Sonography of the scrotum

Adult Acute Scrotal Edema - When Radiologists Can Help to Avoid Unnecessary Surgical Treatment

Acute idiopathic scrotal edema is a commonly painless self-limiting condition causing scrotal swelling, and is usually seen in children. In some cases, this condition is difficult to differentiate it from other causes of acute scrotum. In the right clinical scenario, ultrasonography has been used to confirm the diagnosis. We describe the ultrasound and CT findings of acute idiopathic scrotal edema in a 72-year-old male with coexistent involvement of the inferior abdominal wall.

Imaging modalities for an uncommon inguinal scrotal pathology: A case report and literature review

Inguinal scrotal swelling is a common presentation to surgical clinic with various differential diagnoses. In most circumstances, a good clinical assessment is sufficient to identify the diagnosis. Imaging is necessary when diagnostic difficulty was encountered. The choice of imaging study could affect the management and outcome. A 60-year-old male presented with an enlarging right inguinal scrotal swelling for 5 years. Clinical examination showed a swelling extended from the right inguinal region down to the right scrotum, firm, not reducible, and not separable from the right testis. Differential diagnoses range from the malignant testicular tumor, irreducible inguinal hernia to the soft-tissue tumor. Ultrasonography and computed tomography scan were unable to conclude the origin of the tumor and involvement of the right testis. Inguinal exploration with potential radical orchiectomy was planned and caused much distress to the patient, resulted in delay in surgery. Intraoperatively, the mass was separated from the testis and spermatic cord, and thus, excision biopsy was performed sparing the testis and spermatic cord. Histopathological examination showed cellular angiofibroma. The right choice of imaging modality is important to provide a precise diagnosis and better treatment plan. This could avoid the unnecessary distress to the patient for potential organ lost. A review through the literature showed the ability of magnetic resonance imaging to better delineate the anatomy of inguinal scrotal soft-tissue mass and thus should have been the imaging modality of choice.

Thrombotic and Nonthrombotic Types of Intratesticular Varicoceles: Value of Sonography for the Diagnosis

An intratesticular varicocele is an uncommon entity, and its clinical importance remains unclear. The diagnosis can be made in the case of an intratesticular tortuous vein that shows retrograde flow on color Doppler sonography. The anatomic location and course of the intratesticular varicocele within the testicular parenchyma and its association with the existence of an ipsilateral extratesticular varicocele may vary among patients. The pathophysiologic mechanisms remain unclear; however, it may be questioned whether there is an association between testicular atrophy and intratesticular varicocele development. Although the diagnosis is usually made incidentally, patients may rarely present with acute scrotal pain due to acute thrombosis of an intratesticular varicocele.

Sonography of Scrotal Wall Lesions and Correlation With Other Modalities

The scrotal wall may be involved in a variety of pathologic processes. Such lesions may rise primarily from the layers of the scrotum or may be due to a process arising from scrotal content. Imaging is not needed in most cases, but it may be useful for making such differentiations and for evaluation of possible involvement of the testes and epididymides in cases of primary wall abnormalities. This pictorial essay will show the imaging findings observed in a variety of pathologic conditions affecting the scrotal wall, both common and unusual ones, with an emphasis on clinically relevant findings and features that lead to a specific diagnosis.

Using Imaging to Predict Treatment Response in Genitourinary Malignancies

CONTEXT

Over the previous2 decades, there have been numerous advancements in the diagnostic evaluation, therapeutic management, and postoperative assessment of genitourinary malignancies.

OBJECTIVE

To present a review of current and novel imaging modalities and their utility in the assessment of therapeutic response in the systemic management of renal, testicular, and prostate cancers.

EVIDENCE ACQUISITION

A PubMed/Medline search of the current published literature inclusive of prospective and retrospective original research, systematic reviews, and meta-analyses was conducted evaluating imaging modalities for renal cell carcinoma, prostate cancer, and testicular cancer. All relevant literature was individually reviewed and summarized to provide a concise description of the currently available imaging modalities and their efficacy in assessing treatment response of the genitourinary malignancies targeted in this review.

EVIDENCE SYNTHESIS

Conventional imaging techniques play a pivotal role in predicting the treatment response of genitourinary malignancies and have, therefore, been incorporated into clinical guidelines. Advancements in imaging technology have led to increased utilization for prognostication of a genitourinary cancer's response to therapy.

CONCLUSIONS

A good understanding of current recommended imaging techniques to evaluate treatment response in genitourinary malignancies is of paramount importance for today's clinician, who faces increasing treatment modalities.

