ULTRASOUND SCROTUM

basic approach to ultrasound scotum

1. ULTRASOUND OF ScROTUM By Dr LOHITH VARMA 1 st YEAR PG

2. SEPTA TESTIS

3. Efferent ductules (Vasa efferentia)

4. DUCTUS DEFERENS

5. normal homogeneous echotexture of the testis

6. striated appearance of the septula testis

7. mediastinum testis (arrow) as a linear echogenic band of fibrofatty tissue

8. head (white arrow) and body (black arrow) of epididymis

9. hydrocele (H) appendix testis (arrow)

10. appendages of epididymis (arrows )

11. Color Doppler scan shows normal testicular arteries

12. Testis 1.homogeneous echogenicity 2.mildly coarse echotexture 3.adult diameter measures between 3-5 cm, with a volume of ~20 mL 4.the  tunica (vaginalis/albuginea)  appears as an echogenic outline of the testicle 5.the tunica invaginates to form the linear echogenic  testicular mediastinum  (a.k.a. mediastinum testis) 6.the  rete testis  can be identified in ~20% of patients hypoechoic region near the mediastinum more noticeable if dilated 7. APPENDIX TESTIS attached to upper pole of testicle, near the epididymis not usually seen unless torsion is present spectral Doppler: the testis demonstrates a low-resistance arterial waveform

13. Epididymis epididymal head : round or oblong structure located near the superior pole of the testicle isoechoic or mildly hyperechoic relative to the testicle measures 5-12 mm epididymal body : extends down the posterior aspect of the testicle measures 2-4 mm epididymal tail : curved structure at the inferior pole of the testicle and becomes the proximal  ductus deferens measures 2-5 mm Appendix epididymis : attached at the epididymal head not normally seen unless torsion present spectral Doppler: epididymis demonstrates a low-resistance arterial waveform

14. PROTOCOL FOR ULTRASOUND OF THE SCROTUM EQUIPMENT SELECTION AND TECHNIQUE Use of a high resolution probe (7-15MHZ) is essential when      assessing the internal structures of the scrotum. Low PRF (Pulse repetition frequency ) and high gain colour Doppler capabilities when assessing vessels of a testis. change frequency output of probe (or probes) to obtain accurate length measurements, an overview of pathology and anatomy

15. SCANNING TECHNIQUE Using a towel tuck the penis up over the symphysis to help elevate and immobilise the scrotum. Use warm gel. Begin with a survey scan transversely down the scrotum to compare echogenicity of the testes. Scan each side independently in both longitudinal and transverse planes. You may need to apply slight pressure to immobilise the testis as you scan. However, it is important to scan with minimal pressure to visualize fluid overlying the testis. Locate the epididymal head and follow in transverse down the body and tail. Assess both intra and extra testicular structures with power doppler. The Valsalva manoeuvre or scanning in the upright position should be performed when evaluating for varicoceles or hernias. If a varicocele is identified, the scan should be extended to assess the testicular veins for the point of origin. Such as extratesticular masses that could be compressing the vein (e.g. pelvic lymphadenopathy)

16. A scrotal ultrasound should include the following minimum images Transverse image showing both testes for comparative echogenicity Transverse images of each testis Maximum transverse measurement of each testis Longitudinal images of each testis Maximum longitudinal measurement of each testis Epididymis to include the head , body and tail (bilaterally) Vascularity of each testis with spectral trace Spermatic cord Document the normal anatomy. Any pathology found in 2 planes,      including measurements and any vascularity Groin for lymphadenopathy

17. Acute Scrotal Pain and Swelling Epididymitis and Epididymo-orchitis enlarged and hypervascular epididymis with an inhomogeneous echotexture, most often hypoechoic in appearance. Color Doppler ultrasonographic evaluation has a sensitivity of almost 100% in detecting acute inflammation and is thus a well-established imaging technique for the diagnosis of epididymitis. Associated findings : hydrocele or pyelocele, scrotal wall thickening, fistula formation and calcifications . Abscess formation may complicate acute epididymitis and appears as an avascular hypoechoic area within the epididymis.

18. hypoechoic epididymis with markedly increased vascular flow, consistent with epididymitis.

