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Why ultrasound the scrotum?
testis has 3 cell lines:
descent starts @ 7 - 12th wk GA
stays at inguinal ring until 7th month
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
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
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
Testis rupture - most severe trauma manisfestation
Look for: Parenchymal heterogeneity, irregular contour, tunica albuginea disruption, absence of vascularity
Often requires immediate surgery
LYMPHOMA
Germ cell
YST, Teratoma,
Embryonal CA,
ChorioCA, mixed GST,
Seminoma
Non germ-cell
Leydig and Sertoli
Juv granulosa cell
Lymphoma/leukemia
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
TERATOMA
SEMINOMA
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
TERATOMA
YOLK SAC TUMOR
EPIDERMOID