Sonography of the scrotum

Ultrasound: the triage tool in the emergency department: using ultrasound first

Ultrasound in the emergency department has long been recognized as a powerful screening and diagnostic tool for both physicians and radiologists. In the emergency department, since time is of the essence, it becomes a critical tool in triaging patients. Over the years, ultrasound has gained several advantages over other modalities because of its non-ionizing radiation, portability, accessibility, non-invasive method and simpler learning curve. As a result, ultrasound has become one of the most frequently used diagnostic tools in the emergency department by non-radiologists. The value of ultrasound is implemented in every acute ailment in the emergency department such as trauma, acute abdomen, acute pelvic pain, acute scrotal pain, appendicitis in children and acute deep venous thrombosis. Our objective is to discuss the benefit of using ultrasound as the primary modality for each of these diseases.

Surgically Confirmed Intra- and Extratesticular Hematoma Clinically Mimicing Epididymo-Orchitis and Radiologically Mimicing Traumatic Torsion

Background

Scrotal blunt trauma may result in injuries, such as testicular rupture, dislocation, torsion, hematoma, spermatic cord injury or contusion, and epididymal, scrotal, and urethral injuries. Ultrasonography (US) has a crucial role in the evaluation of those kinds of pathologies. Early diagnosis of testicular rupture may lead to the salvaging of the testicle by prompt surgical exploration within 72 h.

Case Report

A 21-year-old male with right scrotal swelling and pain complaints was admitted to another hospital one month ago. Epididymo-orchitis was diagnosed and the patient was given medical treatment. The patient was admitted to our emergency service with ongoing complaints. The patient stated that the pain and swelling suddenly developed after prolonged marching. On US, a large hematoma was detected between the leaves of the tunica vaginalis, and rupture from the lower pole was diagnosed. On color Doppler US, no vascularity was observed in the heterogeneous testicular parenchyma. Traumatic torsion was primarily suggested. Intraoperatively, an extratesticular hematoma, hematocele, and rupture were confirmed but torsion was not found. Because the hematoma entirely replaced the normal parenchyma, orchiectomy was performed.

Conclusions

Testicular rupture may occur even after moderate sportive action such as prolonged marching. If any delay occurs in diagnosis and/or operation, the coagulum may replace the entire parenchyma. We think that US and clinical findings may sometimes mislead the physicians and cause misdiagnoses, such as inflammation or torsion. In this paper, we present a complex delayed diagnosed example case of testicular rupture clinically mimicing epididymo-orchitis and radiologically mimicing traumatic testicular torsion.

Common and Uncommon Presentation of Fluid within the Scrotal Spaces

Ultrasonography(US) of the scrotum has been demonstrated to be useful in the diagnosis of fluid in the scrotal sac. Grayscale US characterizes the lesions as testicular or extratesticular and, with color Doppler, power Doppler and pulse Doppler, any perfusion can also be assessed. Cystic or encapsulated fluid collections are relatively common benign lesions that usually present as palpable testicular lumps. Most cysts arise in the epidydimis, but all anatomical structures of the scrotum can be the site of their origin. US may suggest a specific diagnosis for a wide variety of intrascrotal cystic and fluid lesions and appropriately guide therapeutic options. The paper reviews the current knowledge of ultrasound in conditions with fluid in the testis and scrotum. The review presents the applications of ultrasonography in the diagnosis of hydrocele, testicular cysts, epididymal cysts, spermatoceles, tubular ectasia, hernia and hematoceles. The aim of this paper is to provide a pictorial review of the common and uncommon presentation of fluid within the scrotal spaces.

MR Spectra of Normal Adult Testes and Variations with Age: Preliminary Observations

OBJECTIVES

The aim was to determine the proton MR (1H-MR) spectra of normal adult testes and variations with age.

METHODS

Forty-one MR spectra of normal testes, including 16 testes from men aged 20-39 years (group I) and 25 testes from men aged 40-69 years (group II), were analyzed. A single-voxel point-resolved spectroscopy sequence (PRESS), with TR/TE: 2000/25 ms was used. The volume of interest was placed to include the majority of normal testicular parenchyma. Association between normalized metabolite concentrations, defined as ratios of the calculated metabolite concentrations relative to creatine concentration, and age was assessed.

