ECR2014 - Ultrasound Evaluation of Scrotal Pathology

Ultrasound evaluation of Scrotal pathology
Poster No.: C-1225

Congress: ECR 2014
Type: Educational Exhibit
Authors: C. Costa, M. Horta; Lisbon/PT
Keywords: Pathology, Education and training, Education, Diagnostic
procedure, Ultrasound-Colour Doppler, Ultrasound, Genital /
Reproductive system male
DOI: 10.1594/ecr2014/C-1225
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Page 1 of 76
Learning objectives
The educational objectives of this exhibit are:
• To recollect the normal anatomy of scrotum, as well as the ultrasonography

technique and adequate scanning protocol used for scrotal evaluation
• Present a pictorial review of the most frequent pathological disorders of the
scrotum and their appearance in ultrasonography, placing emphasis on the
findings most currently found in a radiologist's daily routine
• Get young radiologists familiarized with the ultrasonographic findings of
scrotal pathology
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Background
Scrotal anatomy
The scrotal sac, a dual-chambered protuberance of skin and muscle containing the
testes, epididymis and lower end of the spermatic cords, is made up of numerous
layers, namely the skin, the dartos fascia, the external spermatic fascia, the cremaster
muscle, the internal spermatic fascia and the tunica vaginalis. The layers are usually not
distinguishable at ultrasonography (US). The tunica vaginalis consists of a parietal and
a visceral layer, and between them there is a virtual space where free or collected fluid
may develop.
The testis is surrounded by a thick fibrous layer, the tunica albuginea. Multiple thin
septations arise from this tunica, converging posteriorly to form the mediastinum testis,
which supports the testicular vessels and ducts.
The testis contains hundreds of seminiferous tubules, and they all course centrally,
converging in order to form 20-30 larger ducts, the tubuli recti, that enter the mediastinum
testis and form a network of channels called the rete testis. The rete testis drains into the
efferent ductules in the epididymal head.
The epididymis is an elongated, crescent-shaped structure, located along the superior

and posterior portion of the testicle and constituted by 3 segments. The first and widest
segment is the head, located adjacent to the superior pole of the testis, formed by the
10-15 efferent ductules from the rete testis joining together in order to form the ductus
epididymis that forms the body and the majority of the tail of the epididymis, namely the
second and third segments. The tail extends inferolaterally, eventually continuing as the
vas deferens that finally drains into the spermatic cord.
Each spermatic cord is sheathed in connective tissue and contains a network of arteries,
veins, nerves, as well as the first section of the vas deferens through which sperm pass
in the process of ejaculation. The cords extend from the testes to the inguinal rings the
fascia transversalis, passing through the inguinal canal into the abdominal cavity.
The testicular arteries, arising from the abdominal aorta, are the main blood supply to the
testes. There is collateral circulation from the deferential artery (a branch of the inferior
vesical artery, which arises from the internaliliac) and the cremasteric artery (a branch of
the inferior epigastric artery). The testicular arteries, as well as the pampiniform plexus,
nerves, and lymphatics, converge within the spermatic cord and course toward the tunica
albuginea The remaining portions of the scrotum receive arterial blood from the pudendal
arteries, which arise from the internal iliac artery.
US tecnique
Page 3 of 76
US is the imaging modality of choice for evaluating acute and nonacute scrotal disease.
Scrotal ultrasound exam is ideally performed with the patient in the supine position, with
a rolled towel or pillow placed between the legs to support the scrotum and with the penis
positioned superiorly.
A high-frequency transducer (8-MHz to15-MHz) is used for scanning, but lower frequency
transducers can be employed for an edematous scrotum.
Sagittal and transverse images of each testicle should be obtained, as well as transverse
side-by-side images of both testes in order to compare echogenicity, scrotal wall
thickness and flow symmetry. Color and power Doppler ultrasound can also be used to
detect perfusion and verify abnormal flow patterns.
Normal scrotum in US evaluation
• Scrotal bag : an echogenic smooth band outlining the testis.

• Testis: medium homogeneous echogenicity, although its appearance may
vary according to the amount of fibrous and adipose tissue it contains. The
mediastinum of the testis is seen has an echogenic band along the long
axis of the testis. The tunica albuginea is not normally visible unless fluid
surrounds the testicle.
The testis measures between 3-5cm in length, 2-4cm in width and
approximately 3cm in AP dimension
• Epididymis: usually isoechoic or hypoechoic relative to the testicle. Its body

is isoechoic or slightly hypoechoic relative to the head.
The epididymis measures approximately 6-7cm in length, the head
measures approximately 10-12mm in AP dimension and the body
should have a thickness of less than 4mm.
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Images for this section:
Fig. 1: Scrotal ultrasound: sagittal image of the normal testicle, showing medium
homogeneous echogenicity.
© Department of Radiology, Hospital São Francisco Xavier, Lisboa/ Portugal 2013
Page 5 of 76
Fig. 2: Scrotal ultrasound: transverse image of both testicles, showing normal medium
homogeneous echogenicity.
Page 6 of 76
Fig. 3: Scrotal ultrasound: sagittal image of the normal mediastinum testis, an echogenic
band along the long axis of the testicle. It supports the testicular vessels and ducts.
Page 7 of 76
Fig. 4: Scrotal ultrasound: sagittal image of the normal epididymis head, located adjacent
to the superior pole of the testis, usually isoechoic or hypoechoic relative to the testicle.
Page 8 of 76
Fig. 6: Scrotal ultrasound: sagittal image of the normal epididymis body, usually isoechoic
or slightly hypoechoic relative to the head.
Page 9 of 76
Findings and procedure details
Acute epididymitis and epididymo-orchitis
Inflammatory disease of the epididymis and testis presents with scrotal pain and
swelling, and sometimes fever and chills. The pain can be relieved by elevating the
testis over the symphysis pubis, and this clinical sign, called the Prehn sign, helps
differentiate epididymitis from torsion of the spermatic cord, in which scrotal pain
is not relieved by this maneuver.
Epididymo-orchitis is usually bacterial in origin, although rare causes like

