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Imaging of the scrotum

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imaging of scrotum . radiology

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Imaging of the scrotum

  1. 1. IMAGING OF SCROTUM ROSHAN VALENTINE
  2. 2. ANATOMY OF SCROTUM  Cutaneous bag containing the testis , epididymis and lower part of spermatic cord  Left hemiscrotum is lower than the right – Longer spermatic cord
  3. 3. ANATOMY OF SCROTUM LAYERS OF SCROTUM
  4. 4. ANATOMY OF SCROTUM BLOOD SUPPLY  Sup and deep External pudendal A  Scrotal br of Internal Pudendal A  Cremasteric br of inferior epigastric
  5. 5. ANATOMY OF TESTIS TESTIS  Male gonad  Size : o At birth : 1.5cm(L) x 1.0cm(W) o <12 years : 1-2cc o 10-15cc (2x3x4cms-BaPL) in adults  Puberty achieved : >4cc
  6. 6. ANATOMY OF TESTIS EXTERNAL FEATURES  Upper pole:Oriented forward and lateral  Lower pole : Backward and medial  Anterior border : Convex and smooth , fully covered by tunica vaginalis  Posterior border : Straight and partially covered by tunica vaginalis – Epididymis along the posterolateral wall
  7. 7. ANATOMY OF TESTIS COVERINGS OF TESTIS(Out to in)  Tunica vaginalis  Tunica albuginea  Tunica vasculosa
  8. 8. ANATOMY OF TESTIS BLOOD SUPPLY OF TESTIS  Testicular artery  Collateral supply o Cremasteric artery o Artery to ductus deferens
  9. 9. ANATOMY OF TESTIS LYMPHATIC DRAINAGE
  10. 10. EPIDIDYMIS
  11. 11. SPERMATIC CORD
  12. 12. IMAGING MODALITIES
  13. 13. USG TECHNIQUE  Supine position  7-10Mhz linear array transducer  Direct contact or stand off pad  Examine in long and transverse axes  Size and echogenicity of the testis and epididymis  Scrotal skin thickness  CDFI and PWD  Valsalva and Upright positioning – Venous evaluation
  14. 14. USG ANATOMY  Pre-pubertal testis : Low to medium echogenicity  Post-pubertal : Homogenous and medium echogenicity  Medistinum Testis: Echogenic band in C-C direction  Hypoechoic thin rim of fluid around  Epididymis o Head : 5-12mm o Body : 2-4mm o Tail : 2-5mm  CDFI and PWD(RI : 0.46-0.68)
  15. 15. USG ANATOMY CDFI AND PWD  Low resistance pattern  Mean RI:0.62(0.48-0.75)
  16. 16. MRI OF SCROTUM MRI PROTOCOL  Supine position  Support scrotum by towel  T1 and T2wSE in coronal and axial plane  CE and Fat saturation seq  Thin 4-5mm slices 8-20 cm field of view  Undescended testis : Lower pole of kidneys  Diaphragm : For staging
  17. 17. MRI OF SCROTUM NORMAL MRI ANATOMY
  18. 18. PATHOLOGICAL CONDITIONS
  19. 19. SCROTAL WALL LESION  Non inflammatory  Inflammatory  Malignant
  20. 20. SCROTAL WALL LESION NON INFLAMMATORY o Swelling : HF , idiopathic lymphedema liver failure , venous and lymphatic obstruction o Appearance : ONION RING
  21. 21. SCROTAL WALL LESION INFLAMMATORY LESIONS o Cellulitis • Increased scrotal wall thickness • Hypoechoic areas within • Increased blood flow o Fournier Gangrene • Necrotizing fascitis of the wall • KEPPSS bacteria • Clinical > Imaging • Gas within the scrotal wall • Scrotal wall thickening with normal testis and epididymis
  22. 22. CONGENITAL ANOMALIES
  23. 23. CRYPTORCHIDISM  One or both the testis fail to migrate to the base of the scrotum  Course of testis  80% in inguinal region  Complication : Infertility , malignant degeneration, torsion and inguinal hernia
