|Year : 2019 | Volume
| Issue : 2 | Page : 101-105
Sonography of scrotal abnormality among subfertile and fertile males in Abuja, Nigeria
Kolade-Yunusa Hadijat Oluseyi1, Thairu Yunusa2
1 Department of Radiology, University of Abuja/University of Abuja Teaching Hospital, Gwagwalada, Abuja, Federal Capital Territory, Nigeria
2 Department of Medical Microbiologist and Parasitology, University of Abuja/University of Abuja Teaching Hospital, Gwagwalada, Abuja, Federal Capital Territory, Nigeria
|Date of Web Publication||04-Nov-2019|
Kolade-Yunusa Hadijat Oluseyi
Department of Radiology, University of Abuja Teaching Hospital, Gwagwalada, Abuja FCT
Background Male factor infertility in Nigeria accounts for up to 50% of all infertility cases, most of which happen as a result of abnormalities of testicular function and infection. Male factor can be assessed by seminal fluid analysis; however scrotal ultrasound is now increasingly being used to evaluate males with infertility.
Objectives The objective of this study is to determine the spectrum of scrotal abnormalities on ultrasound in sub-fertile and fertile men.
Patients and method This was a prospective study which spanned for a period of eight months (January–August 2016). A total of 270 patients were included in the study comprising of 180 consecutive males who were being evaluated for sub-fertility and 90 apparently normal fertile adults who underwent a scrotal scan at the radiology department of University of Abuja Teaching Hospital using 7.5 MHz of EMP G70, China scan machine with Doppler facility. All patients were scanned in supine and upright position in both B and Doppler modes and any scrotal abnormalities were recorded.
Result The mean age of sub-fertile and fertile subjects studied was 29 ± 11.4 years and 34 ± 16.3 years, respectively. Scrotal abnormalities were commoner in the sub-fertile group compared to the fertile group with a prevalence rate of 45.0% and 32.2%, respectively. Varicocele was the most common finding in both groups with a higher prevalence rate of 50.6% in the sub-fertile group compared to 48.3% in fertile group. This distribution was statistically significant (P = 0.000). Varicocele was observed more on the left. Hydrocele was the second most common finding in both groups.
Conclusion The role of scrotal scan in evaluating infertility cannot be overemphasized. In this study, ultrasound scan was used to evaluate 45.0% of sub-fertile subjects with scrotal abnormalities. Ultrasound being non-invasive and readily available should be considered as an important investigation in accessing cases of infertility.
Keywords: Ultrasound, sub-fertile, scrotal abnormalities, fertile, males, Abuja
|How to cite this article:|
Oluseyi KYH, Yunusa T. Sonography of scrotal abnormality among subfertile and fertile males in Abuja, Nigeria. Sub-Saharan Afr J Med 2019;6:101-5
|How to cite this URL:|
Oluseyi KYH, Yunusa T. Sonography of scrotal abnormality among subfertile and fertile males in Abuja, Nigeria. Sub-Saharan Afr J Med [serial online] 2019 [cited 2021 Jan 17];6:101-5. Available from: https://www.ssajm.org/text.asp?2019/6/2/101/270251
| Introduction|| |
Scrotal ultrasonography is an imaging test that examines the scrotum and its contents. The testes are male reproductive organs that produce sperm and the hormone testosterone. They are located in the scrotum, along with other small organs, blood vessels, and a small tube called the vas deferens. In recent years, there have been significant advances in the diagnosis and management of male urogenital disorders.,,
Ultrasound imaging of the scrotum uses sound waves to produce images of a man’s testicles and surrounding tissues. Ultrasound is safe, noninvasive, and does not use ionizing radiation.,, Because ultrasound images are captured in real-time, they can show the structure and movement of the body’s internal organs, as well as blood flowing through blood vessels.,, Ultrasound imaging of the scrotum is the primary imaging method used to evaluate disorders of the testicles, epididymis, and scrotum. ,
Male factor infertility in Nigeria accounts for up to 50% of all infertility cases, most are because of abnormalities of testicular function and infection. Male factor can be assessed by seminal fluid analysis and testicular ultrasonography.
