The testis: the unusual, the rare and the bizarre

A review of multiparametric ultrasound imaging in the clinical setting: scrotal contents

The innovative techniques in ultrasound have added a new dimension to investigating superficially located areas such as the contents of the scrotal sac. High frequency transducers, improved technology with the addition of elastography, contrast enhanced ultrasound and microvascular imaging has resulted in a further improvement in diagnostic capabilities. The ability to clearly demonstrate the presence or absence of vascularity within the area under investigation adds an additional dimension to operator confidence in establishing the presence of infarction, global or segmental, or the walls and cavity of an abscess in the testis or epididymis. Increased vascularity of a tumor aids the differential diagnosis based on the flow dynamics of the microbubble contrast, benign lesions likely to retain contrast. Elastography has the ability to ascertain the stiffness of tissue, and when used in conjunction with other ultrasound methods adds to the understanding of the likelihood of a malignant abnormality being present. All the different techniques come under the umbrella term 'multiparametric ultrasound', with the application in the scrotal sac detailed in this article.

Multiparametric Ultrasound for Diagnosing Testicular Lesions: Everything You Need to Know in Daily Clinical Practice

BACKGROUND

Ultrasonography (US) represents the gold standard imaging method for the assessment of testicular lesions (TL). The gray-scale (GSUS) and color-Doppler (CDUS) ultrasound examination allow sonographers to investigate the size, margins, echotexture, and vascular features of TLs with the aim to differentiate benign from malignant lesions. Recently, the use of contrast-enhanced US (CEUS) and sonoelastography (SE) has led to further improvements in the differential diagnosis of TL. Although GSUS and CDUS are often sufficient to suggest the benign or malignant nature of the TL, CEUS can be decisive in the differential diagnosis of unclear findings, while SE can help to strengthen the diagnosis. The contemporary combination of GSUS, CDUS, CEUS, and SE has led to a new diagnostic paradigm named multiparametric US (mp-US), which is able to provide a more detailed characterization of TLs than single techniques alone. This narrative and pictorial review aimed to describe the mp-US appearance of several TLs.

METHODS

An extensive Medline search was performed to identify studies in the English language focusing on the mp-US evaluation of TLs.

RESULTS

A practical mp-US "identity card" and iconographic characterization of several benign and malignant TLs is provided herein.

CONCLUSIONS

The mp-US characterization of TL reported herein can be useful in daily clinical practice.

Ultrasonography of the scrotum: Revisiting a classic technique

Conventional US is the primary imaging modality for the evaluation of the scrotum, due to its high resolution, availability, cost-effectiveness and absence of ionizing radiation. Grayscale and color Doppler US provide a comprehensive assessment of scrotal diseases. The technique represents the mainstay for imaging of acute scrotum. US is highly accurate in the detection, localization and characterization of scrotal masses. Multiparametric US, including conventional US, contrast-enhanced US and tissue elastography has improved the diagnostic performance of the technique in the assessment of testicular diseases. MRI represents a valuable supplemental imaging tool for the investigation of scrotal pathology, mainly recommended in cases of indeterminate US findings. Recommendations recently issued by the European Society of Urogenital Radiology Scrotal and Penile Imaging Working Group (ESUR-SPIWG) refer to the use of scrotal sonography for the evaluation of pathologic entities, including testicular microlithiasis, small, non-palpable incidentally detected testicular masses, varicocele and scrotal trauma. In this review, the technical specifications for scrotal US and the normal sonographic findings are presented. Grayscale and color Doppler US findings of common acute scrotal diseases and scrotal masses are discussed. The complimentary role of multiparametric US and scrotal MRI is addressed. ESUR-SPIWG's guidelines are also reviewed.

The Rare, the Odd, and the Atypical: A Pictorial Essay of Testicular and Paratesticular Diseases

ABSTRACT

Understanding a variety of scrotal diseases is essential to developing an accurate differential diagnosis and is critical in providing optimal patient care. Ultrasound is the imaging modality of choice when evaluating for scrotal pathology, with the major purpose of locating such pathology to either the testis, or epididymis, or other intrascrotal structures, as well as characterizing lesions as solid or cystic. It is generally assumed that most solid intratesticular masses are more likely malignant, whereas most extratesticular ones are benign, although some exceptions to that rule exist. This pictorial essay will focus on rare and less commonly encountered benign and malignant testicular and paratesticular pathologies, which may pose a diagnostic dilemma for interpreting radiologists and treating physicians. Knowledge of their imaging characteristics will help narrow the differential diagnosis and assist in proper patient management and care.