PATIENT SUMMARY

In this review, we summarize available imaging modalities in the evaluation of treatment response in kidney, prostate, or testicular tumors. We believe that a good understanding of current imaging modalities is of paramount importance for healthcare providers treating these cancers.

Torsed appendix epididymis in an adult: misdiagnosis as tumor of tunica vaginalis on sonography

We report the sonographic findings in a case of torsed appendix epididymis that occurred in an adult, which was misdiagnosed as a tunica vaginalis tumor such as cystic mesothelioma. Scrotal gray-scale sonography revealed an ovoid-shaped, heterogeneously hypoechoic mass with multiple tiny cystic foci and thick septa in the sac of the right tunica vaginalis, which abuts to the right epididymal head. Color Doppler sonography showed no blood flow within the mass. Pathological examination revealed torsion of the appendix epididymis.

Testicular microlithiasis is associated with ethnicity and socioeconomic status

Background

There are limited studies about testicular microlithiasis (TML) and background information such as health, lifestyle, and socioeconomic status.

Purpose

To assess the prevalence of TML in relation to socioeconomic status and ethnicity.

Material and Methods

From a database of scrotal ultrasound examinations in a single institution, all men who underwent routine ultrasound examinations for a variety of symptoms from 1998 to 2015 were included. Skilled observers performed all examinations, and presence of any form of intra-testicular calcification, including TML, was recorded on the examination report and a representative image obtained and stored. A total of 1105 cases with TML were reviewed and random sample of 1105 controls from the same database was also reviewed. Demographics were recorded including ethnicity (white, black, and others) and socioeconomic groups (IMD Quintile).

Results

Black men had increased prevalence of TML (odds ratio [OR] = 2.17, 95% confidence interval [CI] = 1.72–2.75) compared with white men. Among the 1105 TML cases, 423 (38.3%) were white, 273 (24.7%) black, 152 (13.8%) had other ethnicities, and 257 (23.2%) had no ethnicity recorded. In the control group of 1105 men without TML, 560 (50.7%) were white, 171 (15.5%) black, 111 (10.0%) had other specified ethnicities, and 263 (23.8%) had no ethnicity recorded. Men from the most deprived socioeconomic groups had higher prevalence of TML than men in the most affluent groups, with a trend in OR from the least deprived to the most deprived group.

Conclusion

Pathogenesis and clinical relevance of TML is unknown but our results point towards possible ethnic and socioeconomic variation in the underlying causes of TML.

Imaging Features of Paratesticular Masses

In this pictorial essay, we review the sonographic and other imaging findings of paratesticular masses in correlation with the pathologic findings. The examples include benign and malignant tumors and also non-neoplastic mass lesions of the paratesticular structures. Diagnostic sonographic findings of these mass lesions as well as correlative findings of other imaging methods are presented.

Normal testes asymmetry evaluated by apparent diffusion coefficient and magnetization transfer ratio

Background In humans, the left testis generally hangs lower than the right and the right is larger than the left. Magnetic resonance imaging (MRI) represents an important adjuvant modality in the investigation of testicular diseases. Purpose To assess if normal testes asymmetry is related to apparent diffusion coefficient (ADC) and magnetization transfer ratio (MTR). Material and Methods The normal testes from 106 men were included. Testicular volume (TV) was calculated by using the ellipsoid formula: length × width × height × 0.52. Diffusion-weighted imaging was performed using a SS EPI diffusion pulse sequence and b-values of 0 and 900 s/mm^-2. Magnetization transfer imaging was obtained using a 3D GRE sequence both with and without an off-resonance radiofrequency pulse. MTR maps were obtained by the following formula: (SIo-SIm) / (SIo) × 100%, where SIo and SIm represent the signal intensity in the baseline image and that in the corresponding image acquired with an off-resonance MT pulse, respectively. The mean and standard deviation of testicular volume (TV), ADC, and MTR of both testes was calculated and compared using a paired sample t-test. Results The mean TV (mL) was greater ( P = 0.006) for the right testis (16.77 ± 4.84) compared to the left (15.97 ± 4.45). ADC of the right testis (1.09 ± 0.12 × 10 ^- 3mm²s^-1) was not different ( P = 0.064) from that of the left testis (1.07 ± 0.12 × 10^-3mm²s^-1). Differences ( P = 0.032) were observed between MTR of the right (46.6 ± 2.1%) and left testis (46.0 ± 2.2%). Conclusion The reported differences in paired testes size was confirmed, introducing a possible relationship with structural and functional asymmetry of normal testes, based on MTR.

