Male reproductive system

Question 1

2. Which of the following favour chronic rather than acute/ subacute torsion of the spermatic cord?

A. Enlarged testis with spherical morphology

B. Good identifcation of the lobular architecture of the affected testis

C. Thickened mediastinum, less echogenic than contralateral

D. Enlarged and more spherical epididymis

E. Hypoechoic small and harder testis

Answer 1

E. Hypoechoic small and harder testis

Absence of hydrocele and normal scrotal wall/skin are other features of chronic torsion.

Question 2

7. A 60-year-old man with elevated PSA and a Gleason 4+3 tumour undergoes investigation with MRI of the prostate. Which is the single best answer?

A. Tumour of the gland is low signal on T2

B. Tumour appears bright on the Apparent Diffusion Coeffcient (ADC)

C. Tumour appears dark on high b-value DWI images

D. Seminal vesicle involvement indicates T2 disease

E. The inguinal nodes are the frst to enlarge with disease progression

Answer 2

A. Tumour of the gland is low signal on T2

Tumor appears as a focus of low signal compared to the normal high signal peripheral zone on T2.

T3 disease indicates extracapsular extension and/or seminal vesicle involvement.

Tumour appears dark on ADC and bright on high b-value DWI images.

Obturator nodes are frst to become involved.

Question 3

17. Non seminomatous Germ Cell Tumour is diagnosed in a 30-year-old man. Which is the single best answer?

A. Non seminomatous Gem Cell Tumour from the majority of testicular Gem Cell Tumour

B. Left-sided tumours frequently metastasize to left PA nodes just above level of left renal vein

C. Right-sided tumours spread initially to aortocaval lymph nodes

D. Echelon nodes are usually left-sided nodes lateral to PA nodes

E. Imaging appearances of nodal disease at late relapse is often more predictable than at initial presentation

Answer 3

C. Right-sided tumours spread initially to aortocaval lymph nodes

Late relapse > 2 years after CR, in absence of second primary tumour. Occurs in up to 7% of patients with less predictable pattern of nodal spread.

NSGT form 40% of testicular GCT compared with 60% seminomatous.

Leftsided tumours metastasize to left PA nodes below the level of the renal vein.

Echelon nodes are usually rightsided, anterior to right psoas

Question 4

19. Which of the following most favours a diagnosis of adult prostate sarcoma rather than adenocarcinoma?

A. Age of patient: 50

B. Size of tumour: 2.3cm

C. Absence of calcifcation

D. Solid and cystic components

E. Invasion of the bladder wall

Answer 4

D. Solid and cystic components

Prostatic sarcomas represent 0.1% of all primary prostate malignancy in adults.

Mean age is younger than that of adenocarcinoma.

Typically presents as a large solid and cystic mass with rapid hypervascular and heterogenous soft tissue occupying all or most of the prostate.

Question 5

20. Considering solid lesions of the paratesticular space, which is the most common benign tumour?

A. Adenocarcinoid tumour

B. Lipoma

C. Haemangioma

D. Leiomyomas

E. Papillary cystadenomas

Answer 5

A. Adenocarcinoid tumour

30% of all paratesticular masses and most common benign neoplasm. Hamartomatous lesions are of probable
mesothelial origin in young adults and usually present either as a painless mass or an incidental fnding

Question 6

22. In prostate cancer, which best describes changes in Magnetic Resonance Spectroscopy (MRS)?

A. Elevated choline

B. Reduced citrate

C. Elevated choline:citrate ratio

D. Elevated citrate:choline ratio

E. Combining MRI with MRS has no increased accuracy in diagnosis of prostate cancer

Answer 6

C. Elevated choline:citrate ratio

Elevated choline + creatine: citrate ratio best describes MRS features of prostate cancer

Question 7

49. Regarding MRI prostate seminal vesicles:

A. Usually low on T2

B. Usually high SI on Diffusion Weighted Imaging (DWI)

C. Typically have low ADC values

D. Are high signal on T2 when atrophic

E. Are low signal when invaded with tumour

Answer 7

E. Are low signal when invaded with tumour

Seminal vesicles may appear low in signal on T2 when atrophic, empty or with tumour involvement

Question 8

50. Regarding prostate MR:

A. The Peripheral Zone (PZ) and Transitional Zone (TZ) are diffcult to distinguish on MR

B. Volume of prostate gland > 60cc precludes brachytherapy

C. The normal PZ is typically heterogeneous on T2

D. Haemorrhage appears as low SI on T1

E. Tumours occur more commonly in TZ than PZ

Answer 8

B. Volume of prostate gland > 60cc precludes brachytherapy

Contraindications to brachytherapy include a volume of over 60cc

Question 9

7) A 40-year-old man has a testicular ultrasound scan, which demonstrates a multilobular mass that is
homogeneous and hypoechoic with Doppler flow seen in internal hypoechoic bands. Which of the following is
the most likely diagnosis?

a. teratoma

b. lymphoma

c. metastasis

d. seminoma

e. focal infarction

Answer 9

d. seminoma

Ninety-five per cent of testicular tumours are germ cell tumours. Others include sex-cord and stromal tumours
such as Leydig cell and Sertoli cell tumours. Primary lymphoma and metastases can also occur in the testicle.
Non-seminomatous germ cell tumours include teratoma, embryonal carcinoma and choriocarcinoma, but these
affect a younger population of 20–30 years. Ultrasound scan is the investigation of choice for detection of a
testicular tumour and for assessing normality of the contralateral testicle. Seminomas present with mass or pain,
and are generally lobulated masses on ultrasound scan with hypoechoic fibrovascular septations in which colour
flow can be visible. T2W MRI demonstrates uniform intermediate signal with band-like low-signal septa. There
is contrast enhancement, especially of the septations. They rarely calcify, but, if they do, the calcification is
speckled or stippled.

Question 10

19) A 20-year-old man has radical orchidectomy for a non-seminomatous germ cell tumour. A CT of the thorax,
abdomen and pelvis shortly after surgery shows no lymphadenopathy or metastasis. Which of the following is themost appropriate follow-up regimen?

a. repeat CT of the chest, abdomen and pelvis only in response to symptoms suggesting recurrence

b. repeat CTof the chest, abdomen and pelvis only when serum tumour markers rise

c. serial serum tumour marker measurement with yearly CT of the chest, abdomen and pelvis

d. serial serum tumour marker measurement with 3-monthly CTof the chest, abdomen and pelvis for 1 year
followed by 6-monthly CTof the chest, abdomen and pelvis for 1 year

e. 3-monthly whole-body PET/CT

Answer 10

d. serial serum tumour marker measurement with 3-monthly CTof the chest, abdomen and pelvis for 1 year
followed by 6-monthly CTof the chest, abdomen and pelvis for 1 year

Stage 1, non-seminomatous, germ cell tumour patients should enter a surveillance programme of this type
following orchidectomy. Such programmes are rarely used for seminoma, particularly when retroperitoneal
radiation treatment is used.

Rising tumour markers between surveillance scans or thereafter should provoke CT of the chest, abdomen and pelvis plus ultrasound scan of the remaining testicle. If no new disease is identified, MRI of the brain is indicated.

Question 11

20) On ultrasound scan, a 30-year-old man is found to have bilateral testicular microlithiasis and unilateral
testicular atrophy. There is a history of orchidopexy of the atrophic testicle. Which of the following is the most
appropriate management?

a. discharge

b. self-examination only

c. follow-up clinical examination and surveillance sonography

d. further investigation with MRI

e. testicular biopsy

Answer 11

c. follow-up clinical examination and surveillance sonography

Atrophic maldescended testes are at higher risk of developing malignancy, particularly seminoma, even after
orchidopexy. The increased risk applies to the contralateral testicle also. Microlithiasis is also associated with
testicular cancer. In combination, these features require clinical and sonographic follow-up.

Question 12

22) A 50-year-old man complains to his general practitioner of painful sexual intercourse. An ultrasound
examination of the penis is performed, which identifies dense, shadow-casting abnormalities of the periphery of
both corpora cavernosa. What is the likely diagnosis?

a. priapism

b. Zoon’s balanitis

c. penile squamous cell carcinoma

d. Peyronie’s disease

e. balanitis xerotica obliterans

Answer 12

d. Peyronie’s disease

The cause of Peyronie’s disease is unknown, but the result is fibrous thickening of Buck’s fascia and the septum
between the corpora cavernosa. Calcified plaques are also seen. The fibrous areas do not engorge with blood,
causing the penis at erection to be bent; this can make intercourse painful or impossible. Priapism is persistent
painful erection of the penis but is not associated with penile calcification. Zoon’s balanitis is an idiopathic
lymphocytic inflammatory condition of the penis, which may respond to topical steroid but is also treated by
circumcision. Balanitis xerotica obliterans is the severe form of penile lichen sclerosus, which is an uncommon
inflammatory dermatosis. It can cause phimosis and urinary retention.

Question 13

23) A 16-year-old male with a history of recurrent sudden severe testicular pain at night has a surgical scrotal
exploration, which establishes that one testicle has a high insertion of the tunica vaginalis on the spermatic cord.
What proportion of patients with this condition will have bilateral disease?

a. none

b. 10%

c. 25%

d. 65%

e. all

Answer 13

d. 65%

A bell-clapper deformity is described. This is bilateral in 50–80% of cases. High insertion of the tunica vaginalis
on the spermatic cord means that this tunica completely surrounds the testis, epididymis and distal spermatic cord,
allowing intravaginal torsion. Extravaginal torsion is rare occurs when testis and tunica twist at the external ring.

Question 14

24) On an axial MRI of the penis, three tubular masses of tissue, occupying much of the cross-sectional area of
the penis, are entirely surrounded by a T1- and T2-hypointense layer. Breach of this layer upstages a penile cancerfrom T1 to T2. From the following choices, name this structure or structures.

a. corpora cavernosa

b. corpora spongiosa

c. cavernosal arteries

d. urethra

e. tunica albuginea

Answer 14

e. tunica albuginea

Invasion of the corpora cavernosa or corpora spongiosa by a penile cancer is via the tunica albuginea, making the
local stage T2. If the urethra, found centrally within the corpora spongiosa, is involved, it becomes T3. Each
corpus cavernosum contains a central artery. Having rapidly flowing blood, this will also be hypointense on both
T1W and T2W images because of flow void.