Paratesticular lesions: Aetiology and appearances on ultrasound

BACKGROUND

Ultrasound (US) is the primary modality for the investigation of scrotal pathology, including both intra- and paratesticular abnormalities.

OBJECTIVE

To describe the abnormalities of the paratesticular space.

MATERIALS/METHODS

The paratesticular space contains the epididymis, spermatic cord and the tunica vaginalis cavity and is affected by a variety of inflammatory or tumoral entities. Differential diagnosis based on US criteria is frequently problematic, as the findings are non-specific.

RESULTS

Some general rules apply: (i) unlike testicular lesions, extra-testicular entities are usually benign in the adult, (ii) the first steps to accurate diagnosis include careful localization of the lesion and assessment of its consistency (solid or cystic) and (iii) magnetic resonance imaging can be useful for further tissue characterization of lesions suspected to contain fat, but surgical biopsy will often provide the definite diagnosis. Contrast-enhanced ultrasound (CEUS) has been applied with limited experience indicating a narrow role, primarily for the differential diagnosis of echogenic cystic entities and the delineation of a necrotic abscess from a solid neoplasm.

DISCUSSION

The various abnormalities are discussed and illustrated.

CONCLUSION

This manuscript summarizes the literature on paratesticular lesions and the value of US in diagnosis.

Case Report: Testicular Sarcoidosis: The Diagnostic Role of Contrast-Enhanced Ultrasound and Review of the Literature

Sarcoidosis is a multisystemic disease histologically characterized by non-caseating epithelioid granulomas and multinucleated giant cells; the etiology is still uncertain, and likely related to a complex interplay between environmental and genetic factors. The genitourinary system is affected in fewer than 0.2% of all clinically diagnosed cases of sarcoidosis and in 5% of those identified in autopsy studies. In this report, we describe a case of a 42–year-old male with one hypoechoic lesion per testis on B-mode evaluation; contrast-enhanced ultrasound (CEUS) on both lesions was carried out. During the early phase, the masses showed a hypovascular appearance as compared to the surrounding testicular tissue, maintaining the hypo-enhancement in the late phase. Tissue biopsy for pathological evaluation confirmed testicular sarcoid involvement, showing non-caseating granulomas. Allowing visualization of testicular microvascularisation, CEUS may play an important role in excluding malignancy, avoiding unnecessary aggressive treatment for benign conditions, such as sarcoidosis. A review of the literature of reported cases since 2004 of sarcoidosis involving the testis is also included.

Current status of percutaneous testicular biopsy for focal lesions

OBJECTIVE

The purpose of this review is to evaluate the current role of percutaneous testicular biopsy in the diagnosis of focal testicular lesions.

CONCLUSION

Percutaneous testicular biopsy can be either fine needle aspiration biopsy or trucut core needle biopsy. It is a well-tolerated and effective procedure useful in small testicular lesions, multifocal lesions, hematological malignancies, and focal lesions in single testis.

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.

Intrascrotal and osseous sarcoidosis mimicking intrascrotal organ cancer and bony metastasis

We report a case of sarcoidosis with concomitant epididymis, testes, and phalanxes involvement mimicking intrascrotal organ cancer and metastatic bony disease. A 23-year-old man developed blurred vision and hyperemia of the left eye, and was diagnosed as having left iritis. A chest computed tomography scan detected bilateral hilar lymphadenopathy and lung nodular shadows. A transbronchial lung biopsy revealed a non-caseating granuloma and he was diagnosed with sarcoidosis. One year after the onset of his eye symptoms, he noticed enlargement of his right scrotum. Magnetic resonance imaging detected lesions of the right epididymis, bilateral testes, and bilateral phalanxes. A technetium-99m scintigram revealed a high accumulation in the bilateral bones of extremities. These radiological findings mimicked intrascrotal organ cancer and metastatic bony disease. Pathologic evaluation following the right epididymectomy revealed non-caseating granulomas compatible with sarcoidosis. Three and half years after the appearance of intrascrotal and bony lesions, they improved spontaneously. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 373-376).

