Spermatozoa-containing simple cysts of the rete testis

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.

Aspectos ultra-sonográficos das alterações não-neoplásicas do testículo

Processos patológicos dos testículos são muito comuns, incluindo-se lesões tumorais e não-tumorais neste contexto. A ultra-sonografia com transdutor de alta freqüência tornou-se a modalidade de imagem de escolha para a avaliação desses órgãos. Este método ajuda a melhor caracterizar lesões intratesticulares e em muitas situações sugere um diagnóstico mais específico, principalmente nos casos em que há manifestações clínicas similares, tais como dor, inchaço e aumento volumétrico locais. O mapeamento com Doppler colorido é importantíssimo para demonstrar padrões anormais de perfusão testicular e auxilia no diagnóstico de condições clínicas agudas. Neste ensaio iconográfico os autores sumarizam os mais comuns achados clínicos, patológicos e as principais características diagnósticas de lesões testiculares, tais como microlitíase, cisto simples, espermatocele, varicocele, ectasia tubular da rete testis, orquite, hematomas e condições mais raras. A familiaridade com as características ecográficas e clínicas destas alterações é essencial para o estabelecimento do diagnóstico correto e início da terapêutica mais eficaz, quando necessária.

Scrotal US for evaluation of infertile men with azoospermia

PURPOSE

To evaluate prospectively the accuracy of scrotal ultrasonography (US) in distinguishing obstructive azoospermia from nonobstructive azoospermia in infertile men by using histologic findings as the reference standard.

MATERIALS AND METHODS

The institutional review board approved the study, and informed consent was obtained from each patient. Twenty infertile men (mean age, 34.7 years; 40 testes) with azoospermia were evaluated at scrotal US, with an emphasis on the course of the proximal genital duct: mediastinum testis, epididymal head, epididymal body, and epididymal tail. Testicular volumes were calculated by using the formula: length x height x width x 0.71. On the basis of histologic results, azoospermia was divided into two groups (obstructive vs nonobstructive) in all cases except one. Scrotal US findings between obstructive and nonobstructive azoospermia were compared. The Fisher exact and Wilcoxon signed rank sum tests were used to assess differences between both groups.

RESULTS

Of 20 infertile men with azoospermia, 14 were proved to have obstructive azoospermia; the others had nonobstructive azoospermia. According to US findings, epididymal abnormalities in the head, body, and tail were significantly associated with obstructive azoospermia (17 [61%], 18 [64%], and 20 [71%] of 28 testes, respectively; P < .001 for all), while abnormalities of the mediastinum testis between both groups were not significant (P > .05). By taking epididymal abnormalities into account, sensitivity, specificity, and accuracy of scrotal US for differentiation of obstructive from nonobstructive azoospermia were 82.1% (23 of 28 scrota), 100% (12 of 12 scrota), and 87.5% (35 of 40 scrota), respectively. The median testicular volume in obstructive azoospermia was 11.6 mL (range, 7.7-25.8 mL) and that in nonobstructive azoospermia was 8.3 mL (range, 1.2-16.4 mL) (P < .05).

CONCLUSION

Evaluation of the epididymis and measurement of testicular volume with scrotal US are important in distinguishing obstructive azoospermia from nonobstructive azoospermia in infertile men.

Benign intrascrotal lesions

PURPOSE

We summarize important clinical, pathological and diagnostic features of benign intrascrotal lesions, including paratesticular lesions (adenomatoid tumors, fibrous pseudotumors, cystadenomas, spermatoceles, hydroceles, varicoceles and hernias) and intratesticular lesions (tunica albuginea cysts, testicular simple cysts, epidermoid cysts, cystic ectasia of the rete testis, intratesticular varicocele, adrenal rest tumors and splenogonadal fusion). This review provides the reader with a better understanding of benign lesions that occur in the scrotum.

MATERIALS AND METHODS

A directed MEDLINE literature review of benign scrotal lesions and of each individual lesion was performed. This information was enhanced with relevant information from select journals and texts. Particular emphasis was placed on clinical, pathological and diagnostic features.

RESULTS

Intrascrotal lesions continue to provide a diagnostic challenge for physicians. A diagnosis can be made with a thorough history, physical examination and understanding of the pathophysiological processes of the structures contained within the scrotum. Lesions that are suspicious for malignancy should prompt urological consultation and radiological imaging. Ultrasound aids in the diagnosis in instances of uncertainty. Ultimately surgery may be necessary to make a histological diagnosis.

CONCLUSIONS

Clinical assessment, physical examination and an understanding of benign intrascrotal processes are key to making a diagnosis. Ultrasound has an important role and adds essential information. If surgery is necessary and a benign process is recognized, a testis sparing procedure should be performed.