tuberculosis, sarcoidosis, brucellosis, cryptococcus, and mumps should be
considered in the appropriate context.
US evaluation shows an enlarged, heterogeneous, hypoechoic (or hyperechoic if

there is hemorrhage) epididymis (Fig. 6, 7, 8, 9). Reactive hydrocele is common
(Fig 10) and scrotal wall edema and thickening (Fig 11) may be present. In 20%-40%
of cases, a secondary involvement of the testicle occurs due to direct spread of
the infection, and US also shows an enlarged, heterogeneous and hypoechoic
testicle (Fig 12 and 13). Increased vascularity at color and power Doppler US is the
hallmark of scrotal infection, representing hyperemia of the epididymis, testis, or
both. Acute epididymitis is associated with a high-flow, low-resistance pattern.
Sometimes it may be difficult to distinguish focal heterogeneous areas of

inflammation from neoplastic lesions solely on the basis of gray-scale appearance,
and that is why a testicle with heterogeneous echogenicity should be followed to
complete resolution of the inflammatory process and documented with US to rule
out tumor or infarction.
Complications of epididymitis/epididymo-orchitis include infarction, abscess and

pyocele.
Testicular abscess (Fig 15, 16) is a sequela of epididymo-orchitis but can also be
caused by mumps, infarction or trauma. The US appearance is diverse. The testicle
is usually enlarged, containing an ill-defined, heterogeneous and hypoechoic area
containing fluid or internal echoes. An irregular wall can be seen and there is
typically peripherical hypervascularity.
Acute inflammation may also progress to chronic epididymitis, a condition

characterized by persistent scrotal pain. Atgray-scale US, the epididymis is
enlarged and shows diverse echogenicity, although in most cases will show
increased echogenicity. Calcifications within the epididymis may also be present.
Page 10 of 76
Granulomas can be seen in cases of tuberculosis, brucellosis, sarcoidosis,
leprosy, and syphilis.
Primary orchitis is a rare condition and usually caused by mumps. Bilateral

involvement occurs in 14%-35% of cases. The testis appear enlarged, with
decreased echogenicity and increased vascularity.
Intratesticular venous flow is hard to detect in normal testes, so increased and

easily detected testicular venous flow is highly suggestive of orchitis.
Testicular Torsion
Testicular torsion is one of the most common indications for scrotal ultrasound,
for it must be identified and treated within a few hours after its onset in order to
prevent infarction of the hemodynamicallycompromised testicle.
The predisposing factors to torsion include a long and narrow mesentery and
a congenital abnormality called the "bell-clapper deformity", which consists on
a failure of normal posterior anchoring of the gubernaculum, epididymis and
testis, leaving the testis free to swing and rotate within the tunica vaginalis. This
abnormality is bilateral in most cases.
The risk of infarction varies with the degree of torsion. Torsion of 90 degrees
causes lymphatic and venous obstruction and may not cause infarction for days.
But torsion of 720 degrees obstructs arterial flow and may cause ischemia and
infarction within 2 hours.
If diagnosed and surgically treated within the first 6 hours, the salvage rate is nearly
100%, but if left untreated for more than 12 hours it may decrease to only 20%.
It can occur at any age, however, it is most frequent in young teenage boys,
and clinically manifests with acute scrotal pain and swelling, as well as nausea,
vomiting, and a low-grade fever. The pain cannot be relieved by elevation of the
scrotum.
Gray-scale US findings are nonspecific for testicular torsion, and often appear
normal in the early phases of torsion.
US evaluation within the first 4-6 hours usually shows decreased echogenicity of
the testicular parenchyma with edema, but may be heterogeneously increased with
superimposed hemorrhage.
Page 11 of 76
24 hours after onset, the testis has a heterogeneous echotexture due to vascular
congestion, hemorrhage, and infarction (Fig 17, 18).
Venous thrombus may be visible in the spermatic cord as enlarged, clot-filled,

occluded veins of the pampiniform plexus.
Scrotal wall thickening and reactive hydrocele are common findings.
Color and power Doppler US demonstrates absent or decreased flow with low peak
systolic velocity in the symptomatic testis compared to the opposite one.
With spontaneous detorsion, Doppler findings may be normal or demonstrate

reactive hyperemia. The major clue to detorsion is the spontaneous and rapid
improvement in patient's symptomatology.
The appendix testis and appendix epididymis can also suffer torsion, clinically
presenting with acute scrotal pain and a small palpable nodule on the superior
aspect of the testis, exhibiting a bluish discoloration of the overlying skin - the
"blue dot" sign.
US evaluation reveals a hyperechoic mass with a central hypoechoic area adjacent

to the testis, and increased peripheral flow may be seen around the twisted
testicular appendage at color Doppler US.
The treatment for this condition is conservative and essentially focused on pain
relief.
In many cases, the appendix suffers atrophy and may even calcify within a few
days.
Nonpalpable Testis
Testis may be nonpalpable if they are congenitally absent, or in case of atrophy, ectopia
or cryptorchidism.
Ectopic testis may be found in the contralateral hemiscrotum, in the perineum, femoral
canal or superficial inguinal pouch, the latter being the most common ectopic location.
Cryptorchidism is a complete or partial failure of the intraabdominal testes to descend

