testicular torsion, testicular trauma, testicular tumor, acute epididymitis, Fournier gangrene, varicocele.

1. Doppler ultrasound of acute scrotum
Samir Haffar M.D.
Assistant Professor of Internal Medicine

2. Doppler ultrasound of acute scrotum
• Normal anatomy of scrotum
• Normal US of scrotum
• Normal Doppler US of scrotum
• Doppler US of acute scrotum

3. Diagrammatic representation
of testis in cross-section
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
250 – 400 lobules
Each lobule contains 1 – 3 seminiferous tubules
Sspermatocyte – Sertoli cell – Leydig cell (testesterone)

4. Rete testis within mediastinum testis
Carkaci S et al. J Clin Ultrasound 2010 ; 38 : 21 – 37.
Rete testis drains into epididymis through 10 – 15 efferent ductules
Epididymis consists of head, body, & tail
Tail of epididymis continues as vas deferens

5. Anatomy of epididymis
6 cm in length – Best evaluated in longitudinal view
• Head Superior pole of testes
5 – 12 mm Usually isoechoic to testis
• Body Posterolateral aspect of testis
2 – 4 mm Usually hypoechoic to testis
• Tail Inferior pole of testes
5 – 12 mm Usually hypoechoic to testes
Curves to form ductus deferens
Lee JC et al. Ultrasound Quarterly 2008 ; 24 : 3 – 16.

6. Arterial supply & venous drainage of scrotal contents
Zwiebel WJ et al. Introduction to vascular ultrasonography.
Elesevier Saunders, Philadelphia, USA, 5th edition, 2005.

7. Testicular blood supply
Lee JC et al. Ultrasound Quarterly 2008 ; 24 : 3 – 16.

8. Wittenberg AF et al. Curr Probl Diagn Radiol 2006 ; 35 : 12 – 21.
Testicular artery
Deferential artery
Cremasteric artery
Pampiniform venous plexus
Vas deferens
Genito-femoral nerve
Components of spermatic cord

9. Doppler ultrasound of acute scrotum
• Normal anatomy of scrotum
• Normal US of scrotum
• Normal Doppler US of scrotum
• Doppler US of acute scrotum

10. Equipment
Canadian Association for Radiologists
• Real time linear or curved linear transducers
• Highest frequency: 7 MHz or higher
• Sufficient resolution to detect characteristics of lesions
• Highest possible Doppler frequencies: 5 to 10 MHz
• Total US exposure as low as reasonably achievable
ALARA principle
• Standoff pads can be used to improve imaging
www.car.ca
Atri M et al. CAR standard for performing scrotal ultrasound examinations. April 28, 2011

11. Sonographic technique of scrotum – 1
• Supine position & scrotum supported by towel
• Testes examined in two planes: longitudinal & transverse
• Skin thickness in each hemi-scrotum evaluated
• Color & pulsed Doppler optimized for low-flow velocity
• Compare both testes for size, echogenicity & vascularity
• Compare both epididymis for size, echogenicity & vascularity
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.

12. Scanning technique of scrotum – 2
• Bilateral testicular spectral Doppler tracings recorded
• Palpable scrotal lesion Palpate lesion & put probe on it
• Acute scrotum Asymptomatic side scanned first
Power Doppler also used
• Tumor of testis found Search for abdominal adenopathies
• Additional techniques Valsalva or upright positioning
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.

13. Tunica vaginalis
Scrotal wall thickness: Normal value 2 – 8 mm
Tunica vaginalis: Small amount of fluid between two layers
Tapping CR & Cast JE. Ultrasound 2008 ; 16 : 226 – 233.

14. Tunica albuginea
Echogenic line surrounding testis
Better visualized in presence of small amount of fluid
Dogra VS et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
Longitudinal sonogram of testis

15. Normal adult testis
Length: 4 – 5 cm
Width: 2 – 4 cm
Antero-posterior: 3 cm
Cokkinos DD et al. Curr Probl Diagn Radiol 2011 ; 40 : 1 – 14.
Transverse viewLongitudinal view

16. Side-by-side comparaison image
Gray scale image Color Doppler
Median raphe
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.

17. Normal mediastinum testis
Echogenic band running across testis on sagittal US scan
Dogra VS et al. Radiology 2003 ; 227 : 18 – 36.

18. Normal rete testis
Normal structure seen in 20% of patients
Hypoechoic striated appearance of rete testis
Finger-like projections into parenchyma
Adjacent to mediastinum testis
Wittenberg AF et al. Curr Probl Diagn Radiol 2006 ; 35 : 12 – 21.

