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Scrotal ultrasound

... a talk with balls

Why ultrasound the scrotum?

Accessible. Accurate. No radiation

Normal Anatomy

  • testis ovoid 4x3x2 cm

  • epididymis

  • spermatic cord

Embryology

testis has 3 cell lines:

  • germ cells
  • sertoli cells
  • leydig cells

descent starts @ 7 - 12th wk GA

stays at inguinal ring until 7th month

Microlithiasis

Always get midline trans view of testes side-by-side to compare both in grayscale and with Doppler. Also view inguinal canal and the epididymal regions

Acute testicular pain ddx: Torsion and Epididymitis.

If you see abnormal mass, is it intra or extra-testicular? Most intra-parenchymal masses are malignant while most extra-testicular lesions are benign

Painless testicular mass - suspect cancer or metastasis.

2 -3 mm echogenic foci, no shadowing

> 5 foci per transducer field in one or both testis

?association with testicular germ cell tumor

Nature, March 2011

Testicular microlithiasis - a feature of Testicular Dysgenesis Syndrome (TDS)

TDS occurs during fetal development

TDS associated with crytorchidism, sub-fertility, testicular atrophy, gonadal dysgenesis

All are risk factors for germ cell tumors

Management depends on whether the man is asymptomatic or has symptoms of "TDS"

If asymptomatic - regular self-examination

If assoc with TDS - ?biopsy

Undescended testis are usually small

Echotexture can be preserved

Spermatic cord echogenic

Newborns

Associations: renal agenesis/ectopic; inc risk of CA (50X), torsion, trauma

Take home points

  • Hydrocele
  • Torsion
  • Epididymo-orchitis
  • Fournier’s Gangrene
  • Inguinal Hernia
  • Tumor
  • Scrotal trauma
  • Varicocele
  • Cryptorchidism
  • Incidentals

Cryptorchidism

THE TOP TEN

Varicocele

Pampiniform plexus veins > 3 mm

Retrograde flow in internal spermatic vein

L 78%; R 6%; Bilateral 16%

Supine, standing, Valsalva

Use low flow Doppler

10 -15% all men

40 - 75% infertile men

Pitfall: varicocele secondary to left renal tumor invading renal vein

TESTICULAR PSEUDOANEURSYM

Break in parenchyma

Hypo-echoic fracture line is seen in only 17%

Presence of vascularity suggests salvage-ability

TESTIS FRACTURE

Scrotal trauma

Testicular dislocation

Penetrating injury

"M" - superior to testis; "T" - testis

Usually from injury to spermatic cord vessels

Avascular complex mass superior

SPERMATIC CORD HEMATOMA

Traumatic torsion

Tunica albuginea disruption

Hydrocele

Testicular torsion

Location: Tunica vaginalis

Scrotal fluid surrounding testis, except of 'bare area'

Acute or chronic, scrotal or spermatic cord

Causes: congenital, infantile, primary idiopathic, secondary to inflammation or trauma

Doppler is 80 - 90% sensitive in acute torsion

Spectral doppler less helpful

Grayscale can be normal acutely

Salvage rates drop after 6 hrs.

Change testis echotexture - may be too late!

Pitfalls: tort/untort; partial tort; orchitis; tumor

Tumor

Testis rupture - most severe trauma manisfestation

Look for: Parenchymal heterogeneity, irregular contour, tunica albuginea disruption, absence of vascularity

Often requires immediate surgery

Relatively avascular

intraparenchymal hematoma

LYMPHOMA

Scrotal trauma

Germ cell

YST, Teratoma,

Embryonal CA,

ChorioCA, mixed GST,

Seminoma

Non germ-cell

Leydig and Sertoli

Juv granulosa cell

Lymphoma/leukemia

Epidydimo-orchitis

Heterogenous testicular parenchyma

Hypoechoic areas of intra-testicular hematoma

Enlarged, hyperemic epididymis and/or testis on color Doppler

Orchitis follows in 20-40% of epididymitis due to contiguous spread

Increased number and conc of vessels

Pitfall - ddx torsion, tumor

Tumor

TERATOMA

SEMINOMA

Polymicrobial necrotizing fasciitis

Associations: diabetes, penetrating trauma

Typically older patient with older comorbidities

Epidydimo-orchitis

Use highest freq linear probe

Set doppler to detect low flow

Masquerades. Follow up

Is it intra or extra-testicular?

Indirect: through the int inguinal ring

Direct: through floor of the inguinal canal - Hesselbach's

Valsalva and stand

Inferior epigastrics, and pampiniform plexus

2

3

Partial Torsion

SEMINOMA

Fournier's gangrene

inguinal hernia

TERATOMA

YOLK SAC TUMOR

EPIDERMOID

Dr Kevin Ho, Body and Interventional Fellow, St Paul's Hospital

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