Varicocele can be reliably diagnosed with ultrasound which will show dilation of the vessels of the pampiniform plexus to greater than 2 mm. The patient being studied should undergo a provocative manoeuvre, such as Valsalva manoeuvre, to increase intra-abdominal venous pressure and increase the dilatation of the veins.,,
Doppler ultrasound is a technique of measuring the speed at which blood is flowing in a vessel. An ultrasound machine that has a Doppler mode can see reverse direction of blood in a varicocele with a Valsalva, increasing the sensitivity of the examination.,, Reflux varicocele can be demonstrated with colour Doppler ultrasound scan (CDUS). During Valsalva manoeuvre, there will be a change/reversal of the colour flow and increase in diameter of the vein. Pulsed spectral analysis will show evidence of flow reversal as well as the duration of reflux.
The health and economic impact of subfertility in the general public are enormous and the global burden of scrotal abnormalities is also high because these abnormalities can result in depression. The aim of this study was to determine the common pathologies of the scrotum in fertile and sub-fertile patients attending the radiology department in University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria.
| Materials and methods|| |
The study was carried out at the radiology and microbiology departments of University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria.
Consecutive adult males between 16 years and 70 years were divided into two groups. The first group was made up of subjects sent to the radiology department for evaluation for infertility while the second group was made up of normal male adults that came for routine scan with no history of challenge at conception but had their seminal fluid analysed in the microbiology department. Both groups of subjects recruited separately and were informed of the research and consented to participate in the study were enrolled.
Inclusion criteria: This includes all patients being evaluated for infertility who had a scrotal scan in the radiology department and patients who consented to participate in the study. The main inclusion criteria for the fertile subjects were those with no history of challenge at conception, history of childbirth, and adequate sperm count.
Exclusion criteria: Patient who discontents to be part of the study.
This was a prospective study which spanned for over eight months (January–August 2016).
Study sample size
The minimum sample size was calculated using the following formula:
using local prevalence of 65.0%. The calculated sample size was 158.9 (2.5% for attrition of the minimum sample size of 155.0). Two hundred and seventy patients were scanned in the radiology department for the determination of scrotal abnormalities.
Ultrasonographic assessment of the scrotal contents was done using EMP G70 ultrasound machine manufactured by Shenzhen Emperor Electronic Technology® China 2011 with high-resolution 7.5 MHz linear probe. Images were obtained in both B-mode and colour Doppler. Images of the testes were acquired in the longitudinal and transverse planes with the patient in supine and standing positions followed by physical examination of the testes.
The criteria for the diagnosis of varicocele were: (1) the largest plexus pampiniformis vein measured more than 2 mm in diameter in supine position or >3 mm in the standing position; (2) more than 1 mm increase in size of the largest vein during Valsalva on gray-scale examination; (3) more than 2-s retrograde flow during Valsalva manoeuvre on colour Doppler US. A combination of criteria 1 and 2 or 1 and 3 was regarded as diagnostic of varicocele. An epididymal cyst was diagnosed by the presence of cysts (on the epididymis) that were hypoechoic and circumscribed with good through transmission and posterior wall enhancement. A suspicion of testicular tumour was defined as the presence of focal hypoechoic lesion within the normally homogenous testis. The presence of multiple, diffuse, non-shadowing hyperechoic foci was diagnosed as microlithiasis. The presence of echo-free (or faintly echoic) collection of fluid in the tunica vaginalis (or surrounding the testis) was diagnosed as hydrocele. 
Data were analysed using SPSS 19.0 software 2010 by IBMR, USA. The chi square-test and Fischer exact test was used to perform and establish any statistical difference. Probability values of <0.05 was considered as statistically significant.