Question 15

(Ped) 30) An 8-year-old boy has sudden-onset, severe, unilateral, testicular pain. What is the most likely cause?

a. torsion of appendix testis

b. torsion of appendix epididymis

c. torsion of testis

d. epididymitis

e. orchitis

Answer 15

c. torsion of testis

Torsion of the testicle is the commonest acute problem in the prepubertal age group. Including all ages below 20
years, epididymitis occurs in a ratio of 3:2 with torsion. This ratio is 9:1 above 20 years. Torsion of the testicular
appendages accounts for around 5% of scrotal pathology overall, with the appendix testis being affected far more
commonly than the appendix epididymis.

Question 16

36) A 70-year-old man with biopsy-proven prostate carcinoma has an MRI of the prostate to assess suitability for
radical prostatectomy. There is bilateral, multifocal, peripheral-zone, low-signal change on small FOV T2W
images in locations corresponding on more than one scan plane. These changes are confined within the prostatic
capsule. However, enlarged lymph nodes are seen in the left internal and common iliac groups. No other disease
is seen, including on a CT of the abdomen and pelvis and a radioisotope bone scan. What is the TNM stage of
this patient’s cancer?

a. T2b N1 M0

b. T2c N1 M0

c. T2c N1 M1

d. T3 N1 M0

e. T3 N1 M1

Answer 16

c. T2c N1 M1

Being bilateral prostate-confined disease, this cancer is T2c. Internal iliac, obturator, external iliac and sacral are
regional nodal groups. Common iliac, para-aortic and inguinal involved lymph nodes are regarded as metastases.

Question 17

39) A 55-year-old man has biopsy-proven penis cancer. An MRI is performed. Which of the following is the best
reason for performing this examination?

a. to confirm the diagnosis

b. to refute the diagnosis

c. to perform local staging

d. to assess metastatic spread

e. to assess regional lymph node involvement

Answer 17

c. to perform local staging

MRI offers good soft-tissue contrast that is of value in local staging of the primary tumour. Local extent is used
to guide the type of treatment, which includes partial penile amputation, total penectomy and radiation therapy.
MRI will also show enlarged regional lymph nodes, but the principal purpose of MRI is local staging. CT can
also be used for nodal spread and metastatic disease

Question 18

44) A 14-year-old boy slides off his saddle while cycling, injuring his testicles. On ultrasound scan, one testicle
has a paratesticular complex cystic mass, loss of testicular outline and several avascular planes within the testicle.
Which of the following is the most appropriate management?

a. discharge with analgesia

b. admission for analgesia

c. admission for elective surgery

d. admission for surgery the following day

e. immediate surgical intervention

Answer 18

e. immediate surgical intervention

Testicular rupture is described; it is an indication for immediate surgical intervention to salvage the testicle and
prevent anti-sperm antibody development (testicles are immune-privileged sites). Other consequences of
testicular trauma are fracture, haematoma and haematocele. Associated torsion may occur, due to traumastimulated, forceful, cremasteric muscle contraction.

Question 19

46) A 35-year-old male is prompted to see his general practitioner by his wife, who has noticed blood in the man’s
semen. An ultrasound scan of the scrotum is performed. What is the most common appearance that would
accompany this symptom?

a. normal appearances

b. enlarged spermatic cord, epididymis and testicle with decreased echogenicity

c. testicular enlargement showing a hypoechoic lesion with a fluid–fluid level

d. paratesticular ‘bag of worms’ appearance

e. scrotal skin thickening

Answer 19

a. normal appearances

Investigation in most cases of haemospermia is not fruitful. In patients under 40 years, the causes are usually
idiopathic or inflammatory (prostatitis, epididymo-orchitis, urethritis and urethral warts). The same causes apply
in those over 40 years, but further possible causes include prostate cancer, benign prostatic hypertrophy, prostatic
or seminal vesicle calculi, hypertension and carcinoma of the seminal vesicles.

Question 20

49) Into which of the following lymph node groups does lymph from the scrotum initially drain?

a. para-aortic at the L1–2 level

b. superficial inguinal

c. obturator

d. internal iliac

e. presacral

Answer 20

b. superficial inguinal

Testes drain to the para-aortic nodes at the L1–2 level. The penile body drains to superficial inguinal nodes, while
the proximal penis lymph drainage is to deep inguinal nodes. Appreciation of these patterns of lymph drainage is
of vital importance when staging testicular, penile and other scrotal malignancies

Question 21

51) A 40-year-old man has a right-sided intratesticular mass of indeterminate ultrasound appearance. A CT scan
of the chest, abdomen and pelvis reveals an enlarged, round, cystic, right paracaval lymph node just caudal to the
right renal vein. Other enlarged cystic lymph nodes are demonstrated in the mediastinum. No enlarged suprarenal
or retrocrural nodes are seen. Considering these findings, which tumour type is most likely to be found in the
orchidectomy specimen?

a. epidermoid tumour

b. malignant teratoma

c. seminoma

d. metastatic lung squamous cell carcinoma

e. adenomatoid tumour

Answer 21

b. malignant teratoma

Seminoma tends to spread to contiguous nodes with the primary sites being, for a right-sided testicular tumour,
right paracaval and interaortocaval nodes just below the junction of the right renal vein and inferior vena cava.
Left-sided testicular tumours usually spread first to nodes just caudal to the left renal vein. Teratoma and other
malignant, non-seminomatous, germ cell tumours of the testes can occupy mediastinal nodes without such direct
cranial extension along the nodal groups. Nodes involved by seminoma tend to be soft-tissue density while nodes
inhabited by non-seminomatous, germ cell tumours are frequently cystic. Metastases to the testicle are rare on
account of the testicle being an immunologically privileged site with a blood–testicular barrier. Adenomatoid
tumour is a benign epididymal lesion. Epidermoid tumour is also benign, appearing as an intratesticular,
hypoechoic lesion, characteristically with an echogenic capsule. Classically, it assumes an ‘onion-skin’
appearance of concentric echogenic layers. Internal shadowing can be produced by calcification.

Question 22

62) A patient with a raised PSA has MRI of the prostate. There is diffuse, low-signal change throughout the
peripheral zone on T2W images. At the right base, there is focal high signal on T1W images. At the left base
there is restricted diffusion. In the right mid-gland, spectroscopic analysis reveals a choline plus creatine/ citrate ratio of considerably less than 0.8. In the left mid-gland, there is a diminished contrast wash-in rate. At the apex,
the relative peak enhancement is less than in other regions of the prostate. Which is the most likely site of focal
prostate carcinoma?

a. left base

b. right base

c. left mid-gland

d. right mid-gland

e. apex

Answer 22

a. left base

In staging prostate cancer with MRI, the large-FOV T1W sequence is useful for demonstrating haemorrhage (high
signal), enlarged lymph nodes and bone metastases. Small-FOV T2W images of the prostate in axial, coronal and
sagittal planes show the zonal anatomy well, with normal peripheral zone returning high signal. Cancer within
the peripheral zone typically returns low signal on T2W images. Othertypical findings in carcinoma of the prostate
are increased relative peak enhancement, increased contrast wash-in rate, reversal of the choline plus
creatine/citrate ratio on spectroscopy, restricted diffusion and increase in permeability on pharmacokinetic
modelling

Question 23

82) A 20-year-old man presents with a 4-week history of a scrotal mass. There has been no trauma and no pain.
Ultrasound scan confirms an intratesticular, partly cystic, heterogeneous mass. Which of the following tumour
markers is most likely to be elevated?

a. CA-125 and AFP

b. CA-15-3 and CEA

c. PSA

d. CA-19-9

e. AFP and b-hCG

Answer 23

e. AFP and b-hCG

The patient’s age and ultrasound findings favour a non-seminomatous germ cell tumour. These are associated
with elevated serum AFP and b-hCG. Together, CA-125 and AFP are associated with hepatocellular carcinoma,
while CA-125 is also associated with ovarian cancer. CA-15-3 and CEA together are serum markers associated
with breast cancer. PSA is associated with prostate cancer as well as several benign prostate conditions. CA-19-
9 is mainly associated with malignancy of the pancreas and biliary tree.

Question 24

88) On MRI of the penis, a squamous cell carcinoma is typically seen as hypointense to the corpora on T1W and
T2W images. What is the most likely appearance of this cancer on T1W images following intravenous contrast
administration?

a. no change in signal compared with that on the pre-contrast T1W sequence

b. post-contrast enhancement greater than that of the corpus spongiosum but less than that of the corpora
cavernosa

c. post-contrast enhancement less than that of all corpora

d. post-contrast enhancement greater than that of all corpora

e. post-contrast enhancement greater than that of the corpora cavernosa but less than that of the corpus
spongiosum

Answer 24

c. post-contrast enhancement less than that of all corpora

Most cancers of the penis (95%) are squamous cell carcinoma, but basal cell carcinoma, sarcoma, melanoma,
lymphoma and urethral transitional cell carcinoma are also possible. Typical appearances of a primary penile
cancer are of an ill-defined infiltrating lesion hypointense to the corpora on both T1W and T2W images. Tumours
enhance following contrast, but to a lesser degree than the normal corporal bodies. Signal characteristics of
melanotic melanoma will be notably different from the other tumour types, returning a bright signal on T1W
images.

Question 25

3 A 42 year old man presents with a non-tender testicular lump. On examination he is noted to have
gynaecorriastia. The B-HCG, a-fetoprotein and lactate dehydrogenase levels are within normal limits. US
demonstrates an irregular hypoechoic nodule. What is the most likely diagnosis?

(a) Choriocarcinoma

(b) Leydig cell tumour

(c) Lymphoma

(d) Seminoma

(e) Yolk sac tumour

Answer 25

(b) Leydig cell tumour

Leydig cell tumours represent 1-3% of all testicular cancers, and are most common in men aged 30-60 years.
They are stromal tumours, which form in the interstitial tissues that support the testes. The Leydig cells produces
hormones, thus such tumours are typically hormonally active and lead to feminising or virilising syndromes; 30%
secrete estradiol, resulting in gynaecomastia. B-HCG, AFP and LDH levels are typically normal (B-HCG is
‘always’ raised in choriocarcinoma and in 83% of seminomas; AFP is raised in >90% of yolk sac tumours).

Question 26

6 A 58 year old man presents after an occupational health check revealed a PSA of 1.1 ng/ml. He has a slightly
firm left side of the prostate on digital rectal examination. Which of the following statements is correct?