RESULTS

Quantified metabolites of the spectra were choline (Cho), creatine (Cr), myo-inositol (mI), scyllo-inositol, taurine, lactate, GLx compound, glucose, lipids, and macromolecules resonating at 0.9 ppm (LM09), around 20 ppm (LM20), and at 13 ppm (LM13). Most prominent peaks were Cho, Cr, mI, and lipids. A weak negative correlation between mI and age (P = 0.015) was observed. Higher normalized concentrations of Cho (P = 0.03), mI (P = 0.08), and LM13 (P = 0.05) were found in group I than in group II.

CONCLUSIONS

1H-MR spectra of a normal adult testis showed several metabolite peaks. A decrease of levels of Cho, mI, and LM13 was observed with advancing age.

KEY POINTS

• Single-voxel PRESS MRS of a normal testis is feasible. • 1H-MR spectra of a normal testis showed several metabolite peaks. • Most prominent peaks were Cho, Cr, mI, and lipids. • A decrease of Cho, mI, and LM13 was seen with advancing age.

Sonographic appearances of the epididymis in boys with acute testicular torsion but preserved testicular blood flow on color Doppler

BACKGROUND

Little attention has been given to the sonographic appearances of the epididymis in testicular torsion.

OBJECTIVE

To describe the position and morphology of the epididymis in childhood acute testicular torsion when testicular flow is present on color Doppler sonography.

MATERIALS AND METHODS

We studied the sonographic findings in boys with clinically and surgically proven acute testicular torsion who were examined sonographically from May 2013 to May 2014 and who had preserved intratesticular flow on color Doppler sonography. We retrospectively evaluated the sonograms with emphasis on the epididymal findings.

RESULTS

In all nine boys with confirmed torsion but with preserved intratesticular flow on color Doppler sonography, the epididymal head had an unexpected configuration and size, and no close relationship with the upper pole of the testis. In five of these children the spermatic cord appeared twisted on the affected side. In the remaining four boys the spermatic cord appeared straight.

CONCLUSION

The position and morphology of the head of the epididymis were abnormal in all boys with acute testicular torsion but with preserved testicular flow.

Advantage of Adding Diffusion Weighted Imaging to Routine MRI Examinations in the Diagnostics of Scrotal Lesions

Background

The purpose of the study is to identify the diagnostic value of adding diffusion weighted images (DWI) to routine MRI examinations of the scrotum.

Material/Methods

The study included 100 testes of 50 patients with a unilateral testicular disease. Fifty normal contralateral testes were used as a control group. All patients underwent conventional MRI and DWI examinations of the scrotum. The results of MRI and DWI of the group of patients treated surgically were correlated with histopathological findings. The MRI and DWI results of non-surgical cases were correlated with the results of clinical, laboratory and other imaging studies. Comparison of the ADC value of normal and pathological tissues was carried out followed by a statistical analysis.

Results

There was a significant difference between ADC values of malignant testicular lesions and normal testicular tissues as well as benign testicular lesions (P=0.000). At a cut-off ADC value of ≤0.99, it had a sensitivity of 93.3%, specificity of 90%, positive predictive value of 87.5%, and negative predictive value of 94.7% in the characterization of intratesticular masses.

Conclusions

Inclusion of DWI to routine MRI has a substantial value in improving diagnosis in patients with scrotal lesions and consequently can reduce unnecessary radical surgical procedures in these patients.

