Imaging of the Epididymis

Epididymal Adenomatoid Tumour: A Case Report

Adenomatoid tumours are rare benign neoplasm involving the para testicular region, mostly the tail of the epididymis. They are typically small, firm and asymptomatic masses in the scrotal region and often discovered incidentally during physical examination or imaging studies. It is very challenging to differentiate them clinically and radiologically from malignant intratesticular solid tumours, which may lead to unnecessary orchidectomies. This case report presents the clinical management of a 57-year-old male patient with adenomatoid tumour of the epididymis, highlighting the diagnostic workup, surgical approach and postoperative outcomes. In addition, a comprehensive literature review was conducted to discuss the morphological and immunohistochemical features to improve understanding of these rare lesions and assist in accurate diagnosis and appropriate management.

Case report: Long term follow-up of a large unilateral epididymal cyst in a stallion used for teaching: Is this condition associated with infertility?

A 30-year-old Lusitano stallion presented with an enlarged right epididymis. The ultrasound scan revealed a cyst-like formation and the histopathological examination was compatible with epididymal cyst located at the body/tail transition, epididymal spermatocele and sperm granuloma and epididymitis. However, these conditions did not seem to affect the animal's reproductive performance, nor did the semen parameters analyzed over the 8 years after the diagnosis show significant changes. Nevertheless, since the ejaculate contains mostly sperm cells from the tail of the epididymis, where fertile spermatozoa are stored until ejaculated, a deep knowledge of the different conditions that can affect this organ is of the utmost importance.

Pitfalls and Practical Challenges in Imaging of the Pediatric Scrotum

ABSTRACT

Ultrasound is the modality of choice for evaluation of the pediatric scrotum, as it provides excellent image quality without the use of radiation, need for sedation/anesthesia, or use of contrast material and can be used for serial examination. Ultrasound of the scrotum has proven to be useful for assessment of a wide gamut of congenital, infectious, inflammatory, endocrine, neoplastic, and traumatic abnormalities in pediatric patients of all ages from the tiniest premature infant to a fully grown young adult. This review article presents a varied spectrum of conditions that may affect the pediatric scrotum, what the radiologist needs to know to meet the challenge of limiting the differential diagnosis, and how to avoid pitfalls when imaging the scrotum.

Pearls and Pitfalls of Pediatric Scrotal Imaging

Ultrasonography (US) is the primary imaging modality for the evaluation of pediatric scrotal disease. The ability to obtain exceptional anatomical detail and testicular perfusion information without ionizing radiation makes it the essential tool for evaluating scrotal pain and palpable masses. Challenges arise in both the performance and interpretation of scrotal US in the child. Optimizing imaging parameters and recognizing key differentiating US features help minimize misinterpretations that can lead to poor patient outcomes. Key pearls and pitfalls in pediatric scrotal ultrasound methods and diagnoses are reviewed. Knowledge of what is normal for the various ages of childhood from neonate through adolescence is necessary for accurate US analysis. Imaging evaluation of key causes of the acute painful scrotum including testicular appendage torsion, epididymitis, and testicular torsion are discussed. Sonographic features for the diagnosis of benign and malignant scrotal masses, microlithiasis, and cryptorchidism are reviewed.

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.

Historical trends for the standards in scrotal ultrasonography: What was, what is and what will be normal

BACKGROUND

Ultrasonography is the gold standard imaging method for scrotal investigation. Colour Doppler ultrasonography, contrast-enhanced ultrasonography and sonoelastography allow sonographers to assess size, echotexture, vascular features and stiffness of the scrotal organs and abnormalities. Scrotal ultrasonography has been used to investigate male reproductive health, scrotal pain, masses and trauma. However, ultrasonography thresholds/classifications used to distinguish normal and pathologic features of the scrotal organs have changed over time, and have not yet been fully standardized.

OBJECTIVES

To evaluate historical trends for the standards in scrotal ultrasonography: what was, what is and what will be normal.

METHODS

An extensive Medline search was performed identifying the most relevant studies in the English language from inception to date.

RESULTS

We provide here (i) a brief overview of the history of ultrasonography, (ii) current indications for scrotal ultrasonography and (iii) previous and current normal values, cut-offs and classifications of the main colour-Doppler ultrasonography parameters/characteristics of the scrotal organs, as derived from recent guidelines and evidence-based studies. In addition, we report recommendations and the clinical utility of contrast-enhanced ultrasonography and sonoelastography. Finally, we discuss critical issues needing further evidence and future directions to fill in the current gaps.