into the scrotal sac, so they can be positioned anywhere along the path of descent. The
most common location, however, is the inguinal canal.
There are some complications related to cryptorchidism, such as infertility, torsion, bowel
incarceration and even an increased risk for malignant degeneration, seminoma being
Page 12 of 76
the most common tumor associated with this condition. This increased risk for malignancy
remains even after orchiopexy.
US evaluation is excellent in location of testes, high up in scrotum or within the inguinal

canal, however its use is limited in intra-abdominal, pelvic or retroperitoneal testes (in
these difficult cases, MRI is more sensitive in detecting the testicle).
The undescended testis is normally smaller and slightly less echogenic than the normal
testis. It may be mistaken for a large lymph node or the pars infravaginalis gubernacula
(Fig 19).
Scrotal calcification
Scrotal calcification can be divided in intratesticular and extratesticular.
Intratesticular calcification is related to the presence of phleboliths, spermatic granulomas

or vascular calcification, although it may also be associated with tumours. Testicular
microlithiasis, a rare condition consisting of multiple scattered echogenic foci within the
testis, represents the formation of microliths from degenerating cells in the seminiferous
tubules, and has been proved to be associated with tumors of the testis, both benign
and malignant.
Testicular microlithiasis consists of multiple tiny echogenic foci with a variable distribution
within the testis, measuring 1-3 mm in diameter, usually with a symmetrical distribution of
foci, although a unilateral pattern can also be found. They show no acoustic shadowing,
probably owing to their small size (Fig 20.21.22).
A cluster of calcification within a hypoechoic area in the testis suggests a testicular

tumour (Fig 23) or chronic testicular infarction (due to trauma or torsion or secondary to
severe epididymitis). The distinction between the two conditions may be difficult, but focal
infarction is usually peripheral and wedge-shaped, with linear edges containing specks
of calcification.
Extratesticular calcification is more frequent than intratesticular one and usually means
benign disease, often being related to previous inflammatory disease of the epididymis.
The focus of calcification is usually solitary and the site of calcification points towards
the diagnosis.
The scrotal pearl (Fig 24) is a calcified body measuring up to 1cm in diameter and located
between the internal and external layers of the tunica vaginalis, whose etiology is still
unclear, probably representing a fibrinous deposit in the tunica vaginalis or a remnant of
a detached torsed appendix testis or appendix epididymis.
Page 13 of 76
Occasionally, the tunica vaginalis may calcify extensively and produce a linear plaque
with acoustic shadowing.
Calcification in the epididymis is common in chronic epididymitis (Fig 25). Granulomatous

disease should also be considered in such cases.
Benign cystic conditions of the scrotum
• Benign intratesticular conditions:
Cystic lesions
Usually incidental findings, cystic lesions are not always benign, for some tumors may
suffer cystic degeneration due to hemorrhage or necrosis.
But unlike cystic tumors, testicular benign cysts do not require surgery, only conservative
treatment.
Cysts of the tunica albuginea - Usually solitary and unilocular (although they can also
be multiple and multilocular), they are simple cysts enclosed by a cuboid or cylindrical
epithelium. The etiology of these cystic lesions is unknown, but they probably have a
mesothelial origin. Ranging from 2-5mm in size, they are usually asymptomatic and
detected only when there is a palpable mass.
They can calcify, remaining as a palpable calcification, which casts an
acoustic shadow at US.
Simple cysts - these pure serous liquid lesions are enclosed by a thin, smooth wall,
and have a variable size, ranging from 2mm to 2cm. They are located adjacent to the
mediastinum testis, usually solitary (but may be multiple) and frequently associated with
extratesticular spermatoceles. Trauma, surgery or prior inflammation constitute some of
the suspected causes.
At US they are anechoic, well-defined lesions, with no perceptible wall and with through-
transmission (Fig 26,27,28).
Epidermoid cysts - also known as keratocysts, they are benign tumors of germ cell
origin, ranging in size from 1-3cm.
Page 14 of 76
The US appearance of these cyst varies with the degree of maturation. The classic
appearance is an "onion-ring" pattern with alternating hyperechoic and hypoechoic
layers, with no internal blood flow on Doppler US.
Tubular ectasia of rete testis
A benign condition common in men older than 55 years, resulting from partial
or complete obstruction of the efferent ducts due to trauma or inflammation. The
US appearance is of several fluid-filled tubular structures in or adjacent to the
mediastinum testis, frequently bilateral (Fig 29,30).
• Benign extratesticular conditions:
These extratesticular cystic lesions are more common than the intratesticular
ones, and can be found in the spermatic cord, epididymis,
tunica albuginea, or tunica vaginalis.
Spermatoceles are more common than epididymal cysts, and almost always
arise in the epididymis head. They represent cystic dilatation of the efferent
ductules of this segment of the epididymis and therefore contain spermatozoa
and a proteinaceous fluid. They are predominantly solitary, with size up to 2-3-cm
diameter, and septations are common.
Epididymal cysts contain clear serous fluid and may arise throughout the
epididymis. They are often multiple, with usual size <1 cm, and can be found
anywhere along the epididymis.
Distinguish epididymal cysts from espermatoceles usually has no clinical

relevance.
Both spermatoceles and epididymal cysts may result from previous episodes of
epididymitis or trauma.
At US evaluation these lesions are quite similar, usually indistinguishable,

emerging as well-defined hypoechoic lesions with posterior acoustic
enhancement (Fig 31,32,33,34,35,36).
Occasionally, the proteinaceous content of spermatoceles may give them a milky,