19. “two-tone testes”
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
Portion nearest probe: normal testicular reflectivity
Portion distal to vessel: decreased testicular reflectivity
Refractive artefact through walls of trans-mediastinal vessels
Trans-mediastinal vessels causing „„two-tone‟‟ artefact

20. • Presentation Painless mass – More often on left
• Two types Type 1: reproductive potential
Type 2: no reproductive potential
• Association Cryptorchidism, indirect inguinal hernia,
hydrocoele, microlithiasis, rete testis, cancer
• US features Well-defined testis with identical reflectivity
Color Doppler as ipsilateral testis
Mediastinum observed helps in diagnosis
• Management Conservative
Polyorchidism
100 reported cases – More than two testes
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.

21. Polyorchidism
Fewer than 100 reported cases
Carkaci S et al. J Clin Ultrasound 2010 ; 38 : 21 – 37.
Normal vascularity in
both left testes
Color Doppler USCoronal gray-scale US
Normal right testis
Two normal left testes
Two testes on left
Normal right testis
T2-weighted MRI

22. Normal epididymis
Deurdulian C et al. RadioGraphics 2007 ; 27 : 357 – 369.
Normal epididymal head
Isoechoic to testis
Sagittal US image
Normal epididymal body & tail
Hypoechoic to testis
Coronal US image

23. Scrotal appendages
Sellars MEK et al. Eur Radiol 2003 ; 13 : 127 – 135.
Appendix testis: Upper pole of testis – 90%
Appendix epididymis: Head of epididymis – 6%
On occasion, both appendages may be seen in same patient
5 scrotal appendages formed during development

24. Testicular appendages
Detectable only when hydrocele is present
Woodward PJ et al. RadioGraphics 2003 ; 23 : 215 – 240.
Appendix testis
Upper pole of testis
Müllerian duct remnant
Appendix epididymis
Head of epididymis
Mesonephric remnant

25. Doppler ultrasound of acute scrotum
• Normal anatomy of scrotum
• Normal US of scrotum
• Normal Doppler US of scrotum
• Doppler US of acute scrotum

26. Doppler ultrasound of scrotum
• Color, power & spectral Doppler
• Low flow settings
• Identical Doppler settings to evaluate symmetry of flow
Flow in symptomatic side vs asymptomatic side
• If color Doppler imaging cannot detect flow
Use of power Doppler to increase flow sensitivity

27. • Increased gain
• Decreased PRF
• Small color box
• Low wall filter
Low flow settings

28. Side-by-side comparaison image
Color Doppler image
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Important component of each testicular examination

29. Prominent trans-mediastinal artery & vein
Normal variant
Branch of testicular artery traverses toward center of testis
Seen unilaterally in 50% or bilaterally in 25%
Usually in superior half of testis
Usually accompanied by large vein
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.

30. Centripetal artery & recurrent rami
Centripetal artery coursing toward mediastinum
Then curving back as recurrent rami
Transverse color Doppler US of normal testis
Cindy A et al. J Diag Med Sonography 2006 ; 22 : 221 – 230.

31. Flow in intra-testicular, epididymal
& cremasteric artery
1 Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
2 Schneble F et al. Ultraschall Med 2011 ; 32 : E51 – E56.
Low flow
High resistance
Cremasteric artery
High flow
Low resistance
Epididymal arteryIntra-testicular artery
High flow
Low resistance
Normal RI: 0.54 0.08 2

32. Color & power Doppler US in normal testis
68 normal children – 6 weeks to 13 years
Barth RA & Shortliffe LD. Radiology 1997 ; 204 : 389 – 393.
Power Doppler more sensitive than color Doppler
for detection of intra-testicular blood flow in children
• Color Doppler Intra-testicular blood flow in 88%
• Power Doppler Intra-testicular blood flow in 97%
• Combined Intra-testicular blood flow in 100%

33. Doppler ultrasound of acute scrotum
• Normal anatomy of scrotum
• Normal US of scrotum
• Normal Doppler US of scrotum
• Doppler US of acute scrotum

34. Acute scrotum
 Inflammatory conditions → Testiculitis
 Vascular conditions → Torsion
 Scrotal trauma → Trauma
 Testicular tumors → Tumors
 Inguinal hernia
 Acute idiopathic scrotal edema
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
Four T‟s

35. Acute scrotum
 Inflammatory conditions
– Acute epididymitis Most common cause
– Acute orchitis
– Testicular abscess
– Cellulitis
– Fournier gangrene
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.

