Scrotal ultrasound- By Dr Nishant Mishra .pptx

Scrotal Ultrasound

1. Scrotal ultrasound Dr. Nishant Mishra MBBS (IMS, BANARAS HINDU UNIVERSITY, VARANASI) MD RADIODIAGNOSIS (PGI, ROHTAK) EX- MEDICAL OFFICER TELEMEDICINE RRC B.H.U SENIOR RESIDENT DOCTOR K.M MEDICAL COLLEGE, MATHURA CONSULATANT RADIOLOGIST R.K MISSION HOSPITAL, VRINDAVAN

2. topics Anatomy of scrotum scanning protocol Epididymis Intratesticular fluid Congenital anomalies Acute Scrotum Epididymitis and orchitis Testicular Torsion Bell Clapper deformity Hydrocele Varicocele Testicular trauma Scrotal Hernia ​

3. 3 Anatomy of scrotum and scanning protocol Testicle • The testes produce sperm and androgens. • The testicle is an oval shaped structure with a homogeneous echogenicity on ultrasound. Epididymis • The epididymis carries sperm away from the testicle to the vas deferens. • The epididymis is composed of head, body, and tail. The head may measure up to 10 mm. • The epididymis is normally hypoechoic and has less blood flow compared to the testicle. Rete testis • The rete testis is a network of tubules that carries sperm from the seminiferous tubules in the testicle towards the epididymis. It transports and concentrates sperm. Mediastinum testis • The mediastinum testis is fibrous tissue in the hilum of the testicle, from which fibrous septa radiate towards the testicular periphery. It provides structural support to the rete testis.

4. 4 Transrectal ultrasound shows an enlarged prostate with a volume of approximately 34 cc. It shows irregular cavities / cystic spaces of turbid fluid, suggestive of an intraprostatic abscess. Extra-prostatic spread is noted on the right side. ACUTE SCROTUM Urgent evaluation, diagnosis and treatment because untreated testicular torsion may result in loss of the testis. Unilateral acute and severe pain with high riding, horizontally displaced testis = Testicular Torsion Epididymitis is associated with edema and gradual pain. Signs and symptoms overlap.

5. 5 Testicular torsion Testicular torsion is twisting of the testicle around the spermatic cord and the vascular pedicle. Torsion presents with acute scrotal pain and is a surgical emergency. Torsion may lead to irreversible testicular infarction if not detorsed within a few hours. De-torsion within 6 hours has an excellent prognosis. Detorsion aft er 24 hours has a poor prognosis for testicular salvage Transverse grayscale ultrasound (left image) shows slight enlargement of the left testis relative to the right. There is an absence of arterial or venous flow within the left testis on color Doppler (right image), consistent with testicular torsion.

6. 6 Transrectal ultrasound shows an enlarged prostate with a volume of approximately 34 cc. It shows irregular cavities / cystic spaces of turbid fluid, suggestive of an intraprostatic abscess. Extra-prostatic spread is noted on the right side. The bell-clapper deformity predisposes to torsion due to a small testicular bare area. The bare area is the testicular attachment site and normally prevents the testicle from rotation. Ultrasound findings of torsion are dependent on the time elapsed since torsion: Hyperacute (within a few hours): Ultrasound shows a hyperechoic and shadowing torsion knot of twisted epididymis and spermatic cord, with no blood flow in the affected testicle. Acute (between a few hours and 24 hours): Affected testicle is enlarged and heterogeneous. Missed torsion (>24 hours): Affected testicle is enlarged and mottled, with scrotal skin thickening and increased flow in the scrotal wall. A complex or septated hydrocele may be present.

7. 7 Transrectal ultrasound shows an enlarged prostate with a volume of approximately 34 cc. It shows irregular cavities / cystic spaces of turbid fluid, suggestive of an intraprostatic abscess. Extra-prostatic spread is noted on the right side. Scrotal trauma Scrotal hematoma The sonographic appearance of an acute scrotal hematoma is an echogenic, extra-testicular mass with no Doppler flow. When large, the hematoma can compress the testicle. When the hematoma evolves into a complex, multiseptated mass-like lesion, the distinction between the extra-testicular hematoma and the testicle may become difficult. Proper distinction is necessary to avoid mistaking the hematoma for a testicular mass.

8. 8 Testicular hematoma Testicular hematoma produces a peripheral hypoechoic lesion that may mimic tumor. Even with a history of trauma, a suspicious testicular lesion requires further evaluation to exclude malignancy, typically with a short-term follow-up. Testicular hematoma: Sagittal grayscale ultrasound (left image) shows a heterogeneous hypoechoic mass within the testicle, which has no internal Doppler flow (right image). Given recent trauma, this was thought to represent a hematoma. Follow up ultrasound (not shown) demonstrated decrease in size of the hematoma.

