Doppler ultrasound of acute scrotum
Samir Haffar M.D.
Assistant Professor of Internal Medicine
Doppler ultrasound of acute scrotum
• Normal anatomy of scrotum
• Normal US of scrotum
• Normal Doppler US of scrotum
• Do...
Diagrammatic representation
of testis in cross-section
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
250 – 400 lobules
...
Rete testis within mediastinum testis
Carkaci S et al. J Clin Ultrasound 2010 ; 38 : 21 – 37.
Rete testis drains into epid...
Anatomy of epididymis
6 cm in length – Best evaluated in longitudinal view
• Head Superior pole of testes
5 – 12 mm Usuall...
Arterial supply & venous drainage of scrotal contents
Zwiebel WJ et al. Introduction to vascular ultrasonography.
Elesevie...
Testicular blood supply
Lee JC et al. Ultrasound Quarterly 2008 ; 24 : 3 – 16.
Wittenberg AF et al. Curr Probl Diagn Radiol 2006 ; 35 : 12 – 21.
Testicular artery
Deferential artery
Cremasteric artery
...
Doppler ultrasound of acute scrotum
• Normal anatomy of scrotum
• Normal US of scrotum
• Normal Doppler US of scrotum
• Do...
Equipment
Canadian Association for Radiologists
• Real time linear or curved linear transducers
• Highest frequency: 7 MHz...
Sonographic technique of scrotum – 1
• Supine position & scrotum supported by towel
• Testes examined in two planes: longi...
Scanning technique of scrotum – 2
• Bilateral testicular spectral Doppler tracings recorded
• Palpable scrotal lesion Palp...
Tunica vaginalis
Scrotal wall thickness: Normal value 2 – 8 mm
Tunica vaginalis: Small amount of fluid between two layers
...
Tunica albuginea
Echogenic line surrounding testis
Better visualized in presence of small amount of fluid
Dogra VS et al. ...
Normal adult testis
Length: 4 – 5 cm
Width: 2 – 4 cm
Antero-posterior: 3 cm
Cokkinos DD et al. Curr Probl Diagn Radiol 201...
Side-by-side comparaison image
Gray scale image Color Doppler
Median raphe
McGahan J et al. Diagnostic ultrasound, Informa...
Normal mediastinum testis
Echogenic band running across testis on sagittal US scan
Dogra VS et al. Radiology 2003 ; 227 : ...
Normal rete testis
Normal structure seen in 20% of patients
Hypoechoic striated appearance of rete testis
Finger-like proj...
“two-tone testes”
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
Portion nearest probe: normal testicular re...
• Presentation Painless mass – More often on left
• Two types Type 1: reproductive potential
Type 2: no reproductive poten...
Polyorchidism
Fewer than 100 reported cases
Carkaci S et al. J Clin Ultrasound 2010 ; 38 : 21 – 37.
Normal vascularity in
...
Normal epididymis
Deurdulian C et al. RadioGraphics 2007 ; 27 : 357 – 369.
Normal epididymal head
Isoechoic to testis
Sagi...
Scrotal appendages
Sellars MEK et al. Eur Radiol 2003 ; 13 : 127 – 135.
Appendix testis: Upper pole of testis – 90%
Append...
Testicular appendages
Detectable only when hydrocele is present
Woodward PJ et al. RadioGraphics 2003 ; 23 : 215 – 240.
Ap...
Doppler ultrasound of acute scrotum
• Normal anatomy of scrotum
• Normal US of scrotum
• Normal Doppler US of scrotum
• Do...
Doppler ultrasound of scrotum
• Color, power & spectral Doppler
• Low flow settings
• Identical Doppler settings to evalua...
• Increased gain
• Decreased PRF
• Small color box
• Low wall filter
Low flow settings
Side-by-side comparaison image
Color Doppler image
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition...
Prominent trans-mediastinal artery & vein
Normal variant
Branch of testicular artery traverses toward center of testis
See...
Centripetal artery & recurrent rami
Centripetal artery coursing toward mediastinum
Then curving back as recurrent rami
Tra...
Flow in intra-testicular, epididymal
& cremasteric artery
1 Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
2 Schneble F ...
Color & power Doppler US in normal testis
68 normal children – 6 weeks to 13 years
Barth RA & Shortliffe LD. Radiology 199...
Doppler ultrasound of acute scrotum
• Normal anatomy of scrotum
• Normal US of scrotum
• Normal Doppler US of scrotum
• Do...
Acute scrotum
 Inflammatory conditions → Testiculitis
 Vascular conditions → Torsion
 Scrotal trauma → Trauma
 Testicu...
Acute scrotum
 Inflammatory conditions
– Acute epididymitis Most common cause
– Acute orchitis
– Testicular abscess
– Cel...
Doppler US findings in epididymo-orchitis
Ultrasound
Direct signs Enlarged heterogenous epididymis
Enlarged heterogeneous ...
Acute epididymo-orchitis
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
Increased vascularity of both
testis & epid...
Epididymo-orchitis / pyocele
Low-level echoes – Multiple septations
Thickening of overlying scrotal skin
Sidhu PS et al. E...
Epididymo-orchitis / Epididymal abscess
Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011.
European ...
Orchitis
• Causes Usually in patients with epididymitis
Primary orchitis (rare): mumps – HIV
• US 1. Edema: diffuse low re...
Orchitis / Striated testis
Striated appearance
Small complex hydrocele
Gray-scale ultrasound
Significant hyperemia
Color D...
Complicated orchitis
Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011.
European Foundation of Socie...
Causes of striated testis
• Prominent rete testis
• Orchitis
• Torsion
• Testicular fibrosis
• Trauma
• Neoplasm (lymphoma...
Striated testis / Senile fibrosis
First described in 1996 1
1 Cohn EL et al. J Urol 1996 ; 156 : 180 – 181.
2 Loberant N e...
Testicular abscess
• Cause Usually secondary to epididymo-orchitis
• Suspicion Testicular swelling persists after treatmen...
Testicular abscess
Hypervascular margin of lesion
No flow within lesion
Color Doppler USGray-scale ultrasound
Heterogeneou...
Brucellosis
Genitourinary complications: 2 – 10% of patients
Lee JC et al. Ultrasound Quarterly 2008 ; 24 : 3 – 16.
Hypoec...
Cellulitis
4 day-old male with swollen penis & scrotum after circumcision
Skin thickening
Hyperemia of scrotal skin
Peri-t...
Fournier’s gangrene
Aggressive necrotizing fasciitis of perineum
• Presentation Males 50-70 years – Diabetes 50%
Soft-tiss...
Fournier gangrene
Emergency – Prompt medical & surgical treatment
McGahan J et al. Diagnostic ultrasound, Informa Healthca...
Acute scrotum
 Vascular conditions
– Acute testicular torsion
– Torsion of appendages
– Varicocele: idiopathic – Intra-te...
Presentation of acute testicular torsion
• Young patients: almost all under age of 20
• Sudden pain followed by nausea, vo...
Salvage rate in acute torsion
• Within first 6 hours 100% salvage rate
• Within 6 to 12 hours 70% salvage rate
• Within 12...
Normal anatomy
Tunica vaginalis attached to posterior lateral aspect of scrotal wall
Prando D. Ultrasound Quarterly 2002 ;...
Bell-clapper anomaly
Tunica vaginalis completely surrounds testis
Intra-vaginal torsion
Prando D. Ultrasound Quarterly 200...
Doppler US of acute testicular torsion
• US Enlarged testis
Normal or decreased echogenicity of testis
Multifocal hyperech...
Acute torsion / less than 6 hours
Longitudinal view of left testis
Power Doppler
No flow to left testis
Spectacle US view
...
Acute torsion / more than 6 hours
Heterogeneous echotexture
Areas of increased echogenicity
“hemorrhage”
Side-by-side imag...
Acute torsion / Bell-clapper anomaly
Bilateral in most cases
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
Diagnosed by...
Acute torsion / whirlpool sign of spermatic cord
Aso C et al. RadioGraphics 2005 ; 25 : 1197 – 1214.
Absence of color flow...
Acute torsion / Incomplete or partial (< 360°)
Mernagh JR et al. Curr Probl Diagn Radiol 2004 ; 33 : 60 – 73.
Two weeks la...
Acute torsion / Incomplete or partial (< 360°)
Prando D et al. Abdom Imaging 2009 ; 34 : 648 – 661.
Pulsed Doppler US
Incr...
Acute torsion / Torsion-detorsion syndrome
Intermittent left scrotal pain - Asymptomatic at examination
Dogra et al. Ultra...