36. Doppler US findings in epididymo-orchitis
Ultrasound
Direct signs Enlarged heterogenous epididymis
Enlarged heterogeneous testis
Indirect signs Reactive hydrocele or pyocele
Scrotal wall thickening
Doppler
Epididymal or testicular hypervascularity
High flow PSV > 15 cm/sec
Low resistance RI < 0.5
Easily detectable venous flow
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.

37. Acute epididymo-orchitis
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
Increased vascularity of both
testis & epididymis
Heterogeneous epididymis & testis
Enlargement of epididymal head
Reactive hydrocele

38. Epididymo-orchitis / pyocele
Low-level echoes – Multiple septations
Thickening of overlying scrotal skin
Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011.
European Foundation of Societies of Ultrasound in Medicine & Biology.

39. Epididymo-orchitis / Epididymal abscess
Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011.
European Foundation of Societies of Ultrasound in Medicine & Biology.
Acute epididymitis not responding to anti-bacterial therapy
Focal area of mixed reflectivity containing debris
in epididymal head

40. Orchitis
• Causes Usually in patients with epididymitis
Primary orchitis (rare): mumps – HIV
• US 1. Edema: diffuse low reflectivity
2. Striated pattern
3. Venous infarction (hemorrhage)
Areas of mixed or increased reflectivity
• Complications Abscess – Infarction – Necrosis
• Evolution Resolve completely
Small testis with fibrosis: heterogeneous
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.

41. Orchitis / Striated testis
Striated appearance
Small complex hydrocele
Gray-scale ultrasound
Significant hyperemia
Color Doppler US
Loberant N et al. Ultrasound Quarterly 2010 ; 26 : 37 – 44.

42. Complicated orchitis
Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011.
European Foundation of Societies of Ultrasound in Medicine & Biology.
Predominantly low reflective testis
Multiple areas of high reflectivity

43. Causes of striated testis
• Prominent rete testis
• Orchitis
• Torsion
• Testicular fibrosis
• Trauma
• Neoplasm (lymphoma – leukemia)
Striated pattern without clinical findings & normal
color Doppler has no clinical importance
Loberant N et al. Ultrasound Quarterly 2010 ; 26 : 37 – 44.

44. Striated testis / Senile fibrosis
First described in 1996 1
1 Cohn EL et al. J Urol 1996 ; 156 : 180 – 181.
2 Loberant N et al. Ultrasound Quarterly 2010 ; 26 : 37 – 44.
Striated pattern without clinical findings & normal
color Doppler has no clinical importance
Striated atrophic right testis
Spectacle view US
Normal vascularity
Color Doppler image

45. Testicular abscess
• Cause Usually secondary to epididymo-orchitis
• Suspicion Testicular swelling persists after treatment
• US Irregular walls
Low level internal echoes
Hypervascular margins of lesion
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
Not distinguished from acute epididymitis at early stage

46. Testicular abscess
Hypervascular margin of lesion
No flow within lesion
Color Doppler USGray-scale ultrasound
Heterogeneous hypoechoic complex
collection within enlarged testicle
Wittenberg AF et al. Curr Probl Diagn Radiol 2006 ; 35 : 12 – 21.
70-year-old diabetic patient with acute epididymo-orchitis

47. Brucellosis
Genitourinary complications: 2 – 10% of patients
Lee JC et al. Ultrasound Quarterly 2008 ; 24 : 3 – 16.
Hypoechoic nodules within testis & epididymis
Small hydrocele
Gradual onset, longer duration, no leukocytosis, & positive serology

48. Cellulitis
4 day-old male with swollen penis & scrotum after circumcision
Skin thickening
Hyperemia of scrotal skin
Peri-testicular fluid collection
Sagittal sonogram
Bilateral scrotal abscesses incised & drained at surgery
Transverse sonogram
Increased flow around testis
Adjacent complex fluid collection
Sung T et al. Am J Roentgenol 2006; 186 : 483 – 490.

49. Fournier’s gangrene
Aggressive necrotizing fasciitis of perineum
• Presentation Males 50-70 years – Diabetes 50%
Soft-tissue gas detected as “crepitus”
• Delay of dg Onset of symptoms to diagnosis: 5 days
• US Scrotal wall thickening
Multiple pockets of gas: “dirty shadow”
Normal underlying testes
• Treatment Surgical resection of devitalized tissues
• Prognosis High morbidity & mortality rate
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.

