Testicular Nuclear Medicine Scan :Testicular Nuclear Medicine Scan NMT1713 By: Macarena Ayala


Objectives :2 Objectives Apply understanding to case studies Describe the anatomy & physiology of the male genitalia. Explain proper testicular scan procedures & techniques. Define and distinguish testicular torsion from epididymititis


Patient :3 Patient Adam Thomas was playing a ruby match against his neighboring town. At approximately 12 noon another player accidentally kicked him in the scrotal area. He was unable to finish the game due to severe scrotal pain and swelling.


Presentation :4 Presentation A 22-year-old man presented with 3 days of right testicular pain and swelling. Rugby player who experienced blunt trauma to the scrotal area. The pain has persisted over the three days, becoming more diffuse and dull in nature.


Doppler Ultrasound :5 Doppler Ultrasound An enlarged, heterogeneous right testicle. Examination of the right testicle showed absent flow in the testicle but with a small amount of peritesticular flow present. The left scrotal contents were normal. Recommend Nuclear Medicine exam for confirmation.


Male Anatomy :6 Male Anatomy Scrotum: pouch that encompasses the testes; allows suspension from pelvic cavity Testes: develop in the abdomen but descend to normal position in the scrotum usually by birth & are draped with tunica vaginalis on the anterolater surface Slightly flat & oval average size 4cm long Left testis slightly lower than right Spermatic Cord: connective tissue, passes through scrotum superior to testes across anterior side of pubis into groin Spermatic Ducts: after leaving the testes sperm travels through 4 types of ducts Ductus Epididymis: forms the body & tail of epididymis


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Physiology :8 Physiology Testes are the male gonads which produces spermatozoa and testosterone Each testes is supplied by a testicular artery initially from the abdominal aorta Blood supple enters the posterior aspect of testicle & prevents it from rotating back into the scrotum Testicular arteries enter testis to form capsular arteries which branch into centripetal arteries and form U loops at ends to increase blood supply


Indications :9 Indications Differentiate between torsion, epididymitis, & orchitis Evaluation of scrotal mass Evaluation of groin pain Evaluate blood supply to testes Evaluation of increased perfusion caused by inflammatory disease Assess damage to the testicles caused by an injury


Common Causes :10 Common Causes Males predisposed to testicular torsion, results from inadequate connective tissue within scrotum More common in infancy age to adolescence Undescended testicle Trauma to scrotum Strenuous exercise Congenital abnormality; Bell Claper deformity Sexual arousal/activity Active cremasteric reflux Cold weather


Main Purpose :11 Main Purpose Differentiate between: Epididymitis: infection in the testes Testicular torsion: twisting of the testes shuts off it’s blood supply Infarction: area of necrotic tissue; sudden death from lack of blood perfusion


Testiculat Torsion :12 Testiculat Torsion


Other differentials: :13 Other differentials: Epididymo-orchitis: sexually transmitted Gonococcus, Clamydia trachomantis Testicular abscess: complication epididymo-orchitis or torsion Testicular blunt trauma: cause hematoma and contusion, rupture of testis Testicular tumors: most common teratomas Viral-orchitis: mumps, rubella


Statistics :14 Statistics In the U.S. torsion occurs in males younger than 25 years of age approximately 1/4000 More common in left testicle Most common in 10-19 years Salvage rates: 100% under 6 hours onset of pain 20% viability after 12 hours 0% viability greater than 24 hours


Patient History :15 Patient History History or family history of cancer? Type & how long ago? Are you in pain now? How long since pain started? Where exactly is the pain? What was the activity at the onset of pain? History of this type of pain? Have you had any recent trauma to that region? Have you had any prostate problems? Other department specific question?


Patient History :16 Patient History No history or family history of cancer. Patient is in pain at the present moment. Pain has persisted over the last 3 days. Pain is only in the right testicle. During a rugby match the patient was kicked in the scrotal area. No previous history of this type of pain. Patient does not have any prostate problems. Doppler Ultrasound showed an enlarged, heterogeneous right testicle. No loops of peristalsing bowel are present. Right testicle showed absent flow in the testicle itself but with a small amount of peritesticular flow present. Left testicle appeared normal.


Patient Symptoms :17 Patient Symptoms Light-headedness Trauma induced onset of severe unilateral scrotal pain Scrotal swelling


Patent Preparation :18 Patent Preparation Identify the patient Verify doctor’s order Have patient empty bladder if possible Be cautious as patient is usually in pain Explain procedure


Testicular Scan :19 Testicular Scan Uses a camera to take pictures of the testicles after a radioactive material accumulates in testicular tissue Note acute pain in one testicle of male under age of 25 is considered a surgical emergency!