Magnetic resonance imaging of the scrotum: pictorial review with ultrasound correlation

The purpose of this review is to showcase the added value of scrotal magnetic resonance imaging (MRI) in the workup of neoplastic and non-neoplastic entities. While ultrasound (US) remains the first-line imaging modality for evaluating scrotal pathology, MRI may add valuable information, particularly when US findings are equivocal. The inherent soft tissue resolution characteristics of MRI, as well as the ability to detect subtle enhancement and provide wider field-of-view imaging, can prove useful in evaluating inconclusive US findings. The added value of MR in these instances is critical as it may have a significant impact on patient management.

Value of Multiparametric US in the Assessment of Intratesticular Lesions

Purpose To evaluate the diagnostic accuracy of multiparametric ultrasonography (US) consisting of gray-scale US, color Doppler US, strain elastography, and contrast agent-enhanced US in the assessment of intratesticular lesions. Materials and Methods Institutional review board approval was obtained for this retrospective study. From January 2012 to December 2015, 55 focal testicular lesions that were indeterminate on gray-scale US scans were further characterized with color Doppler US, strain elastography, and contrast-enhanced US. Strain elastography was performed to assess tissue elasticity, and hard lesions were defined as malignant. Color Doppler US and contrast-enhanced US were performed to determine the absence or presence of vascularization. Avascular lesions were defined as benign. Histopathologic results or follow-up examinations served as reference standards. Correct classification rate, sensitivity, specificity, and likelihood ratio were calculated. Results Of 55 testicular lesions, 43 (78.2%) were benign and 12 (21.8%) were malignant. Single-modality sensitivities and specificities were 66.7% and 88.4% for color Doppler US, 100% and 76.7% for contrast-enhanced US, and 100% and 72.1% for strain elastography, respectively. Among 12 malignant lesions, color Doppler US failed to demonstrate vascularization in four (33.3%) lesions, which were positive for cancer at contrast-enhanced US. By combining strain elastography and contrast-enhanced US, a sensitivity of 100% and specificity of 93.0% were achieved in differentiating benign and malignant focal testicular lesions. Positive likelihood ratio was 5.7 for color Doppler US, 4.3 for contrast-enhanced US, 3.6 for strain elastography, 14.3 for strain elastography combined with color Doppler US, and 14.3 for strain elastography combined with contrast-enhanced US. Conclusion Multiparametric US allows for a reliable differentiation of benign and malignant intratesticular lesions and can potentially be useful in deciding whether orchiectomy can be replaced with follow-up or less invasive organ-sparing strategies. ^© RSNA, 2017.

Testicular Seminoma and Its Mimics: From the Radiologic Pathology Archives

Testicular seminoma is the most common malignant tumor of the testis. It classically manifests as a painless mass. Radiologic evaluation with high-frequency ultrasonography (US) is critical for diagnosis. Seminomas are usually homogeneously hypoechoic masses at US. In challenging cases, magnetic resonance (MR) imaging may help confirm that a mass is intratesticular and provide data for local staging. Computed tomography (CT) provides valuable information for staging, including the presence and size of retroperitoneal lymph nodes. Testicular seminoma is treated with radical inguinal orchiectomy and is highly curable even at advanced stages of disease. Several neoplastic and nonneoplastic conditions may mimic testicular seminoma at imaging. Benign mimics include segmental infarction, hematoma, infection, epidermoid cyst, adrenal rests, sarcoidosis, splenogonadal fusion, and sex cord-stromal tumors. Malignant mimics include nonseminomatous germ cell tumors, lymphoma, and metastases. These conditions are individually reviewed with emphasis on features that allow differentiation from seminoma. Spermatocytic tumor, formerly known as spermatocytic seminoma, accounts for only 1% of testicular tumors. It is distinct from classic seminoma, with unique histologic, molecular, and genetic features. It affects an older patient population than classic seminoma and demonstrates indolent clinical behavior. Radiologists serve a key role in diagnosis, staging, and surveillance of patients with seminoma. A thorough knowledge of related clinical, radiologic, and pathologic findings will help the radiologist contribute to high-quality interdisciplinary care of affected patients.