(a) Prostate biopsy is not indicated

(b) Six core biopsies should be performed during transrectal prostate biopsy

(c) Local anaesthetic is not required for transrectal prostate biopsies

(d) Antibiotic prophylaxis is mandatory for transrectal prostate biopsies

(e) A 12 MHz probe should be used for transrectal prostate biopsies

Answer 26

(d) Antibiotic prophylaxis is mandatory for transrectal prostate biopsies

Elevated PSA or an abnormal DRE are indications for biopsy in asymptomatic men. The sextant biopsy protocol
has now been found to give too many false negatives and has been largely replaced by extended core protocols.
Local anaesthesia and antibiotic cover are now standard care. A 5-7.5 MHz probe is usually used.

Question 27

22 Regarding prostate sarcoma in adult patients, which of the following statements is correct?

(a) Rhabdomyosarcoma is the commonest subtype

(b) The PSA is usually elevated

(c) The prostate is not usually enlarged

(d) Calcification is typical

(e) Heterogeneous enhancement with cystic change is typical

Answer 27

(e) Heterogeneous enhancement with cystic change is typical

Sarcoma of the prostate is a rare tumour characterized by a large heterogeneous enhancing mass.
Rhabdomyosarcoma is more commonly seen in children; leiomyosarcoma more commonly in adults. The PSA is
not usually affected due to the lack of epithelial involvement.

Question 28

23 A 23 year old man is diagnosed with a stage I germ cell tumour of the testis. After primary treatment, what is
the current method of choice for surveillance of the retroperitoneum?

(a) Serial US

(b) Serial MRI

(c) Serial CT

(d) Serial laparoscopy

(e) Serial lymphangiography

Answer 28

(c) Serial CT

In recent times imaging surveillance of the retroperitoneum after surgery has been developed as an acceptable
strategy to reduce the chance of subsequent morbidity and mortality. CT currently remains the modality most
commonly used, although concerns have been raised regarding the radiation dose in this group of young patients.
This has led to potential interest in MRI but as yet, this has not been widely dopted.

Question 29

48 A 50 year old man presents 4 weeks after a bout of acute epididymitis with fever, leucocytosis, a swollen foul
smelling, red, tender scrotum with palpable crepitus. The degree of inflammation is observed to be rapidly
spreading over a 24 hour period. Which of the following statements is true?

(a) MRI is the best test to investigate extent of spread

(b) Ultrasound is useful in investigating the extent of spread

(c) CT is the best test to investigate the extent of spread

(d) Anaerobes are the most common responsible organism

(e) Staphylococcus is the most common responsible organism

Answer 29

(c) CT is the best test to investigate the extent of spread

Fournier’s gangrene is a rapidly spreading necrotizing fasciitis that involves the genital or peri-anal regions. It
usually has an identifiable predisposing event. It is polymicrobial in origin with E. coli being the commonest
identifiable organism. CT is the best investigation for assessing the degree of spread, and can identify
complications such as abscess formation. Treatment is urgent, complete debridement.

Question 30

3 A 40 year old man presents with a scrotal mass. US shows a smooth, round, well defined thin walled 2 cm
hypoechoic lesion in the epididymal head. The lesion contains low level echoes which move on close
examination. The most likely diagnosis is?

(a) Epididymal cyst

(b) Spermatocoele

(c) Adenomatoid tumour

(d) Papillary cystadenoma

(e) Haemangioma

Answer 30

(b) Spermatocoele

Epididymal cysts and spermatocoeles are common benign cystic lesions of the epididymis. They can be
differentiated by the presence of low level echoes in spermatocoeles, which move on careful examination.
Occasionally, spermatocoeles contain crystallised material which can give the initial impression that the lesion is
hyperechoic.

Question 31

7 A 60 year old man with a prostate specific antigen of 15 ng/ml and a smooth feeling prostate on digital rectal
examination is referred for prostate biopsy. Which of the following statements is incorrect?

(a) A transperineal rather than transrectal approach is possible

(b) Urinary retention is a common complication

(c) Both peripheral and transitional zones should be sampled

(d) A negative biopsy does not exclude prostate cancer

(e) Prophylactic antibiotics should be given routinely

Answer 31

(b) Urinary retention is a common complication

Prostate biopsy is performed usually via a transrectal route for patients with an elevated (age-specific) PSA, or
an abnormal DRE. Complications include haematuria (frequent and usually transient), PR bleeding, infection and
retention (uncommon). A negative initial biopsy does not exclude cancer and repeat biopsy (sometimes with
extended core protocols) may be required.

Question 32

10 A 45 year old man with a childhood history of orchidopexy for undescended testis presents with a painless
mass in his right hemiscrotum. US shows a discrete uniform hypoecoic mass confined within the tunica albuginea.
MRI shows the lesion is of uniformly low signal intensity on T2W. Serum aFP is normal and B-HCG is elevated. What is the likeliest diagnosis?

(a) Teratoma

(b) Yolk sac tumour

(c) Seminoma

(d) Embryonal cell carcinoma

(e) Lymphoma

Answer 32

(c) Seminoma

Seminoma presents in a slightly older age group than the nonseminomatous germ cell tumours. It has the highest
rate of association with undescended testis. Lymphoma typically has a more diffuse infiltrative pattern and is the
commonest bilateral tumour.

Question 33

30 A 63 year old man is diagnosed with prostate cancer on needle biopsy. Staging MRI shows a solitary low
signal intensity lesion on T2W extending from the right peripheral zone into the seminal vesicle on that side. No
abnormal local LNs are seen. Bone scintigraphy is unremarkable. What is the TNM staging of this cancer?

(a) T1c NO MO

(b) T2cNOMO

(c) T3a NO MO

(d) T3b NO MO

(e) T4a NO MO

Answer 33

(d) T3b NO MO

T1 c cancers are impalpable tumours detected on needle biopsy. T2c tumours are intra-capsular but involve both
lobes. T3a cancer.s are extra-capsular without other organ involvement. T3b cancers involve the seminal vesicles.
T4 cancers have direct extension into adjacent organs other than the seminal vesicles.

Question 34

44 A 40 year old man undergoes a scrotal ultrasound as part of his investigations for infertility. US shows multiple
hypoechoic serpiginous tubular structures with slow flow within them, superior and lateral to the left testicle.
Which of the following statements is false?

(a) Renal US should also be performed

(b) This lesion can be treated with embolisation via a RIJ vein approach

(c) This lesion can be treated with laparoscopic surgery

(d) Treatment does not improve sperm quality

(e) Coil embolisation is preferred to particulate embolization

Answer 34

(d) Treatment does not improve sperm quality

This is a left sided varicocoele. An obstructing left renal lesion should be excluded. Sperm quality is improved in
up to 53% of patients. The commonest approach for embolisation is via the right CFV vein but the RIJ jugular
may also be used.

Question 35

46 With regards to nuclear imaging of the scrotum in cases of suspected torsion which of the following statements
is false?

(a) 99mTc-Pertechnetate is the radioisotope of choice

(b) A peripheral rim of increased activity with a central photopaenic zone is seen in delayed or missed torsion

(c) An area of increased activity extending from the iliac vessels to the scrotum is seen in torsion

(d) Torsion of the hydatid of morgagni is seen as a photopaenic defect

(e) It should not be performed in children under the age of 2 years

Answer 35

(d) Torsion of the hydatid of morgagni is seen as a photopaenic defect

Torsion of the hydatid cannot be identified on scintigraphy as the structure is too small to be accurately defined.
An area of increased activity extending from the iliac vessels to the scrotum can sometimes indicate increased
perfusion to the scrotum via the pudendal Vessels (nubbin sign).

Question 36

60 Which of the following structures are mullerian duct remnants?

(a) Hydatid of Morgagni

(b) Epididymis

(c) Vas deferens

(d) Ejaculatory duct

(e) Tunica albuginea

Answer 36

(a) Hydatid of Morgagni

The mullerian duct degenerates at around 6 weeks in the male due to production of mullerian inhibiting factor by
Sertoli cells, its remnants form the appendix testis and the utricle.

Question 37

66 A 58 year old man is found to have a midline prostatic cystic lesion on MRI. Which of the following is not
part of the differential diagnosis?

(a) Prostate carcinoma

(b) Recent TURP

(c) Utricular cyst

(d) Posterior urethral diverticulum

(e) Ejaculatory duct cyst

Answer 37

(a) Prostate carcinoma

Other causes include mullerian duct cyst and vas deferens cyst.

Question 38

70 A 55 year old man presents with a vague longstanding history of scrotal discomfort. US shows a right sided
lesion, predominantly composed of branching cystic structures lying immediately posterior to the mediastinum.
At MRI, the lesion is hypointense on T1W and isointense on T2W. Which of the following is the likeliest
diagnosis?

(a) Sertoli cell tumour

(b) lntratesticular varicocoele

(c) lntratesticular tubular ectasia

(d) Congenital cystic dysplasia

(e) Teratoma

Answer 38

(c) lntratesticular tubular ectasia

Dilatation of the rete testis is due to blockage of the efferent ductules. It is usually bilateral and lies in the region
of the mediastinum. Most testicular tumours are of low signal intensity on T2W.

Question 39

71 A 63 year old man with an elevated PSA is diagnosed with prostate cancer following needle biopsy. He
undergoes an MRI examination to help stage his disease. Which of the following sequences would be most helpful
in identifying location and local extent of the tumour?

(a) T1 Weigf1ted

(b) T1 Weighted with intravenous gadolinium

(c) T2 Weighted

(d) Fat suppressed T1

(e) Fat suppressed T2

Answer 39

(c) T2 Weighted

T2 weighted imaging clearly depicts the distinction between the peripheral zone and the remainder of the gland.
Tumours are seen as foci of low signal on T2. Haemorrhage from recent biopsy can cause confusion. Fat
suppression and intravenous gadolinium is not necessary

Question 40

73 A 31 year old male presents with a painless lump of the testicle. He is referred for an US, which demonstrates
a well circumscribed encapsulated lesion measuring 2 cm in diameter, containing alternating hypo/ hyperechoic
layers. There is no flow on Doppler imaging. What is the likely diagnosis?

(a) Choriocarcinoma

(b) Epidermoid

(c) Lymphoma

(d) Seminoma

(e) Yolk sac tumour

Answer 40

(b) Epidermoid

The classic US ‘onion-skin’ appearance of an epidermoid cyst of the testis is described. These are benign teratomas
containing ectodermal components. The alternating hypo/ hyperechoic layers are due to compact keratin layers
contrasted with loosely arranged desquamated squamous cells.