9. 9 Transrectal ultrasound shows an enlarged prostate with a volume of approximately 34 cc. It shows irregular cavities / cystic spaces of turbid fluid, suggestive of an intraprostatic abscess. Extra-prostatic spread is noted on the right side. Testicular rupture Testicular rupture causes capsule disruption, often with protrusion of testicular parenchyma through the defect. Rupture is often associated with a testicular hematoma or contusion. Prompt diagnosis is critical, as testicular viability is dependent upon timely repacking of the seminiferous tubules back inside the capsule. Testicular rupture results in disruption of the blood-testis barrier and may be associated with future infertility due to the formation of anti -spermatozoa anti bodies.

10. 10 Scrotal Infection Epididymitis Epididymitis is infection of the epididymis, almost always ascending from the urinary tract. The classic clinical presentation of epididymitis is acute unilateral scrotal pain. A key ultrasound finding of epididymitis is an enlarged epididymis with increased color Doppler flow relative to the testicle. An associated hydrocele may be present, which often contains low-level echoes . The main differential based on clinical presentation is testicular torsion, which would demonstrate decreased testicular blood flow. In contrast, epididymitis features normal testicular blood flow.

11. 11 Transrectal ultrasound shows an enlarged prostate with a volume of approximately 34 cc. It shows irregular cavities / cystic spaces of turbid fluid, suggestive of an intraprostatic abscess. Extra-prostatic spread is noted Epididymitis: Sagittal grayscale ultrasound (left image) of the testicle and epididymis shows a markedly enlarged epididymis measuring 1.7 cm ( calipers ). Incidental note is made of an epididymal cyst (arrow). The testicle has a normal sonographic appearance. Transverse color Doppler of the epididymis (right image) demonstrates markedly increased flow n the right side.

12. 12 Epididymo orchitis Epididymo orchitis is infection which has spread from the epididymis to the testicle. Epididymo -orchitis has a similar ultrasound appearance to epididymitis, but blood flow to the testicle will also be increased. Infection and secondary inflammation can cause venous hypertension, which is a risk factor for focal testicular ischemia. ltrasound shows an enlarged prostate with a volume of approximately 34 cc. It shows irregular cavities / cystic spaces of turbid fluid, suggestive of an intraprostatic abscess. Extra-prostatic spread is noted on the right side.

13. 13 Transrectal ultrasound shows an enlarged prostate with a volume of approximately 34 cc. It shows irregular cavities / cystic spaces of turbid fluid, suggestive of an intraprostatic abscess. Extra-prostatic spread is noted Fournier gangrene is necrotizing fasciitis of the scrotum and perineum, a highly morbid and surgically emergent condition. Infection is usually polymicrobial. The key imaging finding is the presence of subcutaneous gas, often evaluated with CT. The appearance on ultrasound is of multiple echogenic foci in the subcutaneous tissues with dirty posterior shadowing. t side. Fournier gangrene

14. 14 The “- celes ” and cystic lesions Hydrocele A hydrocele is excess fluid in the scrotum surrounding the testicle. Most are asymptomatic. A hydrocele may be congenital (due to patent processus vaginalis in utero or infancy), idiopathic, or post-inflammatory. Regardless of etiology, there is never fluid at the bare area where the testicle is attached to the tunica vaginalis. Hematocele A hematocele is blood in the scrotum due to trauma or torsion.

15. 15 VARICOCELE A varicocele is a dilated venous pampiniform plexus in the scrotum. A primary varicocele is due to incompetent valves of the internal spermatic vein. A secondary (reactive) varicocele is due to increased venous pressure caused by obstruction, usually caused by retroperitoneal mass. Varicocele is a common cause of infertility, seen in up to 40–75% of males presenting to an infertility clinic. Varicoceles are much more common on the left, as the left testicular vein drains into the left renal vein at straight angle, whereas the right testicular vein drains directly into the infrarenal IVC. 85% of varicoceles are left-sided and 15% are bilateral. An isolated right-sided varicocele should prompt a search for a right-sided retroperitoneal mass. On ultrasound, varicoceles appear as multiple tubular and serpentine anechoic structures >2–3 mm in diameter in the region of the upper pole of the testis and epididymal head. The varicoceles follow the spermatic cord into the inguinal canal and can be compressed by the transducer. Careful optimization of Doppler parameters shows the slow venous flow within the varicocele.

