Scrotum Written Comp
Student Name: Christina Nolte
Date Submitted: May 29, 2014
Directions:


Students are required to complete each area based on the scan comp completed to receive maximum
points.
There are 10 sections; each section is worth a maximum of 5 points. Answers provided must relate to
specific information requested. Additional information including non-applicable information will result in
point deduction
Before the exam: Patient Interview, Chart Review, Possible Pathology, Patient Set Up, and Preparation
Section 1:
Identify the patient’s age, sex, ethnicity, current symptoms and pertinent history relevant to the exam.
Answer: An ultrasound testicular scan was ordered to rule out abscess. The patient was a 59-year-old Caucasian
male experiencing bilateral scrotal pain and swelling for a period of two days following a tick bite on his scrotal sac.
The patient stated there was itching and burning of the scrotal sac after the bite occurred. The scrotal sac
appeared swollen, erythematous, and was also warm to the touch. The patient stated this was the first occurrence
of scrotal problems, and he denied a history of cryptorchidism, male infertility, hydrocele, epididymitis, orchitis,
spermatic cord torsion, varicocele, scrotal abscess, scrotal hernia, scrotal mass, scrotal trauma, or a family history
of testicular carcinoma. The information provided on the patient chart correlated with the patient’s statements.
Identify the patient’s labs relevant to the exam (as high, low, or normal) and explain what the patient’s lab values
indicate.
If the patient had no labs, identify the labs relevant to the exam (with normal values) and explain what deviations
in these lab values indicate.
Answer: The patient chart showed no lab values available for review, and the patient stated no blood was drawn. A
lab value relevant to this exam is white blood cell count (WBC). The normal range of WBCs in the blood is 4,50010,000 white blood cells per microliter. A WBC count less than 4,500 is below normal and may be due to a number
of things. In this patient’s case, a low number of WBCs may indicate a severe bacterial infection caused by
anaplasmosis or ehrlichiosis, which are tick-borne diseases that can be caused by two different bacteria. These
diseases lower the number of WBCs by suppressing the production of tumor necrosis factor alpha, a cellular
product that promotes inflammation and immune response. On the other hand, a WBC count greater than 10,000
is above normal and is called leukocytosis. Leukocytosis may be due to a number of things, but most likely
infection resulting in abscess formation in this patient’s case.
Identify the patient’s previous exams and results relevant to this exam.
If the patient had no previous exams, identify one other imaging modality that could be used to evaluate your
patient’s symptoms. Explain why this modality would be used in conjunction with sonography.
Answer: The patient stated he had no previous imaging studies, and there were no previous exams listed in PACS,
or the patient chart. Another imaging modality that could be used to evaluate the patient’s symptoms is computed
tomography (CT). CT is an imaging modality that utilizes radiation and computers to produce detailed images of
the body. CT is normally used as a follow up to sonography when tumors are found in the scrotum. CT is able to
determine the presence of extension of pathology to other parts of the body.
Scrotum Written Comp
Grade for Section 1
5
Section 2:
Based on the patient’s clinical history, labs, and previous exams and results, what did you expect to find during this
exam and why?
Answer: I expected to see a scrotal abscess during the exam. I chose this pathology based on the patient’s chief
complaint and presenting symptoms of bilateral pain, swelling, redness, and increased temperature of the scrotal
sac following a tick bite. The clinical history provided by the patient and the lack of lab values did not rule out the
possibility of abscess. Had the WBC count been drawn, and within normal limits, then it wouldn’t have been as
likely to suspect abscess.
Grade for Section 2
5
Section 3:
Describe how you identified the patient and educated the patient on the exam being performed. Identify the
patient set up and exam preparation.
Answer:

Patient Identification:
o

Patient education:
o

In the holding area, I introduced myself and checked the patient’s wristband, then compared the
first and last name along with the medical record number to the request sheet. In the exam
room, I asked the patient to verify his name and date of birth, and compared it to the
information provided on the machine before beginning the exam.
I told the patient I was a student that would be performing an ultrasound of his scrotal sac and
testicles. I told the patient that ultrasound uses sound waves to produce images of structures
within the body. I explained I would apply warm gel to the scrotal skin as a couplant and use a
transducer to image the testicles, epididymis, and contents of the scrotal sac. I told the patient
the sonographer would check my images and may scan behind me to make sure we provided the
information necessary for the doctor to make a diagnosis. I explained the images would be sent
to the radiologist who would interpret the exam, and send the results to the emergency room
physician who would provide the results of the exam.
Patient set up:
o
Before approaching the patient, I prepared the room by placing a clean sheet on the stretcher for
sanitary purposes. I folded another clean sheet in half and placed it at the foot of the stretcher. I
grabbed two clean towels. I rolled the first towel and placed it on top of the sheet on the
stretcher, and I left the second towel folded and placed it on top of the sheet on the stretcher. I
made sure warm gel was available to prevent contraction and thickening of the scrotal sac during
the exam. I wiped the probe down with a sani-cloth, and then washed my hands before
approaching the patient.
o
After entering the exam room, I explained the procedure and explained the set up to the patient.
The patient was in a wheelchair already dressed in a gown with his pants and undergarments
removed with a blanket covering his lower limbs. I told the patient I would give him specific
instructions on how to set himself up, and then I would step out to give him privacy. First, I
instructed the patient to lay supine on the stretcher, and I demonstrated how to place the towel
Scrotum Written Comp
in between his thighs. Next, I instructed the patient to place his scrotum on top of the rolled
towel to isolate and immobilize it. Then, I instructed the patient to place his penis on top of his
abdomen, and cover it up with the second towel, tucking both sides beneath him and allowing
for patient modesty. Last, I instructed the patient to cover himself up with the second sheet
provided, so he would be completely covered when I reentered the room.
Grade for Section 3
5
During the Exam: Sonographic findings of structures, pathologies, measurements, and instrumentation
Section 4:
Identify the sonographic features of the scrotal contents.
Answer:
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

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
Right and left testicle:
o
Homogeneous echotexture
o
Medium-level echogenicity
o
Anechoic area surrounding right and left testicle- more prominent on the right side
Right and left epididymis:
o
Crescent shape
o
Homogeneous echotexture
o
Isoechoic echogenicity compared to testicles
o
Minimal color flow
Scrotal wall:
o
Slightly heterogeneous echotexture
o
Hyperechoic echogenicity compared to testicles
o
Numerous tubular, serpiginous, anechoic, slightly tortuous structures located posterior, and
inferior to the right and left testicles
Right and left spermatic cord:
o
Heterogeneous echotexture of skin and scrotal sac tissue
o
Medium-level echogenicity
Right appendix testis:
o
Small, ovoid structure located on superior pole of right testis
o
Echogenic
o
No color flow
Right and left mediastinum testis:
o
Linear echogenic band extending craniocaudally within testes
Scrotum Written Comp
Grade for Section 4
5
Section 5:
Identify all protocol measurements obtained and identify if each measurement is normal or abnormal. If
abnormal, what is indicated?
Answer:

Right testicle:
o
4.58 x 2.66 x 2.08 cm


Right epididymis:
o


Slightly smaller than the normal range of 10-12 mm

May be a normal variant for this patient because it is so close to the normal range
4.53 x 2.95 x 1.81 cm

Length and width measurements fall within normal range, but the AP measurement is
slightly smaller than the normal range of 2-3 cm

May be a normal variant for this patient because it is so close to the normal range
Left epididymis:
o

8.6 mm
Left testicle:
o

Within the normal range of 3-5 x 2-3 x 2-3 cm
9.2 mm

Slightly smaller than the normal range of 10-12 mm

May be a normal variant for this patient because it is so close to the normal range
Scrotal wall thickness:
o
o
Right: 10 mm