Question 41

4. A 34 year old man presents with a dull ache and a focal non-tender lesion in the right inguinal region. It is
   heterogeneous on ultrasound and CT. On MR, it has a heterogeneous signal intensity on T1- and T2-weighted
   imaging, which enhances post-gadolinium. Which of the following is the likely diagnosis?

a. Haematoma

b. Lipoma of the cord

c. Neurofibroma

d. Abscess

e. Malignancy in an undescended testis

Answer 41

4. e. Malignancy in an undescended testis

Lipoma of the cord will have a high signal on both T1-weighted and T2-weighted images. Neurofibroma will
demonstrate a target sign on T2-weighted images and is of low attenuation on CT. Abscess will be clinically
apparent, hypoechoic on ultrasound and have high signal on T2-weighted images. Haematomas are usually of
higher attenuation on CT with varying appearances on MR, but do not demonstrate contrast enhancement.

Question 42

5. A 65 year old man undergoes a penile MR for staging of penile cancer. Which of the following is true?

a. Corpus spongiosum has a high signal on T1-weighted images

b. On T2-weighted images, the periurethral tissue has high signal intensity relative to the corpus spongiosum

c. Corpus spongiosum enhances more rapidly following gadolinium as compared to the corpora cavernosa

d. MR can reliably differentiate between Buck’s fascia and tunica albuginea

e. A pelvic coil is preferred for local staging of penile cancers

Answer 42

5. c. Corpus spongiosum enhances more rapidly following gadolinium as compared to the corpora cavernosa

Both corpus spongiosum and the corpora have a low signal on T1-weighted images and high signal on T2-
weighted images. The periurethral tissue is low signal on T2-weighted images. MR cannot reliably differentiate
between Buck’s fascia and tunica albuginea. They are depicted as a single, thick, low-signal rim. A surface coil
is used for local disease staging.

Question 43

6. A 69 year old man undergoes an MR for staging of prostate cancer. Which of the following is true regarding
   MR imaging of the prostate gland?

a. The zonal anatomy is best depicted on T1-weighted images

b. The central zone has a higher signal than the peripheral zone on T2-weighted images

c. The low signal intensity posterolateral to the capsule on T2-weighted imaging represents the seminal vesicles

d. The proximal urethra is usually identified easily

e. Post-contrast, the peripheral zone enhances more than the central zone

Answer 43

6. e. Post-contrast, the peripheral zone enhances more than the central zone

The zonal anatomy is best depicted on T2-weighted images. The proximal urethra is not routinely identifiable,
unless the patient is catheterised or has had previous TURP. Seminal vesicles are bright on T2-weighted images;
the low-intensity structures indicate the neurovascular bundles. The peripheral zone has a higher signal on T2-
weighted images and enhances more.

Question 44

17. A 70 year old man undergoes an MR examination of the prostate to assess the stage of prostatic carcinoma.
    Which of the following is the least accurate?

a. Obliteration of the rectoprostatic angle is suggestive of extracapsular spread

b. Bladder and rectal involvement are best seen on coronal images

c. Focal low signal in the seminal vesicles on T2-weighted imaging is a feature of invasion

d. On T2-weighted images, prostate cancer usually demonstrates low signal intensity in contrast to the normal
peripheral zone

e. Prostatic volume measurements are bigger on CT than MR

Answer 44

17. b. Bladder and rectal involvement are best seen on coronal images

Bladder and rectal involvement are best appreciated on axial and coronal images. MR is much more accurate for
prostatic volume assessment and CT usually overestimates prostatic volume

Question 45

30. A 38 year old man with a swollen right hemiscrotum has an ultrasound examination.
    Which of the following is true?

a. The epididymis is hypoechoic compared to the normal testis

b. Seminomas are most commonly hyperechoic compared to the normal testis

c. The majority of extratesticular tumours are benign

d. Lipomas are the commonest intratesticular benign tumours

e. Epidermoid cysts are most commonly seen in the head of the epididymis

Answer 45

30. c. The majority of extratesticular tumours are benign

The epididymis is iso- or hyperechoic compared to the testis. Seminomas are homogenous masses and hypoechoic
to the testis. Epidermoid cysts are the commonest intratesticular benign neoplasm. Lipomas are the commonest
benign tumours in the spermatic cord.

Question 46

41. A 24 year old man is referred for an ultrasound examination following blunt trauma to the scrotum. Which
    of the following is not true?

a. The left testis is more susceptible to blunt trauma

b. Intratesticular haematomas need to be followed up until resolution

c. Penetrating injuries are more likely to be bilateral compared to blunt injuries

d. An ultrasound finding of an intact tunica albuginea allows the confident exclusion of a testicular rupture in the
absence of a haematocoele

e. An atrophic testis is more likely to dislocate

Answer 46

41. a. The left testis is more susceptible to blunt trauma

The testis suffers blunt trauma against the thigh or the symphysis pubis and the right testis, being higher, is more
susceptible. Intratesticular haematomas should be followed up to resolution to rule out an underlying neoplasm
and also rule out any ensuing complications such as abscess formation which may necessitate orchidectomy

Question 47

42. A 62 year old man presents with bilateral testicular enlargement. Ultrasound reveals bilateral smoothly
    enlarged testes with diffuse hypoechoic areas and normal epididymis. Which of the following is the most likely
    diagnosis?

a. Lymphoma

b. Metastasis from prostatic cancer

c. Seminoma

d. Tuberculosis

e. Leydig cell tumour

Answer 47

42. a. Lymphoma

This is the wrong age group for Leydig cell tumour (childhood) and seminoma (around 40 years). Lymphoma is
the commonest tumour in this age group. It is more likely to have a diffuse hypoechoic appearance and be bilateral
as compared to metastasis, which usually presents with multiple focal lesions. Tuberculosis of the testis is most
often secondary to epididymitis

Question 48

(Ped) 53. A four year old boy presents with sudden severe right scrotal pain, nausea and vomiting. An ultrasound
and colour Doppler examination scan are performed. Which of the following is true regarding a diagnosis of acute
testicular torsion?

a. Normal grey-scale appearances exclude torsion

b. Scrotal skin thickening indicates an infection

c. Testicular hyperaemia does not exclude torsion

d. A hydrocoele indicates a different diagnosis

e. Non-twisted spermatic cord excludes testicular torsion

Answer 48

53. c. Testicular hyperaemia does not exclude torsion

An enlarged, diffusely hypoechoic avascular testis with an associated twisted cord is diagnostic of testicular
torsion. The testicular echogenicity can be normal in the very early phase of torsion. A detorted testis often
demonstrates hyperaemia. Scrotal skin oedema and hydrocoele can also be features of torsion.

Question 49

QUESTION 1
A 48-year-old man presents with a painless swelling in the right scrotum. He has a past medical history of bilateral
undescended testes and subsequent orchidopexy. On examination, there is a firm right testicular lump but no
inguinal lymphadenopathy. On ultrasound, a well-defined, homogeneous hyporeflective mass was found within
the right testicle. The right epididymis and contralateral testicle appeared normal. What is the most likely
diagnosis?

A Leukaemic testicular infiltrate

B Testicular epidermoid cyst

C Testicular metastasis

D Testicular seminoma

E Testicular teratoma

Answer 49

D Testicular seminoma

The clinical history and ultrasound appearances are highly suggestive of testicular seminoma.

Question 50

QUESTION 3
A 65-year-old man is referred to the urology outpatient clinic with a painless right testicular lump. On ultrasound,
there is a 3-cm heterogeneous mass within the right testicle that has concentric rings of alternating hypo- and
hyperechogenicity, giving the mass a ‘whorled’ appearance. A subsequent MRI shows this mass to have
alternating low and high signal intensity layers on T2w sequences. What is the most likely diagnosis?

A Melanoma metastases

B Orchitis

C Testicular abscess

D Testicular epidermoid cyst

E Testicular microlithiasis

Answer 50

D Testicular epidermoid cyst

Question 51

@#e QUESTION 4
A 13-year-old boy presents to the Emergency Department with sudden onset of left scrotal pain, fever and
vomiting. The referring clinician suspects left testicular torsion and requests an urgent ultrasound prior to surgical
exploration. Which of the following radiological findings would suggest that the left testis is still viable?

A A diffusely enlarged hypoechoic left testis

B A normal echogenicity testis on grey-scale imaging

C A small shrunken left testis with a surrounding hydrocoele and scrotal wall thickening

D Absent blood flow within the left testis on colour flow Doppler but good flow within the tunica vaginalis

E An enlarged heterogeneous left testis

Answer 51

B A normal echogenicity testis on grey-scale imaging

The section on testicular torsion within the comprehensive review by Fiitterer et al provides useful additional
information

Question 52

@#e QUESTION 5
A 25-year-old man presents with a tender right scrotum. Which one of the following statements best describes
the expected ultrasound findings in acute, uncomplicated epididymo-orchitis?

A A small atrophic right testis

B A well-defined testicular mass of mixed echogenicity that has a whorled appearance and reduced flow on colour
Doppler

C Multiple small (approx. 1 mm) echogenic foci scattered throughout the

D Patchy areas of increased echogenicity within the testis with reduced flow on colour Doppler

E Well-defined, patchy areas of decreased echogenicity within the right

Answer 52

E Well-defined, patchy areas of decreased echogenicity within the right

In the early phase of acute orchitis, there is oedema of the testis leading to swelling and diffuse low reflectivity
on ultrasound. The ultrasound appearances then evolve to increasingly well-defined areas of patchy low
reflectivity. Colour Doppler flow is typically increased within these areas of low reflectivity.

Question 53

@#e QUESTION 6
A 35-year-old man is discovered to have a right testicular mass on ultrasound. Which additional ultrasound
finding would suggest a diagnosis of teratoma rather than seminoma?

A A testicular mass that contains areas of calcification

B A testicular mass that demonstrates increased colour Doppler flow

C A testicular mass that is homogeneously anechoic with posterior acoustic enhancement

D A testicular mass that is hypoechoic compared with the surrounding testicular parenchyma

E A testicular mass that has well-defined margins

Answer 53

A A testicular mass that contains areas of calcification

Question 54

QUESTION 25
A 62-year-old man has an MRI pelvis for biopsy-proven prostate cancer. Following thorough review of the
examination, tire reporting radiologist concludes that the patient’s disease stage is T3N0M0. Which one of the
following findings was likely to have been present on MRI?

A The prostatic capsule is breached with seminal vesicle invasion.

B Regional nodes > 10 mm in size.

C Tumour extends into both lobes of the prostate.