Utility of Real-Time Shear Wave Elastography in the Assessment of Testicular Torsion

Real-time shear-wave elastography (SWE) is a newly developed method which can obtain the stiffness of tissues and organs based on tracking of shear wave propagation through a structure. Several studies have demonstrated its potential in the differentiation between diseased and normal tissue in clinical practices, however the applicability to testicular disease has not been well elucidated. We investigated the feasibility and reproducibility of SWE in the detection of testicular torsion. This prospective study comprised 15 patients with complete testicular torsion. Results obtained from SWE along with conventional gray-scale and color Doppler sonography and post-operative pathology were compared. The results revealed that (i) the size of injured testis was increased and the twisted testis parenchyma was heterogeneous. The blood flow signals in injured testis were barely visible or absent; (ii) The Young’s modulus, including Emean, Emax, Emin and SD values in the border area of torsional testis were higher than those of normal testis (Emean, 78.07±9.01kPa vs 22.0±5.10kPa; Emax,94.07±6.53kPa vs 27.87±5.78kPa; Emin, 60.73±7.84 kPa vs 18.90±4.39kPa; SD, 7.67±0.60 kPa vs 2.30±0.36 kPa, [P<0.05]); The Emax and SD values in the central area of the torsional testis were higher than the corresponding area of the normal testis (Emax, 8.23±0.30 kPa vs 3.97±0.95kPa; SD, 1.5±0.26kPa vs 0.67±0.35kPa,[P<0.05]) and Emin values was lower than those of normal testicles(0.93±0.51kPa vs 1.6±0.36kPa; [P<0.05]); (iii) The Young's modulus measurement between two physicians showed good agreement. The pathological findings were accordance with SWE measurement. SWE is a non-invasive, convenient and high reproducible method and may serve as an important alternative tool in the diagnosis and monitoring the progression of the acute scrotums, in additional to conventional Doppler sonography.

Adult type granulosa cell tumor of the testis: Radiological evaluation and review of the literature

A testicular granulosa cell tumor of the adult type is very rare. Isolated case reports and small series have been published in the English literature. Here, we analyze an incidentally discovered testicular granulosa cell tumor in a 29-year-old man to discuss the radiological evaluation of this entity and review the literature.

Scrotal calculi in clinical practice and their role in scrotal pain: A prospective study

PURPOSE

Scrotal calculi are rare, and their clinical significance is uncertain. Scrotal pain is a frequent, hard-to-manage problem in urology clinics. Our purpose in this study was to determine the relationship between the presence of scrotal calculi and scrotal pain in a prospective manner.

METHODS

Sonography and color Doppler ultrasound of the scrotum were performed in 758 consecutive patients referred with scrotal pain. The pain was rated by using an 11-point numeric rating scale; scores were compared among patients with scrotal calculi with and without additional scrotal pathology.

RESULTS

Scrotal calculi were detected in 73 of the 758 patients (9.6%). Scrotal pain (n = 50 [61%]) and a palpable mass in the scrotum (n = 25 [30.5%]) were the most common complaints in patients with scrotal calculi. Hydrocele (n = 17 [29.8%]) and varicocele (n = 15 [26.3%]) were the most commonly associated abnormalities; there was a statistically significant association between the presence of scrotal calculi and hydrocele (p < 0.01). Scrotal pain was present in 61 (83.5%) patients with scrotal calculi, and this association was significant (p < 0.001). The presence of scrotal pain and the correlation between location of calculi and pain in patients without additional scrotal abnormalities were also significant (p = 0.04 and p < 0.004, respectively).

CONCLUSIONS

The prevalence of scrotal calculi was 9.6%, and hydrocele was found to be associated with scrotal calculi. We also found a significant relationship between the presence of calculi and scrotal pain. Because the etiology of scrotal pain is essential for appropriate treatment, scrotal calculi should be kept in mind when making a differential diagnosis of scrotal pain. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 43:406-411, 2015.

Scrotal imaging

Pathological lesions within the scrotum are relatively rare in imaging except for ultrasonography. The diseases presented in the paper are usually found in men at the age of 15-45, i.e. men of reproductive age, and therefore they are worth attention. Scrotal ultrasound in infertile individuals should be conducted on a routine basis owing to the fact that pathological scrotal lesions are frequently detected in this population. Malignant testicular cancers are the most common neoplasms in men at the age of 20-40. Ultrasound imaging is the method of choice characterized by the sensitivity of nearly 100% in the differentiation between intratesticular and extratesticular lesions. In the case of doubtful lesions that are not classified for intra-operative verification, nuclear magnetic resonance is applied. Computed tomography, however, is performed to monitor the progression of a neoplastic disease, in pelvic trauma with scrotal injury as well as in rare cases of scrotal hernias involving the ureters or a fragment of the urinary bladder.