  24. 24. CRYPTORCHIDISM USG EXAMINATION  Localisation  Follow up post orchiopexy  Areas: Inguinal canal , suprapubic and femoral areas  Intraabdominal testis – USG less sensitive  USG features : Iso to hypoechoic , smaller in size , mediastinum testis
  25. 25. CRYPTORCHIDISM MRI  Look till lower pole of the kidneys  Round/ovoid  Along the path of descent  ID o Signal intensity pattern • Hypointense – T1 • Hyperintense – T2 o Mediastinum Testis o Differentiating from nodes: Position
  26. 26. RETRACTILE TESTIS  Due to hyperactive cremasteric muscle reflex  Slides back and forth between scrotum and ext inguinal ring  Self- limiting and no treatment ECTOPIC TESTIS  Location outside the descent path  Sites : Femoral canal , suprapubic or even C/L scrotal pouch
  27. 27. ACUTE SCROTUM
  28. 28. EPIDIDYMITIS AND ORCHITIS  MC cause in post-pubertal adults  Cause : UTI by KEPPs>STDs  If inflammation extends into testis : Epididymo-orchitis  C/F : Pain , fever , dysuria +/- urethral discharge  PREHN sign: pain relieved on elevating testis over pubic symphysis  Complications: Chronic pain , infertility , gangrene , abscess , infarction , atrophy and pyocele
  29. 29. EPIDIDYMITIS AND ORCHITIS USG FINDINGS OF EPIDIDYMITIS  Enlarged  Hypo/heteroechoic  Indirect signs of inflammation : Hydrocele , scrotal wall thickening , pyocele USG FINDINGS IN ORCHITIS  Heterogeneous echogenicity  Multiple hypoechoic lesions if focal  Usually unilateral( diff from Lymphoma & Leukemia)
  30. 30. EPIDIDYMITIS AND ORCHITIS CDFI and PD  100% sensitivity  Hyperemia  High flow , low resistance pattern  RI< 0.5  Reversal of diastolic flow in acute epididymoorchitis – s/o Venous infarction
  31. 31. EPIDIDYMITIS AND ORCHITIS MRI on Epididymitis  Enlarged epididymis with high signal intensity on contrast enhanced T1W  Area of hemorrhage and hyper vascularity MRI on Orchitis  Homogeneous/heterogen eous hypointense on T2W
  32. 32. TORSION Torsion Extravaginal Neonates Entire sac rotates Intravaginal In Vaginal sac Pubertal
  33. 33. TORSION
  34. 34. TORSION BELL CLAPPER DEFORMITY
  35. 35. TORSION  Rotation of testis on long axis of spermatic cord Torsion Venous Edema and hemorrhage Arterial Ischemia and necrosis
  36. 36. TORSION SALVAGE RATE o <6 hours – 100% o 6-12 hrs – 70% o 12-24 hrs - 20%
  37. 37. TORSION CLINICAL FEATURES  Sudden onset of pain  Nausea  Vomiting  Low grade fever  O/E : Swollen , tender and inflamed hemiscrotum
  38. 38. TORSION USG features  Vary with duration and degree of rotation  Grey Scale – Nonspecific (Normal if hyperacute)  < 6 hours : Testicular swelling and hypoechogenicity  >24hrs: Heterogeneous due to congestion , hemorrhage and infarction  Enlarged hypoechoic epididymal head : if deferential artery is involved  Scrotal wall thickening  Reactive hydrocele
  39. 39. TORSION CDFI  CDFI or PD signal present with clinical manifestation : Doesnot exclude torsion  Absence of identifiable intratesticular flow o Sensitivity 86% o Specific 100% o Accuracy 97%
  40. 40. SPECTRUM OF APPEARANCES
  41. 41. Torsion of appendix testis  Blue dot sign : Torsion of appendix  USG o Hyperechoic mass with central hypoechoic area adjacent to superior poleof testis/epididymis o Reactive hydrocele o Scrotal skin thickening o Increased peripheral flow on CDFI o To rule out testicular torsion and acute epididymo-orchitis
