in the management of an undescended testicle (UDT). These investigators hypothesized that ultrasound remains over-used by referring physicians; they characterized the trends, patterns, and impact of ultrasound use for UDT and re-affirmed its limited diagnostic value for this indication. The records of boys aged 0 to 18 years with UDT in Ontario, Canada, between 2000 and 2011 were reviewed by using health administrative data housed at the Institute for Clinical and Evaluative Sciences (ICES). A second review of boys referred to the authors’ institution with UDT between 2007 and 2011 was conducted to complement the health administrative data. Trends in frequency, distribution, and costs of ultrasound use were assessed. Time delays between diagnosis and definitive management were compared between the ultrasound and non-ultrasound groups. Using the authors’ institutional data, these researchers analyzed demographic patterns of ultrasound use and compared its diagnostic accuracy by using surgical findings as the gold standard. Ultrasound was used in 33.5 % of provincial referrals and 50 % of institutional referrals. Children who underwent ultrasound experienced an approximate 3-month delay in definitive surgical management. Ultrasound correctly predicted physical examination findings in only 54 % of patients. Physicians in community practice, and those with fewer years in practice, were more likely to order ultrasound. The authors concluded that ultrasound has limited value for the management of UDT but remains widely over-used, with an increasing trend over time. They stated that this practice has negative implications for access to care and cost-containment; wide-spread educational efforts should be undertaken, targeting current and future referring physicians.

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Furthermore, an UpToDate review on “Undescended testes (cryptorchidism) in children: Clinical features and evaluation” (Cooper and Docimo, 2015) states that “Imaging is not routinely warranted to locate non-palpable testes. Imaging studies lack the sensitivity and the specificity to alter the need for exploratory surgery. In a systematic review, the sensitivity and specificity of ultrasonography in detecting non-palpable testes were 45 and 78 %, respectively. In contrast, the sensitivity and specificity of exploratory surgery are nearly 100 %.

Imaging may be necessary to evaluate conditions in the differential diagnosis or for surgical planning. As examples:

• Ultrasonography may be indicated to look for gonads or a uterus in a phenotypically male infant with bilateral non-palpable testes (to evaluate the possibility of disorder of sexual development).
• Ultrasonography may be warranted in obese boys, in whom intra-canalicular testes may be difficult to palpate and would change the surgical approach (from laparoscopic to inguinal). In a systematic review of the literature, the accuracy of ultrasonography in identifying inguinal or scrotal testes was 92 %, but the included studies were of poor quality and lacked important clinical information (e.g., position of contralateral testis, associated clinical findings, etc.)”.

Testicular Torsion

McDowall and colleagues (2018) stated that a positive whirlpool sign (WS) is defined as the presence of a spiral-like pattern when the spermatic cord is assessed during US, using standard, high-resolution US(HRUS) and/or color Doppler sonography (CDS), in the presence of testicular torsion (TT). These investigators evaluated the validity and accuracy of this sign by performing a comprehensive systematic literature review and meta-analysis. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a comprehensive literature search was performed (August, 2017), using the following databases: BMJ Best Practice, Cochrane Library, Embase, PubMed, Scopus, and Web of Science. Selected studies were further assessed for relevance and quality using the Oxford 2010 Critical Appraisal Skills Program (CASP). Of the studies assessed, a total of 723 participants were included, with a mean of 72.3 (SD 71.9) participants. Of the participants, 226 (31.3 %) were diagnosed with TT. Meta-analysis of the studies that provided sufficient data resulted in a pooled sensitivity and specificity of the WS of 0.73 (95 % CI: 0.65 to 0.79) and 0.99 (95 % CI: 0.92 to 0.99), respectively. Removal of all neonates increased the pooled sensitivity to 0.92 (95 % CI: 0.70 to 0.98) while the pooled specificity remained almost unchanged at 0.99 (95 % CI: 0.95 to 1.00). The estimated summary effect of all studies with sufficient data was 4.34 (95 % CI: 1.01 to 7.67; n = 394; p = 0.001). A large degree of heterogeneity was suggested by an I2 statistic of 88.27 % (95 % CI: 68.60 to 98.68 %). Removal of neonatal subjects increased the estimated summary effect to 5.32 (95 % CI: 1.59 to 9.05; n = 375; p = 0.001). The authors concluded that the WS, when correctly diagnosed, may be viewed as a very definitive sign for TT in the pediatric and adult populations; however, its role in neonates is limited.