50. Fournier gangrene
Emergency – Prompt medical & surgical treatment
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Thickening
of scrotal skin Foci with dirty
shadowing (air)
US detects gas before it becomes clinically palpable
Normal testis

51. Acute scrotum
 Vascular conditions
– Acute testicular torsion
– Torsion of appendages
– Varicocele: idiopathic – Intra-testicular – Secondary
– Henoch-Schönlein purpura
– Thrombosis of pampiniform plexus veins
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.

52. Presentation of acute testicular torsion
• Young patients: almost all under age of 20
• Sudden pain followed by nausea, vomiting, & low-grade fever
• Pain cannot be relieved by elevating the scrotum
• Swollen, tender, & inflamed hemi-scrotum
• Cremasteric reflex usually absent
• Transverse location of testis instead of vertical position
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.

53. Salvage rate in acute torsion
• Within first 6 hours 100% salvage rate
• Within 6 to 12 hours 70% salvage rate
• Within 12 to 24 hours 20% salvage rate
Patriquin HB et al. Radiology 1993 ; 188 : 781 – 5.

54. Normal anatomy
Tunica vaginalis attached to posterior lateral aspect of scrotal wall
Prando D. Ultrasound Quarterly 2002 ; 18 : 41 – 57.
Extra-vaginal torsion
Less frequent
Peri-pubertal

55. Bell-clapper anomaly
Tunica vaginalis completely surrounds testis
Intra-vaginal torsion
Prando D. Ultrasound Quarterly 2002 ; 18 : 41 – 57.
180
Blood supply reserved Blood supply compromised
720
Most frequent (80%)
Peripubertal

56. Doppler US of acute testicular torsion
• US Enlarged testis
Normal or decreased echogenicity of testis
Multifocal hyperechogenicity of testis: infarction
Enlargement & nodularization of epididymis
Reactive hydrocele
Thickening of scrotal skin
• Doppler Complete (≥ 360 ) Absence of flow
Partial (< 360 ) Decreased flow& elevated RI
Prando D. Ultrasound Quarterly 2002 ; 18 : 41 – 57.

57. Acute torsion / less than 6 hours
Longitudinal view of left testis
Power Doppler
No flow to left testis
Spectacle US view
No abnormalities
Longitudinal view of right testis
Power & pulsed Doppler
Blood flow to right testis

58. Acute torsion / more than 6 hours
Heterogeneous echotexture
Areas of increased echogenicity
“hemorrhage”
Side-by-side image
Lack of flow within left testis
Color Doppler US of left testis
Stengel JW et al. Am J Roentgenol 2008 ; 190 : S35 – S41.

59. Acute torsion / Bell-clapper anomaly
Bilateral in most cases
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
Diagnosed by US in presence of moderate hydrocele
Hydrocele encircling distal third of spermatic cord
Testis
Hydrocele
Spermatic cord

60. Acute torsion / whirlpool sign of spermatic cord
Aso C et al. RadioGraphics 2005 ; 25 : 1197 – 1214.
Absence of color flow
Reactive hydrocele
Scrotal wall thickening
Right testis
Normal color flow
Left testis
Edematous spermatic cord
with anechoic structures
“dilated lymphatic vessels”
Right spermatic cord

61. Acute torsion / Incomplete or partial (< 360°)
Mernagh JR et al. Curr Probl Diagn Radiol 2004 ; 33 : 60 – 73.
Two weeks later

62. Acute torsion / Incomplete or partial (< 360°)
Prando D et al. Abdom Imaging 2009 ; 34 : 648 – 661.
Pulsed Doppler US
Increased RI Absent diastolic flow Reversed diastolic flow
Absent or reversed diastolic flow:
Severe epididymo-orchitis (venous infarction)
Scrotal trauma (venous occlusion)

63. Acute torsion / Torsion-detorsion syndrome
Intermittent left scrotal pain - Asymptomatic at examination
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
Increased blood flow to left testis
Left testis
Hyperemia with resolution of pain is highly suggestive
Right testis
Normal blood flow to right testis

64. Doppler US in acute testicular torsion
Normal color Doppler US does not exclude:
1. Early torsion
2. Partial torsion
3. Torsion/detorsion syndrome
If high clinical suspicion: repeat Doppler US in 1 – 4 hours
Datta V et al. Ultrasound Quarterly 2011 ; 27 : 127 – 128.