Sonography of the scrotum

Ultrasonography (US) with a high-frequency (7.5-10-MHz) transducer has become the imaging modality of choice for examination of the scrotum. US examination can provide information valuable for the differential diagnosis of a variety of disease processes involving the scrotum that have similar clinical manifestations (eg, pain, swelling, or presence of mass). The pathologic condition that may be at the origin of such symptoms can vary from testicular torsion to infection to malignancy. The ability of color and power Doppler US to demonstrate testicular perfusion aids in reaching a specific diagnosis in patients with acute scrotal pain. This review covers the anatomy of the scrotum and the scanning protocol for scrotal US, as well as detailed descriptions of disease processes and their US appearances. Newly described conditions such as intratesticular varicoceles and other benign intratesticular cystic lesions are also discussed.

Benign intratesticular cystic lesions: US features

Benign intratesticular lesions are rare, but recognition is important to avoid unnecessary surgical intervention. The ultrasonographic (US) features that help differentiate benign from malignant intratesticular lesions are emphasized by the authors. Benign lesions include intratesticular simple cysts, tubular ectasia, epidermoid cyst, tunica albuginea cyst, intratesticular varicocele, abscess, and hemorrhage (infarction). US features of cystic malignant neoplasms that help in differentiation of them from benign cystic lesions are also presented. The US appearance of epidermoid cysts varies with the maturation, compactness, and quantity of keratin present. Of the cystic malignant testicular tumors, which can occur anywhere in testicular parenchyma, teratomas are the most frequent to manifest as cystic masses. An abnormal rind of parenchyma with increased echogenicity usually surrounds these lesions. An intratesticular spermatocele communicates with the seminiferous tubules, whereas simple ectasia of the rete testis does not do so directly. These cysts contain spermatozoa and can be septate. The US findings of intratesticular varicocele are similar to those of extratesticular varicocele and include multiple anechoic, serpiginous, tubular structures of varying sizes. Improvements in gray-scale and Doppler US technology allow subtle distinctions between benign and malignant testicular lesions that were not possible a decade earlier.

[Cystic dysplasia of the rete testis and ipsilateral kidney agenesis in children]

BACKGROUND

Cystic dysplasia of rete testis, a rare abnormality, is often associated with renal agenesis.

CASE REPORT

A 5-year-old boy was examined because he presented large scrotum. This was initially considered as hydrocele. Surgery showed a cystic dysplasia of the testis that in this patient was associated with ipsilateral renal agenesis.

CONCLUSION

This congenital abnormality, explained on the basis of embryological development, has been reported in 15 children. The testis appears cystic at surgical exploration; echography can affirm diagnosis and MRI can give specific features. A conservative attitude is proposed as this lesion is benign. Long-term follow-up is recommended for possible painful effects or growth of the lesion.

Intratesticular Spermatocele in Occurrence With Seminiferous Tubular Ectasia

The sonographic findings of an intratesticular spermatocele occurring with seminiferous tubular ectasia are discussed. A literature review revealed that intratesticular spermatoceles are extremely rare. This uncommon finding, as well as the etiology and ultrasound appearance of epididymal spermatoceles, tubular ectasia, and intratesticular cysts, are included. Awareness of the appearance of these benign entities may eliminate the need for more invasive diagnostic procedures.

Imaging and management of atypical testicular masses

Most testicular masses are germ cell malignancies and require radical orchiectomy. There are other causes of testicular masses, however, some of which have characteristic imaging and clinical features. A presumptive diagnosis may be possible for some of these atypical testicular masses. This may result in testis-preserving surgery or nonoperative management.

Intratesticular spermatocele

High resolution ultrasound has increased our awareness of benign testicular cysts that appear to arise from the intratesticular sperm conduit system of the intratesticular ducts of the mediastinum and rete testis. The location of these benign cysts in the area of the mediastinum and rete testis and the absence of signs of a germ cell tumor may permit testicle preservation. These benign cysts may contain sperm. We present a case of a benign sperm-containing cyst with visible communication to the rete testis, designated an intratesticular spermatocele and managed with testicle preservation.

Tubular ectasia of the rete testis: an ultrasound diagnosis

Tubular ectasia of the rete testis is a rare benign entity that is often associated with some degree of obstruction at the epididymal level, either post-traumatic or postinfectious in nature. Its characteristic ultrasound findings have been well described in the radiologic literature. We report 6 cases of dilated rete testis diagnosed by ultrasound at our hospital over a 2-year period. Recognition of tubular ectasia by ultrasound, in the appropriate clinical setting, may eliminate unnecessary testicular biopsy or orchiectomy.