19. ENLARGED HETEROGENEOUS EPIDIDYMAL HEAD (ASTERISK) EDEMATOUS AND ENLARGED RIGHT TESTICLE. BOTH DEMONSTRATE INCREASED VASCULARITY ON COLOR DOPPLER EVALUATION. FINDINGS ARE CONSISTENT WITH EPIDIDYMO-ORCHITIS.

20. TORSION Normally, the tunica vaginalis fixates the posterior aspect of the testicle. bell clapper deformity : If the tunica vaginalis joins high on the spermatic cord, it leaves the testicle free to rotate within the scrotal sac

21. TORSION A sensitive and specific sign for torsion is the so-called real-time whirlpool sign , which is characterized by a spiral twist or rotation of the spermatic cord

22. Enlarged heterogeneous left testicle Color Doppler evaluation shows flow in the right but not in the left testicle

23. altered blood flow incomplete torsion elevated resistive index (RI >0.75)  3 to and fro flow complete torsion an absence of blood flows in both the testis and epididymis salvage of the testis is directly related to the time between onset and detorsion (whether it be surgical or spontaneous)  : <6 hours: ~100% salvage 6-12 hours: 50% 12-24 hours: 20%

24. TRAUMA A discontinuity in the usual testicular parenchyma is considered a testicular fracture hypoechoic, linear stripe within the testicle that does not demonstrate vascularity

25. testicular trauma. heterogeneous echotexture with irregular contours

26. Palpable Lumps and Incidental Findings Epididymal Cyst well-circumscribed anechoic lesions The cysts demonstrate posterior acoustic enhancement due to their clear serous fluid content.

27. Testicular Cyst solitary, anechoic, well circumscribed, round to oval lesions. Measures 2 to 20mm examination for solid or mural components is advised in order to not miss a potentially malignant cystic lesion.

28. Epidermoid Cyst most common benign testicular masses (1%-2% of testicular tumors) and have no malignant potential. The echogenic keratin can lead to a solid appearance on ultrasonography. Doppler evaluation does not demonstrate internal vascularity. Epidermoid cysts show different ultrasonographic appearances depending on their maturation A lamellated pattern of alternating hypoechoic and hyperechoic layers forming an onion-ring/skin pattern is a classic presentation of a maturing epidermoid cyst not be distinguished from malignant neoplasms such as teratomas

29. Complex solid and cystic-appearing lesion in the testicle does not demonstrate internal vascularity

30. Spermatocele arise in the epididymal head cystic dilatation of the tubules of the efferent ductules Ultrasonographically they are indistinguishable from epididymal cysts. but spermatoceles tend to be larger in size and may present as a multilocular cystic lesion with internal echoes

31. Varicocele Varicoceles form due to impaired drainage of blood from the spermatic cord causing abnormal dilatation of the pampiniform plexus multiple hypo- or anechoic tubular structures greater than 2 to 3 mm in diameter. During the Valsalva maneuver the varicocele may enlarge and it may demonstrate flow reversal on color Doppler imaging depending on grade Varicoceles are most commonly found on the left side

32. Grading of varicocele grade I no dilated intrascrotal veins reflux in spermatic cord veins of the inguinal region during Valsalva maneuver grade II prominent veins at upper pole of testis reflux at upper pole veins during Valsalva maneuver grade III no major dilatation in supine position dilated veins up to lower pole of testis seen only in standing position reflux at lower pole veins during Valsalva maneuver grade IV dilated veins even in supine position reflux during Valsalva maneuver grade V dilated veins reflux without Valsalva maneuver

33. HYDROCELE hydrocele is a large collection of fluid between the visceral and parietal layers of the tunica vaginalis and the most common cause of painless scrotal swelling

34. GERM CELL TUMORS 1. SEMINOMA : most common testicular malignancy (35%- 50% of all cases) 2. non- seminomatous germ cell tumors (NSGCTs)

35. SEMINOMA seminomas appear as hypoechoic solid lesions with internal blood flow, which can range from small lesions to large masses that replace the entire testicle

36. non- seminomatous germ cell tumors heterogeneous and cystic masses with irregular margins Echogenic foci within the mass may be seen, which can represent calcification, hemorrhage, or fibrosis .

37. large heterogeneously echogenic mass involving the majority of the left testicle. This mass was found to be a mixed germ cell tumor (including embryonal carcinoma 65%, teratoma 15%, choriocarcinoma 10%, yolk sac tumor 5% and seminoma <5%) on pathology evaluation after left orchiectomy

38. THANQ