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.

Testicular sarcoidosis masquerading as testicular carcinoma

We present a case of a 27-year-old man with a history of weight loss. A chest x-ray demonstrated hilar lymphadenopathy and he was treated with anti tuberculosis treatment. He noticed a painless left scrotal swelling and a scrotal ultrasound scan raised the possibility of testicular cancer. He underwent an orchidectomy and histology confirmed a testicular sarcoidosis. He was commenced on steroid treatment.

Male infertility: the role of imaging in diagnosis and management

The investigation of male infertility is assuming greater importance, with male factors implicated as a causal factor in up to half of infertile couples. Following routine history, examination and blood tests, imaging is frequently utilised in order to assess the scrotal contents for testicular volume and morphology. Additionally, this may give indirect evidence of the presence of possible reversible pathology in the form of obstructive azoospermia. Further imaging in the form of transrectal ultrasound and MRI is then often able to categorise the level of obstruction and facilitate treatment planning without resort to more invasive imaging such as vasography. Ultrasound guidance of therapy such as sperm or cyst aspiration and vasal cannulation may also be performed. This article reviews the imaging modalities used in the investigation of male infertility, and illustrates normal and abnormal findings that may be demonstrated.

Focal testicular lesions: colour Doppler ultrasound, contrast-enhanced ultrasound and tissue elastography as adjuvants to the diagnosis

The aim of this review is to illustrate the potential of different and newer ultrasound techniques beyond conventional B-mode imaging, including colour Doppler ultrasound, contrast-enhanced ultrasound (CEUS) and tissue elastography, in the characterisation of both benign and malignant intratesticular lesions. Normally, testicular malignancies, either primary or secondary, demonstrate an increase in colour Doppler signal. However, there is a diversity of benign testicular lesions that may mimic testicular malignancies. The use of CEUS improves characterisation of testicular lesions, and confirms lack of vascularity in benign abnormalities such as epidermoid cysts, infarctions, abscesses and changes following trauma. Tissue elastography allows further evaluation of the cellular consistency of the abnormality. Familiarity with the appearances seen with these ultrasound techniques in both benign and malignant abnormalities should aid in improving confidence in arriving at the correct diagnosis.

Fournier's gangrene developing secondary to infected hydrocele: A unique clinical scenario

We report the first case of Fournier's gangrene (FG) developing secondary to an infected hydrocele worldwide. We present a case report with a brief overview of the literature relating to FG and its aetiology, diagnosis and management. A 70 year-old male was referred by his General Practitioner with a 2 week history of worsening symptoms of scrotal discomfort and swelling. Following clinical examination, an initial diagnosis of an infected right-sided hydrocele was made and treatment, consisting of antibiotics, was initiated. Despite showing good clinical improvement, several days later, necrotic areas were observed over the right hemiscrotum with spreading cellulitis. A diagnosis of FG was made. The patient was started on triple-therapy antibiotics and taken to the operating room for urgent surgical debridement. Necrotic skin and subcutaneous tissue extending over the perineum and lower anterior abdomen was debrided down to healthy tissue. A further debridement took place 2 days later. The patient continued to improve and was eventually discharged under the care of Plastic Surgeons for reconstruction of the soft tissue defect. FG is a type of necrotising fasciitis predominantly affecting the male perineal, perianal, genital and anterior abdominal wall regions. It has a significant mortality rate, and the key to survival is early detection and treatment consisting of antibiotics and surgical debridement of the affected area. To the best of our knowledge, this is the first reported case of FG developing secondary to an existing hydrocele without any prior urological intervention. The case highlights the important clinical diagnostic and therapeutic interventions required to prevent complications associated with this, potentially fatal, condition.

Extra-pulmonary manifestations of sarcoidosis

Although, the diagnosis and evaluation of sarcoidosis has traditionally remained confined to the chest, its multi-system nature has been widely recognized. Radiological features of pulmonary sarcoidosis are well known but extra-pulmonary manifestations can produce a plethora of non-specific imaging findings that can affect subcutaneous tissue, and the neurological, cardiac, gastrointestinal, urological, liver, spleen, and skeletal systems. In the literature, there are various case reports and specific system reviews but there are few reviews that encompass all the extra-pulmonary manifestations. In this paper, we comprehensively review the imaging features of extra-pulmonary sarcoidosis with characteristic features as well as atypical presentations. In addition, we discuss the emerging role of nuclear medicine in sarcoidosis.

