Imaging orchitis epidydmitis epidydmo orchitis IMAGING OF LOWER URINARY TRACT INFECTION LUTI include different cases for oral radiodiagnosis examination all over the world CT /MRI Plain X ray ultrasound TRANSRECTAL ULTRASOUND images Cystitis Prostatitis urethritis Orchitis Epidydmitis Epidydmo-orchitis funiculitis Vastitis/differentitis Seminal vesiculitis

1. Orchitis
epididymitis
epidydmo-orchitis
imaging
Dr. Ahmed Esawy
MBBS M.Sc MD
Dr Ahmed Esawy

2. Evaluation of the Scrotum
 Three Key Areas:
 Testicle
 Epididymis
 Surrounding layers
Dr Ahmed Esawy

3. Evaluation of the Scrotum
 Three Key Areas
-Testicle
- Epididymis
-Surrounding layers
Dr Ahmed Esawy

4. These two transverse ultrasound images demonstrate the normal blood flow through
the left testicle.The left ultrasound image shows an area through the mid testicle
without color Doppler; the right image shows blood flow towards the transducer (red)
and flow away from the transducer (blue).
Dr Ahmed Esawy

5. These two ultrasound images demonstrate a normal blood flow pattern in the testicle.
The left is a longitudinal image and the right is a transverse image through the right
testicle of the same patient. Compare this waveform with later images of pathologies of
the testis for greater appreciation of what is being demonstrated.
Dr Ahmed Esawy

6. These two ultrasound images demonstrate waveforms seen with color Doppler and pulsed
wave Doppler.The pulse wave signal seen of the right testicle (left picture) shows a vessel
with flow away from the transducer (white arrow). On the right is an ultrasound image
showing Doppler signal in a vessel in the left testicle having blood flow towards the
transducer.
Dr Ahmed Esawy

7. Blood FlowWaveform for theTestis
Diferential artery: high resistance
Cremasteric artery: high resistance
Testicular artery: low resistance
Dr Ahmed Esawy

8. The ultrasound image on the left demonstrates a normal tunica vaginalis surrounding the
testis.On the right, the left testis is surrounded by a hydrocele. Notice the parietal layer of
the tunica vaginalis apposed to the testis and the large fluid filled space and parietal layer.
This is a large hydrocele, which is only partially demonstrated on this view.
Dr Ahmed Esawy

9. Scrotal sac
infection
Dr Ahmed Esawy

10. Scrotal ultrasound showing a normal appearing testicle with a scrotal free
fluid with newly developed septations and echogenic debris and
thickened scrotal skin without evidence of free air within the scrotal wall
Dr Ahmed Esawy

11. Chronic pyocele. Longitudinal US with panoramic view
of right scrotum shows low level internal ecoes (P), with
thickened and calcified wall (c) with posterior acoustic
shadowing (S), inferiorly displaced right testis (T).
Dr Ahmed Esawy

12. Post inflammatory secondary hydrocele Longitudinal US
of scrotum shows, septations(S), inflamed testis (T).
Dr Ahmed Esawy

13. Acute orchitis pyocele
Dr Ahmed Esawy

14. Scrotal abscess pyocele
Dr Ahmed Esawy

15. Dr Ahmed Esawy

16. Inflammatory Diseases of Scrotal wall
Dr Ahmed Esawy

17. Cellulitis of Scrotal Wall:
Ultrasonographic findings include thickening of the
scrotal wall and loss of uniform hyperechogenecity of the
scrotal wall.Testis and epididymis may be normal.
Complications: Scrotal wall abscess.
Dr Ahmed Esawy

18.  Idiopathic scrotal edema in a 1-year-old boy.Transverse
US scan of both hemiscrota shows marked thickening
of the scrotal walls ( ).The testes (T) and their tunicae
appear normal. Increased vascularity was seen at color
Doppler imaging.
Dr Ahmed Esawy

19. : Inflammatory diseases of scrotal contents include
· Acute epididymitis and epididymo-orchitis,
· Chronic epididymitis and epididymo-orchitis
· Acute orchitis and Complications of inflammatory
diseases of the testis and epididymis.
Dr Ahmed Esawy