Doppler US in acute testicular torsion
Normal color Doppler US does not exclude:
1. Early torsion
2. Partial torsion
3. To...
Conditions with decreased blood flow in testes
• Poor technical parameters
• Pediatric population: small testicular volume...
Testicular torsion mimic
Large hydrocele
Decreased blood flow to right testis
Pressure on testis from large hydrocele
Dogr...
• Causes Idiopathic – Acute epididymitis – Trauma
Sickle cell disease – Hypercoagulable states
• Presentation Testicular p...
Segmental testicular infarction / Round shape
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
Negative tumor ...
Segmental testicular infarction / Wedged shape
Saxon P et al. Emerg Radiol 2012 in press.
MRI or CEUS when Doppler US find...
Testicular appendigeal torsion
7 to 14 years old boys – Appendix testis (95%)
• Examination Firm nodule on upper testis
Bl...
“blue dot sign”
Clinical tender "blue dot sign“
Torsion of testicular appendage
Testicular appendigeal torsion
Hypoechoic extra-testicular mass
Peripheral hyperemia separate from epididymis
Resolved on ...
• CDU imaging is now the gold standard for diagnosis
• CDU imaging highly operator dependent
• Cut-off values Vein diamete...
Idiopathic varicocele
Reversed flow lasting longer than 1 - 2 seconds
Detected during Valsalva maneuver & resolved with it...
Sarteschi’s classification of varicocele
Supine & standing positions
Sarteschi LM. G Ital Ultrasonologia 1993 ; 4 : 43 – 9...
Sarteschi’s classification/Grade 1
Pauroso S et al. J Ultrasound 2011 ; 14 : 199 – 204.
Reflux in vessels seen
only during...
Sarteschi’s classification/Grade 2
Pauroso S et al. J Ultrasound 2011 ; 14 : 199 – 204.
Small varicosities exhibiting
refl...
Sarteschi’s classification/Grade 4
Pauroso S et al. J Ultrasound 2011 ; 14 : 199 – 204.
Relaxing condition
Venous reflux e...
Sarteschi’s classification/Grade 5
Pauroso S et al. J Ultrasound 2011 ; 14 : 199 – 204.
Venous diameter does not
increases...
• Presentation Testicular pain
• Association Extra-testicular varicocele: common – left
• US Anechoic structures from medi...
Intra-testicular varicocele
Color Doppler US
Valsalva maneuver
demonstrating color Doppler flow
Stewart VR & Sidhu PS. Cli...
Secondary varicocele
Increased pressure on abdominal spermatic vein
Dogra VS et al. Radiology 2003 ; 227 : 18 – 36.
Non-co...
Henoch-Schönlein purpura
Aso CE et al. RadioGraphics 2005 ; 25 : 1197 – 1214.
Scrotal wall thickening
Scrotal tunica thick...
Thrombosis of pampiniform plexus veins / rare
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
Thrombus within veins ...
Acute scrotum
 Inflammatory conditions
 Vascular conditions
 Scrotal trauma
 Testicular tumors
 Inguinal hernia
 Acu...
• Scrotal or testicular edema
• Testicular fracture or rupture
• Scrotal hematoma
• Scrotal hydrocele
• Scrotal hematocele...
Testicular Trauma / Intra-testicular hematoma
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
2 hypoechoic le...
Testicular Trauma / Tunica albuginea rupture
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
Discontinuation of tuni...
Testicular Trauma / Fracture line
Fracture line through mid-aspect of testis
Sidhu PS et al. European Course Book – Ultras...
Testicular trauma / Hematocele
Kurian R & de Bruyn R. Ultrasound 2006 ; 14 : 216 – 222.
Turgut AT et al. Ultrasound Clin 2...
Evolution of testicular hematoma
Longitudinal view 2 weeks later
Hematoma has largely resolved
Poorly defined hypoechoic a...
Acute scrotum
 Inflammatory conditions
 Vascular conditions
 Scrotal trauma
 Testicular tumors
 Inguinal hernia
 Acu...
Clinical presentation of testicular tumors
• Palpable mass Usual presentation
• Acute scrotum 10 % of patients (hemorrhage...
Primary testicular tumors
• Germ cell tumors Seminoma (most common)
90% Embryonal carcinoma
Choriocarcinoma
Teratoma
Mixed...
Doppler US of testicular tumors
• Usual appearance
Homogenous & low reflectivity
• Wide range of appearances
High reflecti...
Classic testicular seminoma
Hypoechoic – Homogeneous
Gray-scale US
Hypoechoic lobulated lesion
Power Doppler US
Mildly inc...
Testicular teratoma
Dogra VS et al. RadioGraphics 2001 ; 21 : S273 – S281.
Multiple cystic areas (2 - 15 mm)
Process invol...
Burned-out germ cell tumor / Azzopardi scars
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008...
Sertoli cell tumor
Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011.
European Foundation of Societi...
Peutz-Jeghers syndrome
Aso C Eet al. RadioGraphics 2005 ; 25 : 1197 – 1214.
Melanin pigmentation of lips
Characteristic of...
Para-aortic lymph node in testicular cancer
Enlarged para-aortic lymph node with cystic degeneration
Cokkinos DD et al. Cu...
Testicular macro-calcification
• Benign lesion Intra-testicular cyst
Epidermoid cyst
Sertoli cell tumor
Granulomatous dise...
Testicular microlithiasis
Bright foci of 1 – 2 mm without acoustic shadowing
Stengel JW et al. Am J Roentgenol 2008 ; 190 ...
Testicular microlithiasis associated with seminoma
Transverse scanLongitudinal scan
Chen JL et al. J Clin Ultrasound 2010 ...
Non-Hodgkin lymphoma
< 1% of patients with lymphoma
Hypoechoic mass replacing
most of testis
Longitudinal view of right te...
Testicular metastases
Malignant melanoma
Robertson E & Baxter G. Ultrasound 2010 ; 18 : 86 – 88.
Hypervascularity of hypoe...
• Presentation Mass which may be painful
• Involvement Most commonly involves epididymis
Solitary testicular involvement u...
Testicular sarcoidosis
Recent diagnosis of sarcoidosis from skin lesion biopsy
Multiple hypoechoic areas within testis & e...
Testicular adrenal rests
Essential to recognize (avoid unnecessary orchidectomy)
• Cause Congenital adrenal hyperplasia
Mo...
Adrenal rest / Adrenal remnants
Aso CE et al. RadioGraphics 2005 ; 25 : 1197 – 1214.
Nodule in epididymal head
Several hyp...
• Presentation Painless lump – Most common on left
• US Homogeneous hypoechoic mass
Difficult to separate from testis
• Do...
Spleno-gonadal fusion
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
Color Doppler US
Ordered vessels at cen...
Intra-testicular cystic lesions
Rare – Avoid unnecessary surgical intervention
• Benigns Tunica albuginea cyst
Frequent In...
Cyst of tunica albuginea
Ma OJ et al. Emergency ultrasound, 2nd edition.
Bhatt S et al. Diagn Interv Radiol 2011 ; 17 : 52...
Cyst of tunica vaginalis
Tunica vaginalis cyst visible in presence of hydrocele
Sidhu PS et al. European Course Book – Ult...
Intra-testicular simple cyst
≥ 40 years – Solitary – Near mediatinum
• Causes Congenital, post-trauma, post-inflammatory
•...
Intra-testicular cyst
Anechoic lesion – Imperceptible wall – Posterior enhancement
Surrounding thin rim of testicular pare...
Epidermoid cyst
Mistaken for malignancy if absence of classic US findings
• Manifestation Painless mass in 20 – 40 year ol...
Intra-testicular epidermoid cyst
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
Stengel JW et al. AJR 2008 ;...
Tubular ectasia of rete testis
Benign – Very common – > 50 years – Bilateral in 1/3
• Causes Epididymal obstruction (infec...
Tubular ectasia of rete testis
Frequent association with spermatocele or epididymal cyst
Turgut AT et al. Ultrasound Clin ...
Cystic dysplasia of testes
Rare – Congenital – Renal malformation
Enlarged testis
Multiple irregular anechoic areas
measur...
Epididymal cyst
Common (20 – 40% of asymptomatic men)
Lee JC et al. Ultrasound Quarterly 2008 ; 24 : 3 – 16.
Epididymal ta...
Spermatocele
Cystic dilatations of efferent ductules
Well defined cyst in epididymal head – Fluid debris level
Typical of ...