  42. 42. TORSION MRI  Early diagnosis of incomplete torsion  ‘WHIRLPOOL’ pattern : twisted cord as multiple low intensity curvilinear pattern  Torsion knot as signal void  Intermittent torsion : Enlarged testis and Hyperintense on T1 and T2  MR Spectroscopy - Decreased levels of beta – ATP in acute torsion
  43. 43. TORSION
  44. 44. TORSION  Tc-99m Pertechnate scan
  45. 45. SCROTAL TRAUMA  Mostly direct injury  Open and penetrating injury – Immediate surgery usually  Blunt injury o Exclude testicular rupture(emergency) o Hematoma from hematocele o Follow up
  46. 46. SCROTAL TRAUMA USG  Hematoma – Well defined hypoechoic SOL  Rupture – Irregular contour, hypo/hyperechoic areas  Scrotal hematoma – Non specific wall thickening  Hematocele – Int echoes in the fluid in vaginal sac  Chronic hematocele – Thick septae and wall thickening
  47. 47. SCROTAL TRAUMA MRI  When USG is non yielding  Testicular rupture : Loss of integrity of tunica albuginea
  48. 48. TESTICULAR TUMORS
  49. 49. Testicular Cancer CLASSIFICATION o Germ Cell (90%) - Malignant • Seminoma • Non-seminoma (embryonal cell, choriocarcinoma, teratoma, yolk sac) • Mixed o Non-Germ cell –rare; usually benign • leydig • sertoli o Secondary • leukemia, lymphoma • met (prostate)
  50. 50. TESTICULAR TUMOR  MC malignancy affecting young men of 20-34 yrs of age  Risk factors: Cryptoorchidism , testicular atrophy(mumps), testicular microlithiasis, klinefelters ,downsyndrome  C/F: Painless mass, vague discomfort  USG : differentiate Intratesticular(malignant) and Extratesticular(benign) lesions
  51. 51. TESTICULAR TUMOR GERM CELL TUMOR  90-95% of testicular cancers GCT Seminomatous Non Seminomatous
  52. 52. GERM CELL TUMORS  TUMOR MARKERS o LDH o AFP(Never elevated in Seminoma) o hCG(choriocarcinoma , majority of NSGCT)
  53. 53. SEMINOMA  MC testicular tumor  4th to 5th decade  Best prognosis  Chemosensitive and radiosensitive
  54. 54. SEMINOMA Seminoma Typical(85%) Anaplastic(10%) Spermatocytic (Best Px)
  55. 55. SEMINOMA USG  Homogenous hypoechoic lobulated lesion  Entire testis replaced by tumor(>50%cases)  Cystic components are rare  Confined to Tunica albuginea  Mets to Lung , brain
  56. 56. SEMINOMA
  57. 57. SEMINOMA MRI  T1W : Homogenous and relatively isointense  T2W : Hypointense
  58. 58. NSGCT  3rd – 4th decade  Can have multiple histologic patterns USG Inhomogneous echotexture(71%) o Ill defined margins(45%) o Echogenic foci(35%) o Cystic components(61%) MRI o T1W : Isointense to Hyperintense o T2w : Hypointense o Gd-T1 :Heterogenous (necrosis, mixed cell types)
  59. 59. NSGCT
  60. 60. EMBRYONAL CARCINOMA  3rd decade  USG o Predominantly hypoechoic o Poorly defined margins o Inhomogeneous echotexture o Invades Tunica and distorts the contour of testis
  61. 61. YOLK SAC TUMOR  Endodermal sinus tumor/infantile embryonal carcinoma  80% of pediatric testicular tumors  AFP   USG o Inhomogeneous o Echogenic foci
  62. 62. CHORIOCARCINOMA  Highly malignant  Microvascular invasion – hence hematogenous mets  USG : Heterogenous mass
  63. 63. TERATOMA  Composed of all three germ cell layers  Any age group  USG o Large and inhomogenous mass o Cystic components more common
  64. 64. BURNT-OUT GERM CELL TUMOR  When growth > supply  Histology : No tumor cells , but replaced by scar and fibrous tissue  USG o Small echogenic foci / hypoechoic mass or merely an area of calcification