Testicular Ischemia Due to a Band Around the Spermatic Cord

We present a case of an 18-year-old boy who was admitted to our hospital with a 2-day history of pain in the right scrotum. Ultrasound examination showed signs of ischemia, with dampened testicular arterial flow and bell-clapper deformity. Surgery revealed a constricting fibrous band around the distal spermatic cord resembling the bell-clapper deformity.

Multiparametric Sonography of Testicular Hematomas: Features on Grayscale, Color Doppler, and Contrast-Enhanced Sonography and Strain Elastography

We investigated the appearances of intratesticular hematomas on multiparametric sonography combining grayscale, color Doppler, and contrast-enhanced sonography and strain elastography. Over a 3-year period, 17 hematomas in 8 patients were analyzed. Blunt trauma (n = 7) and surgery (n = 1) were preceding events. Grayscale sonography showed well-defined oval or round predominantly hypoechoic and heterogeneous, peripherally (n = 13) or centrally (n = 4) located lesions. Three showed contrast enhancement of septations, and 4 showed peripheral lesion rim enhancement. On strain elastography, the mean strain ratio was 1.19 (range, 0.41-2.36), and elasticity score were 3 or lower (n = 13) and 5 (n = 4). Multiparametric sonography shows nonenhancement with contrast and predominantly "soft" elastographic properties and aids in the interpretation of the benign nature of intratesticular hematomas.

MR Imaging of the Penis and Scrotum

Traditionally, due to its low cost, ready availability, and proved diagnostic accuracy, ultrasonography (US) has been the primary imaging modality for the evaluation of scrotal and, to a lesser extent, penile disease. However, US is limited by its relatively small useful field of view, operator dependence, and inability to provide much information on tissue characterization. Magnetic resonance (MR) imaging, with its excellent soft-tissue contrast and good spatial resolution, is increasingly being used as both a problem-solving tool in patients who have already undergone US and as a primary modality for the evaluation of suspected disease. Specifically, MR imaging can aid in differentiating between benign and malignant lesions seen at US, help define the extent of inflammatory processes or traumatic injuries, and play a vital role in locoregional staging of tumors. Consequently, it is becoming more important for radiologists to be familiar with the wide range of penile and scrotal disease entities and their MR imaging appearances. The authors review the basic anatomy of the penis and scrotum as seen at MR imaging and provide a basic protocol for penile and scrotal imaging, with emphasis on the advantages of MR imaging. Pathologic processes are organized into traumatic (including penile fracture and contusion), infectious or inflammatory (including Fournier gangrene and scrotal abscess), and neoplastic (including both benign and malignant scrotal and penile tumors) processes.

Management of Low-Stage Testicular Seminoma

Management of testicular seminoma has benefited from numerous advances in imaging, radiotherapy, and chemotherapy over the last 50 years leading to nearly 100% disease-specific survival for low-stage seminoma. This article examines the evaluation and management of low-stage testicular seminoma, which includes clinical stage I and IIA disease. Excellent outcomes for stage I seminoma are achieved with active surveillance, adjuvant radiotherapy, and adjuvant single-agent carboplatin. Current areas of research focus on optimizing surveillance regimens and minimizing the morbidity and long-term complications of adjuvant treatment. Radiotherapy continues to be the primary treatment option for patients with clinical stage IIa disease.

Distribution of Epididymal Involvement in Mumps Epididymo-orchitis

OBJECTIVES

To evaluate characteristic sonographic findings for mumps orchitis with epididymal involvement.

METHODS

This study included 18 patients (aged 12-18 years) with mumps orchitis. We assessed the volume, echogenicity, and vascularity of the testes and the transverse diameter, echogenicity, and vascularity of the epididymal head, body, and tail. We classified 4 types of epididymal involvement: 1A, focal swelling of the epididymal head with hypervascularity only on the swollen head; 1B, focal swelling of the epididymal head with hypervascularity on the entire epididymis; 1C, diffuse swelling of the entire epididymis with hypervascularity; and 2, no epididymal involvement. The Student t test was used to evaluate the significance of the size of each part of the epididymis and the epididymal head-to-tail diameter ratio.