Ultrasonography of pediatric urogenital emergencies: review of classic and new techniques

Urogenital emergencies are fairly common in the pediatric population, and a timely and correct diagnosis is necessary to avoid possible future infertility. In this field, ultrasonography is essential, as it has the advantages of being radiation-free and readily accessible. In particular, a high-frequency transducer allows precise evaluation of the morphology and vascularity of the scrotum, which is on the surface of the body. Beyond conventional techniques, new advanced imaging techniques have been developed, including elastography and contrast-enhanced ultrasonography. However, several pitfalls remain in the diagnosis of urogenital diseases using ultrasonography. Thus, accurate knowledge and sufficient experience with the technique are essential for making a correct diagnosis. This review provides an overview of pediatric urogenital emergency pathologies and recent ultrasonography techniques.

Potential role of imaging in assessing harmful effects on spermatogenesis in adult testes with varicocele

Varicocele is characterized by an abnormal dilatation and retrograde blood flow in the spermatic veins. Varicocele is the leading correctable cause of male infertility. Although it is highly prevalent in infertile men, it is also observed in individuals with normal fertility. Determining which men are negatively affected by varicocele would enable clinicians to better select those men who will benefit from treatment. To assess the functional status of the testes in men with varicocele, color Doppler sonographic parameters were evaluated. Testicular arterial blood flow was significantly reduced in men with varicocele, reflecting an impairment of spermatogenesis. An improvement in the testicular blood supply was found after varicocelectomy on spectral Doppler analysis. Testicular contrast harmonic imaging and elastography might improve our knowledge about the influence of varicocele on intratesticular microcirculation and tissue stiffness, respectively, providing possible information on the early damage of testicular structure by varicocele. Magnetic resonance imaging (MRI), with measurement of apparent diffusion coefficient has been used to assess the degree of testicular dysfunction and to evaluate the effectiveness of varicocele repair. Large prospective studies are needed to validate the possible role of functional sonography and MRI in the assessment of early defects of spermatogenesis in testes with varicocele.

An intratesticular arteriovenous malformation identified incidentally during ultrasound evaluation of scrotal trauma

Intratesticular arteriovenous malformation (AVM) is an extremely rare benign testicular lesion. Ultrasonography (US) usually reveals a hypoechoic solid vascular mass within the testicular parenchyma. Herein, we report our experience with a young patient in whom an intratesticular AVM was found incidentally by US during the workup of scrotal trauma.

Ultrasound Emergencies of the Male Pelvis

Male pelvic emergencies are uncommon, and symptoms typically include scrotal pain, scrotal enlargement, or a palpable scrotal mass or all of these. Ultrasound is often the first-line modality for evaluation of male pelvic emergencies, which may be stratified into vascular, infectious, or traumatic causes. Entities such as testicular torsion, Fournier gangrene, and testicular dislocation are surgical emergencies and should not be missed or misdiagnosed, as this may cause a significant delay in urgently necessary treatment. Radiologists need to be familiar with the role of imaging as well as the key characteristic imaging findings of these injuries to direct the appropriate management.

Review of paratesticular pathology: findings on ultrasound and MRI

The paratesticular scrotal contents consist of the spermatic cord, epididymis, and fascia, which originate from the embryologic descent of the testis through the abdominal wall. Historically, the primary diagnostic modality has been high-resolution ultrasound. Magnetic resonance imaging (MRI) is an alternative imaging option. Both contrast MRI and diffusion weighted imaging can assist in differentiating between benign and malignant lesions. Unlike the testis which most disease processes are malignant, a wide spectrum of benign disease processes affects the paratesticular region either in isolation or as part of a contiguous disease process from adjacent organs. The familiarity with the epidemiology, pathogenesis, and imaging features can aid the radiologic diagnoses and guide appropriate clinical management. In this article, we review the ultrasound and MR characteristics of various paratesticular pathologies.

Imaging of Extranodal Genitourinary Lymphoma

The genitourinary (GU) system is commonly affected by disseminated lymphoma. Rarely, lymphoma can originate from and remain localized to one of the GU organs and thus presents as primary extranodal disease. Up to 40% of lymphomas present as extranodal disease, with only 3% having the GU system as the primary site of involvement. This article describes and correlates the radiologic and pathologic features of extranodal lymphomatous disease affecting the GU system with specific focus on the kidneys, adrenal glands, testicles, and ovaries. Lymphoma of the uterine body and cervix, external female genitalia, urinary bladder, and prostate gland is briefly discussed.