16. 16 Transrectal ultrasound shows an enlarged prostate with a volume of approximately 34 cc. It shows irregular cavities / cystic spaces of turbid fluid, suggestive of an intraprostatic abscess. Extra-prostatic spread is noted on the right side. Varicocele: Transverse grayscale ultrasound of the left scrotum (left image) shows dilated serpiginous vessels posterior to the left testi s, which demonstrate increased Doppler fl ow with Valsalva maneuver (right image).

17. 17 Epididymal cysts and spermatocele A spermatocele is cystic dilation of the epididymis filled with spermatozoa, usually occurring in the epididymal head, but potentially occurring anywhere in the epididymis. Classic ultrasound appearance is an epididymal cyst with internal low-level mobile echoes. A simple epididymal cyst and a spermatocele cannot be reliably distinguished by ultrasound.

18. 18 Simple testicular cyst A simple testicular cyst meets sonographic criteria for a simple cyst (smooth posterior wall, imperceptible wall thickness, completely anechoic, posterior through transmission). e of approximately 34 cc. It shows irregular cavities / cystic spaces of turbid fluid, suggestive of an intraprostatic abscess. Extra-prostatic spread is noted on the right side.

19. 19 Tubular ectasia of the rete testis is nonpalpable, asymptomatic, cystic dilation of the tubules at the mediastinum testes caused by epididymal obstruction. Tubular ectasia is often accompanied by an epididymal cyst or spermatocele. Tubular ectasia of the rete testis is common in older patients and may be bilateral. Imaging shows numerous tiny dilated structures in the region of the mediastinum testis, often seen in conjunction with an epididymal cyst/spermatocele. Tubular ectasia is benign and no treatment is necessary. traprostatic abscess. Extra-prostatic spread is noted on the right side. Tubular ectasia of rete testis Transverse color Doppler ultrasound of the right testicle (left image) shows cystic dilation at the mediastinum testes (arrow). There is no flow within the lesion. This appearance is highly suggestive of tubular ectasia, although an avascular mass may rarely have a similar appearance. Sagittal ultrasound (right image) shows elongation of the cystic dilation (arrows) along the mediastinum testes, which is confirmatory for tubular ectasia .

20. 20 Transrectal ultrasound shows an enlarged prostate with a volume of approximately 34 cc. It shows irregular cavities / cystic spaces of turbid fluid, suggestive of an intraprostatic abscess. Extra-prostatic spread is noted on the right side. The tunica albuginea is the capsule overlying the testis. A cyst of the tunica albuginea presents as a palpable superficial nodule that resembles a BB. No treatment is necessary. Ultrasound shows a typically small, simple, extra-testicular cyst. Tunical cyst

21. 21 Intratesticular masses are usually malignant (90–95%). Conversely, most extratesticular masses are benign in an adult, although a pediatric mass in this location may be malignant. The retroperitoneum should always be evaluated if an intratesticular mass is seen. Likewise, if retroperitoneal adenopathy is seen in a reproductive-age male, the testicles should always be examined. Most scrotal masses are hypoechoic relative to normal testicular parenchyma. On Doppler ultrasound, most masses will have increased vascularity with high diastolic flow, producing a low resistance waveform. Testicular Masses Approach to a testicular mass -

22. 22 Malignant germ cell tumor (GCT): Seminoma Seminoma is the most common testicular malignancy. It has a favorable prognosis. Seminoma typically occurs in middle-aged men and it accounts for about half of all GCTs. It is usually more homogeneous than nonseminomatous germ cell tumors (NSGCT). It tends to be uniformly hypoechoic on ultrasound. Uncommonly, hCG may be elevated The spermatocytic subtype of seminoma occurs in slightly older men (mid-fifties) and has excellent prognosis with orchiectomy only. Tumor markers are not elevated. Seminoma: Grayscale (left image) and color Doppler show a heterogeneous hypoechoic vascular mass (yellow arrows) in the left testis. Note the presence of numerous tiny echogenic foci (red arrows) representing microlithiasis.

23. 23 Non seminomatous germ cell tumors (NSGCT) include embryonal carcinoma, teratoma, yolk sac tumor, choriocarcinoma, and mixed subtypes. Mixed germ cell tumor is the most common NSGCT, and is the second most common primary testicular malignancy after seminoma (about 1/3). The most common components of mixed NSGCT are embryonal carcinoma and teratoma. It may contain elements of seminoma Embryonal cell carcinoma in its pure form is rare and in adults is typically seen as a component of mixed germ cell tumors. The infantile form, called endodermal sinus tumor or yolk sac tumor, is the most common testicular tumor of infancy. AFP is elevated. Teratoma is rare in its pure form in adults, but is seen in 50% of mixed NSGCT. Teratoma is classified as mature, immature, and malignant. In adults, teratomas are usually malignant. In children, teratomas are usually benign, with the mature subtype most commonly seen. Choriocarcinoma is the most aggressive and rare NSGCT. Choriocarcinoma metastasizes early, especially to brain and lung. Metastases tend to be hemorrhagic. hCG is always elevated and gynecomastia may result from elevated chorionic gonadotropins. es / cystic spaces of turbid fluid, suggestive of an intraprostatic abscess. Extra-prostatic spread is noted on the right side. Malignant germ cell tumors : Nonseminomatous germ cell tumors (NSGCT)