Acute scrotum
 Inflammatory conditions
 Vascular conditions
 Scrotal trauma
 Testicular tumors
 Inguinal hernia
 Acu...
Inguinal hernia
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
Bowel loop herniation into scrotum
Increased tunical...
Complications of inguinal herniorrhaphy
• Hernia recurrence
• Epididymo-orchitis
• Hematoma Inguinal canal & scrotum
• Tes...
Scrotal wall edema
Marked thickening of scrotal wall
Following inguinal hernia repair
Sidhu PS et al. European Course Book...
Testicular ischemia
after inguinal hernia repair
Dellabianca C et al. J Ultrasound 2011 ; 14 : 205 – 207.
No intra-testicu...
Acute scrotum
 Inflammatory conditions
 Vascular conditions
 Scrotal trauma
 Testicular tumors
 Inguinal hernia
 Acu...
Acute idiopathic scrotal edema
• Etiology Possible allergic origin
• Presentation From 4 months to 18 years
Sudden onset o...
Acute idiopathic scrotal edema
Aso C Eet al. RadioGraphics 2005 ; 25 : 1197 – 1214.
Marked thickening of scrotal walls
Nor...
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Doppler ultrasound of acute scrotum

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testicular torsion, testicular trauma, testicular tumor, acute epididymitis, Fournier gangrene, varicocele.

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  • Testes are ovoid in shape with medium-level echoes and measure 5×3×2 cm each. Tunica albugineais the fibrous covering of the testicle and is covered by the tunica vaginalis. The tunica albuginea can be seen with a high-frequency transducer as an echogenic line. Septa extend from the tunica albuginea into the testicle, dividing the testis into 250 to 400 lobules. The posterior surface of the tunica albuginea is reflected into the interior of the testis, forming the incomplete septum known as the mediastinum testis. Sonographically, the mediastinum testis is seen as an echogenic band running in a cephalocaudal direction. Each lobule consists of one to three seminiferous tubules supporting the Sertoli cells, Leydig cells sceretingtestesterone and the spermatocytes that give rise to sperm. The seminiferous tubules open through the tubulirectiinto dilated spaces called the rete testis within the mediastinum.
  • The rete testis drains into the epididymis through 10 to 15 efferent ductules. The epididymis, consisting of a head, body, and tail, is located superior to and is contiguous with the posterior aspect of the testis.The tail of the epididymis continues as the vas deferens.
  • Testicular artery Arise from aorta Supply testis High flow – Low resistanceDeferential artery Arise from vesical artery Supply epididymis &amp; vas deferens High flow – Low resistance Cremasteric artery Arise from inferior epigastric artery Supply wall of scrotum Low-flow – high-resistancePampiniform venous plexus is the draining vein of the testicle, which forms around the upper half of the epididymis and continues into the testicular vein through the inguinal ring.The right testicular vein empties into the IVC and the left testicular vein drains into the left renal vein.
  • Anterior &amp; posterior epididymal artery arise from testicular artery.
  • The scrotum is divided into right and left halves by a fibrous septum called the “median raphe”. Each testis is able to move in the scrotum by the presence of the tunica vaginalis, which has two layers, a visceral layer attached to the surface of the testis and a parietal layer attached to the scrotal wall. A minute amount of fluid is interposed between the two layers. This is similar to the visceral and parietal pleura. The tunica vaginalis does not cover the posterior aspect of the testis at its attachment to the scrotal wall.
  • Even if infection and torsion are not clinically suspected, a sonographic evaluation of testicular blood flow must be routinely included.
  • Each testis is able to move in the scrotum by the presence of the tunica vaginalis, which has two layers, a visceral layer attached to the surface of the testis and a parietal layer attached to the scrotal wall. A minute amount of fluid is interposed between the two layers. This is similar to the visceral and parietal pleura. The tunica vaginalis does not cover the posterior aspect of the testis at its attachment to the scrotal wall.
  • Low resistance flow in the epididymis because anterior &amp; posterior epididymal arteries originate from testicular artery.
  • One study demonstrated that the resistive index of testes of healthy volunteers is rarely less than 0.5More than half of patients with epididymo-orchitis, the resistive index is less than 0.5.Use of a peak systolic velocity threshold of 15 cm/s results in a diagnostic accuracy of 90% for orchitis &amp; 93% for epididymitis.
  • Sexually transmitted Chlamydia trachomatisand Neisseria gonorrhea are frequent pathogens in men younger than age 35. In prepubertal boys and men older than age 35, the disease is most frequently caused by Escherichia coli and Proteus mirabilis.Acute epididymitis first affects the tail of the epididymis in retrograde spread of infection from the bladder and prostate via vas deferens.If there is continued progression, it involves the body and head of the epididymis and, eventually, the testes. Orchitis develops in 20% to 40% of cases of epididymo-orchitis by direct spread of infection. Isolated orchitis is rare and is generally due to viral causes such as mumps, human immunodeficiency virus (HIV) or due to post-traumatic inflammation.
  • Linear bands of varying appearance radiate within the testis perpendicular to its long axis, in a similar orientation to the testicularfibrous septae. These striations may be hypoechoic against normal background of low-level echoes or may appear as hypoechoic &amp; hyperechoic bands. First described in 1996, striated testis may be unilateral or bilateral, may involve a portion or the entire testis, and may be seen in a symptomatic or asymptomatic testis.
  • Scrotal wall cellulitis can develop in obese, diabetic, or immunocompromised patients. Clinically, the scrotum is swollen, tense, warm, and red. Sonographic features: increased scrotal wall thickness &amp; hypoechoic areas showing hypervascularity on color Doppler US.Scrotal wall cellulitis may progress to form scrotal abscess that usually is identified by presence of irregular walls &amp; low-level internal echoes
  • Differential diagnosis: 1- scrotal hernia with gas-containing bowel2- penetrating trauma to the scrotum
  • Degree of torsion can vary from one-quarter twist (90°) to up to three complete turns (1,080°) of the vascular pedicle.
  • Diffuse hypoechogenicity and enlargement when compared with the contralateral side.
  • The bell-clapper deformityThe tunica vaginalis completely encircles distal spermatic cord, epididymis &amp; testis rather than attaching to posterolateral aspect of testis.
  • Arterial flow need not be absent for torsion to be present.Since venous obstruction usually precedes arterial obstruction (veins have thinner walls than the arteries and consequently are more sensitive to the compression), the early manifestation of the testicular torsion can be a diminished arterial velocity and a decreased diastolic flow with a consequently increased resistive index, indicating severe obstruction or occlusion to the outflow of blood.Evaluation of the Doppler waveform obtained in normal testicular arteries yielded an RI of 0.67 ± 0.07(range 0.50–0.80) [35] or a mean RI of 0.62 (range, 0.48–0.75).Reference: Siegel MJ (1997) The acute scrotum. RadiolClin North Am 35:959–976.
  • Firm palpable nodule on superior aspect of testisBluish discoloration on overlying skinCremasteric reflex still be elicited
  • Idiopathic varicoceles are more common on the left side where the left spermatic vein enters perpendicular to the left renal vein.The right spermatic vein enters obliquely into the inferior vena cava and this appears to have some protective effect on the right side.
  • Several classification systems have been proposed. The most widely used are the ones developed by Sarteschi which involves examinations done with the patient lying down and standing and distinguishes five different stages and by Dubin which requires examination of patients in supine position &amp; includes three stages. Sarteschi classification: Grade 4:enhancement of venous reflux after Valsalva’smanoeuvre is the criteria that allows the distinction between this grade from the previous and the next one.
  • Nutcracker phenomenon: Compression of left renal vein between superior mesenteric artery and aorta.
  • Several systemic diseases can occur with scrotal involvement. The testes are affected in 15%–37% of patients with Henoch-Schoinleinpurpura. In this disease, scrotal symptoms may precede other manifestations. US findings include scrotal wall thickening, epididymal enlargement, and reactive hydrocele. Involvement is bilateral in the vast majority of cases; hence, this entity should be considered when bilateral US findings similar to those of inflammatory epididymitisare visualized.
  • The venous return of the left testicle may be impaired for various reasons, including the longer course of left spermatic vein &amp; ‘‘nutcracker phenomenon’’ corresponding to entrapment of the left renal vein by the superior mesenteric artery anteriorly andthe aorta posteriorly. Theoretically this condition may, in turn, be a predisposing factor for stasis and thrombosis.