Acute segmental testicular infarction at contrast-enhanced ultrasound: early features and changes during follow-up

OBJECTIVE

The purpose of this retrospective study was to assess whether contrast-enhanced ultrasound is useful for characterization of acute segmental testicular infarction.

MATERIALS AND METHODS

Twenty men with acute scrotal pain and suspected segmental testicular infarction underwent contrast-enhanced ultrasound. Three patients underwent orchiectomy. For the other patients, the final diagnosis was based on the absence of tumor markers and a change in the size or shape of the tumor during follow-up. Forty-nine color Doppler ultrasound studies (16 within 24 hours of the onset of pain; 14, 2-17 days after pain onset; 19 after 1 month or more), and 38 contrast-enhanced ultrasound studies (13 within 24 hours after pain onset; nine, 2-17 days; 16 after 1 month or more) were performed.

RESULTS

Fourteen of 16 lesions examined within 24 hours were oval, and two were wedge shaped. Eight lesions were isoechoic to the testis, six were hypoechoic, and two had mixed echogenicity. Twelve lesions were avascular and four were hypovascular at color Doppler examination. Contrast-enhanced ultrasound showed avascular parenchymal lobules in all cases and without perilesional rim enhancement in 12 of 13 studies. Two to 17 days after the symptoms appeared, contrast-enhanced ultrasound showed avascular lobules in all cases and perilesional rim enhancement in eight examinations. After 1 month or more, contrast-enhanced ultrasound depicted intralesional vascular spots in 12 of 14 infarcts. Perilesional enhancement was absent.

CONCLUSION

Recognition of lobular morphologic characteristics and the presence of perilesional rim enhancement at contrast-enhanced ultrasound can increase confidence in the diagnosis of segmental testicular infarction compared with reliance on gray-scale and color Doppler findings. Changes in lesion features during follow-up confirm the differential diagnosis from other testicular lesions and allow conservative management.

Targeted testicular excision biopsy: when and how should we try to avoid radical orchidectomy?

Small, incidental testicular lesions are often benign, but in the past have usually been treated by orchidectomy. An alternative is an operative excision biopsy, with localization by ultrasound if necessary, and characterization of the lesion by frozen section analysis. The present review summarizes the indications for the procedure, lists the likely diagnoses, and describes the technique. Frozen section is accurate for distinguishing benign from malignant lesions, testicular function is usually preserved, and there is no evidence that oncological safety is impaired. Such testis-preserving surgery is a rewarding ground for collaboration between urologists, radiologists, and pathologists.

Segmental testicular infarction in a young man simulating a testicular tumor

A 19-year-old boy presented with a 48-hour history of acute onset severe right scrotal pain with minimal scrotal swelling. High-frequency US including color Doppler demonstrated a wedge-shaped, heterogeneous, avascular testicular mass diagnosed preoperatively as a segmental testicular infarction (STI). This was proved at surgery and subsequent histology. The preoperative diagnosis of STI was suggested based on the young man's presentation of severe pain and the sonographic appearance of the mass. Entertaining the preoperative diagnosis of STI from a testicular tumor is important for testis-sparing surgery even though STI in the pediatric age group is extremely rare.

Tubular ectasia of the rete testis: a diagnostic dilemma

Tubular ectasia of the rete testis is a pathologically benign process with complex and varied aetiology. It must be differentiated from neoplastic disease of the testis clinically with patient age, mode of presentation, tumour marker status and the characteristic ultrasound and Doppler study findings. Awareness and diagnosis of this clinical entity can prevent unnecessary surgical intervention in these patients.

Ultrasound imaging of the scrotum

Although there is a wide variety of scrotal pathology, the clinical features are not always particularly discriminatory. These may include pain, generalized swelling or a focal mass. Ultrasound examination of the testes with a high-frequency linear transducer is the primary (and usually the only) diagnostic modality required for evaluation of the testes. This article outlines the technique of scrotal ultrasound and illustrates some of the more common testicular and extratesticular pathologies encountered.