low-level echogenic appearance. They may even appear solid if completely filled
with echogenic fluid.
Page 15 of 76
Malignant conditions of the scrotum
• Malignant intratesticular conditions:
While the majority of extratesticular masses are benign, intratesticular masses are more
likely to be malignant.
Most solid testicular masses are malignant.
Testicular cancer accounts for only 1-2% of all malignant lesions in men.
There are some known risk factors this malignancy, namely white men, cryptorchism,
Klinefelter syndrome and gonadal dysgenesis.
Patients generally present with a unilateral, painless scrotal mass, although some may
mention minor discomfort in the scrotum. Sometimes there is just a diffuse enlargement
of the testicle. Constitutional symptoms such as fever are infrequent.
At the time of presentation, only 4-14% of patients have symptoms related to

metastization.
Gray-scale US examination is nearly 100% sensitive for detection of testicular

malignancies, although it cannot provide the histologic and morphologic diagnosis.
Most malignant tumors of the testicle are hipoechogenic related to the testicular
parenchyma. But the presence of hemorrhage, necrosis or calcification may increase
the echogenicity of these lesions. Additionally, there are many benign intratesticular
conditions, such as hematoma, abscess, orquitis, infarction and granuloma, that mimic
testicular malignancy and must be taken into account in the differential diagnosis.
In the majority of malignant tumors, color and power Doppler US will reveal increased
vascularity, but this is not a specific feature for the diagnosis of malignancy, and
sometimes it is not easy to prove increased blood flow in small tumors.
There are two main types of malignant tumors of the testis: Germ Cell Tumors and
Gonadal Stromal Tumors.
Germ Cell Tumors
Germ Cell Tumors account for 90-95% of testicular tumors and are divided in two
groups, seminomatous and nonseminomatous, both having different biological behavior,
treatment and prognosis.
Page 16 of 76
Seminoma is the most common single-cell type of testicular tumors in adults, accounting
for nearly 50% of all germ cell tumors.
They have a peak incidence in the fourth and fifth decades, and are rare before puberty.
Seminomas are less aggressive than other testicular tumors and are highly sensitive to
radiation and chemotherapy, therefore are associated with a favorable prognosis.
At the time of presentation, nearly 25% of patients show lymphatic spread to

retroperitoneal lymph nodes and hematogenous metastases to lung, brain or both.
Nonseminomatous germ cell tumors (NSGCTs) arise in younger men, having a peak
incidence in the second and third decades.
They include embryonal cell carcinoma, teratoma, yolk sac tumor, and choriocarcinoma.
Mixed tumor histology is common.
These lesions are more aggressive than seminomas, frequently invading the tunica
albuginea and causing distortion of the testicle contours. Metastization is also more
common, and they are less sensitive to radiation and chemotherapy, therefore these
masses hold a worse prognosis.
On gray-scale US scans, seminoma appears as a homogeneous, hypoechoic lesion,

usually confined by the tunica albuginea and rarely extend to peritesticular structures
(Fig 37,38,39,40). In more than half the cases, the entire testis is replaced by tumor.
Infrequently, there may exist cystic components, which represent liquefaction necrosis
or dilation of rete testis caused by tumor-related occlusion. Calcifications are not seen.
At US evaluation, NSGCTs have heterogeneous echotexture and irregular margins, and

when a multihistologic pattern is present, the appearance depends on the proportions of
each component. Cystic, hemorrhagic, fibrotic and necrotic areas, as well as calcifications
are common (Fig 41,42).
Small masses (<1.5 cm) tend to be hypovascular. Larger masses tend to be

hypervascular with distorted vessels. Doppler characteristics are not helpful in
differentiating tumor types.
Gonadal Stromal Tumors
Gonadal Stromal Tumors represent 3-6% of testicular tumors, and arise from the
supporting stromal tissue of the testis.
They include Leydig cell tumors, Sertoli cell tumors and the very rare granulosa
cell tumors.
Page 17 of 76
These lesions are normally small and usually discovered incidentally.
Leydig cell tumor is the most common type of gonadal stromal tumor of the
testis and can occur in any age group. Patients present with a painless scrotal
enlargement and gynecomastia due to secretion of androgens by the lesion.
Children present with symptoms of precocious puberty due to the same motive.
Gonadal Stromal Tumors do not have a specific US appearance, but usually appear
as small, well-defined hypoechoic lesions. In some cases there may exist foci of
hemorrhage and/or necrosis.
Secondary malignant lesions of the testis
Lymphoma is the most common secondary malignant lesion of the testicle. It is

also the most frequent testicular neoplasm in older men (>60 years old), and the
most usual bilateral tumor of the testicle.
Histologically, they are almost exclusively diffuse non-Hodgkin lymphoma B-cell

tumors.
Clinically, patients present with a painless enlarged testis and, less commonly,
with constitutional symptoms.
At US examination, these tumors resemble seminomas, appearing as

homogeneous, hypoechoic lesions, or multifocal hypoechoic lesions of various
sizes, with or without hemorrhage and necrosis. But unlike seminomas, these
masses sometimes involve the spermatic cord and epididymis. Color Doppler US
shows increased vascularity regardless of the size of the lesion.
Leukemia (both acute and chronic) is the second most common secondary
malignant lesion of the testicle, many times diagnosed during clinical remission.
This happens because systemic chemotherapy does not reach the intratesticular
tumor in sufficient concentration to eliminate the tumor cells.
The US appearance is similar to that of lymphoma.
Metastization from other tumors to the testis is uncommon, and usually happens in
a context of diffuse and advanced spreading of the disease. Metastases originate
most commonly from prostate, renal, lung, and gastrointestinal carcinoma and
malignant melanoma.
The US appearance is variable (Fig 43,44).
Page 18 of 76
Tumorlike Lesions in the Testis
Some intratesticular lesions detected by US within the testicle may mimic a tumor
at US, and these include orchitis, hemorrhage, ischemia or infarction and scar
tissue from prior biopsy.
The clinical presentation holds the key to a precise diagnosis.
These lesions are often more ill-defined than tumors, but the US appearance can
be deceiving.
Intratesticular hematoma may be similar to a neoplasm, but it appears avascular at