RESULTS

Orchitis was unilateral in 13 patients and bilateral in 5. Of 23 affected hemiscrotums, 7 (30.4%) were type 1A, 4 (17.4%) type 1B, 2 (8.7%) type 1C, and 10 (43.5%) type 2. In 11 patients with unilateral epididymal involvement, the mean diameters ± SDs of the epididymal heads on the affected and contralateral sides were 1.11 ± 0.19 (range, 0.7-1.7) and 0.65 ± 0.14 (0.3-0.9) cm (significantly different, P <.001). The diameters of the epididymal tails on the affected and contralateral sides were 0.51 ± 0.41 (0.2-0.8) and 0.46 ± 0.21 (0.3-0.6) cm (not statistically different, P = .106). The mean head-to-tail ratios on the affected and contralateral sides were 2.28 ± 0.49 (1.29-3.00) and 1.41 ± 0.22 (1.00-1.75; significantly different, P < .001). In all types 1A and 1B, the ratio was higher than 2.00; in 22 of 23 unaffected epididymides, the ratio was lower than 2.00.

CONCLUSIONS

Focal swelling of epididymal heads was a characteristic sonographic finding of mumps epididymo-orchitis, and a head-to-tail ratio higher than 2.00 can be a useful diagnostic finding.

Isolated epididymal injury after blunt scrotal trauma from high velocity paintball round

Isolated epididymal injury without associated underlying scrotal or testicular injury in the setting of blunt trauma is exceedingly rare. We present a case of an isolated epididymal injury incurred after scrotal trauma from a high velocity paintball round. Ultrasound demonstrated an enlarged, hypoechoic left epididymis with no evidence of underlying testicular injury. This case highlights the importance of obtaining imaging to evaluate for signs of testicular rupture, potentially obviating the need for surgery. It also reinforces the need for appropriate protective gear when participating in activities with potential for high velocity scrotal trauma.

Grayscale and color Doppler features of testicular lymphoma

Pooled data from 16 radiology centers were retrospectively analyzed to seek patients with pathologically proven testicular lymphoma and grayscale and color Doppler images available for review. Forty-three cases were found: 36 (84%) primary and 7 (16%) secondary testicular lymphoma. With unilateral primary lymphoma, involvement was unifocal (n = 10), multifocal (n = 11), or diffuse (n = 11). Synchronous bilateral involvement occurred in 6 patients. Color Doppler sonography showed normal testicular vessels within the tumor in 31 of 43 lymphomas (72%). Testicular lymphoma infiltrates through the tubules, preserving the normal vascular architecture of the testis. Depiction of normal testicular vessels crossing the lesion is a useful adjunctive diagnostic criterion.

Ovary and testicle and everything in between: lesions and imaging in the newborn

Assessment of the neonatal reproductive tract requires an understanding of embryology, awareness of common clinical presentations, and familiarity with normal newborn variation. This review of the neonatal reproductive tract emphasizes the use of sonography in the evaluation of developmental, acquired, and neoplastic conditions in male and female newborns. Anchored in embryologic origins, the discussion also includes descriptions of findings that may be encountered in prenatal imaging. Comments on clinical correlation are included to guide appropriate triaging of these complex cases. Imaging pearls and pitfalls are incorporated into this review, including the recognized effects of maternal hormones in female infants.

Harlequin testicle and other uncommon pathologies masquerading at routine scrotal ultrasound

Many scrotal conditions manifest similarly as pain, swelling, a palpable abnormality, or a combination of these symptoms. Most common scrotal pathologies have characteristic accompanying sonographic findings. Less common pathologies can have similar clinical presentations, and imaging with scrotal ultrasound is required to aid in proper diagnosis. This article focuses on several of these less commonly encountered scrotal pathologies--including testicular segmental infarction, scrotal filariasis, scrotal mesothelioma, seminiferous tubule fibrosis, and scrotal leiomyosarcoma--and compares and contrasts them to more routine diagnoses. Familiarity with both typical and atypical scrotal conditions is necessary to make accurate diagnoses at ultrasound to guide appropriate treatment and avoid unnecessary surgery.