The study was approved by the Ethical Committee of the hospital.
| Results|| |
This study was carried out among 270 adult males who met the inclusion criteria and were between the ages of 16 and 75 years. This includes 180 sub-fertile subjects and 90 fertile subjects. The mean age of sub-fertile and fertile subjects studied was 29 ± 11.4 years and 34 ± 16.3 years, respectively, with the highest proportion within the age range of 21–30 years accounting for 45.6% of sub-fertile study population scanned ([Table 1]) while the highest proportion within the age range of 31–40 years accounting for 40.0% of fertile study population scanned ([Table 2]). However, the distribution was statistically significant (P = 0.000). The lowest proportion being 70 years and above, 3.3% among sub-fertile ([Table 1]), and 0.0% for fertile subjects ([Table 2]). However, the distribution was not statistically significant (P = 0.08).
|Table 1 Age and distribution of abnormal radiologic findings among sub-fertile subjects|
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|Table 2 Age and distribution of abnormal radiologic findings among fertile subjects|
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From the 270 subjects scanned comprising 180 sub-fertile and 90 fertile subjects, 4 subjects were from the sub-fertile group in the age group of 16–20 years and all had abnormal scrotal scan giving a prevalence rate of 100%; 51 (62.2%) had abnormal scrotal scan and 31 (37.8%) had normal sonogram in the age group of 21–30 years among the sub-fertile subjects ([Table 1]); while 4 with a prevalence rate of 16.0% had abnormal ultrasound scan among the fertile subjects ([Table 2]), the remaining subjects within the age group of 21–30 years had normal scrotal scan; this distribution was statistically significant (P = 0.001); 11 (25.6%) had abnormal scrotal scan and 32 (74.4%) had normal sonogram the age group of 31–40 years among the sub-fertile subjects ([Table 1]). While 26 (72.2%) had normal scrotal scan and 10 with a prevalence rate of 27.7% had abnormal scan among the fertile subjects, this distribution was statistically not significant (P = 0.9, [Table 2]); 5 (23.8%) had abnormal scrotal scan and 16 (76.2%) had normal scan within the age group of 41–50 years among the sub-fertile subjects ([Table 1]). While 7 (70.0%) had normal scan and 3 (30.0%) had abnormal scan among the fertile subjects, this distribution was not statistically significant (P = 0.1, [Table 2]). Out of the 14 males in the 51–60 years age group among the sub-fertile group, 6 (42.9%) had abnormal scrotal scan findings while 8 (57.1%) had normal scrotal findings. This distribution was statistically significant (P = 0.001, [Table 1]).
The scrotal abnormalities in both groups of subjects scanned varied; 41 subjects scanned had varicocele giving a prevalence rate of 50.6% among sub-fertile subjects ([Table 3]), while 14 subjects had varicocele among fertile subjects ([Table 4]). Among sub-fertile subjects scanned, varicocele was predominantly observed in the left scrotal sac in 31 subjects, while only 10 subjects had varicocele in the right scrotal sac. This distribution was statistically significant (P = 0.000; [Table 3]). Among fertile subjects, seven subjects had varicocele in left and right scrotal sac, respectively ([Table 4]). The distribution of varicocele on the left and right among fertile group was not statistically significant (P = 0.08). Three (42.8%) subjects scanned among the fertile group and nine (28.1%) subjects scanned among the sub-fertile group had bilateral scrotal varicocele.
Hydrocele was the second most prominent findings after varicocele, among the sub-fertile and fertile subjects scanned. A total of 22 subjects scanned had hydrocele with a prevalence rate of 27.1% among sub-fertile subjects ([Table 3]) while 7 subjects had hydrocele among fertile subjects ([Table 4]). Among 22 sub-fertile subjects scanned, 17 had hydrocele in the left scrotal sac, while 5 subjects had hydrocele in the right scrotal sac ([Table 3]). Other scrotal scanned findings among sub-fertile subjects were spermatocele, tumours, epididymal cyst, and testicular cyst. These scrotal scan findings were also observed among fertile subjects with exception of testicular cyst.