Evaluation of Benign Testicular Lesions/ Masses

Fakhralddin and associates (2020) stated that scrotal leiomyomas are benign tumors arising from the dartos layer of the scrotal wall. The exact cause of this tumor is still unclear. Malignant transformation to leiomyosarcomas has been reported. These researchers presented the case of a 52-year old man who complained of a painless lump on the right side of the scrotum that lasted for 12 years. Physical examination revealed a single, firm, and non-tender, mobile lump on the anterior aspect of the right scrotum. Both testes were normal and no inguinal lymph nodes could be palpated; US scan of the scrotum showed a 40 mm × 20 mm hypo-echoic, poorly vascular lesion in the scrotum. Under spinal anesthesia, the mass was excised. Histopathological and immunohistochemical findings were consistent with the diagnosis of scrotal leiomyoma. These investigators stated that leiomyomas may originate from any location in the genitourinary system where there is smooth muscle. Scrotal smooth muscle tumors can be categorized into leiomyomas, atypical or symplastic leiomyomas, which are not hypercellular and lack mitotic activity, and leiomyosarcomas. Ultrasound is the first-line imaging investigation in patients with suspected scrotal masses. Magnetic resonance imaging (MRI) can be more sensitive and accurate, but is usually not needed. A definitive diagnosis requires histological examination of a resected specimen. Based on the above-mentioned histological criteria, immunohistochemistry, physical examination, and ultrasound findings, this case was a typical scrotal leiomyoma. Typical leiomyomas and atypical ones behave similarly. Thus, they are managed only with surgical excision, while leiomyosarcomas need a wide 3 to 5 cm margin resection that includes the subcutaneous tissue and fascia and negative margins. Both recurrence and malignancy have been described. Close follow-up is needed to detect recurrence. The authors concluded that scrotal leiomyoma is a rare benign mesenchymal tumor of the middle-aged men. The current report described the clinical and histopathological characteristics to help reduce erroneous diagnoses of this rare tumor.

Asanad and colleagues (2020) noted that leiomyomas are benign mesenchymal neoplasms that originate from smooth muscle cells. Leiomyoma of the testis is extremely rare. These researchers presented a case demonstrating a 1.3 cm hypo-ehoic mass of the left testis but with significant enhancement on contrast-enhanced scrotal US concerning for a malignant neoplasm in a 33-year old Hispanic man. However, his final pathology revealed a benign disease, specifically intra-testicular leiomyoma. We discuss the role of contrast-enhanced scrotal ultrasound in this disease process. These investigators stated that previous studies described an intra-testicular leiomyoma with “moderate” flow on color Doppler US, whereas their patient’s lesion did not demonstrate a significant increase in flow on color Doppler US. The discrepancy in findings on conventional and Doppler US between reported cases suggested that testicular leiomyomas may have unique findings on contrast-enhanced US when compared to other sonographic techniques. These researchers stated that further research is needed to better characterize the role of contrast-enhanced US in the evaluation of benign testicular lesions.