color Doppler US, and many times there is a previous history of trauma (Fig 45,46).
Focal orchitis can also mimic a malignant tumor, appearing at US as an ill-defined

hypoechoic lesion with variable echogenicity, with increased vascularity at color
Doppler evaluation. There are frequently concomitant acute symptoms.
In a patient with a focal, nonpalpable, hypoechoic, intratesticular lesion, a history

of previous testicular biopsy suggests a benign change after the procedure, and
US follow-up is advisable.
Granulomatous orchitis can also manifest as a testicular mass, and may be caused
by several pathogens including tuberculosis, syphilis,
fungi, and parasites. It is more frequent in middle-aged men with a history of

testicular trauma, and is clinically characterized by testicular enlargement and
sometimes even scrotal pain.
Usually this condition has a more indolent course, and tends to involve the
epididymis to a much greater extent than the testis.
But it can be extremely difficult to differentiate granulomatous orchitis from a

testicular tumor, because both may appear as either a focal or a diffuse mass with
inhomogeneous echotexture.
Gray-scale US shows an irregularly hypoechoic testicle, with increased blood flow

at the periphery of the lesion but no flow inside the lesion. The final diagnosis can
only be confirmed after orchiectomy.
• Malignant extratesticular conditions:
Paratesticular tumors are rare, and most of them involve the epididymis.
Page 19 of 76
These tumors clinically present as a painless firm scrotal mass.
Adenomatoid tumors represent 30% of these masses, and are benign neoplasms
with no reported metastases or recurrence after excision.
At US appearance they have variable echogenicity.
Papillary cystadenoma of the epididymis is also a rare benign tumor, often

associated with von Hippel-Lindau disease.
The US appearance is also very diverse, ranging from a primary cystic mass with
an intramural solid component to an almost completely solid mass.
Other rare tumors of the epididymis include leiomyoma, lipoma, rhabdomyoma,

lymphoma, and lymphangioma (Fig 47,48).
Only about 25% of solid tumors of the epididymis are malignant,
and the majority are metastases from other tumors.
Trauma
Frequently results from motor vehicle accident, athletic injury or a direct blow. It may
lead to contusion, hematoma, fracture, or rupture of the testis. Rupture demands a fast
diagnosis for it is a surgical emergency, and a precocious surgery can save the testicle.
US findings in testicular trauma are variable.
Up to one third of cases will show an echogenic fluid collection representing an acute
hematocele (Fig 49). Focal areas of altered parenchymal echogenicity may signify
intratesticular hemorrhage or infarction, not necessarily with evidence of testicular
rupture.
An interruption of the tunica albuginea, in a heterogeneous testis with irregular poorly

defined borders and scrotal wall thickening highly suggests rupture. Color and power
Doppler US help demonstrate disruption in the normal capsular blood flow of the tunica.
In a case of suspected testicular fracture or rupture, or in the presence of a large

hematocele, scrotum exploration is advisable.
Testicular Prostheses
Page 20 of 76
The indications for insertion of testicular prosthesis include orchidectomy for a number
of causes such as malignancy, torsion and orchitis.
The most common substance used around the world in the manufacture of these implants
is silicone;
At US the prosthesis appears as an anechoic oval structure in the scrotum.
Silicone may cause some sound enhancement and reverberation artifacts (Fig 50).
Hydrocele, Hematocele and pyocele
These three conditions represent accumulation of fluid (correspondingly serous fluid,

blood and pus) between the visceral and parietal layers of the tunica vaginalis.
In the majority of cases, the normal scrotum usually has a minimum amount of fluid
between these two layers, which is seen at US evaluation and is not considered
hydrocele.
Hydrocele is an abnormal accumulation of serous fluid. There are congenital hydroceles,

which are caused by patency of the processus vaginalis, allowing the entrance of
peritoneal fluid in the scrotal sac, and there are acquired hydroceles, which develop in a
context of trauma, infection, torsion or, in rare cases, tumor.
At US, hydroceles are anechoic fluid collections, usually surrounding the anterolateral
aspects of the testis, avascular on Doppler evaluation. (Fig 51,52). Sometimes, internal
low-level echoes may be seen, indicating a high protein or cholesterol content (Fig 53,
54).
Hematoceles and pyoceles are less common than hydroceles.
Hematoceles are typically secondary to trauma, previous surgery, torsion or tumor.
Pyoceles result from the rupture of an intratesticular abscess into the virtual space
between the two layers of the tunica vaginalis, or sometimes from an untreated
epididymo-orchitis.
At US both conditions are complex cystic lesions, with internal echogenic content,
septations and loculations (Fig 55,56,57,58). In chronic cases, scrotal wall thickening and
calcifications may also exist.
Varicocele
Page 21 of 76
Varicocele is an abnormal dilatation and tortuosity of the veins of the pampiniform
plexus, usually due to incompetent valves in the internal spermatic Vein (idiopathic
varicocele), leading to an impaired drainage of blood into the spermatic cord veins
in the upright position or during the Valsalva maneuver.
This condition develops over time, and affects nearly 15% of adult men.
It may also be a consequence of venous compression caused by hydronephrosis