  • Potential complications of delayed diagnosisTesticular ischemic necrosisAbscessLoss of spermatogenesis
  • Discontinuity of the echogenic tunica albuginea is indicative of testicular rupture and necessitates emergent surgery
  • Scrotal massTwo important questions to answer.Is the mass intratesticular or extratesticular?Is the mass cystic or solid?A good rule of thumb is that intratesticular masses are malignant until proven otherwise, whereas extratesticularintrascrotal masses are generally benign.A second rule of thumb is that a solid lesion is malignant until proven otherwise,whereas cystic lesion is generally benign.
  • Ten percent of patients with testicular tumors present with acute scrotum, most likely from intratumoral hemorrhage.
  • Seminomatous is the most common tumor type accounting for approximately 50% of germ cell tumors. Seminomatoustumours occur almost exclusively in men in their 40s and rarely in younger men/boys.They have one of the best prognoses as they are sensitive to radiotherapy and chemotherapy. They are often associated with elevated b-human chorionic gonadotrophin hormone (bHCG). A large amount of the testis can be replaced by tumor; necrosis is common histologically and 10% have been shown to have cystic areas.Lymphatic spread to retroperitoneal lymph nodes and/or haematogenous spread to the lungs and/or brain can occur.
  • Much has been written about the sonographic appearance of the various malignant testicular tumors. Although of intellectual and academic interest, diagnosing and distinguishing among the various cell types is rarely of practical import to general radiologist because the finding of any potentially malignant mass within testicle generally prompts orchiectomy or at least biopsy.Percutaneous testicular biopsy should never be performed in the setting of intratesticular mass. Rare exception being the young leukemia patient with probable testicular leukemia.
  • Cystic teratomas may manifest as cystic massUsual appearance: inhomogeneous mass containing cystic &amp; solid areas of various sizes which helps differentiate them from simple cysts.
  • Azzopardi:
  • First a brief word on testicular biopsy. Percutaneous testicular biopsy is technically feasible and is often performed in the evaluation of male infertility.However, percutaneous testicular biopsy should never be performed in the setting of an intratesticular massA rare exception being the young leukemia patient with probable testicular leukemia. Requests for percutaneous biopsy of a focal testicular mass generally arise from young trainees in academic centers (usually in the month of July). These requests should be courteously but emphatically denied, and the patient should be scheduled for an open biopsy in theoperating room. There, the urologist delivers the testicle via an inguinal approach before bivalve, random or ultrasound guidedbiopsy of the gland on a sterile towel. This way, if the testicular lesion is malignant, any potential tumor spillage occurs on the towel rather than into the patient, and long-term prognosis is significantly improved. Of note, recent reports from outside the United States state that percutaneous biopsy of focal testicular masses may be safe, but this should be avoided until further data are available and the standard of care allows this practice
  • Limited testicular microlithasis (LTM): &lt; 5 microliths on one US image.Testicular microlithiasis can be associated with several conditions such as: CryptorchidismAlveolar microlithiasiscongenital urethroperineal fistulaKlinefelter syndromeGerm cell neoplasm.In our series, associated cryptorchidism was the most common (four of eight cases [50%]).
  • Bilateral tumors &amp; tumor-like masses1- Non-Hodgkin’s lymphoma2- Acute lymphoblastic leukemia3- Chronic lymphocytic leukemia4- Metastases 5- Adrenal rest hyperplasia
  • Testicular adrenal rests are hyperplastic adrenal cortical tissue originating from aberrant adrenal tissue that adheres to the gonads anddescends with the testes or ovary during the developmental stages.
  • Testicular adrenal remnants grow under adrenocorticotropic hormonesLeading to “adrenal rest tumors”Essential to recognize this association to avoid unnecessary orchidectomy.
  • Hamm et al stress the importance of palpability and claim that palpable intratesticular cysts should be removed.This recommendation would include simple cysts if they were palpable. However, Hamm et al reported that all of their cystic neoplasms (13 of 16, excluding three epidermoid cysts) except one had US features of complicated cyst. They did not encounter a cyst that appeared simple at US, was palpable, and turned out to be a neoplasm. Reference: Hamm B, Fobbe F, Loy V. Testicular cysts: differentiation with US and clinical findings. Radiology 1988; 168:19–23.
  • Epidermoid cysts are the commonest benign tumours arising from the testis though accounting for only 1-2% of all resected testicular masses.As the ultrasound findings are frequently non-specific, orchidectomy is often performed.
  • Also known as cystic transformation of rete testis.
  • Cystic dysplasia of the testis is a rare congenital malformation, usually found in children and occasionally in young adults, that consists of multiple small cysts, affecting part or the whole testis and originating in the mediastinal area. This disorder results in enlargement of the testis and atrophy of the remaining parenchyma. The dysplasia has been explained on the basis of an embryologic defect that prevented connection of the tubules of the rete testis with the efferent ducts. Of interest is the association of cystic dysplasia with renal agenesis, bilateral renal dysplasia, and duplication of the renal collecting systems. On ultrasound, it appears as an enlarged testis with multiple irregular anechoic areas measuring a few millimeters each.
  • Epididymal cysts contain clear serous fluid. The etiology of cyst formation is unclear. Trauma and epididymitis are implicated as possible contributory factors.
  • Almost always arise in the epididymal head.Low level echo within it. Indistinguishable from epididymal cysts when present within the epididymal head.
  • Causes of testicular ischemia: 1- Spermatic cord torsion: most common cause 2- Secondary to severe epididymitis with vessel compression3- Inguinal hernia repair4- Spontaneous thrombosis of funicular vessels5- Xanthogranulomatous or filarialfuniculitis
  • Doppler ultrasound of acute scrotum

    1. 1. Doppler ultrasound of acute scrotum Samir Haffar M.D. Assistant Professor of Internal Medicine
    2. 2. Doppler ultrasound of acute scrotum • Normal anatomy of scrotum • Normal US of scrotum • Normal Doppler US of scrotum • Doppler US of acute scrotum
    3. 3. Diagrammatic representation of testis in cross-section Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66. 250 – 400 lobules Each lobule contains 1 – 3 seminiferous tubules Sspermatocyte – Sertoli cell – Leydig cell (testesterone)
    4. 4. Rete testis within mediastinum testis Carkaci S et al. J Clin Ultrasound 2010 ; 38 : 21 – 37. Rete testis drains into epididymis through 10 – 15 efferent ductules Epididymis consists of head, body, & tail Tail of epididymis continues as vas deferens
    5. 5. Anatomy of epididymis 6 cm in length – Best evaluated in longitudinal view • Head Superior pole of testes 5 – 12 mm Usually isoechoic to testis • Body Posterolateral aspect of testis 2 – 4 mm Usually hypoechoic to testis • Tail Inferior pole of testes 5 – 12 mm Usually hypoechoic to testes Curves to form ductus deferens Lee JC et al. Ultrasound Quarterly 2008 ; 24 : 3 – 16.
    6. 6. Arterial supply & venous drainage of scrotal contents Zwiebel WJ et al. Introduction to vascular ultrasonography. Elesevier Saunders, Philadelphia, USA, 5th edition, 2005.
    7. 7. Testicular blood supply Lee JC et al. Ultrasound Quarterly 2008 ; 24 : 3 – 16.
    8. 8. Wittenberg AF et al. Curr Probl Diagn Radiol 2006 ; 35 : 12 – 21. Testicular artery Deferential artery Cremasteric artery Pampiniform venous plexus Vas deferens Genito-femoral nerve Components of spermatic cord
    9. 9. Doppler ultrasound of acute scrotum • Normal anatomy of scrotum • Normal US of scrotum • Normal Doppler US of scrotum • Doppler US of acute scrotum
    10. 10. Equipment Canadian Association for Radiologists • Real time linear or curved linear transducers • Highest frequency: 7 MHz or higher • Sufficient resolution to detect characteristics of lesions • Highest possible Doppler frequencies: 5 to 10 MHz • Total US exposure as low as reasonably achievable ALARA principle • Standoff pads can be used to improve imaging www.car.ca Atri M et al. CAR standard for performing scrotal ultrasound examinations. April 28, 2011
    11. 11. Sonographic technique of scrotum – 1 • Supine position & scrotum supported by towel • Testes examined in two planes: longitudinal & transverse • Skin thickness in each hemi-scrotum evaluated • Color & pulsed Doppler optimized for low-flow velocity • Compare both testes for size, echogenicity & vascularity • Compare both epididymis for size, echogenicity & vascularity Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
    12. 12. Scanning technique of scrotum – 2 • Bilateral testicular spectral Doppler tracings recorded • Palpable scrotal lesion Palpate lesion & put probe on it • Acute scrotum Asymptomatic side scanned first Power Doppler also used • Tumor of testis found Search for abdominal adenopathies • Additional techniques Valsalva or upright positioning Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
    13. 13. Tunica vaginalis Scrotal wall thickness: Normal value 2 – 8 mm Tunica vaginalis: Small amount of fluid between two layers Tapping CR & Cast JE. Ultrasound 2008 ; 16 : 226 – 233.