24. 24 Transrectal ultrasound shows an enlarged prostate with a volume of approximately 34 cc. It shows irregular i NSGCT generally occur in younger patients compared to seminomas, typically in young men in their twenties and thirties. NSGCT tend to be more aggressive than seminomas. Local invasion into the tunica albuginea and visceral metastases are common. A heterogeneous testicular mass which contains solid and cystic components and coarse calcification is a typical appearance for a NSGCT. It is not possible to distinguish the various subtypes of NSGCT on ultrasound. abscess. Extra-prostatic spread is noted on the right side.

25. 25 Tra Burnt-out germ cell tumor • Burnt-out germ cell tumor is a primary testicular neoplasm that is no longer viable in the testicle even though there is often viable metastatic disease, especially retroperitoneal. • In the testicle, focal calcification with posterior shadowing is characteristic. A mass may or may not be present. • Treatment is orchiectomy in addition to systemic chemotherapy. approximately 34 cc. It shows irregular cavities / cystic spaces of turbid fluid, suggestive of an intraprostatic abscess. Extra-prostatic spread is noted on the right side.

26. 26 Transrectal ultrasound shows an enlarged prostate with a volume of approximately 34 cc. It shows irregular cavities / cystic spaces of turbid fluid, suggestive of an intraprostatic abscess. Extra-prostatic spread is noted on the right side. Testicular microlithiasis Testicular microlithiasis is the presence of multiple punctate intratesticular calcifications. There is a controversial association between microlithiasis and testicular neoplasm. While the overall absolute risk for developing testicular cancer remains very small in the presence of microlithiasis, the relative risk may be increased. Current guidelines do not support screening by ultrasound or tumor markers, but patients with microlithiasis may perform self-examinations and be seen in follow-up as needed. At least 5 microcalcifications must be present per image to be called microlithiasis. If there are less than 5 microcalcifications the term limited microlithiasis is used. Microlithiasis can produce a starry sky appearance if calcifications are numerous. In the liver, hepatitis can cause a starry sky appearance due to increased echogenicity of the portal triads.

27. 27 Transrectal ultrasound shows an enlarged prostate with a volume of approximately 34 cc. It shows irregular cavities / cystic spaces of turbid fluid, suggestive of an intraprostatic abscess. Extra-prostatic spread is noted on the right side. Transverse grayscale ultrasound shows numerous echogenic foci within both testes, consistent with microlithiasis.

28. 28 The most common metastases to the testicles are leukemia and lymphoma, as the relevant chemotherapeutic agents do not cross the blood-testis barrier. Hematologic malignancies typically present in older patients, tend to be bilateral, and may be infiltrative with diff use testicular enlargement Testicular metastases

29. 29 Transrectal ultrasound shows an enlarged prostate with a volume of approximately 34 cc. It shows irregular cavities / cystic spaces of turbid fluid, suggestive of an intraprostatic abscess. Extra-prostatic spread is noted on the right side. Benign testicular tumors An epidermoid is a keratin-filled cyst with a distinctive onion skin appearance of concentric alternating rings of hypo- and hyper echogenicity. If suspected, local excision is performed instead of the standard orchiectomy typically performed for presumed malignant masses. Sex cord-stromal tumors are 90% benign but are sonographically indistinguishable from malignant tumors . Orchiectomy is therefore the standard treatment. Leydig cell tumor can present with gynecomastia due to estrogen secretion. Sertoli cell tumor is associated with Peutz-Jeghers and Klinefelter syndromes. Testicular epidermoid: Transverse grayscale ultrasound (left image) demonstrates a circumscribed, encapsulated mass in the testicle with peripheral calcification and onion skin appearance. There is no demonstrable Doppler flow within the mass (right image )

30. 30 Transrectal ultrasound shows an enlarged prostate with a volume of approximately 34 cc. It shows irregular cavities / cystic spaces of turbid fluid, suggestive of an intraprostatic abscess. Extra-prostatic spread is noted on the right side. Sarcoidosis Sarcoidosis may involve either the testis, the epididymis, or both. Scrotal involvement is rare, but presents clinically as painless scrotal enlargement. The ultrasound appearance of testicular sarcoid is indistinguishable from a solid malignant mass. If sarcoidosis is suggested by clinical history, the testicular mass must be biopsied to exclude malignancy. Without tissue pathology, a mass cannot be assumed to be sarcoid.