Initial Evaluation of Infertility

The 2007 French Urological Association’s guidelines on “Optimal evaluation of the infertile male” (Huyghe et al, 2008) noted that an infertility evaluation should be carried out if a couple has not achieved conception after 1 year of unprotected intercourse. An evaluation should be carried out earlier if male or female infertility risk factors exist and if the couple questions its fertility potential. The initial screening of the man should include a reproductive history and a physical examination conducted by a urologist or a specialist in male fertility and 2 semen analyses (SA). Additional procedures and testing may be used to elucidate problems discovered during the full evaluation. The minimal initial endocrine evaluation should include serum total testosterone and serum follicle-stimulating hormone (FSH) levels. An endocrine evaluation should be carried out if sperm concentration is abnormally low, sexual function is impaired, and when other clinical findings suggest a specific endocrinopathy. A post-ejaculatory urinalysis should be performed if ejaculate volume is less than 1 ml, except in patients with bilateral vasal agenesis or possible hypogonadism. With a diagnosis of retrograde ejaculation, specific management should be considered before advising assisted reproductive technology (ART). Scrotal US is indicated when physical examination of the scrotum is difficult or inadequate, or when a testicular mass is suspected. Transrectal US (TRUS) is indicated in patients who are azoospermic or have a low ejaculate volume. Specialized testing of semen is not required for routine diagnosis of male infertility. However, some tests may be useful for a few patients to identify a male factor contributing to unexplained infertility, or to select therapy (e.g., ART). Before performing intra-cytoplasmic sperm injection (ICSI), karyotyping and Y-chromosome analysis should be offered to men who have non-obstructive azoospermia and severe oligospermia. Genetic testing for gene mutations of the ABCC7 (ex-CFTR) gene should be offered to male and female partners before proceeding with treatments that use the sperm of men with congenital bilateral absence of the vas deferens or congenital unilateral abnormality of the seminal tract. Genetic counseling may be offered when a genetic abnormality is suspected in the male or female partner, and it should be provided when a genetic abnormality is detected. Genetic testing in the female partner, when non-symptomatic, should only be advised by a physician from a multi-disciplinary team registered by the ministry of health. Evaluation by testis biopsy and deferentography should be performed by a urologist or an andrologist registered for sperm retrieval.

Kamischke et al (2009) stated that male infertility is often involved in the couples infertility; thus, the diagnostic work-up of the couple should always entail gynecologists and andrologists. The key objective of the inter-disciplinary diagnostic work-up is the direction of the couple to potential treatments, bearing in mind that spontaneous pregnancies occur often in infertile couples. Well-established pathways for the male diagnostic work-up in infertility exist only marginally. A minimal andrological evaluation should be carried out at least in all infertile men after 1 year of unsuccessful unprotected intercourse or earlier if established male or female risk factors are present. Components of the minimal evaluation of the male partner should include at least a reproductive history and 2 SA according to World Health Organization (WHO) standards. An evaluation by an andrologist should be performed as routine procedure; however, a full andrological evaluation is especially important if the initial evaluation showed an abnormal male reproductive history or an abnormal semen analysis. Further evaluation of the male partner should also be considered in couples with unexplained infertility and in couples in whom there is a treated female factor and persistent infertility. In addition to the requirements of a minimal evaluation, a full evaluation for male infertility should include in addition at least a physical and genital examination. Based on the results of the andrological evaluation, the physician may recommend additional evaluations, which may include an endocrine evaluation, US of the scrotal content and/or prostate and seminal vesicles, genetic screening and the conductance of a diagnostic/therapeutic testicular biopsy.

Le et al (2020) stated that scrotal US is not a routine investigation in the clinical approach to male infertility analysis. In a descriptive, cross-sectional analysis, these investigators examined the role of testicular Doppler US in male infertility assessment and its relation to semen parameters in non-azoospermic men. This study entailed a total of 558 men from infertile couples; they examined at the Hue Center for Reproductive Endocrinology and Infertility, Hue University Hospital from June 2016 to May 2018. Some cohort characteristics, semen analysis, and testicular Doppler US were analyzed. Men with acute systemic diseases, acute urinary tract infection (UTI), hepatic dysfunction, malignant diseases, retrograde ejaculation, cryptorchidism, or azoospermia were excluded. The mean volumes of the right and left testicles were 8.87 and 8.77 ml, respectively. The total volume of the 2 sides was 17.63 ± 4.34 ml (95 % CI: 17.27 to 18.00 ml). The mean right resistive index (RI) was 0.61 ± 0.23, and the mean left RI was 0.59 ± 0.01. The rate of normal semen quality was 23.2 % in group with varicocele, and 30.6 % in group with non-varicocele. The US results from the normal semen group were much different from those of the abnormal semen group regarding testicular volume: mean right testis volume: 9.67 ± 1.88 ml versus 8.75 ± 2.34 ml, p = 0.0096; mean left testis volume: 9.54 ± 1.78 ml versus 8.51 ± 2.44 ml, p = 0.0047; mean total volume of 2 sides: 19.21 ± 3.60 ml versus 17.26 ± 4.59 ml, p = 0.005 (varicocele group); mean right testis volume: 9.21 ± 2.21 ml versus 8.63 ± 2.21 ml, p = 0.029 (non-varicocele group). The other indexes of color Doppler US (peak systolic velocity, end diastolic velocity, RI) were not found to correlate with semen quality. The authors concluded that testicular volume that exhibited a close relation to the semen parameters could be used as a clinical prediction factor for the quality of semen.