Multiparametric ultrasound findings in a patient with polyorchidism

Polyorchidism is a rare condition usually incidentally discovered in young patients investigated with ultrasound for unrelated reasons. It is characterized by the presence of unilateral or, rarely, bilateral supernumerary testes which, depending on the type of polyorchidism, may have their own epididymis and vas deferens. Ultrasound, including B-mode and color Doppler technique, represents the primary imaging modality for the evaluation of scrotal diseases, including the characterization of supernumerary testes, which normally appear identical to the ipsilateral testicular parenchyma on every ultrasonographic technique performed. The role of MRI is thus limited to confirming ultrasonographic findings and excluding the presence of malignancy. Contrast-enhanced ultrasound is a recently introduced ultrasonographic technique providing detailed and sensitive visualization of the perfusion pattern of structures. It can thus be added to the conventional ultrasonographic examination in order to establish the diagnosis, negating the use of more expensive and time-consuming imaging modalities. We present a young patient with an incidentally found supernumerary testis, where new distinctive ultrasonographic findings, like the identification of transmediastinal vessels and a cystic appendage along with the perfusion pattern on contrast-enhanced ultrasound, established the diagnosis of polyorchidism.

Is There Any Difference Between Seminomas and Nonseminomatous Germ Cell Tumors on Shear Wave Elastography? A Preliminary Study

OBJECTIVES

The purpose of this study was to evaluate the ability of shear wave elastography (SWE) to differentiate seminomas from nonseminomatous germ cell tumors.

METHODS

Approval for this retrospective study was obtained from the local Ethics Committee of Istanbul University Cerrahpasa Medical School. Fifteen patients with malignant testicular lesions were examined by grayscale sonography, color or power Doppler sonography, and SWE between February 2011 and October 2015. The size of each lesion, Doppler signal parameters, echogenicity, presence of microlithiasis, unifocality or multifocality, and histopathologic findings were the main factors evaluated.

RESULTS

The mean age of the patients was 33 years (range, 25-55 years). There were no differences between seminomas and nonseminomatous germ cell tumors in terms of Doppler signals, echogenicity, microlithiasis, or focality. Only the homogeneous and heterogeneous echogenicity patterns differed significantly. However, a significant difference was evident in SWE-derived quantitative data.

CONCLUSIONS

Seminomas and nonseminomatous germ cell tumors do not differ significantly on grayscale or Doppler sonography, except in terms of homogeneity. However, SWE seems to differentiate seminomas from nonseminomatous germ cell tumors.

Diagnosis of clinical and subclinical varicocele: how has it evolved?

In this review, we examine the evolution and application of various diagnostic modalities for varicoceles starting with venography, scintigraphy, and thermography and their role in the evaluation of a varicocele patient. Some of these methods have been supplanted by less invasive and more easily performed diagnostic modalities, especially ultrasound and Doppler examination of the scrotum. Advances in ultrasound and magnetic resonance imaging hold the potential to expand the role of imaging beyond that of visual confirmation and characterization of varicoceles. The ability to identify the early indicators of testicular dysfunction based on imaging findings may have implications for the management of varicoceles in the future.

Factitious Disorder Presenting with Attempted Simulation of Fournier's Gangrene

Fournier's gangrene is a severe polymicrobial necrotizing fasciitis of the perineal, genital, or perianal regions. The classic presentation is severe pain and swelling with systemic signs. Crepitus and cutaneous necrosis are often seen. Characteristic CT findings include subcutaneous gas and inflammatory stranding. Unless treated aggressively, patients can rapidly become septic and die. Factitious Disorder is the falsification of one's own of medical or psychological signs and symptoms. Many deceptive methods have been described, from falsely reporting physical or psychological symptoms, to manipulating lab tests, or even injecting or ingesting foreign substances in order to induce illness. We present a case of a 35-year-old man with factitious disorder who attempted to simulate Fournier's gangrene by injecting his scrotum with air and fluid. We will review the clinical presentation and diagnosis of Factitious Disorder, as well as Fournier's gangrene.

US of the Inguinal Canal: Comprehensive Review of Pathologic Processes with CT and MR Imaging Correlation

Ultrasonography (US) has a fundamental role in the initial examination of patients who present with symptoms indicating abnormalities of the inguinal canal (IC), an area known for its complex anatomy. A thorough understanding of the embryologic and imaging characteristics of the contents of the IC is essential for any general radiologist. Moreover, an awareness of the various pathologic conditions that can affect IC structures is crucial to preventing misdiagnoses and ensuring optimal patient care. Early detection of IC abnormalities can reduce the risk of morbidity and mortality and facilitate proper treatment. Abnormalities may be related to increased intra-abdominal pressure, which can result in development of direct inguinal hernias and varicoceles, or to congenital anomalies of the processus vaginalis, which can result in development of indirect hernias and hydroceles. US is also helpful in assessing postoperative complications of hernia repair, such as hematoma, seroma, abscess, and hernia recurrence. In addition, it is often the modality initially used to detect neoplasms arising from or invading the IC. US is an important tool in the examination of patients suspected of having undescended testes or posttraumatic testicular retraction and is essential for the examination of patients suspected of having torsion or infectious inflammatory conditions of the spermatic cord. Online supplemental material is available for this article. ^©RSNA, 2016.