    14. 14. Tunica albuginea Echogenic line surrounding testis Better visualized in presence of small amount of fluid Dogra VS et al. Ultrasound Clin 2006 ; 1 : 55 – 66. Longitudinal sonogram of testis
    15. 15. Normal adult testis Length: 4 – 5 cm Width: 2 – 4 cm Antero-posterior: 3 cm Cokkinos DD et al. Curr Probl Diagn Radiol 2011 ; 40 : 1 – 14. Transverse viewLongitudinal view
    16. 16. Side-by-side comparaison image Gray scale image Color Doppler Median raphe McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
    17. 17. Normal mediastinum testis Echogenic band running across testis on sagittal US scan Dogra VS et al. Radiology 2003 ; 227 : 18 – 36.
    18. 18. Normal rete testis Normal structure seen in 20% of patients Hypoechoic striated appearance of rete testis Finger-like projections into parenchyma Adjacent to mediastinum testis Wittenberg AF et al. Curr Probl Diagn Radiol 2006 ; 35 : 12 – 21.
    19. 19. “two-tone testes” Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302. Portion nearest probe: normal testicular reflectivity Portion distal to vessel: decreased testicular reflectivity Refractive artefact through walls of trans-mediastinal vessels Trans-mediastinal vessels causing „„two-tone‟‟ artefact
    20. 20. • Presentation Painless mass – More often on left • Two types Type 1: reproductive potential Type 2: no reproductive potential • Association Cryptorchidism, indirect inguinal hernia, hydrocoele, microlithiasis, rete testis, cancer • US features Well-defined testis with identical reflectivity Color Doppler as ipsilateral testis Mediastinum observed helps in diagnosis • Management Conservative Polyorchidism 100 reported cases – More than two testes Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
    21. 21. Polyorchidism Fewer than 100 reported cases Carkaci S et al. J Clin Ultrasound 2010 ; 38 : 21 – 37. Normal vascularity in both left testes Color Doppler USCoronal gray-scale US Normal right testis Two normal left testes Two testes on left Normal right testis T2-weighted MRI
    22. 22. Normal epididymis Deurdulian C et al. RadioGraphics 2007 ; 27 : 357 – 369. Normal epididymal head Isoechoic to testis Sagittal US image Normal epididymal body & tail Hypoechoic to testis Coronal US image
    23. 23. Scrotal appendages Sellars MEK et al. Eur Radiol 2003 ; 13 : 127 – 135. Appendix testis: Upper pole of testis – 90% Appendix epididymis: Head of epididymis – 6% On occasion, both appendages may be seen in same patient 5 scrotal appendages formed during development
    24. 24. Testicular appendages Detectable only when hydrocele is present Woodward PJ et al. RadioGraphics 2003 ; 23 : 215 – 240. Appendix testis Upper pole of testis Müllerian duct remnant Appendix epididymis Head of epididymis Mesonephric remnant
    25. 25. Doppler ultrasound of acute scrotum • Normal anatomy of scrotum • Normal US of scrotum • Normal Doppler US of scrotum • Doppler US of acute scrotum
    26. 26. Doppler ultrasound of scrotum • Color, power & spectral Doppler • Low flow settings • Identical Doppler settings to evaluate symmetry of flow Flow in symptomatic side vs asymptomatic side • If color Doppler imaging cannot detect flow Use of power Doppler to increase flow sensitivity
    27. 27. • Increased gain • Decreased PRF • Small color box • Low wall filter Low flow settings
    28. 28. Side-by-side comparaison image Color Doppler image McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008. Important component of each testicular examination
    29. 29. Prominent trans-mediastinal artery & vein Normal variant Branch of testicular artery traverses toward center of testis Seen unilaterally in 50% or bilaterally in 25% Usually in superior half of testis Usually accompanied by large vein Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
    30. 30. Centripetal artery & recurrent rami Centripetal artery coursing toward mediastinum Then curving back as recurrent rami Transverse color Doppler US of normal testis Cindy A et al. J Diag Med Sonography 2006 ; 22 : 221 – 230.
    31. 31. Flow in intra-testicular, epididymal & cremasteric artery 1 Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66. 2 Schneble F et al. Ultraschall Med 2011 ; 32 : E51 – E56. Low flow High resistance Cremasteric artery High flow Low resistance Epididymal arteryIntra-testicular artery High flow Low resistance Normal RI: 0.54 0.08 2
    32. 32. Color & power Doppler US in normal testis 68 normal children – 6 weeks to 13 years Barth RA & Shortliffe LD. Radiology 1997 ; 204 : 389 – 393. Power Doppler more sensitive than color Doppler for detection of intra-testicular blood flow in children • Color Doppler Intra-testicular blood flow in 88% • Power Doppler Intra-testicular blood flow in 97% • Combined Intra-testicular blood flow in 100%
    33. 33. Doppler ultrasound of acute scrotum • Normal anatomy of scrotum • Normal US of scrotum • Normal Doppler US of scrotum • Doppler US of acute scrotum
    34. 34. Acute scrotum  Inflammatory conditions → Testiculitis  Vascular conditions → Torsion  Scrotal trauma → Trauma  Testicular tumors → Tumors  Inguinal hernia  Acute idiopathic scrotal edema Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107. Four T‟s
    35. 35. Acute scrotum  Inflammatory conditions – Acute epididymitis Most common cause – Acute orchitis – Testicular abscess – Cellulitis – Fournier gangrene Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
    36. 36. Doppler US findings in epididymo-orchitis Ultrasound Direct signs Enlarged heterogenous epididymis Enlarged heterogeneous testis Indirect signs Reactive hydrocele or pyocele Scrotal wall thickening Doppler Epididymal or testicular hypervascularity High flow PSV > 15 cm/sec Low resistance RI < 0.5 Easily detectable venous flow Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
    37. 37. Acute epididymo-orchitis Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107. Increased vascularity of both testis & epididymis Heterogeneous epididymis & testis Enlargement of epididymal head Reactive hydrocele
    38. 38. Epididymo-orchitis / pyocele Low-level echoes – Multiple septations Thickening of overlying scrotal skin Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011. European Foundation of Societies of Ultrasound in Medicine & Biology.
    39. 39. Epididymo-orchitis / Epididymal abscess Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011. European Foundation of Societies of Ultrasound in Medicine & Biology. Acute epididymitis not responding to anti-bacterial therapy Focal area of mixed reflectivity containing debris in epididymal head
    40. 40. Orchitis • Causes Usually in patients with epididymitis Primary orchitis (rare): mumps – HIV • US 1. Edema: diffuse low reflectivity 2. Striated pattern 3. Venous infarction (hemorrhage) Areas of mixed or increased reflectivity • Complications Abscess – Infarction – Necrosis • Evolution Resolve completely Small testis with fibrosis: heterogeneous Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
    41. 41. Orchitis / Striated testis Striated appearance Small complex hydrocele Gray-scale ultrasound Significant hyperemia Color Doppler US Loberant N et al. Ultrasound Quarterly 2010 ; 26 : 37 – 44.
    42. 42. Complicated orchitis Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011. European Foundation of Societies of Ultrasound in Medicine & Biology. Predominantly low reflective testis Multiple areas of high reflectivity
    43. 43. Causes of striated testis • Prominent rete testis • Orchitis • Torsion • Testicular fibrosis • Trauma • Neoplasm (lymphoma – leukemia) Striated pattern without clinical findings & normal color Doppler has no clinical importance Loberant N et al. Ultrasound Quarterly 2010 ; 26 : 37 – 44.