65. Conditions with decreased blood flow in testes
• Poor technical parameters
• Pediatric population: small testicular volume
• Large hydrocele & hematoma
• Marked scrotal edema: poor penetration of US
• Epididymo-orchitis resulting in testicular infarction (rare)
• Idiopathic testicular infarct (rare)
• Vasculitis: Polyarteritis nodosa – Lupus
• Protein S & antithrombin III deficiency
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.

66. Testicular torsion mimic
Large hydrocele
Decreased blood flow to right testis
Pressure on testis from large hydrocele
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
Normal blood flow of
left testis

67. • Causes Idiopathic – Acute epididymitis – Trauma
Sickle cell disease – Hypercoagulable states
• Presentation Testicular pain
• US Low reflective area may be wedge-shaped
• Doppler Poor or absent color Doppler flow
• DD Malignant lesion: ↑ color Doppler flow
Segmental testicular infarction
dg made following orchidectomy for suspected tumor
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.

68. Segmental testicular infarction / Round shape
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
Negative tumor markers – Regression in size on follow-up US
Focal mixed reflective area No color Doppler within lesion
Patient with underlying epididymitis

69. Segmental testicular infarction / Wedged shape
Saxon P et al. Emerg Radiol 2012 in press.
MRI or CEUS when Doppler US findings are equivocal
Gray-scale US
Low reflective wedged shape area
Color Doppler US
No power Doppler flow

70. Testicular appendigeal torsion
7 to 14 years old boys – Appendix testis (95%)
• Examination Firm nodule on upper testis
Bluish discoloration: “blue dot sign”
Cremasteric reflex still be elicited
• US Iso, hypo or hyperechoic appendix ≥ 5 mm
Peri-appendiceal blood flow
Reactive hydrocele (common)
Skin thickening (common)
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
Role of US: exclude torsion or acute epididymo-orchitis

71. “blue dot sign”
Clinical tender "blue dot sign“
Torsion of testicular appendage

72. Testicular appendigeal torsion
Hypoechoic extra-testicular mass
Peripheral hyperemia separate from epididymis
Resolved on follow-up
Dogra et al. Ultrasound Clin 2006 ; 1 : 55 – 66.
10-year-old boy with testicular pain

73. • CDU imaging is now the gold standard for diagnosis
• CDU imaging highly operator dependent
• Cut-off values Vein diameter 2 2.4 mm at rest
2.9 mm Valsalva
Reflux duration 1 sec – 2 sec
• Classifications Sarteschi Supine & standing
Dubin Supine
Idiopathic varicocele
15% of adult – Almost always on left – Bilateral in 30%
1 Liguori G et al. World J Urol 2004 ; 22 : 378 – 381.
2 Pilatz A et al. World J Urol 2011 ; 29 : 645 – 650.

74. Idiopathic varicocele
Reversed flow lasting longer than 1 - 2 seconds
Detected during Valsalva maneuver & resolved with its release
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.

75. Sarteschi’s classification of varicocele
Supine & standing positions
Sarteschi LM. G Ital Ultrasonologia 1993 ; 4 : 43 – 9.
Examinations done in supine & standing positionsGrade 1 Reflux in inguinal channel only during Valsalva
Scrotal varicosity not evident in standard US study
Grade 2 Small varicosities extend to superior pole of testis
Diameters increase & venous reflux seen only during Valsalva
Grade 3 Vessels enlarged at inferior pole of testis only in standing position
No enlargement detected in supine position
Reflux observed only during Valsalva
Grade 4 Vessels appear enlarged in supine position
Dilatation increased in upright position & during Valsalva
Testicular hypotrophy common at this stage
Grade 5 Venous ectasia even in prone decubitus and supine positions
Reflux at rest & does not increase during Valsalva

76. Sarteschi’s classification/Grade 1
Pauroso S et al. J Ultrasound 2011 ; 14 : 199 – 204.
Reflux in vessels seen
only during Valsalva
Valsalva’s maneuver
No varicosity in inguinal channel
on standard US examination
Relaxing condition

77. Sarteschi’s classification/Grade 2
Pauroso S et al. J Ultrasound 2011 ; 14 : 199 – 204.
Small varicosities exhibiting
reflux only during Valsalva
Valsalva’s maneuverRelaxing condition
Small varicosities extend to
superior pole of testis

78. Sarteschi’s classification/Grade 4
Pauroso S et al. J Ultrasound 2011 ; 14 : 199 – 204.
Relaxing condition
Venous reflux evident in
basal condition
Venous diameter increases
during Valsalva
Valsalva’s maneuver

