Scrotal testicular ultrasound odu Uganda

Ultrasound of the scrotum

1. Scrotal
(Testicular) ultrasound
Dr. BabiryeD

2. Gross anatomy
•The scrotum is
separated into right and
left hemiscrotal
comaprtments by a
septum called the
median raphe.
•Normal scrotal wall
thickness-2-8mm

3. Anatomy:

4. Anatomy:

5. Indications of scrotal ultrasound:
•Symptomatic:
–Palpable mass, scrotal pain, swelling, suspected torsion
–suspected infection; epididymo-orchitis, abscess, etc
–Suspected hydrocele, tumor, scrotal inguinal hernia
•Suspected occult neoplasm e.g. groin LN-pathy, etc
•Infertility, precocious puberty and under-developed,
small or atrophied testes.
•Post trauma assessment
•Follow up on previous findings
•Pre-and post-surgical evaluation
•Cryptochidismor undescended or ectopic testes
•Interventional procedures: diagnostic and therapeutic

6. Technique:
•Explain procedure to patient
•Ensure there is privacy and a warm env’t
•Disrobe waist down,
•Supine position with penis deflected superiorly
•Towel below scrotal sac for support
•Use B-mode, colour, power and spectral Doppler
–7-15Mhz, or low frequency for gross scrotal enlargement
–First scan the asymptomatic side and set the settings.
–low PRF with high gains on Doppler
–Compare both testis on same image on all modes
–Scan the scrotum wall and its contents, spermatic cord area,
inguinal/groin area
•Use Valsalvamanueveror upright position when
assessing for varicesand hernias

7. Scanning protocol and technique
Positioning

9. Normal sonographic appearance
•Testis:
•Homogenous or mildly
coarse with medium
level echogenicity.
•Prepubertal–slightly
hypoechoiccompared
to the adult
•Size: (4-5) x (2.5-3) x (2-
3)cm, volume –20-
30ml.

10. •Covered by echogenic
tunica (albuginea and
vaginalis)
•Ovoid in shape, with a
central echogenic stripe
(the mediastinum –an
invagination of the
tunica)

11. •Rete testis: -a
hypoechoic region near
the mediastinum
–Seen in only 20%of the
patients

12. •Appendix testis –
located at the upper
pole of testis, not
normally seen unless
torsed/when there is a
hydrocele
•Doppler: testis has a
low resistance arterial
flow

13. Testicular appendix

14. Sonographic appearance
•Epididymis:
–Iso-or hyper-echoic to the testis
–Head: round or oblong structure located at the superior
pole of the testis; 5-12mm in diameter.
–Body: extends along the posterior aspect of the testis
•(2-4mm in diameter)
–Tail: found at the lower/inferior pole of the testis
•2-5mm in diameter.
•Continues upwards as the ductusdeferens

15. •Appendix epididymis:
–Attached to epididymal
head, not usually seen
unless torsed or when
there is a hydrocele.
•Doppler: -eppididymis
has a low resistance
arterial flow

16. Image A shows
enlarged epididymis, B
normal

17. •Epididymis appendix

18. Sonographic appearance
•Scrotal wall:
–Normal scrotal wall is 2-8mm thick
–Minimal fluid collection between the 2 tunica vaginalis
layers around the testis (NR -1-3mm-deep)

19. z

20. Testicular abnormalities
•Acute scrotal pain and
swelling
-Epididymitis and
epididymo-orchitis
-Orchitis
-Torsion
-Cellulitis
-Vasitis
-Trauma
•Palpable lumps and
incidental findings
-Epididymal cyst
-Testicular cyst
-Epidermoid cyst
-Spermatocele
-Varicocele
-Hydrocele
-Microlithiasis
-Scrotolith

21. -Adenomatoid tumor
-Germcell tumors
-Non germ cell tumors

22. Epididymitis
•A common cause of
acute scrotal pain in
adolescent boys and
male adults, which is
usually the result of an
acute bacterial infection
•U/S findings
-enlarged and
hypervascular
epididymis
-inhomogeneous
echotexture
-hypoechoicin
appearance
-Ass reactive hydrocele
-Scrotal wall thickening