    44. 44. Striated testis / Senile fibrosis First described in 1996 1 1 Cohn EL et al. J Urol 1996 ; 156 : 180 – 181. 2 Loberant N et al. Ultrasound Quarterly 2010 ; 26 : 37 – 44. Striated pattern without clinical findings & normal color Doppler has no clinical importance Striated atrophic right testis Spectacle view US Normal vascularity Color Doppler image
    45. 45. Testicular abscess • Cause Usually secondary to epididymo-orchitis • Suspicion Testicular swelling persists after treatment • US Irregular walls Low level internal echoes Hypervascular margins of lesion Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107. Not distinguished from acute epididymitis at early stage
    46. 46. Testicular abscess Hypervascular margin of lesion No flow within lesion Color Doppler USGray-scale ultrasound Heterogeneous hypoechoic complex collection within enlarged testicle Wittenberg AF et al. Curr Probl Diagn Radiol 2006 ; 35 : 12 – 21. 70-year-old diabetic patient with acute epididymo-orchitis
    47. 47. Brucellosis Genitourinary complications: 2 – 10% of patients Lee JC et al. Ultrasound Quarterly 2008 ; 24 : 3 – 16. Hypoechoic nodules within testis & epididymis Small hydrocele Gradual onset, longer duration, no leukocytosis, & positive serology
    48. 48. Cellulitis 4 day-old male with swollen penis & scrotum after circumcision Skin thickening Hyperemia of scrotal skin Peri-testicular fluid collection Sagittal sonogram Bilateral scrotal abscesses incised & drained at surgery Transverse sonogram Increased flow around testis Adjacent complex fluid collection Sung T et al. Am J Roentgenol 2006; 186 : 483 – 490.
    49. 49. Fournier’s gangrene Aggressive necrotizing fasciitis of perineum • Presentation Males 50-70 years – Diabetes 50% Soft-tissue gas detected as “crepitus” • Delay of dg Onset of symptoms to diagnosis: 5 days • US Scrotal wall thickening Multiple pockets of gas: “dirty shadow” Normal underlying testes • Treatment Surgical resection of devitalized tissues • Prognosis High morbidity & mortality rate Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
    50. 50. Fournier gangrene Emergency – Prompt medical & surgical treatment McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008. Thickening of scrotal skin Foci with dirty shadowing (air) US detects gas before it becomes clinically palpable Normal testis
    51. 51. Acute scrotum  Vascular conditions – Acute testicular torsion – Torsion of appendages – Varicocele: idiopathic – Intra-testicular – Secondary – Henoch-Schönlein purpura – Thrombosis of pampiniform plexus veins Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
    52. 52. Presentation of acute testicular torsion • Young patients: almost all under age of 20 • Sudden pain followed by nausea, vomiting, & low-grade fever • Pain cannot be relieved by elevating the scrotum • Swollen, tender, & inflamed hemi-scrotum • Cremasteric reflex usually absent • Transverse location of testis instead of vertical position Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
    53. 53. Salvage rate in acute torsion • Within first 6 hours 100% salvage rate • Within 6 to 12 hours 70% salvage rate • Within 12 to 24 hours 20% salvage rate Patriquin HB et al. Radiology 1993 ; 188 : 781 – 5.
    54. 54. Normal anatomy Tunica vaginalis attached to posterior lateral aspect of scrotal wall Prando D. Ultrasound Quarterly 2002 ; 18 : 41 – 57. Extra-vaginal torsion Less frequent Peri-pubertal
    55. 55. Bell-clapper anomaly Tunica vaginalis completely surrounds testis Intra-vaginal torsion Prando D. Ultrasound Quarterly 2002 ; 18 : 41 – 57. 180 Blood supply reserved Blood supply compromised 720 Most frequent (80%) Peripubertal
    56. 56. Doppler US of acute testicular torsion • US Enlarged testis Normal or decreased echogenicity of testis Multifocal hyperechogenicity of testis: infarction Enlargement & nodularization of epididymis Reactive hydrocele Thickening of scrotal skin • Doppler Complete (≥ 360 ) Absence of flow Partial (< 360 ) Decreased flow& elevated RI Prando D. Ultrasound Quarterly 2002 ; 18 : 41 – 57.
    57. 57. Acute torsion / less than 6 hours Longitudinal view of left testis Power Doppler No flow to left testis Spectacle US view No abnormalities Longitudinal view of right testis Power & pulsed Doppler Blood flow to right testis
    58. 58. Acute torsion / more than 6 hours Heterogeneous echotexture Areas of increased echogenicity “hemorrhage” Side-by-side image Lack of flow within left testis Color Doppler US of left testis Stengel JW et al. Am J Roentgenol 2008 ; 190 : S35 – S41.
    59. 59. Acute torsion / Bell-clapper anomaly Bilateral in most cases Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66. Diagnosed by US in presence of moderate hydrocele Hydrocele encircling distal third of spermatic cord Testis Hydrocele Spermatic cord
    60. 60. Acute torsion / whirlpool sign of spermatic cord Aso C et al. RadioGraphics 2005 ; 25 : 1197 – 1214. Absence of color flow Reactive hydrocele Scrotal wall thickening Right testis Normal color flow Left testis Edematous spermatic cord with anechoic structures “dilated lymphatic vessels” Right spermatic cord
    61. 61. Acute torsion / Incomplete or partial (< 360°) Mernagh JR et al. Curr Probl Diagn Radiol 2004 ; 33 : 60 – 73. Two weeks later
    62. 62. Acute torsion / Incomplete or partial (< 360°) Prando D et al. Abdom Imaging 2009 ; 34 : 648 – 661. Pulsed Doppler US Increased RI Absent diastolic flow Reversed diastolic flow Absent or reversed diastolic flow: Severe epididymo-orchitis (venous infarction) Scrotal trauma (venous occlusion)
    63. 63. Acute torsion / Torsion-detorsion syndrome Intermittent left scrotal pain - Asymptomatic at examination Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66. Increased blood flow to left testis Left testis Hyperemia with resolution of pain is highly suggestive Right testis Normal blood flow to right testis
    64. 64. Doppler US in acute testicular torsion Normal color Doppler US does not exclude: 1. Early torsion 2. Partial torsion 3. Torsion/detorsion syndrome If high clinical suspicion: repeat Doppler US in 1 – 4 hours Datta V et al. Ultrasound Quarterly 2011 ; 27 : 127 – 128.
    65. 65. Conditions with decreased blood flow in testes • Poor technical parameters • Pediatric population: small testicular volume • Large hydrocele & hematoma • Marked scrotal edema: poor penetration of US • Epididymo-orchitis resulting in testicular infarction (rare) • Idiopathic testicular infarct (rare) • Vasculitis: Polyarteritis nodosa – Lupus • Protein S & antithrombin III deficiency Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
    66. 66. Testicular torsion mimic Large hydrocele Decreased blood flow to right testis Pressure on testis from large hydrocele Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66. Normal blood flow of left testis
    67. 67. • Causes Idiopathic – Acute epididymitis – Trauma Sickle cell disease – Hypercoagulable states • Presentation Testicular pain • US Low reflective area may be wedge-shaped • Doppler Poor or absent color Doppler flow • DD Malignant lesion: ↑ color Doppler flow Segmental testicular infarction dg made following orchidectomy for suspected tumor Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
    68. 68. Segmental testicular infarction / Round shape Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302. Negative tumor markers – Regression in size on follow-up US Focal mixed reflective area No color Doppler within lesion Patient with underlying epididymitis
    69. 69. Segmental testicular infarction / Wedged shape Saxon P et al. Emerg Radiol 2012 in press. MRI or CEUS when Doppler US findings are equivocal Gray-scale US Low reflective wedged shape area Color Doppler US No power Doppler flow
    70. 70. Testicular appendigeal torsion 7 to 14 years old boys – Appendix testis (95%) • Examination Firm nodule on upper testis Bluish discoloration: “blue dot sign” Cremasteric reflex still be elicited • US Iso, hypo or hyperechoic appendix ≥ 5 mm Peri-appendiceal blood flow Reactive hydrocele (common) Skin thickening (common) Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66. Role of US: exclude torsion or acute epididymo-orchitis
    71. 71. “blue dot sign” Clinical tender "blue dot sign“ Torsion of testicular appendage
    72. 72. Testicular appendigeal torsion Hypoechoic extra-testicular mass Peripheral hyperemia separate from epididymis Resolved on follow-up Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66. 10-year-old boy with testicular pain
    73. 73. • CDU imaging is now the gold standard for diagnosis • CDU imaging highly operator dependent • Cut-off values Vein diameter 2 2.4 mm at rest 2.9 mm Valsalva Reflux duration 1 sec – 2 sec • Classifications Sarteschi Supine & standing Dubin Supine Idiopathic varicocele 15% of adult – Almost always on left – Bilateral in 30% 1 Liguori G et al. World J Urol 2004 ; 22 : 378 – 381. 2 Pilatz A et al. World J Urol 2011 ; 29 : 645 – 650.