Análise quantitativa da ecogenicidade testicular pela técnica do histograma de ovinos da baixada ocidental maranhense

A ultrassonografia é um método de diagnóstico por imagem que permite a avaliação de diferentes órgãos e estruturas corpóreas de maneira não invasiva. No entanto, a avaliação subjetiva das imagens caracteriza um dos grandes entraves na utilização desta técnica de diagnóstico, havendo necessidade de mecanismos que minimizem a subjetividade do exame e a divergência na interpretação dos achados ultrassonográficos. Desta forma este trabalho objetivou caracterizar a ecogenicidade do parênquima e mediastino testicular de ovinos utilizando a técnica do histograma escala-cinza. Foram utilizados 30 animais divididos em três grupos de acordo com a faixa etária (FE): de três a seis meses (FE1), sete a 12 meses (FE2), 13 a 18 meses (FE3) e realizadas varreduras testiculares nos planos frontal, sagital e transversal, elaborando ao final um histograma a partir das imagens ultrassonográficas. Observou-se que tanto a ecogenicidade do parênquima quanto a do mediastino testicular aumentaram gradativamente com a progressão das idades dos animais, com média e desvio-padrão de 95,00±19,05 e 94,35±18,82 para a ecogenicidade do parênquima do antímero direito e esquerdo, respectivamente, e 127,95±12,97 para o mediastino direito e 126,59±11,78 para o esquerdo. A técnica do histograma escala-cinza demonstrou ser um método eficiente na determinação da ecogenicidade testicular, possibilitando o estabelecimento de padrões de normalidade que venham a auxiliar pesquisas futuras no monitoramento do desenvolvimento testicular bem como na detecção de patologias. Para a regimes exclusivos de criação extensiva, como na baixada maranhense, representa ferramenta valiosa para sua utilização em projetos sociais do Estado que atendem a agricultura familiar.

MR imaging of scrotum

Magnetic resonance (MR) imaging of the scrotum has been used as a valuable supplemental diagnostic modality in evaluating scrotal pathology, mostly recommended in cases of inconclusive sonographic findings. Because of the advantages of the technique, MR imaging of the scrotum may provide valuable information in the detection and characterization of various scrotal diseases. The technique may accurately differentiate intratesticular from extratesticular mass lesions and provide important information in the preoperative characterization of the histologic nature of scrotal masses. An accurate estimation of the local extent of testicular carcinomas in patients for whom testis-sparing surgery is planned is possible.

Apparent diffusion coefficient values of normal testis and variations with age

The usefulness of diffusion-weighted magnetic resonance imaging (DWI) in the evaluation of scrotal pathology has recently been reported. A standard reference of normal testicular apparent diffusion coefficient (ADC) values and their variations with age is necessary when interpreting normal testicular anatomy and pathology. We evaluated 147 normal testes using DWI, including 71 testes from 53 men aged 20-39 years (group 1), 67 testes from 42 men aged 40-69 years (group 2) and nine testes from six men older than 70 years (group 3). DWI was performed along the axial plane, using a single shot, multislice spin-echo planar diffusion pulse sequence and b-values of 0 and 900 s mm-2 . The mean and standard deviation of the ADC values of normal testicular parenchyma were calculated for each age group separately. Analysis of variance (ANOVA) followed by post hoc analysis (Dunnett T3) was used for statistical purposes. The ADC values (× 10-3 mm 2 s-1 ) of normal testicular tissue were different among age groups (group 1: 1.08 ± 0.13; group 2: 1.15 ± 0.15 and group 3: 1.31 ± 0.22). ANOVA revealed differences in mean ADC among age groups (F = 11.391, P < 0.001). Post hoc analysis showed differences between groups 1 and 2 (P = 0.008) and between groups 1 and 3 (P = 0.043), but not between groups 2 and 3 (P = 0.197). Our findings suggest that ADC values of normal testicular tissue increase with advancing age.

