Correspondence

More on Stretcher's Scrotum

N Engl J Med 1993; 329:436-437August 5, 1993

Article

To the Editor:

We read Dr. Ragozzino's account (March 18 issue)1 of the recreational athlete who had acute scrotal injury after a seemingly benign session of physiotherapy. Our curiosity lay not with the proposed mechanism of injury but with the use of magnetic resonance imaging (MRI) as a diagnostic tool.

We wonder whether MRI has a role in the diagnostic workup of acute scrotal swelling and pain. We are in an era in which cost constraints are of paramount concern. Would palpation, transillumination, or ultrasonography have been as useful diagnostically? We find it ironic that Dr. Ragozzino's correspondence was published in the same issue as two articles comparing medical expenditures in the United States and Canada.

If American physicians deem MRI to be medically justified and cost effective in the diagnosis of acute scrotal swelling, then the Clintons really do have their work cut out for them.

Paul C. Pereira, B.Sc., M.D.
St. Joseph's Health Centre, Toronto, ON M6R 1B5, Canada

Simon Kingsley, B.Sc.
University of Toronto, Toronto, ON M5S 1A1, Canada

1 References

1. 1

   Ragozzino MW. Stretcher's scrotum. N Engl J Med 1993;328:815-815
   Full Text | Web of Science | Medline

Author/Editor Response

Dr. Ragozzino replies:

To the Editor: The purpose of my letter was not to debate the efficacy of MRI but to bring attention to an unusual mechanism of testicular injury. The response of Dr. Pereira and Mr. Kingsley prompts me to address the efficacy of the technique in this particular case. MRI has not yet become a primary imaging tool for testicular abnormalities, but it is useful1,2.

The presumed diagnosis of the scrotal swelling, by a urologist, was acute epididymo-orchitis. Doxycycline was prescribed. Ultrasonography revealed a lesion thought to be an intratesticular necrotic mass or abscess. MRI was performed for reasons of academic interest at no charge to the patient or his insurance company. It demonstrated that the suspected mass or abscess was a subacute hematoma without an associated neoplasm. There was continuing concern about an underlying neoplasm, given the lack of substantial trauma. Tests for tumor antigens were negative. The patient declined orchiectomy but consented to biopsy with later orchiectomy if frozen sections were positive. Biopsy and follow-up with ultrasonography over a one-year period demonstrated no neoplasm.

Used early in this case, MRI would have saved this patient the cost of doxycycline therapy and ultrasonography. This technique characterized the pathologic process more accurately than did either physical examination or ultrasonography and led the patient to decline orchiectomy.

Effective use of a health care technique requires an accurate assessment of the specific technique and its benefits, risks, costs, and alternatives as applied to specific problems. Such an assessment requires applying the technique in varied clinical situations and publishing the results in the medical literature. De facto rationing of forms of technology such as MRI under the banner of cost containment impedes technology assessment and thwarts improvement in patient care. This ultimately costs society and patients dearly in terms of delayed diagnoses, erroneous diagnoses, and needless therapies.

Mark W. Ragozzino, M.D.
2212 Delaney Ave., Wilmington, NC 28405

2 References

1. 1

   Cramer BM, Schlegel EA, Thueroff JW. MR imaging in the differential diagnosis of scrotal and testicular disease. Radiographics 1991;11:9-21
   Web of Science | Medline

2. 2

   Johnson JO, Mattrey RF, Phillipson J. Differentiation of seminomatous from nonseminomatous testicular tumors with MR imaging. AJR Am J Roentgenol 1990;154:539-543
   Web of Science | Medline