20. Orchitis
=testicular infection
Dr Ahmed Esawy

21. Primary orchitis in isolation is rare and
most commonly caused by mumps
testes appear enlarged
decreased echogenicity.
increased testicular vascularity
Hyperemia and heterogeneity isolated to the testis can be seen
in cases of orchitis, tumor, infarction, and especially in
transient torsion of the testis
Dr Ahmed Esawy

22. Orchitis findings
 The testicle may appear normal or enlarged in size
 The echogenicity may be decreased.
 Reactive hydroceles and skin thickening are
associated with orchitis.
 Increased color Doppler flow to the infected testes.
Chronic orchitis appears as layers of heterogeneous
disruption within the testicle.
 Focal orchitis may occur without involvement of the
epididymis and has the same appearance as a
neoplasm.
Dr Ahmed Esawy

23. Orchitis
Dr Ahmed Esawy

24. Epididymo-orchitis
Dr Ahmed Esawy

25. Testicular abscess
Dr Ahmed Esawy

26. Testicular abscess
Dr Ahmed Esawy

27. Chronic orchitis
Dr Ahmed Esawy

28. Focal Orchitis
The study shows an intraparenchymatous hypoechoic area in
the upper portion of the right testicle, corresponding to focal
acute orchitis.The patient evolved favorably with antibiotic therapy.
Dr Ahmed Esawy

29. Focal Orchitis with Pyocele: Grayscale scrotal
ultrasound image of the right testicle reveals a
round heterogenous hypoechoic region in the
right testicle, which is surrounded by fluid with
echogenic debris, compatible with focal
orchitis and pyocele.
Focal orchitis: Doppler color ultrasound
in the same patient reveals increased
flow within the hypoechoic region,
compatible with focal orchitis
Dr Ahmed Esawy

30. Testicular Abscess
Ultrasound image: heterogeneous mass (ABSC), with an increase
of the perilesional flow, corresponding to an intratesticular abscess
Dr Ahmed Esawy

31. Ischemic orchitis
Sonography of the scrotum shows:
1) hypoechoic left testes
2) 2) swelling of the left testes
3) 3) absence of vascularity in left testes.
These ultrasound and color doppler images suggest left ischemic orchitis. Ischemic orchitis
is a known complication of herniorraphy
Dr Ahmed Esawy

32. ORCHITIS COMPLICATIONS
Dr Ahmed Esawy

33. MRI. Presence of an abscess in the left scrotum with rectal fistula. A,B:Axial (A) and
coronal (B) sections ofT2-weighted sequence where a multiloculated
collection is observed with hypersignal in the left scrotum (asterisk) without extension to
the testes (T), and fistulous tract (arrow) which crosses the anal sphincter
muscle towards the anterior rectal wall. AxialT1-weighted image after contrast agent
injection (C) demonstrating hyposignal from the collection (asterisk) and the
enhancement of its walls.The large field of view provided by MRI facilitates the
assessment of the lesion extent.
Dr Ahmed Esawy

34. Epididymitis
Acute Epididymitis And Epididymo-Orchitis- It is
the most common cause of acute scrotal pain in
Dr Ahmed Esawy

35. Normal Epididymal
Architecture
Right Epididymis Longitudinal Axis
Right EpididymisTransverse Axis
Dr Ahmed Esawy

36. This ultrasound image shows the head of the epididymis (white arrow) next to the testis.
Compared to the normal testicle the epididymis is normally isoechoic or slightly more
echogenic. Notice the coarse composition of the epididymis relative to the echotexture of
the testicle.The contour of the epididymis over the superior portion of the testicle can be
seen on the ultrasound image on the right
Dr Ahmed Esawy

37. These two ultrasound images demonstrate the head of the epididymis.The head of the
epididymis is coarse in appearance compared to the homogenous echotexture of the
testis seen in the image on the right.The white arrow in the left image of a longitudinal
view of the left epididymis points to the head
Dr Ahmed Esawy

38. These two ultrasound images are selections from a scan of the epididymis. Demonstrated is
the body (left image) and tail (right image) of the epididymis.The coarse structure of the
epididymis is due to its extremely long convoluted system of tubules that store sperm.
Demonstrating the head, body, and tail of the epididymis is part of the ultrasound imaging
sequence for the scrotal and testicular scan.
Dr Ahmed Esawy