23. Epididymo-orchitis:
–Can be focal or diffuse
–Enlargement of the
epididymis and testis
–Heterogenous or normal
–Hyperemia; with RI <0.5
•Low resistance waveform
–Scrotal wall thickening
–Hypoechoic
–Reactive hydrocele

25. Orchitis
•Isolated orchitis without
involvement of the
epididymis is rare and
most commonly
secondary to
paramyxovirus infection
(mumps)
•May be diffuse or focal
•U/S
-Enlarged and
heterogeneous testis
-Increased vascularity on
Doppler

26. Testicular abscess

27. Testicular (Fournier’s) gangrene
•Necrotizing fasciitis of
the perineum.
•It’s a urological
emergency
•Gas formation in the
testis ±scrotal wall
US-Thickened scrotal wall
-echogenic gas foci
-testes and
-epididymides spared
due to separate blood
supply
-Peritesticular fluid

28. Testicular torsion:
•Occurs when a testicle torts/ twists on the
spermatic cord resulting in cutting off of blood
supply.
•Can be spontaneous or following trauma
•Common cause of acute scrotal pain
•May have similar presentation as epididymo-
orchitis
•Causes:
–Bell-clapper deformity (intra-vaginal)

29. Bell clapper deformity

30. Testicular torsion on ultrasound:
•Determine viability.
•Grey scale/B-mode:
–Swollen testis
–Still homogenous during early stage before necrosis
–Heterogenous (there is necrosis)
•Ischemic regions appear hypoechoic
•Hemorhage appears hyperechoic when there is reperfusion.
–Reactive hydrocele
–Reactive thickening of the scrotal wall with hyperemia
–Peripheral testicular neovascularization (days after)
•Only peripheral and patchy parts of the testis are perfused.

31. Testicular torsion:
•Doppler of testis and spermatic cord:
–the spermatic cord shows whirpool (twisting) sign
–Altered blood flow
•Incomplete: elevated RI >0.75 with to and fro flow pattern
•Complete: absence of signals in both testis and Epididymis
•Differentials:
–Epididymo-orchitis: (both torsed and detorsed testes)
–Testicular tumor: enlarged heterogenous testes, if no
flow in tumor necrosis
–Testicular abscess: avascular heterogenous area of testis

32. Image 1 demonstrate enlarged
heterogeneous left testicle, image 2
shows the whirlpool sign
Whirl pool sign
Image 1
Image 2

33. Testicular torsion

34. Vasitis (Inflammation of the vas deferens)

35. Testicular trauma:
•Can manifest as fluid collections (hematocele,
hydrocele, or hematoma), testicular disruption
(fracture or rupture) or vascular injury.
•Ultrasound:
–Hematocele–fluid (blood) within scrotum/intra
testicular
–Tunica layer rupture –appears as a discontuniutyor
interruption or crinkling or retracted
–Extrusion of semineferoustubules (testicular
parenchyma) –they may or may not have Doppler signals
–Infarct/ischemia: -heterogenoustestis
–Testicular fracture (defect through the testis) maybe
seen in 17%

36. Testicular trauma –ruptured tunica albuginea
•Extrusion of testicular parenchyma

37. Testicular trauma -hematocele
•Thin septa
•Internal echoes/debris
•Differentials:
–Pyocele
–Testiicularrupture with
Extrusion of semineferous
tubules/ testicular
parenchyma.

38. Testicular trauma -heterogenous

39. Palpable lumps and incidental
findings
Epididymal cyst Spermatocele
Arise from epididymal head
and are indistinguishable from
epididymal cysts.

40. Testicular cyst Epidermoid cyst
•Contain keratin which can
lead to a solid appearance
on US

41. Tunica albuginea

42. scrotal varicoceles
•Due to impaired
drainage of blood from
the spermatic cord
causing abnormal
dilatation of the
pampiniform plexus
•Palpation of the
scrotum may reveal a
mass that is often
described as a “bag of
worms.”