  65. 65. MIXED GERM CELL TUMOR  More common than any other testicular tumor except seminoma  Any combination of cell types  variety of cell types expressed in variable appearance
  66. 66. NGCT  Tumors of gonadal stroma(Leydig , sertoli and gonadoblastoma  May be endocrinally active – precocious puberty , gynecomastia  5% of testicular cancer • higher in peds  90% benign  Indistinguishable from GCT  USG o Small in size o Smooth contour o Homogenous hypoechoic
  67. 67. LEYDIG CELL TUMOR  1-3% of all testicular neoplasm  Usually benign  Hormonally active USG  Hypoechoic nodule MRI  T1W : Isointense  T2W: Hypointense  CE :Hyperenhance
  68. 68. SERTOLI CELL TUMOR  1% of all testicular CA  First 4 decades of life  Mostly benign  MRI imaging NOT SPECIFIC
  69. 69. NGCT LYMPHOMAS  MC testicular neoplasm after 60 years  Can involve C/L seminoma , epididymis and spermatic cord  Appearance o Deposits as focal or diffuse hypoechoic hypervascular areas o Enlarged usually o T1 and T2 hypointense lesions
  70. 70. NGCT METASTASIS  Rare and seen in older patients  Primaries – Lung , Kidney and prostate  USG : Non specific
  71. 71. STAGING OF TESTICULAR CANCER  pTX: Primary tumor cannot be assessed (if no radical orchiectomy has been performed, TX is used.)  pT0: No evidence of primary tumor (e.g., histologic scar in testis)  pTis: Intratubular germ cell neoplasia (carcinoma in situ)  pT1: Tumor limited to testis and epididymis without lymphatic/vascular invasion  pT2: Tumor limited to testis and epididymis with vascular/lymphatic invasion, or tumor extending through the tunica albuginea with involvement of the tunica vaginalis  pT3: Tumor invades the spermatic cord with or without vascular/lymphatic invasion  pT4: Tumor invades the scrotum with or without vascular/lymphatic invasion
  72. 72. STAGING OF TESTICULAR CANCER REGIONAL LYMPH NODES (N)  NX: Regional lymph nodes cannot be assessed  N0: No regional lymph node metastasis  N1: Metastasis in a single lymph node, 2cm in greatest dimension  N2: Metastasis in a single lymph node, 2-5 cm in greatest dimension; or multiple lymph nodes, 5 cm in greatest dimension  N3: Metastasis in a lymph node >5cm in greatest dimension
  73. 73. STAGING OF TESTICULAR CANCER DISTANT METASTASIS (M)  MX: Presence of distant metastasis cannot be assessed  M0: No distant metastasis  M1: Distant metastasis  M1a: Non-regional nodal or pulmonary metastasis  M1b: Distant metastasis other than to non-regional nodes and lungs
  74. 74. STAGING OF TESTICULAR CANCER
  75. 75. STAGING OF TESTICULAR CANCER
  76. 76. RISK STRATIFICATION
  77. 77. CT  MC for tumor spread , Staging and follow up  Detection of lymphadenopathy  Extranodal mets in Lung and liver  Nodes <1cm suspicious if at the site of drainage o Renal hila on left o Aortocaval in right  Cut off for nodes : 7mm  NSGCT : Enlarged necrotic LN or heterogenous contrast enhancement
  78. 78. PET(FDG-PET)  Differentiation of active disease from fibrosis/mature teratoma in patients with residual mass following chemotherapy  Initial staging and disease assessment after orchidectomy  Identification of suspected recurrences in the context of elevated circulating serum markers  Predicting response to treatment.