D Tumour involves only one lobe.

E Tumour invades the bladder neck.

Answer 54

A The prostatic capsule is breached with seminal vesicle invasion.

Stage T3 implies tumour extension through the prostate capsule with/without invasion of the seminal vesicles.

Question 55

QUESTION 28
You are the radiology SpR consenting a 70-year-old man for a transrectal ultrasound (TRUS) prostate biopsy.
Which one of the following is not a recognised complication of this procedure?

A Haematuria

B Haematospermia

C Perirectal bleeding

D Pneumoperitoneum

E Pain/discomfort post-procedure

Answer 55

D Pneumoperitoneum

Almost all patients complain of pain/discomfort afterwards and up to 80% will experience either haematuria or
haematospermia. Perirectal bleeding (up to 37%), infection, vasovagal attack, urinary retention and epididymitis
are other recognised complications. Pneumoperitoneum should not occur because the prostate lies well below the
peritoneal reflection

Question 56

@#e QUESTION 60
A 70-year-old man with prostate cancer has an MRI examination to locally stage the disease. In which part of the prostate gland is a carcinoma most likely
A Central zone

B Peripheral zone

C Peri-urethral zone

D Transitional zone

E Within the verumontanum

Answer 56

B Peripheral zone

Seventy per cent of prostate cancers arise from the peripheral zone.

Question 57

QUESTION 62
A 24-year-old man presents to his GP with increased urinary frequency. Physical examination is normal and he
is referred for ultrasound. Transabdominal ultrasound demonstrates a cystic structure posterior to the urinary
bladder and a TRUS is performed for further evaluation. TRUS reveals a midline anechoic structure in the
posterior portion of the prostate gland, superior to the verumontanum. It does not communicate with either the
bladder or the seminal vesicles. Which of the following is the most likely diagnosis?

A Bladder diverticulum

B External iliac artery aneurysm

C Mullerian duct cyst

D Seminal vesicle cyst

E Urethral cyst

Answer 57

C Mullerian duct cyst

This is the typical description of a Mullerian duct cyst. A seminal vesicle cyst is an important differential;
however, they are not usually seen in the midline.

Question 58

@#e QUESTION 63
A 53-year-old man has an MRI of his pelvis as a staging investigation for bladder cancer. The request card also
states that the prostate is mildly enlarged on digital rectal examination and the serum prostate specific antigen
(PSA) level is borderline elevated. The reporting radiologist reviews the prostate in detail. Which one of the
following statements best describes the MRI findings of a normal prostate gland?

A On Tlw images, the central zone is of higher signal intensity than the peripheral zone.

B On Tlw images, the central zone is of lower signal intensity than the peripheral zone.

C On T2w images, the peripheral zone is of lower signal intensity than the central and transitional zones

D The peripheral zone is of higher signal intensity than the central zone on T2w images.

E The seminal vesicles are hypointense on T2w images.

Answer 58

D The peripheral zone is of higher signal intensity than the central zone on T2w images.

Question 59

QUESTION 64
Regarding the radiological anatomy of the normal prostate gland, which of the following statements is correct?

A The anterior fibromuscular band separates the prostate from the rectum,

B The central zone atrophies with advancing age.

C The neurovascular bundles lie anterolateral to the prostate gland.

D The prostate gland is a flattened conical structure with its apex pointed superiorly.

E The zonal anatomy of the adult prostate gland is seen on transabdominal ultrasound.

Answer 59

B The central zone atrophies with advancing age.

The central zone atrophies with age whilst the transitional zone enlarges by developing benign prostatic
hypertrophy (BPH).

Question 60

QUESTION 65
A 34-year-old man has recently completed his third cycle of chemotherapy for testicular cancer. He now presents
with fever, chills and dysuria. Unenhanced CT of the pelvis shows two well-defined areas of low attenuation
within the prostatic parenchyma. Following intravenous contrast, the normal prostate gland enhances whilst the
low attenuation areas remain unchanged. In addition, there is some stranding within the periprostatic fat. What is
the most likely diagnosis?

A Corpora amylacea

B Prostatic abscess

C Prostatic calculi

D Prostatic cancer

E Prostatic cysts

Answer 60

B Prostatic abscess

Prostatic abscess is a localised process which usually begins in the peripheral zone of the gland but may spread
to other areas. The incidence is increased in diabetic or immunocompromised patients.

Question 61

QUESTION 71
A 74-year-old man with increased urinary frequency and hesitancy is found to have an enlarged prostate on digital
rectal examination. He is referred for a TRUS and biopsy. Which one of the following statements best describes
the TRUS findings of benign prostatic hypertrophy (BPH)?

A Dense echogenic foci are seen at the margin of the peripheral and transitional zones.

B The central zone is enlarged.

C The peripheral zone is enlarged and appears homogeneously hypoechoic.

D The peripheral zone is enlarged and is of mixed echogenicity.

E The transitional zone is enlarged

Answer 61

E The transitional zone is enlarged

The central zone atrophies with age while the transitional zone increases in size as it develops BPH. Peripheral
zone enlargement is not a feature of BPH.

Question 62

QUESTION 75
A 67-year-old man attends the Emergency Department with acute abdminal pain. A CT abdomen is performed
and demonstrates an uncomplicated acute appendicitis. The reporting radiologist notes an incidental finding of a
bulky prostate gland. On axial CT images, which one of the following CT findings is an unequivocal feature of
prostatic enlargement?

A The diaphragmatic urethra is dilated. (Dilatation)

B The prostate is identified 1 cm above the symphysis pubis.

C The prostate is identified 1 cm or less below the symphysis pubis.

D The prostate is identified 2—3 cm above the symphysis pubis.

E The prostate is identified less than 2 cm from the posterior aspect of the symphysis pubis.

Answer 62

D The prostate is identified 2—3 cm above the symphysis pubis.

On CT, as a general rule, the prostate is not considered to be enlarged if an image obtained 1 cm above the
symphysis does not include the prostate. Unequivocal enlargement of the prostate is diagnosed if the prostate is
seen in images 2—3 cm or more above the symphysis pubis.

Question 63

19. A 72-year-old man presents with a 4-month history of painless enlargement of the right testis. He
    undergoes scrotal ultrasound, which demonstrates a uniformly hypoechoic lesion that is enlarging and
    almost replacing all the normal parenchyma of the right testis. It has also caused enlargement of the right
    epididymis and adjacent spermatic cord. Review of the left testis shows a 2.5-cm hypoechoic lesion with
    normal spermatic cord and epididymis. What is the most likely diagnosis?

A. Lymphoma.

B. Leukaemia.

C. Testicular metastases.

D. Bilateral seminoma.

E. Granulomatous epididymo-orchitis

Answer 63

9. A. Lymphoma.

Clinically testicular lymphoma is distinct from other testicular neoplasms in that it occurs in a much older age
group. It is the most common testicular neoplasm over the age of 60 years. It is also the most common bilateral
testicular neoplasm (up to 38% of cases). The epididymis and spermatic cord are commonly involved. The
sonographic appearance is variable and indistinguishable from germ cell tumours. Typically they are discrete
hypoechoic lesions that may completely infi ltrate the testicle. Primary leukaemia of the testis is rare, although it
is a common site of leukaemia recurrence in children. The sonographic appearances are very variable, as the
tumour may be unilateral or bilateral, focal or diffuse, hypoechoic or hyperechoic. Testicular metastases, other
than those from lymphoma or leukaemia, are very rare. Primary sites reported include prostate and lung. They
are generally seen in the setting of widespread disease and are rarely the presenting complaint. Seminoma is the
most common germ cell tumour. The average age of presentation is approximately 40 years. It is typically
uniformly hypoechoic on ultrasound and they are only rarely bilateral (2%). Granulomatous orchitis may manifest
as a testicular mass, but this would be very unusual. Typically this process tends to involve the epididymis fi rst
and to a much greater degree than the testis. Pathogens include TB, syphilis, fungi, and parasites.

Question 64

23. A 72-year-old man presents with a palpable mass adjacent to the right testis. An ultrasound scan is
    performed and this demonstrates a large epididymal cyst. In addition, there is an abnormal area within
    the posterolateral aspect of the right testis, which is rounded in shape on transverse scanning, but more
    elongated on longitudinal scanning. It is hypoechoic, with multiple small cystic areas giving a ‘sponge-like’
    consistency. There is no flow within this on colour Doppler imaging. What is the most likely cause of this?

A. Thrombosed intra-testicular varicocele.

B. Cystic degeneration in a testicular infarct.

C. Chronic testicular abscess.

D. Tubular ectasia of the rete testis.

E. Epidermoid cyst.

Answer 64

23. D. Tubular ectasia of the rete testis.

This is also known as cystic transformation of the rete testis and results from partial or complete obliteration of
the efferent tubules, which causes ectasia and eventually cystic transformation. It is frequently bilateral, but may
be asymmetric. The site is in or adjacent to the mediastinum testis and there are often associated epididymal cysts
or spermatoceles. The key to the correct identifi cation of this abnormality is the elongated shape that replaces
the mediastinum. Intratesticular varicoceles can occur, but they are very rare. It would be even rarer for it to be
thrombosed. Testicular abscess would not usually be multicystic, but would be more rounded with an irregular
wall and low-level internal echoes. Testicular infarction usually manifests as a hypoechoic mass that is largely
avascular. It is not usually cystic. Epidermoid cyst is a rare benign tumour of germ cell origin. It is usually rounded or oval
in shape and classically has a target or ‘onion skin’ appearance of alternating layers of hyper- and hypo-echogenicity. The
outer wall is typically hyperechoic and sometimes calcifi ed.

Question 65

39. A 73-year-old male patient is referred from the urologists with a new diagnosis of prostate cancer. He
    is having an MRI scan to help stage the tumour. The patient reports that he has had a trans-rectal
    ultrasound (TRUS) biopsy done, but cannot remember when and the date is not on the form. The following
    information is present on the request form: ‘The tumour is not palpable on digital rectal examination
    (DRE). The prostate specific antigen (PSA) is 2.4. One of four biopsies was positive and the Gleason score
    from this was 5.’ When you do the MRI scan there is low signal in the peripheral zone on the left. There is
    also low signal on the right, which extends into the seminal vesicles. The images of the pelvis and paraaortic region do not show any evidence of lymphadenopathy. Which of these options would you choose for
    your report?

