Scrotum Flashcards
USF of hydrocoele
Acute hydrocele (AH): Crescentic anechoic fluid collection surrounding anterolateral aspect of testis
• AH: Usually testis is displaced posteromedially
• Chronic hydroceles (CH): Low-level, mobile echoes
• CH: Diffuse scrotal wall thickening, parietal calcifications & scrotoliths
• Power Doppler: May demonstrate movement of internal debris in chronic hydrocele
Checklist for hydrocele
Anechoic fluid collection in tunica vaginalis along anterolateral aspect of testis
USF for testicular cysts
Simple epididymal cyst: Well-defined, anechoic
• May be seen throughout epididymis
• Aspiration of fluid is diagnostic of simple cyst but not usually necessary
• Spermatocele: Well-defined hypoechoic
• Located at head of epididymis
• Low-level echoes due to proteinaceous fluid and spermatozoa
• Spermatoceles usually displace testis anteriorly
• Tunica albuginea cyst: Meets all the characteristics of simple cyst
• Located at upper anterior or lateral aspect of testis
• Simple testicular cyst: Located anywhere in the testis, but most commonly near mediastinum testis • Anechoic center, posterior enhancement
Commonly associated with extratesticular spermatoceles
• Epidermoid cyst: Circumscribed hypoechoic mass
• Target appearance: Hypoechoic halo with central area of increased echogenicity
• “Onion-ring” pattern with alternating hyperechoic and hypoechoic layers
• Congenital cystic dysplasia: Appearance similar to acquired cystic dilation of rete testis
• Pressure atrophy of adjacent testicular parenchyma
• Multiple, interconnecting anechoic cysts of various sizes and shapes
USF of testicular carcinoma
Best diagnostic clue: Discrete hypoechoic or mixed echogenic testicular mass, ± vascularity
• Seminoma is most common pure germ cell tumor of testis
Seminomas are usually well-defined, hypoechoic, solid without calcification or tunica invasion
• Cystic areas, calcification (cartilage, immature bone) ± fibrosis characterize teratoma/teratocarcinoma
• Embryonal cell carcinoma may invade tunica albuginea and distort testicular contour
• Hemorrhage with focal necrosis is typical feature of choriocarcinoma
Tumor < 1.5 ern is commonly hypovascular, and tumors> 1.6 ern are more often hypervascular
• Best imaging tool: US to identify and characterize scrotal mass; CT or MR for metastatic staging; PETto evaluate post-treatment residual masses
Checklist for testicular CA
Consider testicular lymphoma if bilateral lesions identified, and particularly if patient is > 50 years
• Presence of discrete mass on grayscale ultrasound with abnormal intrinsic vessels on color Doppler should raise suspicion of testicular carcinoma
USF of testicular torsion
Best diagnostic clue: Discrete, small, echogenic foci within testicular substance
• Small hyperechoic foci diffusely scattered throughout testicular parenchyma
• 2-3 mm echogenic foci, no posterior acoustic shadowing
• Presence of :<: 5 echogenic foci per transducer field in one testis is abnormal
Examine abdominal organs to evaluate other concomitant pathology like germ cell tumor, neurofibromatosis and congenital anomalies
• Best imaging tool: High resolution US (:<: 7.5 MHz) is modality of choice
Checklist for testicular torsion
Consider CHECKLIST
• Normal US(grayscale & Doppler) does not exclude early or partial torsion o Repeat examination at 1-4 hour intervals if conservatively managed
• Decreased or absent flow on Doppler examination
USF of epididymitis/orchitis
Best diagnostic clue: Enlarged, hyperemic epididymis and/or testis on color Doppler US
• Acute epididymitis: Enlarged epididymis, decreased echogenicity, coarse heterogeneous echo pattern due to edema & hemorrhage
• Chronic epididymitis: Enlarged hyperechoic epididymis
• Orchitis follows in 20-40% of epididymitis due to contiguous spread of infection
Diffuse orchitis: Testis is diffusely enlarged with inhomogeneous echo pattern, thickening of tunica albuginea (in severe infection)
• Spermatic cord may be inflamed, and may appear hypoechoic with associated hyperechoic fat within
Reactive hydrocele containing low level internal echoes, septae, thickening of tunicallayers ± skin edema, all represent changes of periorchitis
• Color Doppler is highly sensitive and specific for epididymo-orchitis
• On color Doppler hyperemia is seen as t number & concentration of vessels in affected region
• Diffuse or focal hyperemia in body and tail of epididymis ± increased vascularity of testis
Checklist for epididymitis
Consider CHECKLIST
• Torsion if low or absent flow within testis
Image Interpretation Pearls
• Hyperemic and enlarged epididymis and/or testis
USF of varicocoele
Dilated serpiginous veins behind superior pole of testis on color Doppler US
• Left (78%), right (6%), Bilateral (16%)
• US should be performed in supine and standing positions
• Multiple, hypoechoic, serpiginous, tubular structures
• Evaluate retroperitoneum secondary varicoceles and abdomen to exclude
• Doppler parameters are optimized for low flow velocities to confirm the venous flow pattern
Bidirectional Doppler sonography (erect with quiet breathing)
• Best imaging tool: US with color Doppler
• Resting and Valsalva color Doppler examination of epididymis
Checklist for varicocoele
Valsalva essential for diagnosis of small varicoceles
• Varicocele is diagnosed when vessel exceeds 2 mm during quiet respiration in supine position
