"Blue balls": A diagnostic consideration in testiculoscrotal pain in young adults: A case report and discussion.

Objective. To distinguish the fact from artifact of an isolated, large, intracranial cyst on prenatal sonography (PSG). Background. The use of PSG is rapidly increasing with most obstetric ultrasounds occurring in general community settings like small hospitals and clinics with personnel who have variable training, experience, and interest levels. In contrast, most PSG articles and books are produced in large subspecialty centers with concentrated referral bases plus both highly-trained and experienced personnel. Design/Methods. We report a series of 2 normal newborn patients who had a large prenatal unilateral intracranial cyst diagnosed by PSG in the 10 years between July of 1989 and 1999 at a rural community hospital. The newborns had imaging studies at birth and their neurodevelopmental progress was followed for several years. Textbook, bibliography and computerized Medline (1966–present) searches including prenatal ultrasound, observer variation, diagnostic errors, reproducibility of results, sensitivity and specificity, accuracy, central nervous system, false-positive, prenatal diagnosis, and brain were examined starting in August 1996 for reports. Results. There were 4079 obstetric ultrasounds performed in 3.5 years, January 1996 through July 1999 at this rural community facility. This rate extrapolates to a total of 11 654 obstetric ultrasounds over the 10-year study period in which the 2 cases of intracranial cyst artifact occurred. Thus, the incidence of 2 intracranial cyst artifacts was estimated as 2/11 654 PSG, a .0002% false-positive rate. Conclusions. This is the first report of the occurrence of PSG artifacts in a community facility. Artifact is a real problem and needs to be specified in differential diagnoses. There are ways to decrease sonographic artifact—or at least to recognize it—so our estimates at a community hospital for its occurrence are presented with the relevant technical and ethical issues. None of these issues have been previously reported in the pediatric literature. Our false-positive rate for large intracranial cyst compares favorably with other reports. Our estimate may inflate our denominator by reporting scans rather than the number of fetuses scanned, and our numerator may miss cases that moved from the community. Confusion differentiating PSG artifact from reality often occurs when interpreting static or frozen real-time images. The signs that sonogram images may be artifacts include defects that: extend outside the fetal body; change shape, size and echogenecity with different scan planes; are not seen on all examinations; and are isolated in an otherwise normal fetus. Failure to offer quality PSG in clinical settings where it is available restricts access of pregnant women to the diagnosis of fetal anomalies, and therefore restricts access to the options of pregnancy termination, fetal therapy like fetal surgery, and delivery options of timing, setting, and mode. We suggest a multidisciplinary approach to prenatal abnormalities like isolated third trimester unilateral intracranial cyst in both primary and tertiary care settings aids interpretation followed by expectant conservative management without elaborate, risky, or terminal interventions. Pediatrics 2000;106:844–849; prenatal ultrasound, brain, quality, fetal termination, ethics. ABBREVIATIONS. PSG, prenatal sonography; MRI, magnetic resonance imaging. The use of prenatal sonography (PSG) is rapidly increasing as more pregnant women are even requesting studies. Most obstetric ultrasounds occur in general community settings like small hospitals and clinics with personnel who have variable training, experience, and interest levels. In contrast, most PSG articles and books are produced in large subspecialty centers with concentrated referral bases plus both highly-trained and experienced personnel.1 Thus the accuracy of PSG in a primary care setting remains an enigma amid reported successes and advances, which must be interpreted based on the uniqueness of their settings.2–4 We report a series of 2 normal newborn patients who had a large prenatal unilateral intracranial cyst diagnosed by PSG between July 1, 1989 and July 1, 1998 at a community hospital. In our 10-year study period, our rate of 4079 obstetric ultrasounds for the 3.5 years of January 1996 through July 1999 (PSG yearly rates: 1113, 1114, 1246, and 606 for 6 months of 1999, respectively) at Franciscan Skemp Healthcare, Mayo Health System, La Crosse, Wisconsin, extrapolates to a total of 11 654 PSG. Thus our incidence of 2 intracranial cyst artifacts was estimated as 2/11 654 PSG, a .0002% false-positive rate. The 1998 and 1999 ultrasounds were 97% inpatient (1210/1246 and 587/ 606, respectively), which is believed representative at Franciscan Skemp Healthcare Obstetrics. Case histories follow our normal newborns who had prenatal intracranial cysts on PSG. We suggest repeat examination and expectant conservative management in view of technical and ethical updates.