All the 31 subjects with left-sided varicocele among sub-fertile subjects were within the 21–30 years age group. A total of 10 subjects with left-sided hydrocele, 3 subjects with right-sided spermatocele, and 2 subjects with left-sided epididymal cyst were seen within the 21–30 years age group and all the five subjects with right-sided hydrocele among the sub-fertile subjects were within 21–30 years age group. There was a positive correlation between age and the side of scrotal abnormality. These differences were statistically significant (P = 0.001, Pearson Chi-Square = 27.167, df = 2, positive Spearman Correlation = 0.430).
| Discussion|| |
The overall prevalence of scrotal abnormalities in sub-fertile and fertile patients at University of Abuja Teaching Hospital (UATH) was 45.0% and 32.2%, respectively. This figure in this current study varies with findings in other parts of Nigeria,, and the world.,,
The overall prevalence of 45.0% among infertile subjects was higher than 38.0% prevalence obtained by other researchers. The overall prevalence of scrotal abnormalities was lower than 55.6% reported among infertile male in northwestern Nigeria, 65.1% among 249 infertile males reported by Tijani and colleaques in the south-west Nigeria. The prevalence in this study was lower than values above 50.0% reported by Sakamoto, Qublan, and Gordon across the world. The differences might be due to the fact that the methodology employed in these studies,,, differs from the method employed in this study. Most of the studies with higher prevalence rate of scrotal abnormalities reported other findings not related to infertility such as acute scrotal emergencies, testicular volume, testicular lie, testicular homogeneity, spermatocele, and epididymal thickening. Studies in northwest Nigeria included haematocele and pyocele. Among the fertile group studied, 29 (32.2%) subjects had scrotal abnormalities; this finding was consistent with report by other researchers. ,,
The predominant abnormal scrotal finding in our study was varicocele among sub-fertile and fertile males. Reports in literature have also described varicocele as the most common identifiable abnormality detected in sub-fertile men on scrotal scan. The prevalence of 50.6% for varicocele among sub-fertile men in these studies was higher than findings reported by other researchers,, where the value of 0.8%, 35.5%, and 29.7% were obtained. In this other study, prevalence of varicocele was determined in men with primary and secondary infertility; this was however not done in this study which may be responsible for the higher prevalence rate. The prevalence rate of varicocele among sub-fertile subjects was lower than the study in the south-west of Nigeria.  Varicocele was predominantly observed in the left scrotal sac among the sub-fertile group but not in the fertile group; this finding is consistent with other reports. , Reports from the literature also showed that abnormal dilatation of the peritesticular veins is more frequently encountered on the left side. The main cause of left-sided varicocele resides in the “nutcracker” phenomenon exerted by the superior mesenteric artery and the aorta on the left renal vein. The reduction of the aorto-mesenteric distance and a decrease of the aorto-mesenteric angle are positively associated with decrease in mean flow velocity in the left renal vein.
Hydrocele was the second prominent abnormal scrotal findings. The findings recorded in this study were consistent with findings by other researchers. ,, Hydroceles are not known to cause issues with fertility directly, however this can cause pain or discomfort during intercourse. Mihmanli and Kantarci were able to demonstrate that idiopathic hydrocele may cause testicular enlargement and increased vascular resistance in the intratesticular arteries, thereby adversely affecting testicular function. 
Most of the abnormal scrotal findings were within 21–30 years age group among sub-fertile male subjects, which was about 60.0%. This may be due to the fact that most of the subjects recruited were within this age group. Also, the age group is the sexually active stage and of marital age. It is expected that sub-fertile couple will seek medical attention for infertility and scrotal ultrasound is an important component of male evaluation.
In this study, all the left-sided varicocele were within the 21–30 years age group and subjects with microlithiasis and suspected tumour among sub-fertile male were all within the 51–60 year age group. Another finding is the concentration of scrotal abnormalities in the left scrotal sac among sub-fertile males; this was statically significant and correlates positively with age of the subjects. This was consistent with findings in the southwest.  Contrarily, among fertile male subjects, abnormal scrotal pathologies were radiologically observed prominently on the right scrotal sac. The reason for the observed pathologies is not readily known.
| Conclusion|| |
The overall prevalence of scrotal abnormalities among infertile males was 45.0%. This was recorded using ultrasound. Varicocele (50.6%) and hydrocele (27.1%) were important and prominent findings in evaluated sub-fertile males which were evidently higher among sub-fertile males than the fertile control subjects. Diagnostic ultrasound is cheap, noninvasive, and a reliable method of evaluation of male infertility.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Shaida N, Berman L. Male Genitourinary Tract. In: Adam A, Dixon AK, Gillard JH, editors. Grainger & Allison’s Diagnostic Radiology: A Textbook of Medical Imaging. 6th ed. New York, NY: Churchill Livingston e; 2014. Chap 40.