or an abdominal neoplasm (secondary varicocele).
Varicoceles are more common on the left side for several reasons, namely: the left
testicular vein is longer and enters the left renal vein at a right angle; in some men,
the left testicular artery curves over the left renal vein and compresses it; the left
testicular vein is more susceptible to compression by the descending colon when
it is distended with feces.
Clinically, there may be a palpable scrotal mass, and the patient often describes it
as feeling "like a bag of worms". An aching pain within the scrotum or a feeling of
heaviness in the testicle are also common symptoms.
One of the main functions of the pampiniform plexus, which is keeping the
temperature of the testicles low, is lost when varicocele is present, and if untreated,
it will lead to testicular atrophy and, consequently, infertility.
US should be performed in both a supine and a standing position.
The veins of the pampiniform plexus normally range from 0.5 to 1.5 mm in diameter,
and the main draining vein can reach 2 mm in diameter.
At US evaluation, varicocele appears as multiple, hypoechoic, serpiginous,

elongated tubular structures larger than 2 mm in diameter, usually best visualized
superior and/or lateral to the testis, but extending posteriorly and inferiorly to the
testis when the varicocele is large. Internal low-level echoes can be perceived
inside the dilatated veins, representing slow venous flow (Fig 59,60,61,62). This
pattern of flow can be confirmed by color flow and duplex Doppler US, which also
shows a phasic variation and retrograde filling during the Valsalva maneuver.
Page 22 of 76
Images for this section:
Fig. 5: Acute epididymitis : enlarged and heterogeneous head of epididymis, with

increased vascularity at color Doppler US.
Page 23 of 76
Fig. 7: Acute epididymitis - enlarged and heterogeneous head of epididymis, with
Page 24 of 76
Fig. 8: Acute epididymitis : enlarged and heterogeneous head of epididymis, with
Page 25 of 76
Fig. 9: Acute epididymitis : enlarged, hypoechoic and heterogeneous body and tail of
epididymis, with increased vascularity at color Doppler US.
Fig. 10: Acute epididymitis - enlarged, hypoechoic and heterogeneous body of