Role of Strain Elastography in the Evaluation of Testicular Torsion: An Experimental Study

OBJECTIVES

To evaluate the utility of real-time strain elastography in experimentally induced testicular torsion at different degrees and torsion hours.

METHODS

Thirty-one Wistar albino rats were divided into 4 torsion groups by twisting left testes (group I, sham operated; group II, 360°; group III, 720°; and group IV, 1080°). Elastography was applied at the 8th and 24th hours of torsion. Elasticity patterns (pattern 1, soft testis; pattern 2, moderately soft testis; pattern 3, predominantly hard testis; and pattern 4, almost entirely hard testis) and strain ratios were recorded. Histopathologic evaluation was done at the 24th hour. Interobserver agreement was analyzed.

RESULTS

Changes in elastographic patterns and strain ratios among groups II, III, and IV were statistically significant at both hours as determined by both radiologists (P < .01). Elastographic patterns changed from 2 to 3 in groups II and III to 4 in group III between the 8th and 24th hours (P < .05), but in group IV, patterns were reversed, and pattern 1 was observed at both hours. Pathologically severe necrosis (grade 4) was seen in left testes in group IV. In the other groups, pathologic grading in the left testes was as follows: mostly grade 1 in groups I and II and mostly grade 2 in group III. Elastography showed that right testes were affected in group IV, with significant differences in elastographic patterns and strain ratios (P < .01). Interobserver agreement for elastographic patterns in right testes was substantial at the 8th hour (κ = 0.72) and otherwise excellent (κ = 0.81-0.85). Concordance of strain ratios between observers was excellent for right and left testes at the 8th and 24th hours (intraclass correlation coefficients, 0.990 at the 8th hour and 0.987 at the 24th hour).

CONCLUSIONS

Our results show that real-time strain elastography can be a complementary method in the evaluation of testicular tissue in testicular torsion and can guide surgeons in their surgical approach.

[Evaluation of testicular volume in 0- to 18-year-old boys by sonography]

BACKGROUND

Reference values are necessary in clinical practice in order to correctly evaluate testicular volume and detect disorders.

OBJECTIVES

The objective of this prospective cross-sectional study was to evaluate reference values for testicular volume dependent on age, height, and weight in boys aged 0-18 years.

MATERIAL AND METHODS

During their inpatient stay, the testes of 174 boys, who were free of disease or therapy that might influence testicular development, were examined by sonography. High resolution ultrasound transducers ranging from 7.5-14 MHz were used for evaluation. The testicular volume was calculated by the ellipsoid formula: length • width • height • (π/6).

RESULTS

The subject age ranged from 0-18 years (average 7.1 ± 5.3 years). At the age of 0-8 years, the left testicular volume (1.2 ml) was less than the right testicular volume (1.3 ml). At the age of 13 years, the testicular volume of all subjects was over 3 ml. Left testicular volume of boys aged 16.5-18 years ranged from 7 to 22 ml and the right testicular volume ranged from 6 to 22 ml.

CONCLUSION

Reference value tables of testicular volume dependent on age, and for the first time dependent on weight and height in boys aged from 0-18 years were compiled. Tables of testicular length, width, and height dependent on age are provided.

First description of herpes simplex virus type 1 epididymo-orchitis: A new clinical form of herpes simplex virus infection during septic shock?

Genital herpes is increasingly caused by herpes simplex virus type 1 (HSV-1), but recurrences are less frequent than with HSV-2. Distinguishing between primary genital infection and reactivation can be difficult, but HSV-1 more often causes severe primary infections and fewer recurrences. However, as virus reactivation is common during septic shock, a severe form of HSV-1 reactivation can occur in locations other than the lungs, which remain the most common site. The case of a 79-year-old Caucasian man who presented with HSV-1 epididymo-orchitis after three episodes of severe sepsis or septic shock in the context of acute biliary necrotizing pancreatitis is described. This is the first reported case of HSV-1 epididymo-orchitis due to virus reactivation during sepsis.

Varicocele: A Review

Varicoceles are relatively common clinical problem that are associated with pain, testicular atrophy, and reduced fertility rates. After a brief historical perspective is presented, this article reviews the anatomy, indications, treatment options, and potential complications related to varicoceles.