31. 31 Transrectal ultrasound shows an enlarged prostate with a volume of approximately 34 cc. It shows irregular cavities / cystic spaces of turbid fluid, suggestive of an intraprostatic abscess. Extra-prostatic spread is noted on the right side. Benign testicular tumor mimics Congenital adrenal rests are embryologic remnants of adrenal tissue trapped within the testis. These are typically seen in newborns with congenital adrenal hyperplasia. Adrenal rests appear as bilateral hypoechoic masses and classically enlarge with ACTH exposure. Polyorchidism /supernumerary testis: An extra testicle has an identical imaging appearance to normal testicular parenchyma. Extranumerary testes carry a slightly increased risk of torsion and testicular cancer

32. 32 Inguinal hernia Inguinal hernia presents as a bulging mass over the groin area and accounts for 75% of abdominal wall hernias. The reported lifetime risk of inguinal hernia is 27% in men and 3% in women. The greater susceptibility of the male population is due to the persistent opening of the abdominal wall muscles for the passage of spermatic cords and testicular vessels. Inguinal hernias can be classified into direct and indirect hernias . Direct hernia is derived from protrusion of the intra-abdominal contents through a weak abdominal wall, while indirect hernia results from protrusion toward the inguinal canal. 

33. 33 Transrectal ultrasound shows an enlarged prostate with a volume of approximately 34 cc. It shows irregular cavities / cystic spaces of turbid fluid, suggestive of an intraprostatic abscess. Extra-prostatic spread is noted on the right side. Case Discussion- Young male presented with right inguinal swelling. On clinical examination, it was an irreducible hernia. Ultrasound was requested to check bowel/fat content of hernia. Ultrasound shows peritoneal fat reaching up to scrotum.  Surgery was done with few hrs showing odematous peritoneal fat as hernia content

34. 34 The transducer is placed next to the lateral edge of the rectus abdominis muscle (RAB). B. The transducer is gradually moved from the superior-medial to inferior-lateral aspects to visualize the inferior epigastric artery (red arrows in A-C) approaching the external iliac artery (EIA). C. The transducer is then pivoted 90° to see the inguinal canal (yellow dashed region) on its short axis. D. Once the short axis of the inguinal canal is located, the transducer can be redirected parallel to the inguinal ligament to identify the inguinal canal in the long axis. White arrowheads indicate vas deferens. EAO, external abdominal oblique muscle; V, testicular vessels; F, fat. Ultrasonography of the normal inguinal canal.

35. 35 Tran indirect inguinal hernia  (more common) herniates  lateral  to the  inferior epigastric vessels  passes through the deep inguinal ring anterior to the  spermatic cord  in males  follows the round ligament in females  Multiple loops of bowel are seen to pass through a dilated right inguinal canal and into the right hemi-scrotum. The bowel wall demonstrates normal flow and peristalsis.

36. 36 Transrectal ultrasound shows an enlarged prostate with a volume of approximately 34 cc. It shows irregular cavities / cystic spaces of turbid fluid, suggestive of an intraprostatic abscess. Extra-prostatic spread is noted on the right side. direct inguinal hernia  (less common) herniates  medial  to the  inferior epigastric vessels   passes through a defect in the  Hesselbach triangle a weakness in the fascial floor of the  inguinal canal  

37. 37 Ultrasonography in man with indirect inguinal hernia. A. The transducer was placed in the short-axis view to visualize the hernia sac, the inside of which contained peritoneal fat and bowels (asterisks in A and B). B. The transducer was placed in the long-axis view to visualize the hernia sac. The deep inguinal ring (black arrow) could be visualized at the cranial side of the hernia sac. White arrowheads indicate spermatid cord

38. 38 Ultrasonography in a patient with direct inguinal hernia. A . Ultrasonography was obtained over Hesselbach’s triangle during the supine resting position. B. Ultrasonography was obtained over Hesselbach’s triangle during the Valsalva maneuver , showing the bowel contents protruding toward the abdominal wall. EAO, external abdominal oblique muscle; IAO, internal abdominal oblique muscle; RAB, rectus abdominis muscle. Black arrows, inferior epigastric artery; asterisks, herniation content (bowels); white arrow, indicating protrusion of the underlying bowels.

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