epididymis, with reactive septated hydrocele.
Page 26 of 76
Fig. 11: Acute epididymitis : Scrotal wall edema and thickening
Page 27 of 76
Fig. 12: Acute epididymo-orchitis : secondary involvement of the testicle, with an
enlarged, heterogeneous and hypoechoic testicle, as well as increased vascularity at
color Doppler US.
Page 28 of 76
Fig. 13: Acute epididymo-orchitis : secondary involvement of the testicle, with an
enlarged, heterogeneous and hypoechoic testicle, as well as increased vascularity at
color Doppler US.
Page 29 of 76
Fig. 14: acute epididymitis : Reactive hipervascularity of the vascular structures of the
spermatic cord
Page 30 of 76
Fig. 15: Testicular abscesses : hypoechoic areas with ill-defined walls, containing fluid
as well as low-level internal echoes.
Page 31 of 76
Fig. 16: Microabscesses of the head and tail of the epididymis, already visible in previous
US studies, probably a sequela of epididymo-orchitis.
Page 32 of 76
Fig. 17: Testicular torsion : an enlarged testicle with highly heterogeneous echotexture
in a 9-year-old boy with an acute onset of scrotal pain and enlargement.
Fig. 18: Testicular torsion - an enlarged testicle with highly heterogeneous echotexture
and absent flow on Doppler evaluation in a 9-year-old boy with an acute onset of scrotal
pain and enlargement. Vascularization is seen in the epididymis area.
Page 33 of 76
Fig. 19: Undescendent testicle - right testicle visualized near the inguinal canal, next to
the external inguinal ring, The left testicle was correctly inserted in the scrotal sac and
was a little bigger than the right one.
Page 34 of 76
Fig. 20: Testicular microlithiasis - multiple tiny echogenic foci within the testis, with no
acoustic shadowing
Page 35 of 76
acoustic shadowing
Page 36 of 76
acoustic shadowing
Page 37 of 76
Fig. 23: Seminoma of the testis with a cluster of calcification.
Page 38 of 76
Fig. 24: Scrotal pearl : a calcified loose body lying between the membranes of the tunica
vaginalis, usually solitary, round and measuring up to 1 cm in diameter, producing a
discrete acoustic shadowing.
Page 39 of 76
Fig. 25: Microcalcifications of the head of epididymis, a common fiding in chronic
epididymitis.
Page 40 of 76
Fig. 26: A small, unilocular simple cyst of the testicle. anechoic, well-defined, with no
perceptible wall.
Page 41 of 76
Fig. 27: Unilocular simple cyst of the testicle. anechoic, well-defined, with no perceptible
wall, and with through-transmission.
Page 42 of 76
Fig. 28: Multilocular cyst of the testicle.
Page 43 of 76
Fig. 29: Tubular ectasia of rete testis : fluid-filled tubular structures in or adjacent to the
mediastinum testis. There is no change in the peri-testicular soft tissues.
Page 44 of 76
Fig. 30: Tubular ectasia of rete testis - fluid-filled tubular structures in or adjacent to the
mediastinum testis. There is no change in the peri-testicular soft tissues.
Page 45 of 76
Fig. 31: Spermatocele / epididymal cyst - a bulky hypoechoic with posterior acoustic
enhancement lesion, occupying practically the entire head of the epididymis. There is
also a discrete pure hydrocele
Page 46 of 76
Fig. 32: Spermatocele / epididymal cyst - a bulky hypoechoic with posterior acoustic
enhancement lesion, occupying practically the entire head of the epididymis.
Page 47 of 76
Fig. 33: Spermatocele / epididymal cyst - a large hypoechoic with posterior acoustic
enhancement lesion of the epididymis head.
Page 48 of 76
Fig. 34: Spermatoceles / epididymal cysts - a patient with a large hypoechoic with
posterior acoustic enhancement lesion, occupying practically the entire head of the
epididymis, with internal septa.
Page 49 of 76
Fig. 35: Spermatocele / epididymal cyst : A small, 5mm hypoechoic lesion in the head of
the epididymis, representing a benign cystic lesion.
Page 50 of 76
Fig. 36: Spermatoceles / epididymal cysts - Two small hypoechoic lesions in the head
of the epididymis.
Page 51 of 76
Fig. 37: Seminoma - a large hypoechoic lesion occupying practically the entire testicle,
hypervascular at color Doppler US. The histological report confirmed a seminoma.
Fig. 38: Seminoma - a large hypoechoic lesion occupying practically the entire testicle,
hypervascular at color Doppler US. The histological report confirmed a seminoma.
Page 52 of 76
Fig. 39: Seminoma - a homogeneous, hypoechoic lesion, confined by the tunica
albuginea. The histological report confirmed a seminoma.
Page 53 of 76
Fig. 40: Seminoma - a hypoechoic lesion, confined by the tunica albuginea. The
histological report confirmed a seminoma.
Page 54 of 76
Fig. 41: Embryonal carcinoma : a large, predominantly hypoechoic lesion with poorly
defined margins and an inhomogeneous echotexture, with a few small cystic-like areas. It
invades the tunica albuginea and causes distortion of the testicle countours in the upper
pole. The histological report confirmed an embryonal carcinoma. A small hydrocele is
present.
Page 55 of 76
Fig. 42: Embryonal carcinoma - a large, predominantly hypoechoic lesion with poorly
defined margins and an inhomogeneous echotexture, with a few small cystic-like areas. It
invades the tunica albuginea and causes distortion of the testicle countours in the upper
pole. The histological report confirmed an embryonal carcinoma. A small hydrocele is
present.
Page 56 of 76
Fig. 43: Testicular metastasis from lung tumor (right testicle) : multiple, bilateral lesions
os the testis, predominantly hypoechoic but with inhomogeneous echotexture, in a patient
with a known small cell lung carcinoma in advanced stage (innumerable metastasis in
the contralateral lung, liver and bone). Autopsy confirmed metastasis of the testis.
Page 57 of 76
Fig. 44: Testicular metastasis from lung tumor (left testicle) : multiple, bilateral lesions os
the testis, predominantly hypoechoic but with inhomogeneous echotexture, in a patient
with a known small cell lung carcinoma in advanced stage (innumerable metastasis in
the contralateral lung, liver and bone). Autopsy confirmed metastasis of the testis.
Page 58 of 76
Fig. 45: Intratesticular hematoma : a hypoechoic, well-defined lesion of the testicular
parenchyma, avascular at color Doppler US, in a patient with a recent history of trauma.
Page 59 of 76
Fig. 46: Intratesticular hematoma : a hypoechoic, well-defined lesion of the testicular
parenchyma, avascular at color Doppler US, in a patient with a recent history of trauma.
Page 60 of 76
Fig. 47: Paratesticular leiomyoma : a solid lesion in the head of epididymis, with
heterogeneous echotexture, showing internal vascularization at color Doppler evaluation,
in a patient with a palpable nodule in the left scrotum. Histological report confirmed a
paratesticular leiomyoma. Both testis showed no pathological findings.
Page 61 of 76
Fig. 48: Paratesticular leiomyoma : a solid lesion in the head of epididymis, with
heterogeneous echotexture, showing internal vascularization at color Doppler evaluation,
in a patient with a palpable nodule in the left scrotum. Histological report confirmed a
paratesticular leiomyoma. Both testis showed no pathological findings.
Page 62 of 76
Fig. 49: Testicular trauma : a small intratesticular hemorrhage in a patient after an
athletic injury. There is no interruption of the tunica albuginea. The remainder testicular
parenchyma is homogeneous.
Page 63 of 76
Fig. 50: Testicular Prosthesis : anechoic oval structure in the hemi scrotum, in a patient
submitted to orchidectomy due to a malignant lesions (seminoma).
Page 64 of 76
Fig. 51: Hydrocele - an anechoic fluid collection within the scrotal sac
Page 65 of 76
Fig. 52: Hydrocele - an anechoic fluid collection within the scrotal sac
Fig. 53: Hydrocele : an anechoic fluid collection within the scrotal sac, with internal low-
level echoes, indicating a high protein or cholesterol content.
Page 66 of 76
Fig. 54: Hydrocele : a large fluid collection, with significant internal echogenic content, in
a patient with several follow-up US evaluations, representing a case of chronic hydrocele.
The left testicle is pushed down by the hydrocele.
Page 67 of 76
Fig. 55: Hematocele : A complex cystic lesions in the scrotal sac and extending to the
ipsilateral inguinal canal, in a patient recently submitted to surgery. The fluid collection is
heterogeneous, non pure, with echogenic content, representing an hematoma.
Fig. 56: Hematocele : a complex fluid collection with septation and debris, that appeared
a few days following a scrotal trauma, indicating hematocele in the cavity of the tunica
vaginalis. The testis is intact. Pyocele has a similar appearance.
Page 68 of 76
Fig. 57: Hematocele : a complex fluid collection with septation and debris that appeared
a few days following a scrotal trauma, indicating hematocele in the cavity of the tunica
vaginalis. The testis is intact. Pyocele has a similar appearance
Page 69 of 76
Fig. 58: Hematocele : Scrotal sac filled with a large, heterogeneous and mixed collection,
with internal non pure cystic áreas and thick septations, in a patient with a few follow-up
US evaluations, representing a case of chronic hematocele.
Page 70 of 76
Fig. 59: Varicocele : enlarged, serpiginous and tortuous veins of the pampiniform plexus.
Page 71 of 76
Internal low-level echoes are obvious, representing slow venous flow.
Page 72 of 76
Page 73 of 76
Page 74 of 76
Conclusion
Ultrasonography is the modality of choice for imaging of scrotal pathology.
Understanding of scrotal anatomy, having a good knowledge of the normal and pathologic
US appearance of the scrotum, application of adequate US technique and familiarity with
scrotal benign and malignant disorders improve the radiologist's ability to make accurate
diagnoses.
Page 75 of 76
References
1. Vikram S. Dogra, Ronald H. Gottlieb, Mayumi Oka, Deborah J. Rubens.