A. Repeat scan in 4 weeks.

B. T1 disease.

C. T2a disease.

D. T2c disease.

E. T3b disease.

Answer 65

39. A. Repeat scan in 4 weeks.

There are a number of important points in this question. Firstly, the date from biopsy must be known to avoid
misinterpreting haemorrhage as disease on MRI. Fortunately, the urologists have provided you with the salient
information necessary to estimate disease stage from the Partin’s tables. Whilst these are clinical features, they
are essential to know when interpreting MRI. The features described indicate a <1% risk of this patient having
extracapsular disease. In combination with the unknown date of the biopsy, it would be prudent to exclude the
possibility that this low signal in the seminal vesicles is not haemorrhage by repeating the scan. If does represent
disease invasion of the seminal vesicles, it would indicate T3b disease.

Question 66

45. A 56-year-old male patient has presented to the urologists with a PSA of 17 ng/ml. He does not have a
    mass palpable on DRE. Two separate TRUS investigations, with a total of eight biopsies, have failed to
    yield a tissue diagnosis. The urologists have asked you to carry out an MRI to help guide their future
    biopsies. As is routine in these difficult cases, magnetic resonance spectroscopy (MRS) is carried out on
    suspicious areas to provide extra information. The MRI identifies an area of low signal in the anterior
    peripheral zone. This reveals an elevated choline and creatine peak, and a reduced citrate peak. Which of
    these features is suggestive of carcinoma?

A. Elevated choline.

B. Reduced polyamine peak.

C. Reduced citrate peak.

D. None of them, MRS is only sensitive in the transition zone.

E. All of them.

Answer 66

45. E. All of them.

MRI is not a primary investigation in the diagnosis of prostate cancer but it is used in staging known disease.
Occasionally, in a patient with a high risk of prostate carcinoma, as in this case, when the urologists have
repeatedly failed biopsies, MRI can be used to help guide biopsy. In this setting MRS can also be used to increase
confi dence in the diagnosis. As with all prostate imaging for cancer, the results are more reliable in the peripheral
zone due to the variability of appearances in the transitional zone. Choline is elevated in prostate cancer, and is
thought to reflect increased cell membrane turnover. Creatine, also detected on MRS, is unchanged. Polyamine
is reduced. Citrate, which is stored in normal prostatic cells, is reduced, presumably because of reduced normal
function within cancerous cells. The (creatine + choline)/citrate ratio has been used to help discriminate prostate
cancer from normal prostate. The role of MRS in the transitional zone is unclear.

Question 67

(Ped) 48. A 12-year-old male presents with a history of sudden onset of severe pain in the right testis. On
examination, the right testis is tender and higher in position compared to the left side. An ultrasound of
testes is requested. Which of the following statements regarding testicular torsion is true?

A. Torsion results in arterial obstruction first followed by venous obstruction.

B. The testis is usually salvageable if corrected within 24 hours.

C. Bell clapper deformity predisposes to testicular torsion.

D. Enlargement and heterogenous echogenicity of the testis is specific for torsion.

E. Clinical differentiation between testicular torsion and epididymo-orchitis is straightforward.

Answer 67

48. C. Bell clapper deformity predisposes to testicular torsion.

Testicular torsion is an emergency. If it is not corrected within 6 hours, testicular salvage is less likely. Torsion
results initially in venous obstruction followed by arterial obstruction. The severity of testicular ischemia depends
on the duration and the degree of torsion (180-720°). Clinical differentiation between testicular torsion and
epididymo-orchitis can be challenging. Two types are described: intravaginal and extravaginal. ‘Bell clapper’
deformity is the term used to describe high attachment of the tunica vaginalis to the spermatic cord that leaves
the testis free to rotate. On ultrasound, the affected testis may have normal echogenicity in the early phase. In the
later phase, the testis enlarges and demonstrates increased or heterogenous echogenicity. An enlargedand torted
spermatic cord may be visualized. Absence of blood flow in the affected testis, with normal flow on the
asymptomatic side, is most specific for torsion. Some arterial flow may persist in incomplete torsion (less than
360). Decreased or reversed diastolic flow on pulsedwave Doppler assessment assists in the diagnosis in such
cases.

Question 68

39 A 65-year-old patient is noted to have a raised prostate-specific antigen (PSA) level by his general practitioner.
He is referred to a urologist and undergoes biopsy which demonstrates prostate cancer. At MRI, which of the
following features is suggestive of stage T3 rather than stage T2 disease?

a Extracapsular extension

b Tumour involves more than one half of one lobe but not both lobes

c Involvement of bladder neck

d Tumour involves both lobes

e Involvement of the external sphincter

Answer 68

39 Answer A: Extracapsular extensions

MRI is used to demonstrate tumour location, extracapsular extension and seminal vesicle invasion. Answer a is
T3 a, b is T2b, c is T4, d is T2c, and e is T4

Question 69

40 A 73-year-old patient had a biopsy demonstrating prostate cancer and subsequently underwent MRI
examination which showed an abnormality. Which of the following features suggests postbiopsy haemorrhage
rather than the prostate cancer tumour?

a Low signal on T2-weighted images in the peripheral zone

b Asymmetry of the neurovascular bundle

c Low signal on T2-weighted images in the seminal vesicles

d High signal on T1-weighted images in the peripheral zone

e Obliteration of the rectoprostatic angle

Answer 69

40 Answer D: High signal on T1-weighted images in the peripheral zone

Haemorrhage is high signal on T1-weighted images and therefore can be distinguished from tumour

Question 70

41 A 38-year-old man attends his GP with testicular pain. He is referred for an ultrasound examination. This
demonstrates 1-2 mm hyperechoic multiple non-shadowing foci throughout both testes. Which of the following
is most likely to be associated with this finding?

a Testicular germ cell tumour

b Epididymitis

C Epididymal cyst

d Scrotal pearl

e Varicocele

Answer 70

41 Answer A: Testicular germ cell tumour

The findings show testicular microlithiasis which is also associated with Klinefelter’s syndrome, cryptoorchidism,
testicular infarcts, granulomas, infertility, male pseudohermaphroditism, Down’s syndrome and alveolar
microlithiasis

Question 71

42 A 42-year-old man is referred for a scrotal ultrasound examination because of a palpable lump that has been
present for two weeks. This demonstrates a focal hypoechoic heterogeneous mass measuring 3 cm. What is the
most likely diagnosis?

a Embryonal cell carcinoma

b Epidermoid cyst

C Teratoma

d Yolk sac tumour

e Seminoma

Answer 71

42 Answer E: Seminoma

Seminoma is the most common pure germ cell tumour and average age is 40.50 years

Question 72

44 A 65-year-old man with a known malignancy presents with a testicular lump that he has noticed increasing in
size over the last three weeks. He is referred for an ultrasound examination. This demonstrates a heterogeneous
4-cm mass in the left testis, which was biopsied and confirmed to be a metastasis from his primary malignancy.
What is the most likely site of primary malignancy?

a Brain

b Adrenal

c Thyroid

d Liver

e Lung

Answer 72

44 Answer E: Lung

Metastases to the testis are more common than seminoma in a patient over the age of 50 years. The most common
sites (in order of frequency) are prostate, lung, kidney, GI tract, bladder, thyroid, melanoma.

Question 73

43 A 30-year-old man attends for a scrotal ultrasound examination having felt a lump. Ultrasound shows a welldefined 2-cm round lesion in the region of the right testis, which has rings of alternating hypo and hyperechoic
echogenicity. No blood flow can be demonstrated on colour Doppler imaging. What is the most likely diagnosis?

a Burned-out tumour of testis (Azzopardi tumour)

b Lymphoma of testis

C Epidermoid cyst

d Seminoma

e Metastasis to testis

Answer 73

43 Answer C: Epidermoid cyst

These are the typical ultrasound appearances of an epidermoid cyst, which is confined to the tunica
albuginea.

Question 74

45 A 35-year-old man attended his general practitioner requesting a vasectomy. On examination there was a
palpable scrotal mass and he was referred for an ultrasound examination. This demonstrated an 8-mm welldefined anechoic area in the head of the right epididymis. What is the most appropriate next step in this patient’s
management?

a Discharge the patient back to GP with no follow-up

b Discharge patient back to GP with no follow-up but recommend that vasectomy may be complicated

C Refer patient to urologist and advise follow-up ultrasound examination

d Refer patient to urologist and advise staging CT examination

e Discharge patient back to GP and advise urology referral

Answer 74

45 Answer A: Discharge the patient back to GP with no follow-up

These findings are consistent with an epididymal cyst, which is incidental to management

Question 75

46 A nine-year-old boy is admitted to hospital 12 hours following the onset of acute scrotal pain and is referred
for an ultrasound examination. Which of the following ultrasound appearances is incompatible with a diagnosis
of testicular torsion?

a Normal grey-scale appearance of both testes

b Hydrocoele

C Scrotal skin thickening

d Diffusely hypoechoic echotexture of one testis

e Cryptoorchidism

Answer 75

46 Answer A: Normal grey-scale appearance of both testes at 12 hours

In acute testicular torsion the typical appearances are of decreased blood flow at one hour and absent blood flow
after four hours, but remember that torsion-detorsion and incomplete torsion can give false negative appearances.
In cryptoorchidism the testes are arrested along their line of development with a l Ox increased risk of torsion.
Normal grey-scale appearances of the testes can occur but changes in appearance usually occur after six hours of
torsion.

Question 76

47 A 26-year-old man presented with a testicular lump and was referred by his GP for an ultrasound examination.
This demonstrated a 3-cm heterogeneous solid mass in the left testicle. What is the most appropriate next step in
his management?

a Repeat ultrasound examination in three weeks following antibiotics

b Staging MRI examination

C Staging CT examination

d Bone scintigraphy

e Biopsy followed by staging examination

Answer 76

47 Answer C: Staging CT examination

Staging CT examination of the chest, abdomen and pelvis is the most appropriate next step following urological
referral.

Question 77

(Ped) 61 A 10-year-old boy presents with acute pain in the upper pole of the right testis. On examination there is
a small, firm right paratesticular nodule, which has a bluish tinge. Ultrasound demonstrates a normal left testis
and an enlarged right testis. There is no focal lesion seen within the right testis and it has normal Doppler flow
within it. Adjacent to the right testis is a small hypoechoic mass with absent Doppler flow. Which of the following
is the most likely diagnosis?

a Testicular torsion

b Torsion of the appendix testis

C Haematocele

d Seminoma

e Acute orchitis

Answer 77

61 Answer B: Torsion of the appendix testis

Torsion of the appendix testis and torsion of the appendix epididymis are the most common causes of acute scrotal
pain in 6-12 year olds. It is not a real surgical emergency as symptoms usually resolve with supportive care.