39. Epididymitis
Inflammation of the epididymis
Symptoms:
Acute scrotal pain
Fever, dysuria, discharge
Ultrasound findings:
Enlarged epididymis, coarse appearance
Chronic-hyperechoic
Acute-hypoechoic, increased blood flow
Dr Ahmed Esawy

40. Right Epididymis Longitudinal Axis
Left Epididymis Longitudinal Axis
Epididymitis
 Infection of epididymis
 Hypoechoic body and tail
of epididymis
 Hyperemia on Doppler
 Pain reduced by
elevation of testicle
Dr Ahmed Esawy

41. These two ultrasound images demonstrate the epididymis. On the left is a transverse
section through the epididymis. Notice its coarse appearance, which is a characteristic of
chronic epididymitis.The ultrasound image on the right is a longitudinal section through the
tail of the epididymis. Notice how large and hyperechoic the epididymis appears in these
two images.This is chronic epididymitis.Acute epididymitis would be hypoechoic.
Dr Ahmed Esawy

42.  Clinically proved epididymitis
in an 11-year-old boy. (a)
Longitudinal US scan of the
right hemiscrotum shows an
enlarged hypoechoic
epididymal head (E), reactive
hydrocele (h), and thickening
of the scrotal wall (*). m =
mediastinum. (b) Color and
pulsed-wave Doppler image
shows increased vascularity in
the epididymal head with a
low-flow, low-resistance
waveform pattern.

43. These two ultrasound color Doppler images demonstrate the blood flow to the
epididymis.The image on the left is a transverse section, and the right a longitudinal
section. Both images demonstrate increased blood flow to the epididymis, which is a
characteristic of chronic epididymitis.

44.  Acute epididymitis in a 9-
year-old boy with scrotal
pain and redness.
Longitudinal US scan shows
that the epididymal head
and body (arrows) are
enlarged and hypoechoic
relative to the normal testis
(T).Wall thickening (*) and
reactive hydrocele (h) are
also seen. Power Doppler
imaging showed increased
perfusion of the epididymis.
Dr Ahmed Esawy

45. EPIDIDYMITIS
The case on the left shows the
typical features of epididymitis.
The epididymis is swollen and
heterogeneous.There is a hydrocele
and scrotal wall thickening.With
color Doppler there is increased flow.
A normal epididymis has only limited color flow.
Dr Ahmed Esawy

46. Right Epididymis Longitudinal Axis
Left Epididymis Longitudinal Axis
Epididymitis
 Infection of epididymis
 Hypoechoic body and tail
of epididymis
 Hyperemia on Doppler
 Pain reduced by
elevation of testicle
Dr Ahmed Esawy

47.  Granulomatous epididymitis in a 17-year-old boy with a
painful scrotal mass. Longitudinal US scan shows a
heterogeneous extratesticular mass (cursors) that
replaces the epididymal tail.The mass resolved with
medical treatment.
Dr Ahmed Esawy

48.  Transverse sonogram of the testis shows an
enlarged and predominantly hypoechoic
epididymis with a reactive hydrocele in a patient
with acute epididymitis.
Dr Ahmed Esawy

49.  Color flow sonogram shows increased vascularity in the epididymis.
An enlarged epididymis with increased vascularity in the appropriate
clinical setting is diagnostic of acute epididymitis.
Dr Ahmed Esawy

50.  Epididymitis. Longitudinal color Doppler
image depicts normal vascularity of the right
testicle, with increased flow in the epididymal
tail and a small hydrocele
Dr Ahmed Esawy

51.  Henoch-Schönlein purpura in a 9-year-old boy with bilateral
scrotal pain and swelling. (a) Longitudinal US scan of the right
hemiscrotum shows thickening of the scrotal wall (*) and scrotal
tunica (arrows), an enlarged epididymal head (E), and a small
hydrocele (h). Similar findings were seen in the left hemiscrotum

52. Acute Epididymitis.
Ultrasound image, axial view of the epididymis tail: increased
in volume and heterogeneous signal because of parenchymatous
inflammatory changes
Dr Ahmed Esawy

53. Epididymal abscess
Dr Ahmed Esawy

54. Acute Epididymitis and Doppler
Longitudinal image: increase in diameter of the left epididymis at the level of the
head, which is heterogeneous with an increase of flow in Doppler mode.
Dr Ahmed Esawy

55. Epididymis
 Acute epididymitis. (a)
Longitudinal US image shows
a markedly thickened,
heterogeneous epididymal tail
(arrowhead) and edema within
the scrotal wall (arrow). T =
testis.
 (b) Color Doppler image shows
increased flow. (c) Photograph
of the gross specimen shows a
markedly thickened,
hyperemic epididymis (arrow).
T = testis.