Sonography of the Scrotum. Radiology. 2003; 227:18-36
2. Paula J. Woodward, Roya Sohaey, Michael J. O'Donoghue, Douglas E.
Green. Tumors and Tumorlike Lesions of the Testis: Radiologic-Pathologic
Correlation. RadioGraphics 2002; 22:189-216
3. Shweta Bhatt, Vikram S. Dogra. Role of US in Testicular and Scrotal
Trauma. RadioGraphics 2008;28:1617-1629
4. Corinne Deurdulian, Carol A. Mittelstaedt, Wui K. Chong, Julia R. Fielding.
US of Acute Scrotal Trauma: Optimal Technique, Imaging Findings, and
Management. RadioGraphics 2007; 27:357-369
5. Dina Ragheb, Joseph L. Higgins Jr. Ultrasonography of the Scrotum:
Technique, Anatomy, and Pathologic Entities. J Ultrasound Med. 2002;
21:171-185
Page 76 of 76

ECR2014 - Ultrasound Evaluation of Scrotal Pathology

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Ultrasound evaluation of Scrotal pathology

Poster No.: C-1225

The educational objectives of this exhibit are:

• To recollect the normal anatomy of scrotum, as well as the ultrasonography

The epididymis is an elongated, crescent-shaped structure, located along the superior

Normal scrotum in US evaluation

• Scrotal bag : an echogenic smooth band outlining the testis.

The testis measures between 3-5cm in length, 2-4cm in width and

approximately 3cm in AP dimension

• Epididymis: usually isoechoic or hypoechoic relative to the testicle. Its body

The epididymis measures approximately 6-7cm in length, the head

measures approximately 10-12mm in AP dimension and the body

should have a thickness of less than 4mm.

© Department of Radiology, Hospital São Francisco Xavier, Lisboa/ Portugal 2013

© Department of Radiology, Hospital São Francisco Xavier, Lisboa/ Portugal 2013

© Department of Radiology, Hospital São Francisco Xavier, Lisboa/ Portugal 2013

© Department of Radiology, Hospital São Francisco Xavier, Lisboa/ Portugal 2013

© Department of Radiology, Hospital São Francisco Xavier, Lisboa/ Portugal 2013

Acute epididymitis and epididymo-orchitis

Epididymo-orchitis is usually bacterial in origin, although rare causes like

US evaluation shows an enlarged, heterogeneous, hypoechoic (or hyperechoic if

Sometimes it may be difficult to distinguish focal heterogeneous areas of

Complications of epididymitis/epididymo-orchitis include infarction, abscess and

Acute inflammation may also progress to chronic epididymitis, a condition

Primary orchitis is a rare condition and usually caused by mumps. Bilateral

Intratesticular venous flow is hard to detect in normal testes, so increased and

Venous thrombus may be visible in the spermatic cord as enlarged, clot-filled,

Scrotal wall thickening and reactive hydrocele are common findings.

With spontaneous detorsion, Doppler findings may be normal or demonstrate

US evaluation reveals a hyperechoic mass with a central hypoechoic area adjacent

Cryptorchidism is a complete or partial failure of the intraabdominal testes to descend

US evaluation is excellent in location of testes, high up in scrotum or within the inguinal

Scrotal calcification can be divided in intratesticular and extratesticular.

Intratesticular calcification is related to the presence of phleboliths, spermatic granulomas

A cluster of calcification within a hypoechoic area in the testis suggests a testicular

Calcification in the epididymis is common in chronic epididymitis (Fig 25). Granulomatous

Benign cystic conditions of the scrotum

• Benign intratesticular conditions:

They can calcify, remaining as a palpable calcification, which casts an

acoustic shadow at US.

Tubular ectasia of rete testis

• Benign extratesticular conditions:

tunica albuginea, or tunica vaginalis.

Distinguish epididymal cysts from espermatoceles usually has no clinical

At US evaluation these lesions are quite similar, usually indistinguishable,

Occasionally, the proteinaceous content of spermatoceles may give them a milky,

• Malignant intratesticular conditions:

Most solid testicular masses are malignant.

At the time of presentation, only 4-14% of patients have symptoms related to

Gray-scale US examination is nearly 100% sensitive for detection of testicular

Germ Cell Tumors

At the time of presentation, nearly 25% of patients show lymphatic spread to

On gray-scale US scans, seminoma appears as a homogeneous, hypoechoic lesion,

At US evaluation, NSGCTs have heterogeneous echotexture and irregular margins, and

Small masses (<1.5 cm) tend to be hypovascular. Larger masses tend to be

Gonadal Stromal Tumors

Secondary malignant lesions of the testis

Lymphoma is the most common secondary malignant lesion of the testicle. It is

Histologically, they are almost exclusively diffuse non-Hodgkin lymphoma B-cell