Triplex Doppler evaluation of the testes in dogs of different sizes

This study aimed to assess whether there are differences in Doppler velocimetry parameters between different sizes. Twenty dogs were equally divided into small and large groups used in this study. The dogs were evaluated using Triplex ultrasound. Testicular artery was located by Colour Doppler in the spermatic cord, marginal to the testes and intratesticular segments and then, spectral Doppler were used to calculate: peak systolic velocity (PSV), end diastolic velocity (EDV), resistance index (RI) and pulsatility index (PI). The mean testicular volume in the left side was significantly higher than the right side, in both groups. Doppler examination showed higher velocities (EDV) at spermatic cord in large dogs; marginal to the testes was observed higher velocities in small dogs; intratesticular region no differences were observed (P < 0.05) and within the groups differences between segments of the artery were also observed for each parameter. The results showed that there are differences in Doppler velocimetry parameters between different sizes.

Imaging of common solid organ and bowel torsion in the emergency department

OBJECTIVE

This article will discuss the most common forms of torsion encountered in the emergency department.

CONCLUSION

Torsion refers to the twisting of an object about its axis and represents the pathophysiologic mechanism underlying an important group of disorders affecting both the bowel and the solid organs of the abdomen and pelvis. Although these disorders typically present with the acute onset of pain, clinical findings are often nonspecific, with imaging playing a key role in diagnosis. Missed or delayed diagnosis may result in complications, such as ischemia; end-organ loss; and, in some cases, death. Therefore, it is critical to have a thorough understanding of the pathophysiology and imaging findings of these entities to avoid the morbidity and mortality associated with a missed or delayed diagnosis.

Imaging and interventional therapy for varicoceles

Varicocele is a common treatable cause of testicular pain, male infertility, and Leydig cell dysfunction. Scrotal ultrasonography has become the modality of choice in the diagnosis and post-treatment follow-up of varicocele. Visualization of dilated veins and reflux into the pampiniform plexus enables accurate diagnosis. Although the pathophysiology of varicocele in testicular dysfunction remains unclear, numerous studies have established significant improvement in the seminal parameters and pregnancy rates after varicocele repair. Interventional therapy is a minimally invasive effective treatment option for primary and salvage varicocele repair. This review discusses sonographic criteria used in the pre- and post-procedural evaluation of varicocele and various interventional techniques for varicocele treatment.

Eleven patients with testicular leydig cell tumors: clinical, imaging, and pathologic correlation

We present the sonographic and magnetic resonance imaging findings of Leydig cell tumors in a series of patients, along with a brief review of the literature. We evaluated the sonographic features of 11 cases of Leydig cell tumors, including echogenicity, size, margins, and patterns of vascularity. The magnetic resonance imaging characteristics of 9 patients were also assessed, with special attention to the appearance of the tumors on T2-weighted imaging and postcontrast T1-weighted imaging. Seven tumors were hypoechoic, and 4 were almost isoechoic. Ten patients showed various patterns of hypervascularity in the tumors, combined in some cases with feeding vessels. One case presented with a single feeding vessel. The tumors showed homogeneous or heterogeneous low signal intensity on T2-weighted imaging and marked enhancement on postcontrast T1-weighted imaging. The small size of these tumors, the various patterns of vascularity on color and power Doppler sonography, and the marked enhancement on postcontrast T1-weighted imaging are considered valuable but generally nonspecific for identification of these tumors.

Ultrasonography evaluation of scrotal masses

Sonography is the ideal modality for evaluation and characterization of a scrotal mass. Extratesticular masses are usually benign, whereas intratesticular masses are generally malignant until proved otherwise. However, it is important to recognize the benign intratesticular conditions, thus possibly preventing orchiectomy when unwarranted, while appreciating the more significant findings of extratesticular masses that may warrant further intervention. This article reviews the anatomy and sonographic findings of scrotal masses. Normal anatomy, general imaging techniques, and assessment of intratesticular and extratesticular disorders will be discussed.