Abnormal because it is larger than the normal range of 2-8 mm

May indicate infection
Left: 14.2 mm

Abnormal because it is larger than the normal range of 2-8 mm

May indicate infection
Grade for Section 5
5
Section 6:
Identify the pathology documented during the exam including location, size, vascularity, and sonographic features.
If no pathology is seen, identify a common pathology seen with this exam and how you would need to modify your
protocol to document this pathology.
Scrotum Written Comp
Answer:

Pathology 1

Varicocele

Location:
o

Size:
o

Enlarged (> 2 mm), tubular, serpiginous, anechoic structures adjacent to the posterior and
inferior portion of the right testis
Pathology 2

Hydrocele

Location:
o


The size of the hydrocele was not measured
Vascularity:
o

Unilateral surrounding the right testicle
Size:
o
Avascular
Sonographic features:
o

Increased flow visualized within prominent veins during the Valsalva maneuver
Sonographic features:
o

Largest vessels measured 3.4 mm in the AP dimension
Vascularity:
o

Right side, posterior and inferior to the right testicle
Anechoic with through transmission
Pathology 3

Scrotal wall thickening

Location:
o
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

Bilateral
Size:
o
Right side- 10 mm
o
Left side- 14.2 mm
Vascularity:
o
Minimal color flow
o
Increased vascularity located within anechoic vessels during Valsalva maneuver
Sonographic features:
o
Slightly heterogeneous echotexture
o
Hyperechoic echogenicity compared to testicles
o
Numerous tubular, serpiginous, anechoic, slightly tortuous structures located posterior, and
Scrotum Written Comp
inferior to the right and left testicles
Grade for Section 6
5
Section 7:
Identify the ultrasound preset, transducer, and frequency utilized to provide diagnostic images and explain why
the specific instrumentation was correct.
Answer:

Preset:
o

The scrotal preset was selected for this type of exam. The scrotal preset was appropriate because
it provided multiple focal zones. The multiple focal zones narrowed the beam width resulting in
improved lateral resolution, and the ability to distinguish structures perpendicular to the sound
beam. In addition to, the preset was appropriate because it compensates for the attenuation or
absorption of sound through the designated organ. Selecting the appropriate preset assists in
optimizing your image quality.
Transducer:
o

A GE M12L linear array transducer was used. This transducer provided the 5 cm of penetration
needed to visualize the testicles in their entirety along with the posterior scrotal wall. It also
offered the best possible axial resolution by providing higher frequencies. The rectangular image
format allowed for a comparison image of the right and left testicles in the transverse plane and
allowed for the full length of the testicles to be viewed from the epididymis at the superior
portion to the inferior portion in the sagittal plane. In addition to, this transducer provided an
extended field of view function needed for the comparison image, and to measure the full length
of the testicles.
Frequency:
o
A frequency of 14 MHz was utilized throughout the exam. This frequency was appropriate
because it penetrated deep enough to see the entire testicle while also operating at the highest
frequency capable of this probe. The high frequency produced maximum image quality because
as frequency increases, the wavelength decreases, thus the axial resolution improves by
improving the ability to distinguish structures parallel to the sound beam.
For your transverse right and left testicle comparison image, identify the depth and focal zone(s) used and explain
why they were correct.
Answer: The depth was set to 5 cm, and three focal zones were used. The focal zones were placed at 2 cm, 3 cm,
and 4.5 cm. The depth of 5 cm was appropriate because it allowed for full visualization of both testicles and the
posterior scrotal wall along with the scrotal contents. The depth setting allowed for comparison of the size,
echogenicity, and vascularity of both testes. The focal zone placements were appropriate because it improved
lateral resolution by narrowing the beam diameter. Narrowing of the beam diameter enhances the ability to detect
structures perpendicular to the sound beam, so evaluation of the echotexture of the testicles and the scrotal
contents was maximized.
Scrotum Written Comp
For your transverse right and left testicle with color Doppler image, identify the color Doppler settings used and
explain why they were correct.
Answer:
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