  79. 79. BENIGN INTRATESTICULAR LESIONS
  80. 80. BENIGN INTRATESTICULAR LESIONS CYSTS  Incidentally detected usually  Symptomatic , palpable and solid component : ? suspicious
  81. 81. BENIGN INTRATESTICULAR LESIONS TUNICA ALBUGINEA CYST  Small palpable masses  Upper anterior/lateral aspect USG  Cystic and peripheral  Internal echoes are rare MRI  Similar to fluid in all sequences
  82. 82. BENIGN INTRATESTICULAR LESIONS TUBULAR ECTASIA  Multiple tiny cystic areas with no flow on CDFI  Associated with epididymal obstruction EPIDERMOID AND DERMOID CYSTS  Rare  Palpable simple cysts  Echogenic margins  No malignant potential
  83. 83. BENIGN INTRATESTICULAR LESIONS ADRENAL RESTS  Associated with CAH  Common embryonic origin of adrenals and gonads  USG o Multifocal o Bilateral hypoechoic lesions
  84. 84. BENIGN INTRATESTICULAR LESIONS CALCIFICATION Calcification Intratesticular Macro(Calcifying tumors) Microlithiasis Extratesticular Scrotoliths
  85. 85. BENIGN INTRATESTICULAR LESIONS CALCIFICATION  Testicular microlithiasis o Multiple small hyperechoic foci +/- shadowing o 5 /transducer field is abnormal o 18-75% association with neoplasia o Follow up required if seen
  86. 86. CALCIFICATIONS
  87. 87.  Occurs as a complication of epidiymo-orchitis  Can rupture into tunica vaginalis – pyocele  USG: Fluid filled hypoechoic/ echogenic areas with peripheral vascularity. Should be correlated with clinical symptoms. TESTICULAR ABSCESS
  88. 88.  Can occur secondary to torsion, vasculitis, leukemia, hypercoagulable state.  Seen as peripherally placed, wedge shaped, hypoechoic mass, with decreased or no vascularity.  Usually shows decrease in size on follow up. TESTICULAR INFARCTION
  89. 89. TESTICULAR INFARCTION MRI  T1W : Isointense o Hemorrhagic infarct : Hyperintense  T2W : Variable but usually hypointense  CE : Rim enhancement
  90. 90. INTRATESTICULAR VARICOCELE  ?etiology. ?significance  May cause pain  (+/-)extratesticular varicoceles  Findings • tubular, serpiginous structures with venous doppler/color flow which increases with valsalva
  91. 91. EXTRATESTICULAR PATHOLOGIES
  92. 92. EXTRATESTICULAR PATHOLOGIES HYDROCELE  Serous fluid in tunica vaginalis  Two types o Congenital: Persistent processus vaginalis o Acquired : Idiopathic , post inflammatory , torsion , trauma or tumor  USG o Anechoic collection around the testis o Internal echoes/Few septations : chronic
  93. 93. EXTRATESTICULAR PATHOLOGIES HEMATOCELE AND PYOCELE  Post hemorrhage and abscess formation  USG o Multiple septations o Echogenic debris o Thickening of scrotal skin o Calcification
  94. 94. EXTRATESTICULAR PATHOLOGIES INGUINOSCROTAL HERNIA  Dx usually clinically  May contain bowel or omentum  Essential to distinguish obstructed from non obstructed  Strangulation o Akinetic dilated bowel loop in the sac o Hyperemia of scrotal soft tissue and bowel
  95. 95. EXTRATESTICULAR PATHOLOGIES EPIDIDYMAL CYST and SPERMATOCELE  MC scrotal lesion  Spermatocele o 20 to obstruction of spermatic pathway o Usually located in head of epididymis  Epididymal Cyst o Less common o Anywhere in epididymis  USG : Anechoic well circumscribed cysts
  96. 96. EXTRATESTICULAR PATHOLOGIES SPERM GRANULOMA  Post vasectomy or epididymal obstruction  USG o Hypoechoic lesion o Focal calcification +/-
  97. 97. EXTRATESTICULAR PATHOLOGIES POSTORCHIDECTOMY SCROTUM  Empty hemiscrotum  Fluid collection /hematoma – Early post-op period  Thickened scrotal wall  Poorly defined hypoechoic lesion – Recurrence  Testicular prosthesis : Made of silicone o Sharply defined anechoic structure with excessive reverberations
  98. 98. EXTRATESTICULAR TUMORS BENIGN Adenomatoid Hemangioma Lipoma Neurofibroma Leiomyoma MALIGNANT Liposarcoma Fibrosarcoma Lymphoma(Adults) Rhabdomyosarcoma in (children)
  99. 99. EXTRATESTICULAR TUMORS  Usually benign  MC : Adenomatoid tumor of epididymis/sper matic cord  USG o Solitary , well defined , round to oval o Variable echogenicity
  100. 100. LIPOMA  MC benign tumor of spermatic cord USG  Well defined homogenous and hyperechoic MRI  Uniform and fat signal intensity in all sequences
  101. 101. SUMMARY  Use of Gray-scale, pulsed, and color Doppler US can help to establish the correct diagnosis of a variety of pathologic conditions involving the scrotum.  MRI is useful adjunct in many cases – to differentiate intra and extratesticular masses .

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