    74. 74. Idiopathic varicocele Reversed flow lasting longer than 1 - 2 seconds Detected during Valsalva maneuver & resolved with its release Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
    75. 75. Sarteschi’s classification of varicocele Supine & standing positions Sarteschi LM. G Ital Ultrasonologia 1993 ; 4 : 43 – 9. Examinations done in supine & standing positionsGrade 1 Reflux in inguinal channel only during Valsalva Scrotal varicosity not evident in standard US study Grade 2 Small varicosities extend to superior pole of testis Diameters increase & venous reflux seen only during Valsalva Grade 3 Vessels enlarged at inferior pole of testis only in standing position No enlargement detected in supine position Reflux observed only during Valsalva Grade 4 Vessels appear enlarged in supine position Dilatation increased in upright position & during Valsalva Testicular hypotrophy common at this stage Grade 5 Venous ectasia even in prone decubitus and supine positions Reflux at rest & does not increase during Valsalva
    76. 76. Sarteschi’s classification/Grade 1 Pauroso S et al. J Ultrasound 2011 ; 14 : 199 – 204. Reflux in vessels seen only during Valsalva Valsalva’s maneuver No varicosity in inguinal channel on standard US examination Relaxing condition
    77. 77. Sarteschi’s classification/Grade 2 Pauroso S et al. J Ultrasound 2011 ; 14 : 199 – 204. Small varicosities exhibiting reflux only during Valsalva Valsalva’s maneuverRelaxing condition Small varicosities extend to superior pole of testis
    78. 78. Sarteschi’s classification/Grade 4 Pauroso S et al. J Ultrasound 2011 ; 14 : 199 – 204. Relaxing condition Venous reflux evident in basal condition Venous diameter increases during Valsalva Valsalva’s maneuver
    79. 79. Sarteschi’s classification/Grade 5 Pauroso S et al. J Ultrasound 2011 ; 14 : 199 – 204. Venous diameter does not increases during Valsalva Valsalva’s maneuverRelaxing condition Venous reflux evident in basal condition
    80. 80. • Presentation Testicular pain • Association Extra-testicular varicocele: common – left • US Anechoic structures from mediastinum testis Involvement of sub-capsular veins described • Doppler Vascular flow of venous type • DD Cystic structures: Prominent rete testis Intra-testicular cyst Intra-testicular varicocele Uncommon (< 2% in symptomatic population) Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
    81. 81. Intra-testicular varicocele Color Doppler US Valsalva maneuver demonstrating color Doppler flow Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302. Serpiginous structure in center of testis with „„tumbling‟‟ echoes within Gray-scale US
    82. 82. Secondary varicocele Increased pressure on abdominal spermatic vein Dogra VS et al. Radiology 2003 ; 227 : 18 – 36. Non-compressible varicoceles on left or right: Retroperitoneal evaluation for retroperitoneal mass LRV evaluation for thrombus or tumor extension • Hydronephrosis • Cirrhosis with PHT • Nutcracker phenomenon • Abdominal & retroperitoneal neoplasm
    83. 83. Henoch-Schönlein purpura Aso CE et al. RadioGraphics 2005 ; 25 : 1197 – 1214. Scrotal wall thickening Scrotal tunica thickening Epididymal enlargement Reactive hydrocele Two days later Typical purpuric lesions on both legs
    84. 84. Thrombosis of pampiniform plexus veins / rare Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107. Thrombus within veins of pampiniform plexus Hypoechoic & thickened vessel walls 34-year-old man presenting with acute scrotum
    85. 85. Acute scrotum  Inflammatory conditions  Vascular conditions  Scrotal trauma  Testicular tumors  Inguinal hernia  Acute idiopathic scrotal edema Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
    86. 86. • Scrotal or testicular edema • Testicular fracture or rupture • Scrotal hematoma • Scrotal hydrocele • Scrotal hematocele Most common findings of scrotal trauma Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107. Several of which are usually concurrent
    87. 87. Testicular Trauma / Intra-testicular hematoma Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302. 2 hypoechoic lesions in right testis Areas of rounded high reflectivity Patient involved in motorcycle accident Gray-scale US Color Doppler US Absence of vascularity Traumatic intra-testicular hematoma
    88. 88. Testicular Trauma / Tunica albuginea rupture Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107. Discontinuation of tunica albuginea (arrows) Protrusion of testicular contents from ruptured tunica (arrowheads) Associated scrotal wall hematoma (asterisk) Necessitates emergent surgery
    89. 89. Testicular Trauma / Fracture line Fracture line through mid-aspect of testis Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011. European Foundation of Societies of Ultrasound in Medicine & Biology.
    90. 90. Testicular trauma / Hematocele Kurian R & de Bruyn R. Ultrasound 2006 ; 14 : 216 – 222. Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107. Large left hydrocele Containing multiple echoes within Acute hematocele Chronic hematocele Complex peritesticular collection Thick internal septations Compressing ipsilateral testis
    91. 91. Evolution of testicular hematoma Longitudinal view 2 weeks later Hematoma has largely resolved Poorly defined hypoechoic area representing hematoma McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008. Longitudinal US view Longitudinal US two weeks later
    92. 92. Acute scrotum  Inflammatory conditions  Vascular conditions  Scrotal trauma  Testicular tumors  Inguinal hernia  Acute idiopathic scrotal edema Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
    93. 93. Clinical presentation of testicular tumors • Palpable mass Usual presentation • Acute scrotum 10 % of patients (hemorrhage) • Metastatic disease 5 – 10 % • Hormonal changes Precocious puberty Gynecomastia 5 – 10 % McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
    94. 94. Primary testicular tumors • Germ cell tumors Seminoma (most common) 90% Embryonal carcinoma Choriocarcinoma Teratoma Mixed germ cell tumors • Gonadal stromal tumors Leydig cell tumors 10% Sertoli cell, granulosa cell, theca cell Primitive gonadal stromal tumors McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008. 2 – 3% are bilateral (synchronous or metachronous)
    95. 95. Doppler US of testicular tumors • Usual appearance Homogenous & low reflectivity • Wide range of appearances High reflectivity Heterogeneous with calcification & cystic changes • Doppler US Increased vascularity even in small tumor (new transducers) Sidhu PS et al. European course book: Ultrasound of the scrotum. European Foundation of Societies of Ultrasound in Medicine & Biology, 2011. Distinguishing various cell types not practical Any suspected mass prompts orchiectomy or surgical biopsy
    96. 96. Classic testicular seminoma Hypoechoic – Homogeneous Gray-scale US Hypoechoic lobulated lesion Power Doppler US Mildly increased flow Wittenberg AF et al. Curr Probl Diagn Radiol 2006 ; 35 : 12 – 21.
    97. 97. Testicular teratoma Dogra VS et al. RadioGraphics 2001 ; 21 : S273 – S281. Multiple cystic areas (2 - 15 mm) Process involves nearly whole testis dd: testicular tubular ectasia Immature teratoma Septated cystic lesion Two solid nodules within Mature teratoma
    98. 98. Burned-out germ cell tumor / Azzopardi scars McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008. Coarse calcification in lower pole Longitudinal view of left testis Retroperitoneal mass Axial color view of abdomen Grown quickly outstripping their blood supply Appear as anything from small echogenic foci to hypoechoic masses
    99. 99. Sertoli cell tumor Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011. European Foundation of Societies of Ultrasound in Medicine & Biology. Well defined tumor with linear wall calcification
    100. 100. Peutz-Jeghers syndrome Aso C Eet al. RadioGraphics 2005 ; 25 : 1197 – 1214. Melanin pigmentation of lips Characteristic of Peutz-Jeghers Several echogenic lesions Burned-out Sertoli cell tumors Bilateral
    101. 101. Para-aortic lymph node in testicular cancer Enlarged para-aortic lymph node with cystic degeneration Cokkinos DD et al. Curr Probl Diagn Radiol 2011 ; 40 : 1 – 14.
    102. 102. Testicular macro-calcification • Benign lesion Intra-testicular cyst Epidermoid cyst Sertoli cell tumor Granulomatous disease of testes • Malignant lesion “burnt-out” tumor Primary testicular tumor Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011. European Foundation of Societies of Ultrasound in Medicine & Biology.
    103. 103. Testicular microlithiasis Bright foci of 1 – 2 mm without acoustic shadowing Stengel JW et al. Am J Roentgenol 2008 ; 190 : S35 – S41. Limited: < 5 microliths per US field Classical: > 5 microliths per US field Relative risk of concurrent neoplasm 20 fold Annual sonographic examination
    104. 104. Testicular microlithiasis associated with seminoma Transverse scanLongitudinal scan Chen JL et al. J Clin Ultrasound 2010 ; 38 : 309 – 313.