Rew et al (2021) noted that scrotal and testicular conditions include benign masses, infections, testicular torsion, and testicular cancer. Common palpable benign scrotal masses include spermatocele, varicocele, and hydrocele. Most patients with these masses require no treatment; however, some varicoceles are associated with impaired fertility, probably as a consequence of an increase in scrotal temperature that results in testicular hyperthermia, oxidative stress, as well as reduced spermatogenesis. Patients with documented infertility or scrotal pain should be referred to a urology subspecialist for consideration of surgical management. Epididymitis and epididymo-orchitis are caused by infection with Neisseria gonorrhoeae, Chlamydia trachomatis, or enteric bacteria. Antibiotics and supportive measures (e.g., scrotal elevation, bed-rest) are recommended for the management of acute epididymitis. Testicular torsion is a urologic emergency that requires rapid surgical exploration and orchidopexy to reduce the risk of testicular loss due to ischemia. Salvage rates exceed 90 % when surgical exploration is carried out within 6 hours of symptom onset. Testicular cancer often manifests as a painless, incidentally discovered mass in a single testis; US is recommended to confirm the diagnosis. The recommended primary intervention for a suspected malignant testicular tumor is radical inguinal orchiectomy.

The American Urologic Association (AUA)/American Society for Reproductive Medicine (ASRM)’s guidelines on “Diagnosis and Treatment of Infertility in Men” (Schlegel et al, 2021) provided the following information:

• Scrotal US should not be routinely performed in the initial evaluation of the infertile male.
• TRUS should not be performed as part of the initial evaluation. Clinicians should recommend TRUS in men with SA suggestive of ejaculatory duct obstruction (i.e., acidic, azoospermic, semen volume of less than 1.5 ml, with normal serum testosterone, palpable vas deferens).
• The scrotum may sometimes be difficult to examine (e.g., in an obese patient or when the dartos muscle remains contracted even in a warm room during the physical examination. In these infrequent cases, color Doppler US may be used to examine spermatic cord veins. However, routine use of US to identify sub-clinical (non-palpable) varicocele is discouraged, as treatment of these varicoceles is not helpful.

Furthermore, an UpToDate review on “Approach to the male with infertility” (Anawalt, 2024) states that “Scrotal or testicular ultrasound are useful if a patient has normal testicular volumes, normal serum testosterone, FSH, and LH, and azoospermia because the likely diagnosis is obstructive azoospermia. Scrotal or transrectal ultrasound should be done if the vasa differentia are not palpable on examination; this finding is important to confirm because it is associated with cystic fibrosis. Congenital absence of the vas deferentia may be the only manifestation of cystic fibrosis. Ejaculatory duct obstruction can be diagnosed by a scrotal or transrectal ultrasound showing dilated seminal vesicles. Transrectal ultrasound might be modestly more sensitive in detecting obstructive azoospermia. Patients with obstructive azoospermia should be referred to a urologist specialized in infertility for further evaluation and treatment. Although there is some controversy about the clinical significance of nonpalpable varicoceles in infertile men, it is not necessary to perform scrotal or transrectal ultrasound to detect small varicoceles because palpation is sufficient to detect large varicoceles that might be associated with male infertility”.

References

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