56.  Tuberculous epididymitis. (a) Longitudinal US image shows a heterogeneous,
hypoechoic mass in the region of the epididymal tail (arrow). It is difficult to
differentiate the mass from a testicular one. T = testis.
Dr Ahmed Esawy

57.  Tuberculous epididymo-orchitis. (a) Longitudinal US image
shows a markedly enlarged epididymal head (arrowhead) with
one large and several smaller hypoechoic masses (curved
arrows).There are also multiple small hypoechoic lesions
within the testis (straight arrows).
Dr Ahmed Esawy

58.  Sarcoidosis. (a)Transverse US image shows a
markedly enlarged, hypoechoic epididymis (E). T =
testis.
Dr Ahmed Esawy

59.  Clinically proved acute epididymitis in a 21-year-old man.
Left:Transverse US scan of right testis and epididymis shows
an enlarged hypoechoic epididymis (arrow). Right:Transverse
color Doppler US scan of same epididymis demonstrates
increased vascularity (arrow).The testis is normal.
Dr Ahmed Esawy

60.  Epididymitis. A, Color and spectral Doppler image showing an
enlarged hypoechoic epididymis and hyperemic blood flow. Note
the normal testicular echo texture and lack of visible testicular
blood flow at this color Doppler scale setting. B, Enlarged
hypoechoic epididymal body (arrowheads) with associated
hydrocele and scrotal wall thickening.

61.  Granulomatous epididymitis in a 17-year-old boy with a
painful scrotal mass. Longitudinal US scan shows a
heterogeneous extratesticular mass (cursors) that replaces
the epididymal tail.The mass resolved with medical
treatment.
Dr Ahmed Esawy

62. Evaluation of Acute Scrotal Pain
Dr Ahmed Esawy

63. epididymo-orchitis
Dr Ahmed Esawy

64. Epididymo-orchitis
 Common cause of acute scrotal pain in young adult
 Clinically: pain relief when the testis is elevated above the symphysis pubis)
 Caused by sexually transmitted organism
 Start at the tail of epididymis
 Complications: abscess- atrophy- infertility-pyocele
 US: enlarged epididymis and testis with hypoechoic heterogenous pattern (
DD lymphoma-leukaemia -metastasis)- Hypervascular on Doppler
May hyperechogenicity if Hge
scrotal wall edema- Hydrocele
Dr Ahmed Esawy

65.  Epididymo-orchitis.
 A, Mottled testicular echo texture with hypoechoic regions.
 B, Color and spectral Doppler image showing testicular hyperemia.
 C, Color Doppler image showing hyperemic, enlarged, hypoechoic
epididymis and testis.

66.  Clinically proved acute epididymo-orchitis in a 32-year-old man.
Transverse US scan of testis shows acute epididymo-orchitis as
focal areas of decreased echogenicity (arrowhead) in testicular
parenchyma (T), resembling a metastatic lesion with reactive
hydrocele (F).These hypoechoic areas were completely resolved at
follow-up US after 2 weeks of antibiotic treatment.
Dr Ahmed Esawy

67. Acute epididymo-orchitis. Longitudinal gray scale US
shows enlarged testis (T), thickened scrotal wall (arrow)
with hydrocele with septations.
Dr Ahmed Esawy

68. Acute epididymo-orchitis. Dual transverse power
Doppler US of both testes shows increased flow in right side
testis compared to normal left testis.
Dr Ahmed Esawy

69. Acute epididymo-orchitis. Pulse Doppler of intra
testicular vessels shows low resistance flow pattern
(arrow) and increased PSV.
Dr Ahmed Esawy

70.  Epididymo-orchitis. Longitudinal color
Doppler image of the left testis shows
diffuse, markedly increased vascularity.
Dr Ahmed Esawy

