Imaging of Penile and Scrotal Emergencies
Penile and scrotal emergencies are uncommon, but when they do occur, urgent or emergent diagnosis and treatment are necessary. Emergent conditions of the male genitalia are primarily infectious, traumatic, or vascular. Infectious conditions, such as epididymitis and epididymo-orchitis, are well evaluated at ultrasonography (US), and their key findings include heterogeneity and hyperemia. Pyocele and abscess may also be seen at US. Fournier gangrene is best evaluated at computed tomography, which depicts subcutaneous gas. Vascular conditions, such as testicular torsion, infarction, penile Mondor disease, and priapism, are well evaluated at duplex Doppler US. The key imaging finding of testicular torsion and infarction is a lack of blood flow in the testicle or a portion of the testicle. Penile Mondor disease is characterized by a lack of flow to and noncompressibility of the superficial dorsal vein of the penis. Clinical examination and history are usually adequate for diagnosis of priapism, but Doppler US may help confirm the diagnosis. Traumatic injuries of the penis and scrotum are initially imaged with US, which depicts whether the penile corpora and testicular seminiferous tubules are contained by the tunicae albuginea; herniation of contents and discontinuity of the tunica albuginea indicate rupture. In some cases, magnetic resonance imaging may be performed because of its ability to directly depict discontinuity of the tunica albuginea. Radiologists must closely collaborate with emergency physicians, surgeons, and urologists to quickly and efficiently diagnose or rule out emergent conditions of the male genitalia to facilitate prompt and appropriate treatment.
Abdominal and Pelvic Aneurysms and Pseudoaneurysms:
Imaging Review with Clinical, Radiologic, and Treatment Correlation
Abnormally enlarged visceral arteries in the abdomen and pelvis must be recognized radiologically because early treatment can improve the quality of life and prevent life-threatening complications. These lesions, typically classified as aneurysms and pseudoaneurysms, are being detected more frequently with increased utilization of imaging and have various causes (eg, atherosclerosis, trauma, infection) and complications that may be identified radiologically. Ultrasonography, computed tomography, and magnetic resonance imaging often enable detection of visceral vascular lesions, but angiography is important for further diagnosis and treatment. Endovascular treatment is often the first-line therapy. Endovascular intervention or open surgical repair is necessary for all visceral pseudoaneurysms and is likely indicated for visceral aneurysms 2 cm or more in diameter. Endovascular exclusion of flow can be achieved with coils, stents, and injectable liquids. Techniques include embolization (“sandwich” or “sac-packing” technique), exclusion of flow with luminal stents, and stent-assisted coil embolization. Management often depends on the location and technical feasibility of endovascular repair. Embolization is usually preferred for aneurysms or pseudoaneurysms within solid organs, and the sandwich technique is often used when collateral flow is present. Covered stent placement may be preferred to preserve the parent artery when main visceral vessels are being treated. It is usually tailored to lesion location, and a cure can often be effected while preserving end-organ arterial flow. Posttreatment follow-up is usually based on treatment location, modality accuracy, and potential consequences of treatment failure. Follow-up imaging may help identify vessel recanalization, unintended thrombosis of an artery or end organ, or sequelae of nontarget embolization. Retreatment is usually warranted if the clinical risks for which embolization was performed are still present.