43. US shows multiple hypo-
or anechoic tubular
structures greater than 2
to 3 mm in diameter

44. Hydrocele:
•Serous fluid collection between the tunica
vaginalis layers surrounding the testis and the
spermatic cord
•Usually asymptomatic unless infected
•Acquired
–Post traumatic, infection, neoplasm, postsurgical,
torsion
•Congenital: common In children
–Communicating: there is incomplete obliteration of PV
•Patent processus vaginalis in communication with
peritonuem

45. Hydrocele:
•Ultrasound:
–Avascular fluid collection (anechoic)
–Internal echoes: cholesterol, septa, calcifications

46. Pyocele:
•Purulent collection of fluid (pus ) in the scrotal sac
usually following surgery, trauma, epididymo-
orchitis
•Ultrasound:
–Heterogenous (complex) fluid collection
–Gas maybe present (speckles/hyperechoic foci rising or
floating)
–±hyperemic wall on doppler

47. Testicular microlithiasis
•Uncommon, usuallybilateralcondition.
•> 5 foci per transducer field is considered abnormal
•Associatiatedwith:
–cryptorchidism
–testicular carcinoma
–Klinefelter’ssyndrome
–Down’s syndrome
–male pseudohermaphroditism
–pulmonary alveolar microlithiasis
–previous radiotherapy
–subfertilitystates

48. Micro-calcifications in a seminoma

49. Scrotolith
•scrotal pearls or scrotal
calculi are mobile
calcifications in the
scrotum.
•20 to torsed appendices
or inflammatory
processes
•Located outside the
testis

50. Testicular cancer
•Common in 20-34yrs, 90% are germ cell tumors
(seminoma and non seminomatous)
•Distribution:
•1
st
decade of life: –yolksac tumors and testicular teratoma
•2
nd
decade of life: -choriocarcinoma
•3
rd
decade of life: -embryonal cell
•4
th
decade of life: -seminoma
•Elderly: lymphoma (usually NHL) and spermatocystic seminoma

51. Testicular carcinoma
•Ultrasound features:
–range from small lesions to large masses that replace the
entire testicle
–Micro-calcifications
–Hypoechoic, solid,
–Focal or diffuse involvement
–Homogenous; occasionally heterogenous
–±cystic degeneration (egseminoma)
–Hyper vascular

54. Testicular ca: seminoma

55. •Malignant teratoma
•-second commonest
germ cell tumor after
seminoma.
•-most aggressive
•-metastasizes early.
•-usually large,
•-heterogeneous with
calcifications

56. Secondary testicular malignancy:
•Lymphoma:
–accounts for 10% of testicular tumors
–Commonest bilateral intra-testicular tumor
–Commonest tumor in men >60yrs
–Can be primary or secondary
–Ultrasound:
•Testicular enlargement
•Diffuse or focal involvement
•Markedly hyper-vascular on doppler
•Hypoechoic echogenicity
•Epididymis may also enlarge

57. Lymphoma:

58. Inguino-Scrotal
hernia

60. Quiz
•A 17-year-old boy
presents with acute onset
of left scrotal pain
approximately 10 hours
earlier. On physical
examination, the left
scrotum is diffusely
tender and mildly
erythematous.
•Describe U/S findings and
give diagnosis
•What other son features
would you look out for?

61. •A 31-year-old man
presents with scrotal
swelling and pain of 2
days' duration.
•Describe the U/S
findings.
•Give a diagnosis and
Ddx

62. •Which sonographic feature is most sensitive
for testicular inflammation?
a) Scrotal skin thickening.
b) Hydrocele.
c) Hyperechoicepididymalechotexture.
d) testicular or epididymalhyperemia.
e) Enlargement of the epididymis or scrotum

63. Spot diagnosis

64. Spot diagnosis
Why is the condition common on
the left side?
Read about the grading

65. Spot diagnosis
Image A Image B