Question 78

42 A 25-year-old male presents with fever and increasing left-sided scrotal pain over a period of three days. He
has also noticed clouding of his urine and complains of dysuria and frequency. Ultrasound of the left
hemiscrotum demonstrates thickening and enlargement of the epididymis and testis on the left. The left testis is
hypoechoic compared to the right. Which of the following appearances on radionuclide imaging would favour a
diagnosis of epididymo-orchitis above testicular tumour?

a Increased perfusion with decreased uptake centrally

b Curvilinear increased activity medially and centrally in the left hemiscrotum on static images

C A’nubbin’ sign; that is, a bump of activity extending medially from the iliac artery

d Markedly increased perfusion through spermatic cord vessels with increased activity of scrotal contents on static
images

e Slight increase in perfusion with increased uptake in the testis alone on static images

Answer 78

42 Answer D: Markedly increased perfusion through spermatic cord vessels with increased activity of scrotal
contents on static images

Option (a) is seen with testicular abscess. Curvilinear increased activity laterally is seen in epididymitis. Option
(c) is seen in acute testicular torsion and (e) in testicular tumour.

Question 79

45 An eight-year-old boy presents acutely with a swollen, inflamed and very tender right testicle. An ultrasound
scan shows a rounded mass of variable reflectivity at the superior aspect of the right testis with surrounding
increased Doppler flow and a small hydrocele. What is the most likely diagnosis?

a Right testicular torsion

b Acute epididymitis

c Torsion of the appendix testis

d Spermatic cord torsion

e Haemorrhagic epididymal cyst

Answer 79

45 Answer C: Torsion of the appendix testis

The appendix testis is the vestigial remnant of the Mullerian duct and is seen as a small projection from the upper
testicular pole in up to 80% of ultrasound examinations. It is common in childhood.

Question 80

46 A 30-year-old man presents with a two-month history of painless right scrotal swelling. An ultrasound scan
shows a well-defined hyporeflective paratesticular mass which shows hypervascularity on colour Doppler. What
is the most likely diagnosis?

a Paratesticular lipoma

b Adenomatoid tumour

C Scrotal haemangioma

d Epididymal papillary cystadenoma

e Malignant fibrous histiocytoma

Answer 80

46 Answer C: Scrotal haemangioma

Benign paratesticular lesions tend to be well defined, painless and show little or no increase in flow on colour
Doppler. Scrotal haemangioma is an exception due to its high vascularity.

Question 81

47 A 65-year-old man represented three years after a prostatectomy for prostate cancer with an increasing
prostate-specific antigen (PSA) and an MRI of the pelvis was performed. What feature best denotes local disease
recurrence?

a Low signal intensity in the prostate bed on axial T2 sequence
b High signal intensity in the prostate bed on axial Ti sequence

C High signal intensity in the prostate bed on axial T2 sequence

d Low signal intensity in the prostate bed on axial STIR sequence

e Low signal intensity in the prostate bed on axial Ti sequence

Answer 81

47 Answer C: High signal intensity in the prostate bed on axial T2 sequence

The usual post-prostatectomy appearance is low signal fibrosis. Increased signal on T2 sequence in the setting of
a rising PSA is indicative of local recurrence.

Question 82

48 A 42-year-old man with a history of infertility, recurrent urinary infections and haematuria was assessed with
a trans-rectal ultrasound scan (TRUS) which shows a midline cystic mass in the prostate gland which does not
communicate with the urethra. What is the most likely diagnosis?

a Ejaculatory duct cyst

b Prostatic abscess

C Retention cyst

d Mullerian duct cyst

e Cystic degeneration of benign prostatic hypertrophy

Answer 82

48 Answer D: Mullerian duct cyst

This is a remnant of the paramesonephric duct which usually regresses by the third foetal month. It is discovered
usually in the third to fourth decade. It tends to be midline and does not communicate with the urethra. It is
associated with increased incidence of carcinomatous transformation.

Question 83

(Ped) 49 Which of the following is associated with an increased risk of testicular cancer?

a No testes within the scrotum in a two-week-old infant born at 26 weeks

b Congenital monorchia

c One testis within the scrotum and one between the internal and external inguinal ring in a newborn infant born
at 31 weeks

d Unilateral undescended testis post-orchidopexy in a nine month old

e Bilateral retractile testes

Answer 83

49 Answer D: Unilateral undescended testis post-orchidopexy in a nine month old

Testes are normally within the scrotum by 28-32 weeks gestational age. Cryptoorchidism is the arrested descent
of testes along their normal course and is associated with an increased risk of testicular cancer (most commonly
seminoma). Orchidopexy does not decrease the cancer risk and the risk extends to the contralateral testis.

Question 84

(Ped) 23 A 10-year-old boy presents with a history of severe left-sided testicular pain lasting for 48 hours. On
examination the left testis is swollen and exquisitely tender. The urinalysis is negative. He undergoes a scrotal
ultrasound. Which of the following are the most likely radiological findings?

a Enlarged hyperechoic left testis with increased peritesticular flow and absent parenchymal flow

b Small atrophied left testis with absent peritesticular and parenchymal flow

C Normal-sized hypoechoic left testis with absent peritesticular and parenchymal flow

d Enlarged hypoechoic left testis with normal parenchymal flow

e Normal-sized hyperechoic left testis with increased peritesticular and parenchymal flow

Answer 84

23 Answer A: Enlarged hyperechoic left testis with increased peritesticular flow and absent parenchymal flow
The diagnosis is subacute or missed testicular torsion when symptoms are present for >24 hours and <10 days.
The salvage rate is dependent on the time interval between onset of pain and surgery and is 80-100% at <6 hours
and near 0% at >24 hours

Question 85

33 A 25-year-old male presents with fever and increasing left-sided scrotal pain over a period of three days. He
has also noticed clouding of his urine and complains of dysuria and frequency. Ultrasound of the left hemiscrotum
demonstrates thickening and enlargement of the epididymis and testis on the left. The left testis is hypoechoic compared to the right. Radionuclide imaging demonstrates markedly increased perfusion through spermatic cord vessels with curvilinear increased activity medially and centrally in the left hemiscrotum on static images. Which of the following statements is most accurate regarding this condition?

a The commonest causative organism in this age group is E. coli

b It is the commonest cause of acute scrotal pain in males under the age of 20

C It is frequently associated with prostatic tenderness

d Tuberculosis is the second commonest cause

e Leads to testicular infarction in approximately 3 % of cases

Answer 85

33 Answer E: Leads to testicular infarction in approximately 3 % of cases

The patient has acute epididymo-orchitis. The commonest causative organisms are Chlamydia and N. gonorrhoea
in <35 year olds, and E. coli and Proteus mirabilis in >35 year olds. Staphylococcus aureus is also a recognised
cause. Testicular torsion is most common in <20 year olds, and acute epididymitis is most common after the age
of 20. Prostatic tenderness is infrequent and TB accounts for 2% of cases, while E. coli and S. aureus account for
85%. Testicular infarction is a recognized complication of acute epididymitis from extrinsic compression of
testicular blood flow.

Question 86

36 A 22-year-old man reluctantly presents to the Emergency Department with a persistent painful erection. What
is the appropriate management?

a Reassurance that it will resolve without active management

b Arterial Doppler to look for abnormal inflow

C Cavernosal aspiration/irrigation

d Angiogram

e Passage of a urethral catheter to allow urination

Answer 86

36 Answer C: Cavernosal aspiration/irrigation

Most cases of priapism are due to veno-occlusive disease with arterial causes being relatively rare and related to
trauma. Even with appropriate aspiration & irrigation followed by anticoagulation/shunt surgery, 50% impotence.

Question 87

38 A 90-year-old man is brought to hospital from his nursing home generally unwell and with a painful scrotum.
Ultrasound imaging of the testes is difficult because of tenderness and hazy echogenic shadowing. The operator
also notices skin crepitus. What is the most likely diagnosis?

a Testicular tumour

b Yeast infection

c DVT

d Fournier gangrene

e Scrotal hernia

Answer 87

38 Answer D: Fournier gangrene

Necrotising fasciitis of the scrotum. The prognosis is usually very poor.

Question 88

39 A 34-year-old man noticed his scrotum appeared swollen and was referred for an ultrasound scan which
demonstrated an anechoic region around the right testis with posterior acoustic enhancement. Both testes were of
normal appearance. What is the most appropriate management?

a Urgent urological referral

b Routine urological referral

c MRI pelvis

d CT pelvis

e Aspiration of fluid

Answer 88

39 Answer B: Routine urological referral

As the patient is symptomatic the surgeon may discuss surgical options such as marsupialisation. The ultrasound
operator needs to be vigilant and thoroughly check the testes for an underlying tumour.

Question 89

40 An 85-year-old man presents with a swelling in his scrotum and is referred for an ultrasound. This shows a
right-sided simple hydrocele. The left testis appears normal and the right testis, while of normal morphology,
appears abnormally bright when imaged through the hydrocele. What technical feature of ultrasonography is
responsible for this appearance?

a Time gain compensation

b Compound imaging

C Harmonic imaging

d Refractive shadowing

e Non-linear waveform propagation

Answer 89

40 Answer A. Time gain compensation

Time gain compensation equalises the image brightness between superficial and deeper structures by
progressively increasing the gain from deeper (later) echoes. This is adjusted for average tissue attenuation. If a
cyst with lower than average attenuation is imaged, the echoes from deeper tissues are over-amplified. Non-linear
waveform propagation is the principle behind harmonic imaging, in that the original pulse is distorted so that it
comes to contain higher frequency components or harmonics.

Question 90

42 An 83-year-old man complains of hesitancy, poor urinary flow, terminal dribbling and double micturition. On
direct questioning he describes nocturia at least five times per night. His prostate feels enlarged on examination,
his PSA is measured to be 9ng/mL and he is referred for a transrectal prostate ultrasound with biopsy. What
feature would be most in keeping with benign prostatic hypertrophy (BPH)?

a Measured volume of 43 cu cm

b Irregular prostatic outline

c Peripheral enlargement predominately of low reflectivity

d Peripheral enlargement with calcium and mixed echogenicity

e Central enlargement with calcium and mixed echogenicity

Answer 90

42 Answer E: Central enlargement with calcium and mixed echogenicity

Size greater than 30 cu cm and peripheral changes are more suspicious of carcinoma. PSA generally increases
with age: 3 ng/mL is considered the upper limit of normal up to 60 years, 4 ng/mL to 70 years and 5 ng/mL for
those over 70.