Regent L. Urogenital diseases in the elderly. Soins Gerontol 2014;9:43-45.
Harvey CJ. Male urogenital disorders. Br. J Radiol 2012;85:91-92.
Sakamoto H, Saito K, Shichizyo T, Ishikawa K, Igarashi A, Yoshida H. Color Doppler ultrasonography as a routine clinical examination in male infertility. Int J Urol 2006;13:1073-1078.
Nashan D, Behre HM, Grunert JH, Nieschlag E. Diagnostic value of scrotal sonography in infertile men: report on 658 cases. Andrologia. 1990;22:387-395.
Hamm B. Sonography of the testis and epididymis. Andrologia. 1994;26:190-210.
Tijani KH, Oyende BO, Awosanya GO, Ojewola RW, Lawal AO, Yusuf AO. Scrotal abnormalities and infertility in West African men: a comparison of fertile and sub-fertile men using scrotal ultrasonography. Afr J Urol, 2014;20:180-183.
Patrick OU, Abiodun ME. Male infertility in Nigeria: a neglected reproductive health issue requiring attention. Journal of Basic and Clinical Reproductive Sciences 2015;4:45-53.
Okorie CO, Pisters LL, Liu P. Longstanding hydrocele in adult Black Africans: is preoperative scrotal ultrasound justified? Niger Med J 2011; 52:173-176. [Full text]
Muhammad ZI, Abdulkadir MT, Joseph BI, Suleiman L, Mohammed A. Scrotal Doppler ultrasound evaluation in Zaria, Nigeria. Niger J Basic Clin Sci 2016;13:89-93.
Bucci S, Liguori G, Amodeo A, Salamè L, Trombetta C, Belgrano E. Intratesticular varicocele: evaluation using grey scale and color Doppler ultrasound. World Journal of Urology, 2007;26:87-89.
Charboneau J, William R, Carol M, Wilson SR. Diagnostic ultrasound. St. Louis: Mosby 1998, ISBN 0-8151- 8683–5.
Qublan HS, Al-Okoor K, Al-Ghoweri AS, Abu-Qamar A. Sonographic spectrum of scrotal abnormalities in infertile men. J Clin Ultrasound, 2007;35:437-41.
Pierik FH, Dohle GR, Van Muiswinkel JM, Vreeburg JTM, Weber RFA. Is routine scrotal ultrasound advantageous in infertile men? Journal of Urology 1999;162:1618-1620.
Gordon SJ, Otite U, Maheshkumar P, Cannon P, Nargund VH. The use of scrotal ultrasonography in male infertility. British Journal of Urology International, 2001;87:417-420.
Agarwal A, Deepinder F, Cocuzza M, Agarwal M, Short R, Sabanegh RAE et al.
Efficacy of varicocelectomy in improving semen parameters: new meta-analytical approach Urology, 2007; 70:532-538.
Araoye O.A. Research methodology with statistics for health and social sciences. 2nd ed. Ibadan: Nathadex Publishers; 2004. p. 120.
Mihmanli I, Kantarci F. Sonography of scrotal abnormalities in adults: an update. DiagnInterv Radiol 2009;15:64-73.
Nicholson A, Rait G, Murray-Thomas T, Hughes G, Mercer CH. Management of epididymo-orchitis in primary care: results from a large UK primary care database. Br J Gen Pract 2010;60:e407-22. doi: 10.3399/bjgp10X532413
[Table 1], [Table 2], [Table 3], [Table 4]