Assessment of Diagnostic Value of Sonography for Cryptorchidism

Cryptorchidism refers to the condition in which the testicle is not positioned in the base of the scrotum. The most important goal of diagnosing and managing the undescended testis is to place the testis in the scrotum to maximize its potential for spermatogenesis. This article provides a comprehensive concept of cryptorchidism, its diagnosis, and complications. This prospective study was performed to assess the value of sonography in the diagnosis of undescended testes. This prospective study was performed to evaluate 124 cases of cryptorchidism. In the authors’ survey, the sensitivity of sonography for determining cryptorchidism was 91%. The most common site of undescended testis was the inguinal canal, and the right undescended testis was localized more than the left undescended testis. The results were compatible with other studies. It was concluded that sonography is the safest, most noninvasive, and most valuable method of detection for undescended testes.

Trauma-Induced Testicular Rupture

Traumatic testicular injuries are relatively uncommon. History, physical examination, clinical findings, and scrotal sonography with Doppler studies are important in diagnosing these injuries. The case presented is a classic example of testicular rupture with necrosis resulting from testicular trauma. In the presence of necrosis, orchiectomy is indicated. Findings consistent with testicular rupture, necrosis, and orchiectomy are discussed.

Straight Vessel Pattern and Rapid Filling Time: Characteristic Findings on Contrast-Enhanced Sonography of Testicular Lymphoma

Six patients with 7 lesions that were histologically confirmed as primary testicular lymphoma were preoperatively investigated with a standardized sonographic protocol including contrast-enhanced sonography. Duplex and contrast-enhanced sonography showed marked hypervascularization in all 7 lesions. On contrast-enhanced sonography, the filling time of lymphomatous lesions was significantly shorter than the filling time of a size-matched sample of 10 patients with seminomas (P < .0001). The sonographic hallmarks of testicular lymphoma in our case series were as follows: (1) sharply demarcated homogeneous hypoechoic testicular lesions with marked hypervascularization; (2) a rapid (<7 seconds) filling time of contrast bubbles; and (3) a straight and parallel course of intralesional vessels on contrast-enhanced sonography.

Sonography of pediatric blunt scrotal trauma: what the pediatric urologist wants to know

Pediatric blunt scrotal trauma is most often the consequence of sports injury and presents a diagnostic challenge because swelling and pain make a scrotal physical exam difficult. US with color flow and duplex Doppler is the first-line imaging modality with the goal of accurate and timely diagnosis of injury requiring surgery to preserve fertility and hormonal function. US imaging findings following blunt scrotal trauma include hydrocele, hematocele, testicular hematoma, testicular fracture, testicular rupture, compromised perfusion/testicular torsion and testicular dislocation. Importantly, several of these findings may coexist. Our goal is to present the pertinent intrascrotal anatomy, US imaging findings for each testicular injury, and contemporary management for each, with emphasis on what our pediatric urology colleagues need to know for optimal patient care.

Laparoscopic TEP repair of inguinal hernia does not alter testicular perfusion

PURPOSE

The effect of laparoscopic TEP repair on testicular perfusion is unclear. The procedure entails dissection of testicular blood vessels off the hernial sac and incorporation of a prosthetic mesh. This carries at minimum, a theoretical risk of compromise in testicular blood supply, which in turn may affect fertility. Our study aims to establish if any alteration in testicular perfusion occurs in very early (24 h), early (1 week) or late postoperative period (3 months) after laparoscopic TEP repair in the Indian population.

METHODS

In our prospective trial, 20 patients underwent unilateral and 8 underwent bilateral laparoscopic TEP hernia repairs using standard technique by experienced surgeons. Flow parameters of testicular, capsular and intratesticular artery were noted using color Doppler ultrasound preoperatively and postoperatively and the postoperative resistive indexes of operated side (n = 36) were compared with preoperative values. Additionally, for unilateral repairs, flow parameters on operated side were compared with the non-operated side.

RESULTS

No statistically significant difference was noticed in the resistive index of the arteries upon comparing these postoperative with preoperative values. For unilateral repairs, the flow parameters of the operated side were comparable with that of non-operated side (i.e. p > 0.05).

CONCLUSION

Laparoscopic TEP performed by experienced surgeons does not alter testicular flow dynamics in early or late postoperative period.