Color PRF: 0.3 kHz
o
Low PRF and high color gain are correct when assessing the vessels of the testes due to the slow
velocity of flow within these vessels
o
The PRF was lowered to the point of aliasing, and then slightly increased it in order to adequately
detect low-flow states of the vessels in the testicles
Color gain: 40 dB
o
Low PRF and high color gain are correct when assessing the vessels of the testes due to the slow
velocity of flow within these vessels
o
To establish proper overall Doppler gain, I turned the gain setting up until speckling occurred,
then turned it back down to the point where speckling disappeared
o
Gain setting was correct because it was adequate to detect and allow for visualization of flow
Color frequency: 6.3 MHz
o
This Doppler setting was correct because transducer frequency is proportional to frequency shift;
thus, a higher Doppler frequency enhances the ability to detect slower flow
Grade for Section 7
5
Exam Findings: Student’s Preliminary Report and Physician’s Interpretation
Section 8:
What did you report to the sonographer and/or physician regarding the exam? Describe your interaction.
Answer:

Sonographer:
o I told the sonographer the patient suffered a tick bite to his scrotal sac two days prior to the
exam. I told the sonographer the patient experienced bilateral scrotal pain and swelling
following the tick bite, and the scrotal sac was also itching and burning. I informed the
sonographer this was the first occurrence of scrotal problems for this patient, and not lab values
were available. I reported that the scrotal sac appeared thickened and hypoechoic structures
were located posterior and inferior to the testicle, likely representing a varicocele. I told the
sonographer I evaluated these structures with and without the Valsalva maneuver. I told her the
right side demonstrated increased flow with color Doppler during Valsalva, while the left side did
not during its evaluation. I told the sonographer I saw an echogenic structure located at the
superior pole of the right testicle. I told the sonographer there was anechoic fluid surrounding
both testes, but it was more prominent on the right side.

Physician (jot pad): The sonographer wrote the jot while I took the patient back to the emergency
Scrotum Written Comp
department. She went over the exam with me once I returned to the department.
o Right varicocele/hydrocele
o Hypoechoic area lateral to right testicle
o Dilated vessels inferior and lateral to the right testicle
o Scrotal wall thickening
Grade for Section 8
4
Section 9:
What was the physician’s interpretation of the exam?
Answer:

Impression:
o
1. Scrotal wall thickening and hyperemia suggesting cellulitis however no discrete mass.
o
2. Small right hydrocele and varicocele. Testicles are unremarkable.
Grade for Section 9
5
Section 10:
Do you agree or disagree with the physician’s interpretation of the exam? Why or why not? (This must be
supported by current literature)
Answer: I agree with the physician’s interpretation that the scrotal wall appeared thickened and hyperemic. I also
agree with the physician’s interpretation that the testicles appeared normal, and a small right hydrocele and
varicocele was present. The scrotal wall measurement was 10 mm on the right and 14.2 mm on the left, which is
above the normal range of 2-8 mm. There were anechoic structures within the scrotal wall and around the testicles
that demonstrated increased blood flow during the Valsalva maneuver. The anechoic structures measured greater
than 2 mm, which suggests the presence of a varicocele. The testicles were surrounded by anechoic fluid, most
likely representing hydrocele because it is the most common fluid collection of the scrotum.
Grade for Section 10
Clinical Site:
Sonographer with credentials and
specialties:
Patient MRN:
Exam order on request:
Performance date of final scan comp:
Is this a second attempt written comp?
5
BMH-Desoto
Audrey Galey, RDMS, AB (2012), OB/GYN (2014); RVT, VT (2012)
0000024028
US Testicular Scan
March 22, 2014
No
Scrotum Written Comp
Points
Description
5

No errors were identified
4

One error was identified
3

Errors identified In less than the ½ of the components required
2

Errors identified In up to ¾’s of the components required
1

Immediate action required
 errors identified in more than ¾’s of the components required
 evidence of an unsafe event (unsafe events may result in failure of
the competency)
 required image not included
Grade: 49/98
by HMM