Question 91

(Ped) 59 A six-year-old boy attends for a scrotal ultrasound following the discovery of a seemingly painless lump
in his left testis. As he is undressed for the ultrasound he is noted to have bilateral gynaecomastia. The ultrasound
reveals a normal-looking right testis and a well-defined hypoechoic mass within the left testis. Which of the
following is the most likely diagnosis?

a Gonadoblastoma

b Seminoma

C Yolk sac carcinoma

d Orchitis

e Leydig cell tumour

Answer 91

59 Answer E: Leydig cell tumour

Leydig cell tumours usually present between three and six years of age. They produce oestrogens or testosterones,
resulting in gynaecomastia or virilisation.

Question 92

1. A patient with urinary symptoms and raised PSA was diagnosed with carcinoma of the prostate on
   histopathology. Which of the following appearances is suggestive of carcinoma of the prostate on MRI?

(a) Peripheral zone lesion with high signal on T1

(b) Peripheral zone lesion with low signal on T1

(c) Peripheral zone lesion with high signal on T2

(d) Peripheral zone lesion with low signal on T2

(e) Peripheral zone lesion with low signal proton density

Answer 92

1. (d) Peripheral zone lesion with low signal on T2

Prostatic carcinoma is best seen as an area of low signal intensity in the peripheral zone of prostate on T2. The
normal glandular tissue returns high signal on T2 images

Question 93

3. A 25-year-old previously well man presents with non-specifc scrotal pain. Ultrasound shows numerous bilateral
   hyperechoic shadows in the testes measuring 1–2 mm. There is no acoustic shadowing seen. The most likely
   diagnosis is?

(a) Post-inflammatory changes

(b) Haemorrhage with infarction

(c) Testicular scarring

(d) Testicular microlithiasis

(e) Large-cell calcifying Sertoli cell tumour

Answer 93

3. (d) Testicular microlithiasis

This occurs when there is a defect in the phagocytic activity of Sertoli cells leaving degenerated intratubular
debris behind. This condition is usually asymptomatic and ultrasound appearances are typically as described.
When testicular microlithiasis is discovered, regular follow up should be performed due to risk of developing a
testicular neoplasm.

Question 94

22. An 80-year-old man presented with bilateral testicular lumps. Ultrasound of the testis shows small, septated,
    cystic lesions in the mediastinum testis, the right worse than the left. Tese lesions are avascular. On MRI, the
    lesions return low signal on T1 while they are isointense to testis on T2. What is the most likely diagnosis?

(a) Teratoma

(b) Tubular ectasias of rete testis

(c) Epidermoid cyst

(d) Spermatocele

(e) Varicocele

Answer 94

22. (b) Tubular ectasias of rete testis

This is usually seen in older men and is thought to be secondary to cystic dilatation of the rete testis. This is a
benign condition and an important differential is teratoma. Ultrasound appearances and MRI features are
characteristic. These lesions are isointense (sometimes undetectable) on T2 (unlike teratoma).

Question 95

29. A 65-year-old diabetic in shock is brought to the Accident & Emergency Department after collapse at home.
    He has a 6-day history of progressive scrotal swelling and pain. Ultrasound shows scrotal thickening and extensive
    echogenic shadows in the subcutaneous layer with posterior acoustic shadowing suggesting air. What is the most likely diagnosis?

(a) Acute epididymo-orchitis

(b) Fournier’s gangrene

(c) Hernia

(d) Normal variant

(e) Traumatic

Answer 95

29. (b) Fournier’s gangrene

Fournier’s gangrene is a progressive necrotising fasciitis in men. Thickening of the scrotal skin and air in the
subcutaneous layer are diagnostic.

Question 96

46. A 40-year-old Caucasian man presented with a painless left testicular nodule. Ultrasound shows a wellcircumscribed, encapsulated, avascular and round lesion measuring 4 cm in size in the left testis. It shows an
    ‘onion-ring’ appearance of alternating areas of hypo- and hyperechogenicity. On MRI, the lesion shows high
    signal on T1 and T2 sequences. What is the most likely diagnosis?

(a) Seminoma

(b) Teratoma

(c) Torsion testis

(d) Epidermoid cyst

(e) Lymphoma of testis

Answer 96

46. (d) Epidermoid cyst

These are the typical radiological appearances of an epidermoid cyst of testis. The ‘onion-ring’ appearance is
secondary to alternating layers of compacted keratin and desquamated squamous cells. The water and lipid
contents of the cyst result in high signal on both T1 and T2.

Question 97

48. Zonal anatomy of the prostate is best seen in which of the following sequences?

(a) T1-weighted images

(b) T2-weighted images

(c) Proton density

(d) STIR

(e) T1 fat saturation

Answer 97

48. (b) T2 weighted images

These demonstrate the zonal anatomy of the prostate well. The prostatic urethra serves as a reference point. The
peripheral zone returns high signal compared with the central or transitional zones.

Question 98

50. A 27-year-old man was diagnosed with testicular seminoma, not invading the scrotal sac. Which of the
    following lymph node groups is most likely to be involved?

(a) Ipsilateral inguinal nodes

(b) Para-aortic nodes

(c) Common iliac nodes

(d) Supraclavicular nodes

(e) Retrocrural lymph nodes

Answer 98

50. (b) Para-aortic lymph nodes

The lymphatics from the testis accompany the veins to the retroperitoneal nodes between the bifurcation and the
kidneys. The local inguinal nodes are involved only if there is invasion of the scrotal wall.

Question 99

8. Regarding testicular ultrasound, which of the following are correct?

(a) Absent testicular blood flow on colour Doppler imaging is pathognomonic of testicular torsion.

(b) There is an association between testicular microlithiasis and Klinefelter’s syndrome.

(c) Testicular cysts are seen in upto 10% of testicular ultrasound studies.

(d) The epididymis is typically enlarged, hypervascular and hyperechoic when inflamed.

(e) The normal epididymis is slightly hypoechoic to the normal testis.

Answer 99

Answers:

(a) Not correct

(b) Correct

(c) Correct

(d) Not correct.

(e) Not correct

Explanation:

In paediatric patients, intratesticular flow can be difficult to demonstrate on colour Doppler. Power Doppler
may be helpful in such cases.
When inflamed epididymis is typically enlarged, hypervascular and hypoechoic. Orchitis is seen in 20% cases
and shows similar appearance.
The normal epididymis is isoechoic to slightly hyperechoic to normal testis.

Question 100

(Ped) 21. Which of the following are correct regarding imaging of the testis:

(a) An appendix is present in over 90 % of males

(b) Examination of the contralateral testis is mandatory in possible torsion

(c) A hydrocele may cause false positive diagnosis of torsion on scintigraphic evaluation

(d) Torsion is most common in the neonatal age group

(e) A torted testis is usually of high echogenicity on ultrasound

Answer 100

Answers:

(a) Correct

(b) Correct

(c) Correct

(d) Not correct

(e) Not correct

Explanation:

Torsion of testis is rare in neonates. A torted testis is usually hypoechoic on ultrasound due to congestion,
infarction and edema.

Question 101

38. Which of the following are correct regarding imaging of prostate cancer:

(a) Can be reliably detected by transrectal ultrasound.

(b) Intravenous contrast is used routinely in MRI.

(c) Normal zonal anatomy of the prostate gland is best seen on T1 weighted MRI.

(d) Usually appears as a high signal intensity lesion on T2 weighted MRI.

(e) Is usually hypoechoic on TRUS.

Answer 101

Answers:

(a) Not correct.

(b) Not correct

(c) Not correct

(d) Not correct

(e) Correct

Explanation:

Only cancer located in the peripheral zone can be reliably detected on TRUS, with 60%-70 % appearing
hypoechoic, 40% are isoechoic and 1% - 5% are hyperechoic.
Intravenous contrast in not used routinely in MRI as it has no superiority of T2WI. T2WI best demonstrates
zonal anatomy with cancer appearing as lesion of low signal within the high signal of peripheral zone.
All the zones have intermediate signal on T1WI on MRI.

Question 102

40. Which of the following are correct regarding testicular microlithiasis:

(a) Extratesticular scrotal calcification is usually benign.

(b) Acoustic shadowing is observed in most cases.

(c) Is associated with infertility.

(d) Is usually unilateral.

(e) May be associated with neurofibromatosis.

Answer 102

Answers:

(a) Correct

(b) Not correct

(c) Not correct

(d) Not correct

(e) Correct

Explanation:

Acoustic shadowing is not seen due to small size of calcification. Infertility is not associated with microlithiasis
(association is 1% same as general population).
Unilaterality is seen only in 2.7% to 27%.

Question 103

41. Which of the following are correct regarding testicular epidermoid cysts:

(a) Are usually multiple and bilateral.

(b) The majority occur in the elderly.

(c) Concentric layers of calcification are characteristic on ultrasound.

(d) A bull’s eye pattern is a recognized appearance on MRI.

(e) Are typically treated by orchidectomy.

Answer 103

Answers:

(a) Not correct

(b) Not correct

(c) Correct

(d) Correct

(e) Not correct

Explanation:

1% of intratesticular tumours are epidermoid and most commonly seen between 20-40 yrs.
They are usually solitary and unilateral, but cases of multiplicity and bilaterality have been recognized

Question 104

(GIT) 31. In the imaging of acute testicular torsion, which of the following are correct:

(a) On sonography, a reactive hydrocoele is seen after 6 hours.

(b) Surgery is successful in 20% of patients who present between 12 and 24 hours after onset of symptoms.

(c) Colour Doppler ultrasound may show increased blood flow in the depididymis.

(d) Hyperperfusion of the testicle on colour Doppler ultrasonography makes testicular torsion unlikely.

(e) Tc-99m pertechnetate scintigraphy typically shows a halo of hyperactivity in the acute phase (first 6 hours).

Answer 104

Answers:

(a) Correct

(b) Correct

(c) Correct

(d) Not correct

(e) Not correct

Explanation:

Spontaneous detorsion of testis may occur leading to unilateral testicle hypoperfusion. Surgery is still indicated
in these cases. Scintigraphy is highly sensitive and specific when performed only. In the acute phase, there is
reduced perfusion in the testis with decreased activity. In the subacute phase, there is a peritesticular reactive
hyperaemia with a hilar or increased tracer activity. Later, there is marked absence of tracer activity.