Ultrasonography of the scrotum in adults

Ultrasonography is the ideal noninvasive imaging modality for evaluation of scrotal abnormalities. It is capable of differentiating the most important etiologies of acute scrotal pain and swelling, including epididymitis and testicular torsion, and is the imaging modality of choice in acute scrotal trauma. In patients presenting with palpable abnormality or scrotal swelling, ultrasonography can detect, locate, and characterize both intratesticular and extratesticular masses and other abnormalities. A 12-17 MHz high frequency linear array transducer provides excellent anatomic detail of the testicles and surrounding structures. In addition, vascular perfusion can be easily assessed using color and spectral Doppler analysis. In most cases of scrotal disease, the combination of clinical history, physical examination, and information obtained with ultrasonography is sufficient for diagnostic decision-making. This review covers the normal scrotal anatomy as well as various testicular and scrotal lesions.

Sonographic findings of typical and atypical scrotal trauma

This review article illustrates sonographic findings in the setting of accidental and nonaccidental scrotal trauma. Although sonographic findings may be irrespective of the type of trauma, the goals of sonographic evaluation are similar in both atypical and typical mechanisms of scrotal injury. Familiarity with findings such as disruption of testicular integrity or vascularity facilitates prompt diagnosis and plays a critical role in clinical management.

Sonographic imaging of extra-testicular focal lesions: comparison of grey-scale, colour Doppler and contrast-enhanced ultrasound

Extra-testicular lesions are usually benign but present with nonspecific grey-scale sonography findings. This study assesses conventional sonographic characteristics in the differentiation of extra-testicular tumoural from inflammatory lesions and whether contrast-enhanced ultrasound has a role. A retrospective database analysis was performed. All patients were examined by experienced sonographers employing standard techniques combining grey-scale, colour Doppler sonography and contrast-enhanced ultrasound. Features recorded were: clinical symptoms, size, location, echogenicity, colour Doppler sonography and contrast-enhanced ultrasound enhancement. Vascularity on colour Doppler sonography and contrast-enhanced ultrasound was graded and compared. The lesions were classified as tumoural or inflammatory. The Chi-square test was used to analyse the sonographic patterns and kappa coefficient to measure the agreement between colour Doppler sonography and contrast-enhanced ultrasound. A total of 30 lesions were reviewed (median diameter 12 mm, range 5-80 mm, median age 52 years, range 18-86 years), including 13/30 tumoural and 17/30 inflammatory lesions. Lesions were hypoechoic (n = 12), isoechoic (n = 6), hyperechoic (n = 2) or mixed (n = 10). Grey-scale characteristics of tumoural vs. inflammatory lesions differed significantly (P = 0.026). On colour Doppler sonography, lesions had no vessels (n = 16), 2-3 vessels (n = 10) and ≥4 vessels (n = 4). On contrast-enhanced ultrasound, lesions showed no vascularity (n = 17), perfusion similar to testis (n = 7) and higher (n = 6). All abscesses identified (n = 9) showed no vascularity on both colour Doppler sonography and contrast-enhanced ultrasound. There was good agreement between these techniques in evaluating vascularity (κ = 0.719) and no significant difference between colour Doppler sonography and contrast-enhanced ultrasound of tumoural vs. inflammatory lesions (P > 0.05). The grey-scale appearances of extra-testicular lesions are essential for characterisation. Colour Doppler sonography and contrast-enhanced ultrasound findings are not useful in that respect. Contrast-enhanced ultrasound is excellent in establishing absence of vascularity.

Sonographic appearances of the postoperative testis

PURPOSE

To describe the sonographic findings observed in the testis in patients who have undergone testicle-sparing surgery and surgical biopsies.

METHODS

We reviewed the color Doppler sonographic findings from 14 patients after testicular interventions: 2 open biopsy procedures for infertility and 12 testicle-sparing surgical procedures (1 for spontaneous intratesticular hemorrhage and 11 for small tumors). Ten patients had benign tumors; one had a malignancy. Three patients were symptomatic; all others were studied as follow-up.

RESULTS

Hypoechoic and hypovascular lesions at site of surgery were seen in 10 of the 11 patients after tumorectomy; no changes were observed in one patient. The lesions were either linear or an irregularly triangular shape, located at the surgical site, and interpreted as scars. Retraction of the testicular surface was detected in two cases. In the eight patients who underwent follow-up, lesions disappeared in one case, became smaller in two, and remained stable in five. Of the two patients who underwent biopsy, one developed peritesticular hematoma, and both had late hypoechoic scars in the testis.

CONCLUSIONS

Hypoechoic and hypovascular scars are a "normal" postoperative pattern after testicle-sparing surgery. They are either linear or triangular, with rectilinear margins. Such findings need to be correctly interpreted and not misinterpreted as recurrences.