Developing high-frequency ultrasound tomography for testicular tumor imaging in rats: an in vitro study

PURPOSE

This paper describes a feasibility study for developing a 35-MHz high-frequency ultrasound computed-tomography (HFUCT) system for imaging rat testicles.

METHODS

The performances of two kinds of HFUCT-attenuation and sound-speed UCT-based on transmission and pulse-echo modes were investigated in this study. Experiments were carried out using phantoms and actual rat testicles in vitro. HFUCT images were reconstructed using a filtered backprojection algorithm.

RESULTS

The phantom experimental results indicated that all types of HFUCT can determine the dimensions of a plastic cylinder with a diameter of 500 μm. Compared to sound-speed HFUCT, attenuation HFUCT exhibited a better performance in recognizing a tiny sclerosed region in a gelatin phantom. Therefore, the in vitro testicular experiments were performed using attenuation HFUCT based on transmission and pulse-echo modes. The experimentally measured attenuation coefficient and sound speed for healthy rat testicles were 2.92 ± 0.25 dB/mm and 1537 ± 25 m/s, respectively.

CONCLUSIONS

A homogeneous texture was evident for healthy testicles using both modes. An artificial sclerosed tumor could also be clearly observed using two- and three-dimensional attenuation HFUCT in both modes. However, an object artifact was apparent in pulse-echo mode because of ultrasound beam refraction. All of the obtained experimental results indicate the potential of using HFUCT as a novel tool for monitoring the preclinical responses of testicular tumors in small animals.

Can ultrasound help to manage patients with scrotal trauma?

Traumatic injuries to the scrotum are uncommon but, when they do occur, frequently lead to serious complications. Early complications include testicular infarction, necrosis and abscess formation; in the longer-term trauma may result in testicular atrophy and subfertility. Early surgical intervention in patients with testicular rupture can significantly improve the clinical outcome and reduce the need for delayed orchidectomy. However, clinical examination of the scrotum following trauma is difficult and frequently inaccurate; this may result in incorrect triage of patients for surgical exploration. Scrotal ultrasound can reliably assess scrotal injuries and diagnose testicular rupture with a high level of accuracy. Additionally, ultrasound can provide important information regarding testicular perfusion, which can further inform decisions on surgical management. This article reviews the sonographic findings that may be encountered in patients with scrotal trauma, with an emphasis on blunt trauma. It describes the pivotal role that ultrasound can play in the accurate triage of these patients to surgical or conservative management.

Imaging of traumatic injuries to the scrotum and penis

OBJECTIVE

The purpose of this article is to review scrotal and penile anatomy, the role of ultrasound in evaluating scrotal and penile trauma, and the vast spectrum of sonographic manifestations of scrotal and penile trauma.

CONCLUSION

Scrotal and penile trauma is an uncommon type of trauma injury. However, knowledge of scrotal and penile anatomy and the appropriate imaging findings associated with acute traumatic injuries is important in establishing the correct diagnosis. Sonography is considered the first choice of imaging modalities in establishing a diagnosis and triaging patients into surgical and nonsurgical treatment.

Cannonball Metastatic Lesions in a Young Male: A Case Report

Testicular germ cell tumors are the most common malignancy among young men. These are highly chemo-sensitive tumors with high cure rates. More than 95% of patients with testicular cancer present with a painless testicular mass. Here we describe a rare initial presentation of testicular cancer in a previously asymptomatic 22-year-old male who presented with widespread metastatic cannonball lesions in his lungs.

Epididymal polar dissociation: a previously undescribed anatomical variant

The normal male external genitalia include the testicles with the epididymis attached posteriorly and the vas deferens arising from this. This case describes an anatomical variation of this normal anatomy not previously reported in the literature. A 17-year-old boy presented with symptoms of intermittent testicular torsion and underwent scrotal exploration. On the left side there was a bell-clapper deformity with the epididymis separated into two parts with the lower pole high in the scrotum and attached to the tunica vaginalis. A normal vas deferens was seen to arise from the isolated lower pole of the epididymis. There was no connection between the vas deferens and the testis or upper pole of epidiymis. This case reminds us of the possibility of anatomical variations and the importance of keeping them in mind to prevent complications at time of surgery.