DISCUSSION

Several studies on scrotal ultrasonography are available. However, guidelines/recommendations dealing with specific ultrasonography applications have been published only in recent years. More recently, the European Academy of Andrology published evidence-based scrotal colour-Doppler ultrasonography reference ranges/normative parameters derived from a cohort of healthy, fertile men. In addition, a standardization of the methodology to evaluate qualitative and quantitative colour-Doppler ultrasonography parameters was reported. Other international societies reported indications, methodological standards, clinical utility and limitations of contrast-enhanced ultrasonography and sonoelastography.

CONCLUSIONS

To date, colour-Doppler ultrasonography normative values for the scrotal organs are available. However, a wide international consensus on assessment and classification of several ultrasonography parameters is still lacking. An alignment of the world societies on these issues is advocated.

Role of color flow Doppler ultrasound in the evaluation of acute scrotal pain

Color flow Doppler ultrasound is a critical tool in the assessment of the scrotum. Ultrasound is the first-line imaging modality and can rapidly differentiate between surgical and nonsurgical conditions, allowing for appropriate and prompt patient management. We review the role of color flow Doppler in the evaluation of acute scrotal pain, highlighting some of the most commonly seen pathologies such as epididymo-orchitis and testicular torsion.

Comparison between Open Epididymal Cystectomy and Minimal Resection of Epididymal Cysts Using a Scrotoscope: A Clinical Trial for the Evaluation of a New Surgical Technique

OBJECTIVE

To provide a new surgical technique for epididymal cyst (EC) treatment and to assess its safety and efficiency.

METHODS

Forty-eight patients with symptomatic EC were randomized into 2 groups. One group (n = 23) received traditional open epididymal cystectomy (OEC) and the other group (n = 25) underwent minimal epididymal cystectomy with scrotoscope (MECS), which provided a clear vision of scrotal contents. Demographic information and perioperative and postoperative outcomes data were obtained and analyzed during a 2- to 6-month follow-up.

RESULTS

No significant differences between the OEC and MECS groups were found in demographic information. Compared with OEC group, the MECS group had a shorter operating time (18.6 ± 2.9 vs 54.5 ± 7.0 minutes; P <.05), shorter incision length (1.1 ± 0.2 vs 4.8 ± 0.6 cm; P <.05), and less blood loss (4.6 ± 1.6 vs 17.0 ± 3.1 g; P <.05). Except for the 8.0% rate (2 of 25) of scrotal edema after MECS and 17.4% rate (4 of 23) of scrotal hematoma after OEC, both groups resulted in 0% incidence of testis or epididymis injury, wound infection, and cyst recurrence based on postoperative outcome data. Significant differences were observed after MECS compared with those after OEC based on the rates of symptom relief (95.2% vs 61.1%; P <.05) and days of wound pain (12.1 ± 2.6 vs 17.7 ± 4.1 days; P <.05).

CONCLUSION

For the first time, our study applied scrotoscope as a new alternative technique for EC treatment. Scrotoscope provides a clear field of vision and makes tissues harvested available for pathologic examination when performing decortications of EC. The results suggest MECS may be a safe, effective, and encouraging new technique.

High-frequency ultrasound findings in epididymal malformations

PURPOSE

This work aims to investigate high-frequency ultrasound findings in epididymal malformations and their clinical significance.

METHODS

Eighty-five of 9,849 patients who had been examined using high-frequency ultrasound for infertility, varicocele, scrotal swelling, and so on had epididymal malformations. A retrospective analysis was conducted on the ultrasound findings of epididymal malformations in these 85 patients.

RESULTS

There were a total of 117 malformed epididymides in 85 patients with epididymal malformations. The detection rate of epididymal malformations using high-frequency ultrasound was 0.86 % (85/9,849).

CONCLUSIONS

High-frequency ultrasound can be used to diagnose epididymal malformation and seminiferous duct blockage.

Orchialgia and the chronic pelvic pain syndrome

This review paper highlights the important health issue of orchialgia and the chronic pelvic pain syndrome. There are a number of specific and non-specific etiologies and different treatment options based on the sub-categorization of orchialgia. The focus of this article is on the specific etiologies of chronic orchialgia as well as non-specific scrotal pain, and the diagnostic evaluation and optimal management of these men. The clinician must be cautious about assuming that orchialgia is constitutive in the chronic pelvic pain syndrome, and must be diligent in ruling out specific etiologies for scrotal pain prior to managing orchialgia as a non-specific chronic pain syndrome.

Mobile echogenicities on scrotal sonography: is the finding associated with vasectomy?

OBJECTIVES

The purpose of this study was to determine whether mobile echogenicities seen in the epididymis on scrotal sonography are associated with prior vasectomy.