Radiopharmacy :20 Radiopharmacy Radionuclide: 99mTc T ½ 6 hours 140 Kev Radiopharmaceutical: Na 99mTcO4- Adult dose: 8-20mCi Pediatric dose: 5mCi min Administration: IV injection, bolus for flow Localization: compartmental to blood supply


Acquisition :21 Acquisition Camera: Small FOV best Large FOV use magnification Collimator: LEHS LEAP = flow LEHR = statics Pinhole = pediatrics Computer Set-up Flow: 2-6sec /frame 1 min Statics: 500k-700k cts Immediate, 5, 10, 15, 20, 25, 30 min Magnification: 1.5-2X


Procedure~30 min :22 Procedure~30 min Remove any attenuating material from FOV Place supine on table, legs adducted or frogleg Secure penis to abdomen (chest) with tape Tape cannot stick to legs, scrotum, or penis Position towel or tape sling under testicles for support Drape privacy cloth after set-up Ensure testes separated camera anterior, as close as possible Scrotum center FOV Lead shielding over thighs, abdomen or under scrotum only on statics reduces background Inject and wait a few seconds to start flow Image immediate blood pool, then static every 5 min for 30 min Optional images = RAO/LAO magnified views, placements of thin marker on raphe of scrotum in one static


Normal Results :23 Normal Results Flow: medial borderline of iliac artery is smooth No significant activity seen in area of testicular, deferential, or prudendal artery Scrotal perfusion: (if present) seen only as poor marginated, minimally intense area of activity Tissue phase: scrotum and contents with homogenous activity


Abnormal Results :24 Abnormal Results Torsion: Flow (perfusion) scan missing perfusion to affected side Tissue phase (statics) photopenic area with activity less than opposite testicle & thigh Increased activity seen on high cord


Abnormal Results :25 Abnormal Results Infarction: Flow (perfusion) increased blood flow through pudendal vesssels Tissue phase halo sign on affected side Epididymitis: acute Flow & tissue phase increased activity Orchitis: flow & tissue phase increased activity, more medial testicular Trauma: diffuse increase with decreased areas (hematoma, hematocele, hydrocele) Tumor: diffuse increase with decreased areas Vascular Tumor: increased flow, increased tissue phase


Artifacts :26 Artifacts Lead shielding block out background vascular from torso/legs Testicles not separated for imaging Sticky side of tape on scrotum/penis 99mTcO4- in a filled bladder interferes with interpretation Patient movement will blur image Previously castrated patients make visualization long & tedious


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Patient Image Findings :29 Patient Image Findings Radionuclide testicular flow study showed increased tracer accumulation to the right scrotum. Static imaging demonstrates persistent increased uptake with a central area of photopenia. The characteristic bull's-eye or donut sign on the radionuclide study is most consistent with a missed or late phase torsion.


Diagnosis :30 Diagnosis Testicular Torsion Recommend this patient for immediate surgery.


Conclusion :31 Conclusion Describe the anatomy & physiology of the male genitalia. Scrotum: sac that holds the testis Testes: males gonads, with individual blood supply Spermatic tissue: tissue that is connected to the testes Explain proper testicular scan procedures & techniques. Gather adequate patent history information Proper patient preparation for clear images Small FOV Phase I: Flow LEAP 2-6sec /frame 1 min Phase II: Statics: LEHR 500k-700k cts Immediate, 5, 10, 15, 20, 25, 30 min


Conclusion :32 Conclusion Define and distinguish testicular torsion from epididymititis Epididymitis: infection in the testes Acute Flow & tissue phase increased activity Testicular torsion: twisting of the testes shuts off it’s blood supply Flow (perfusion) scan missing perfusion to affected side Tissue phase (statics) photopenic area with activity less than opposite testicle & thigh Increased activity seen on high cord Infarction: area of necrotic tissue; sudden death from lack of blood perfusion Flow (perfusion) increased blood flow through pudendal vesssels Tissue phase halo sign on affected side


Questions & Answers :33 Questions & Answers What are the two phases of a testicular scan? Phase 1: Flow Phase 2: Static What phase can lead shielding be used to eliminate background? Static What is the preferred radiopharmaceutical? Na 99mTcO4- What are the doses? Adult dose: 8-20mCi Pediatric dose: min of 5mCi


References :34 References Beltran MR, Testicular Imaging. In: Henkin RE, Boles MA, Dillehay CL (eds). Nuclear Medicine Vol II. Mosby-Year book, Inc. 1996: 1110-1121. Rajfer, Jacob. "Congenital Anomalies of the Testes and Scrotum." In Campbell's Urology, edited by Patrick C. Walsh, et al. Philadelphia: W. B. Saunders, 1998, pp. 2184-2186. Rozauski, Thomas, et al. "Surgery of the Scrotum and Testis in Children." In Campbell's Urology, edited by Patrick C. Walsh, et al. Philadelphia: W. B. Saunders, 1998, pp. 2200-2202. Smith-Harrison LI, Koontz WW: Torsion of the Testis: Changing Concepts. AUA Updates 1990; 32.


The End :The End Thank You for your time!