    105. 105. Non-Hodgkin lymphoma < 1% of patients with lymphoma Hypoechoic mass replacing most of testis Longitudinal view of right testis Blood flow in tumor Color Doppler US
    106. 106. Testicular metastases Malignant melanoma Robertson E & Baxter G. Ultrasound 2010 ; 18 : 86 – 88. Hypervascularity of hypoechoic areas Blood flow of tumor deposits Color Doppler imageGray-scale image Multiple hypoechoic lesions Highly suspicious of tumor deposits
    107. 107. • Presentation Mass which may be painful • Involvement Most commonly involves epididymis Solitary testicular involvement uncommon • US Low reflective focal lesions • DD Primary testicular malignancy Clinical evidence of sarcoid elsewhere Multiple focal lesions Epididymal involvement Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302. Genital sarcoidosis Multi-system disorder – Non-caseating epitheloid granulomas
    108. 108. Testicular sarcoidosis Recent diagnosis of sarcoidosis from skin lesion biopsy Multiple hypoechoic areas within testis & epididymis Lee JC et al. Ultrasound Quarterly 2008 ; 24 : 3 – 16.
    109. 109. Testicular adrenal rests Essential to recognize (avoid unnecessary orchidectomy) • Cause Congenital adrenal hyperplasia More commonly 21-hydroxylase deficiency • US Multiple hypoechoic areas near mediastinum Usually bilateral Frequent epididymal involvement • Doppler Hypervascular: vessels course without θ changes • DD Bilateral malignant tumors: rare (2 – 3%)
    110. 110. Adrenal rest / Adrenal remnants Aso CE et al. RadioGraphics 2005 ; 25 : 1197 – 1214. Nodule in epididymal head Several hypoechoic lesions in upper pole of testis
    111. 111. • Presentation Painless lump – Most common on left • US Homogeneous hypoechoic mass Difficult to separate from testis • Doppler Central vascular pattern toward periphery Disorganized pattern in primary tumor • DD Testicular tumor 99mTc-sulphur colloid scan diagnostic Spleno-gonadal fusion Accessory spleen in pelvis or scrotum fused to gonadal organs Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
    112. 112. Spleno-gonadal fusion Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302. Color Doppler US Ordered vessels at central aspect Splenic tissue at histology Iso-echoic lesion at upper pole Simulating primary testicular tumor Gray-scale US of left testis
    113. 113. Intra-testicular cystic lesions Rare – Avoid unnecessary surgical intervention • Benigns Tunica albuginea cyst Frequent Intra-testicular simple cyst Epidermoid cyst Tubular ectasia of rete testis Intra-testicular varicocele Abscess Hemorrhage (infarction) • Malignants Teratoma Most frequent Rare Large seminoma Dogra VS et al. RadioGraphics 2001 ; 21 : S273 – S281.
    114. 114. Cyst of tunica albuginea Ma OJ et al. Emergency ultrasound, 2nd edition. Bhatt S et al. Diagn Interv Radiol 2011 ; 17 : 52 – 63. Alvarez DM et al. J Clin Imaging Sci 2011 ; 1 : 5 - Partially calcified cyst of tunica albuginea Well defined cyst Posterior enhancement Tunica albuginea cyst with milk of calcium
    115. 115. Cyst of tunica vaginalis Tunica vaginalis cyst visible in presence of hydrocele Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011. European Foundation of Societies of Ultrasound in Medicine & Biology.
    116. 116. Intra-testicular simple cyst ≥ 40 years – Solitary – Near mediatinum • Causes Congenital, post-trauma, post-inflammatory • Size 2 – 20 mm in diameter • Association Extra-testicular spermatocele • Examination Usually not palpable – Not firm even if large • US Anechoic, thin wall, posterior enhancement • Treatment No treatment Palapable cyst should be removed 2 1 Dogra VS et al. RadioGraphics 2001 ; 21 : S273 – S281. 2 Hamm B et al. Radiology 1988; 168 : 19 – 23.
    117. 117. Intra-testicular cyst Anechoic lesion – Imperceptible wall – Posterior enhancement Surrounding thin rim of testicular parenchyma → intratesticular cyst Search for wall irregularity which may suggest cystic tumor Kim W et al. RadioGraphics 2007 ; 27 : 1239 – 1253.
    118. 118. Epidermoid cyst Mistaken for malignancy if absence of classic US findings • Manifestation Painless mass in 20 – 40 year old patient • US features Varies with degree of maturation Type 1 „„Onion-ring‟‟ – Suggestive – Teratoma Type 2 Densely calcified mass Type 3 Cyst with rim & peripheral/central calcification Type 4 Mixed pattern: heterogeneous & poorly defined Suggestive No color Doppler flow - Negative tumor markers • Treatment Enucleation – Orchidectomy (often performed) Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
    119. 119. Intra-testicular epidermoid cyst Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302. Stengel JW et al. AJR 2008 ; 190 : S35 – S41. “Onion-ring‟‟appearance Layers of compacted keratin Well-circumscribed mass Thick hyperechogenic wall Heterogeneous with sonolucent center
    120. 120. Tubular ectasia of rete testis Benign – Very common – > 50 years – Bilateral in 1/3 • Causes Epididymal obstruction (infection – trauma) Post-vasectomy patients • US Multiple hypoechoic oval structures Located in mediastinum testes Absence of color Doppler flow • DD Intra-testicular varicocele Cystic dysplasia of testes: congenital Cystic malignant tumor: Teratoma Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
    121. 121. Tubular ectasia of rete testis Frequent association with spermatocele or epididymal cyst Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107. Fluid-filled dilated tubular structures Nearby intra-testicular cyst Sagittal gray-scale US
    122. 122. Cystic dysplasia of testes Rare – Congenital – Renal malformation Enlarged testis Multiple irregular anechoic areas measuring few millimeters each Pathology specimen showing multiple cysts McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
    123. 123. Epididymal cyst Common (20 – 40% of asymptomatic men) Lee JC et al. Ultrasound Quarterly 2008 ; 24 : 3 – 16. Epididymal tailEpididymal bodyEpididymal head Indistinguishable from spermatocele
    124. 124. Spermatocele Cystic dilatations of efferent ductules Well defined cyst in epididymal head – Fluid debris level Typical of spermatocele Lee JC et al. Ultrasound Quarterly 2008 ; 24 : 3 – 16. Differentiate spermatocele from epididymal cyst by US not possible
    125. 125. Acute scrotum  Inflammatory conditions  Vascular conditions  Scrotal trauma  Testicular tumors  Inguinal hernia  Acute idiopathic scrotal edema Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
    126. 126. Inguinal hernia Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107. Bowel loop herniation into scrotum Increased tunical fluid surrounding the testis Diagnosis supported by visualization of peristaltic activity Fluid Hernia Testis
    127. 127. Complications of inguinal herniorrhaphy • Hernia recurrence • Epididymo-orchitis • Hematoma Inguinal canal & scrotum • Testicular ischemia Rare - more in recurrent hernia repair McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
    128. 128. Scrotal wall edema Marked thickening of scrotal wall Following inguinal hernia repair Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011. European Foundation of Societies of Ultrasound in Medicine & Biology.
    129. 129. Testicular ischemia after inguinal hernia repair Dellabianca C et al. J Ultrasound 2011 ; 14 : 205 – 207. No intra-testicular vascular signal Cremasteric vessel hypertrophy Inhomogeneous hypoechoic testis Bowel loop in scrotum (recurrence of hernia)
    130. 130. Acute scrotum  Inflammatory conditions  Vascular conditions  Scrotal trauma  Testicular tumors  Inguinal hernia  Acute idiopathic scrotal edema Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
    131. 131. Acute idiopathic scrotal edema • Etiology Possible allergic origin • Presentation From 4 months to 18 years Sudden onset of non-hemorrhagic edema Redness of scrotal wall • US Scrotal walls thickening & hypervascularity Characteristic findings • Evolution Resolves spontaneously in 3 – 4 days One or more relapses in next years • Treatment Conservative Aso CE et al. RadioGraphics 2005 ; 25 : 1197 – 1214. Halb C et al. Ann Dermatol Vénéréol 2010 ; 137 : 775 – 781.
    132. 132. Acute idiopathic scrotal edema Aso C Eet al. RadioGraphics 2005 ; 25 : 1197 – 1214. Marked thickening of scrotal walls Normal testes & tunicae Increased vascularity seen at color Doppler imaging 1-year-old boy
    133. 133. References
    134. 134. Thank You

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