METHODS

We prospectively obtained a sonographic video clip of each epididymal body in outpatients sent for scrotal sonography. The presence of punctate mobile echogenicities in the epididymal body was noted, and the indication for the sonogram, patient age, and history of vasectomy were recorded. This study was compliant with the Health Insurance Portability and Accountability Act and was approved by the Institutional Review Board.

RESULTS

Of 345 patients (mean age, 44.9 years), 56 (16.2%) had undergone vasectomy and 289 had not. Mobile echogenicities were found in 8 patients, 7 of whom were postvasectomy. The rates of mobile echogenicities appearing were 12.5% (7 of 56) in the vasectomy group and 0.3% (1 of 289) in the nonvasectomy group (P < .0001, Fisher exact test). Epididymal cysts were seen in 184 of 345 patients (53.3%). There was no significant difference in the presence of epididymal cysts in the patients who had undergone vasectomy compared to those who had not (P = .34), including 30 of 56 postvasectomy patients (53.6%) and 154 of 289 patients without vasectomy (53.3%). Pain was reported by 177 patients (51.3%), including 34 of 56 (60.7%) in the postvasectomy group and 143 of 289 (49.5%) without vasectomy. The presence of pain was similar in both groups (P = .15).

CONCLUSIONS

The presence of mobile echogenicities in the epididymis is almost always a postvasectomy finding and occurs in approximately 12.5% of such patients. There is no significant difference in the rate of epididymal cysts or pain after vasectomy compared to those who have not had vasectomies.

B-mode ultrasound and grey-scale analysis of the epididymis in boars, and the relationship to semen parameters

This study investigated the epididymis of mature boars (n=10) by means of B-mode ultrasound and grey-scale analysis (GSA) for echogenicity (EG) determination using an ultrasound unit HS 1500V, a linear transducer (frequencies 7.5-9.0 MHz), and standardized unit settings. All boars had their epididymal caput, corpus and cauda scanned six times before and after semen collection, respectively, at weekly intervals. Semen was subjected to spermatological examination including volume, total and forward motility, sperm abnormalities, as well as total sperm count and concentration. The caput and corpus both had a homogeneous fine echotexture. The cauda was homogeneous too but had a marbled echotexture. Echogenicity before and after semen collection was caput > corpus > cauda, respectively (p<0.001). Echogenicity was higher before than after semen collection for all parts of the epididymis, respectively (p<0.001). Echogenicity of the caput correlated slightly positively with the total sperm count pre-collection (r=0.301; p=0.020) and with ejaculate volume pre- and post-collection (r=0.302 vs 0.306; p=0.017 vs 0.019), and slightly negatively with sperm concentration post-collection (r= -0.275; p=0.034). No relationship was found for EG of the corpus and cauda for any of the ejaculate parameters. In conclusion, B-mode ultrasound and GSA proved feasible for imaging the epididymis in boars. Single relationships between EG and ejaculate parameters were found and deserve further investigation.

Intratesticular isolated anechoic areas: prevalence, seminal profile, and longitudinal study

OBJECTIVE

The aim of this study was to evaluate the prevalence of intratesticular isolated anechoic areas (ITIAAs) in a large population, the seminal profile, and follow-up of patients with ITIAAs.

METHODS

A total of 2223 patients underwent an andrologic examination and scrotal sonography. In the patients with ITIAAs, a hormonal profile was obtained, and screening for neoplastic markers was performed. In selected cases, standard semen analysis was performed. Finally, a longitudinal study was initiated.

RESULTS

The prevalence of ITIAAs was 2.7% (59 of 2223 cases). In 48 of 59 cases (81.4%), a single ITIAA was found, whereas in the other 11 cases (18.6%), multiple ITIAAs were detected. Among the 59 patients with ITIAAs, we observed concomitant epididymal anechoic areas (EAAs) in 25 (42.4% of cases), specifically in 19 of 48 cases with a single ITIAA and 6 of 11 cases with multiple ITIAAs. Regarding age, 91.5% (54 of 59 cases) of the ITIAAs were found in patients older than 30 years; concomitant EAAs were present in about 50% of the cases. In patients younger than 30 years, no EAAs were detected. The seminal profile showed reduced sperm motility percentages in the patients with ITIAAs and concomitant EAAs. The longitudinal study did not show any significant variation of ITIAA patterns; all neoplastic markers remained negative.

CONCLUSIONS

An ITIAA is a pattern occasionally observed on sonography. The findings suggest that an ITIAA with a concomitant EAA could have a microtraumatic or inflammatory pathogenesis, whereas an ITIAA without a concomitant EAA in young patients could have a dysontogenetic origin.