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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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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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