71.  Epididymo-orchitis.Transverse color
Doppler image demonstrates increased
epididymal flow and a hydrocele
Dr Ahmed Esawy

72. Chronic Epididymoorchitis. Panoramic longitudinal
gray scale US shows enlarged and heterogenous right testis
(t), head of epididymus (E)is enlarged and Funiculitis with
thick spermatic cord (SC).
Dr Ahmed Esawy

73. Chronic tubercular Epididymoorchitis. Longitudinal US
shows enlarged and heterogenous epididymus with calcification, with increased
flow on power Doppler.
Dr Ahmed Esawy

74. Acute epididymo-orchitis in a 47-year-old Sri Lankan man with
multiple myeloma on bortezomib therapy, suffering from fever and acute
scrotal pain, tenderness and induration.
Contrast-enhanced CT (a, b) performed to investigate impending urosepsis depicted a
thickened engorged left spermatic cord, with inhomogeneous vascularisation of the
ipsilateral epididymis (thin arrows) and testis (arrows). Note catheter (in a), thickened and
increased oedematous attenuation of the scrotal skin and external tunicae. CD-US
(c) revealed hypervascularisation of the epididymis (+). Unresponsive to antibiotics,
Klebsiella pneumoniae ultimately required orchiectomy
Dr Ahmed Esawy

75. Surgically confirmed epididymo-orchitis with
pyocele in a 72-year-old diabetic man with
haematuria and enlarged left scrotum, history
of transurethral resection of bladder
carcinoma and bladder neck stricture treated
by long-term catheterisation. Ultrasound
revealed ipsilateral enlarged inhomogeneous
epididymal head (+ in a) and
hypervascularised testis (* in b).
After unsuccessful antibiotic therapy,
contrast-enhanced CT (c, d) showed
hyperaemic left epididymis (thin arrows) and
testis (arrows) compared to contralateral
structures, and development of posterior
scrotal collection (§).Another surgically
proven case of testicular abscess and necrosis
in a 59-year-old man with epididymo-orchitis
unresponsive to medical therapy:
post-contrast CT (e, f) revealed vascular
engorgement along the left spermatic cord
(arrowhead), faintly enhanced epididymal
head (thin arrow in e), and ipsilateral
scrotum occupied by fluid-like collection (*)
with thin peripheral enhancing rim
Dr Ahmed Esawy

76. Inflammatory MyofibroblasticTumor of the
Paratestis
Split-screen transverse sonogram showing a complex cystic mass with multiple septa compressing the left
testis, giving it a commalike appearance (arrows). R.T. indicates right testis.
B, Color-coded oblique sonogram showing no internal vascularity in the multicystic component of the
mass.
C, Panoramic view (the scrotum was traced in a coronal axis, from right to left and then upward along the
left groin).The solid component of the paratesticular IMT (+) abuts the testicular surface (T).
Retrospectively, the hypoechoic area (asterisk) probably represents part of the separate IMT of the
spermatic cord. Dr Ahmed Esawy

77. Idiopathic scrotal edema
Sonography of the scrotum was done in this child who had acute swelling of the
scrotum and penis.
Ultrasound images reveal
1) thickening (11mm.) of the scrotal and penile skin and subcutaneous tissue and
2) 2) marked hyperemia of the scrotum as well as the prepuce.
3) The testes show normal appearance on sonography.
These ultrasound and color doppler images are diagnostic of idiopathic scrotal edema
Dr Ahmed Esawy

78. Idiopathic scrotal edema
Dr Ahmed Esawy

79. Is it easy to differentiate orchitis from testicular torsion ?
No not easy
Dr Ahmed Esawy

80. orchitis
Epididymitis vs. Torsion
 Epididimitis
 Enlarged
 Hypoechoic
 IncreasedVascularity
 Torsion
 Enlarged
 Hypoechoic
 Decreased vascularity
This differentiation in cases of complete continous testicular torsion
Dr Ahmed Esawy

81. differentiation between orchitis
incomplete intermittent testicular torsion
Is difficult and need experience
differentiation between ischemic orchitis
complete testicular torsion
Is difficult and need experience
Dr Ahmed Esawy