79. Sarteschi’s classification/Grade 5
Pauroso S et al. J Ultrasound 2011 ; 14 : 199 – 204.
Venous diameter does not
increases during Valsalva
Valsalva’s maneuverRelaxing condition
Venous reflux evident in
basal condition

80. • Presentation Testicular pain
• Association Extra-testicular varicocele: common – left
• US Anechoic structures from mediastinum testis
Involvement of sub-capsular veins described
• Doppler Vascular flow of venous type
• DD Cystic structures: Prominent rete testis
Intra-testicular cyst
Intra-testicular varicocele
Uncommon (< 2% in symptomatic population)
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.

81. Intra-testicular varicocele
Color Doppler US
Valsalva maneuver
demonstrating color Doppler flow
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
Serpiginous structure in center of
testis with „„tumbling‟‟ echoes within
Gray-scale US

82. Secondary varicocele
Increased pressure on abdominal spermatic vein
Dogra VS et al. Radiology 2003 ; 227 : 18 – 36.
Non-compressible varicoceles on left or right:
Retroperitoneal evaluation for retroperitoneal mass
LRV evaluation for thrombus or tumor extension
• Hydronephrosis
• Cirrhosis with PHT
• Nutcracker phenomenon
• Abdominal & retroperitoneal neoplasm

83. Henoch-Schönlein purpura
Aso CE et al. RadioGraphics 2005 ; 25 : 1197 – 1214.
Scrotal wall thickening
Scrotal tunica thickening
Epididymal enlargement
Reactive hydrocele
Two days later
Typical purpuric lesions on both legs

84. Thrombosis of pampiniform plexus veins / rare
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
Thrombus within veins of
pampiniform plexus
Hypoechoic & thickened
vessel walls
34-year-old man presenting with acute scrotum

85. Acute scrotum
 Inflammatory conditions
 Vascular conditions
 Scrotal trauma
 Testicular tumors
 Inguinal hernia
 Acute idiopathic scrotal edema
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.

86. • Scrotal or testicular edema
• Testicular fracture or rupture
• Scrotal hematoma
• Scrotal hydrocele
• Scrotal hematocele
Most common findings of scrotal trauma
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
Several of which are usually concurrent

87. Testicular Trauma / Intra-testicular hematoma
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
2 hypoechoic lesions in right testis
Areas of rounded high reflectivity
Patient involved in motorcycle accident
Gray-scale US Color Doppler US
Absence of vascularity
Traumatic intra-testicular hematoma

88. Testicular Trauma / Tunica albuginea rupture
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
Discontinuation of tunica albuginea (arrows)
Protrusion of testicular contents from ruptured tunica (arrowheads)
Associated scrotal wall hematoma (asterisk)
Necessitates emergent surgery

89. Testicular Trauma / Fracture line
Fracture line through mid-aspect of testis
Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011.
European Foundation of Societies of Ultrasound in Medicine & Biology.

90. Testicular trauma / Hematocele
Kurian R & de Bruyn R. Ultrasound 2006 ; 14 : 216 – 222.
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
Large left hydrocele
Containing multiple echoes within
Acute hematocele Chronic hematocele
Complex peritesticular collection
Thick internal septations
Compressing ipsilateral testis

91. Evolution of testicular hematoma
Longitudinal view 2 weeks later
Hematoma has largely resolved
Poorly defined hypoechoic area
representing hematoma
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Longitudinal US view Longitudinal US two weeks later

92. Acute scrotum
 Inflammatory conditions
 Vascular conditions
 Scrotal trauma
 Testicular tumors
 Inguinal hernia
 Acute idiopathic scrotal edema
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.

93. Clinical presentation of testicular tumors
• Palpable mass Usual presentation
• Acute scrotum 10 % of patients (hemorrhage)
• Metastatic disease 5 – 10 %
• Hormonal changes Precocious puberty
Gynecomastia
5 – 10 %
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.

94. Primary testicular tumors
• Germ cell tumors Seminoma (most common)
90% Embryonal carcinoma
Choriocarcinoma
Teratoma
Mixed germ cell tumors
• Gonadal stromal tumors Leydig cell tumors
10% Sertoli cell, granulosa cell, theca cell
Primitive gonadal stromal tumors
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
2 – 3% are bilateral (synchronous or metachronous)

95. Doppler US of testicular tumors
• Usual appearance
Homogenous & low reflectivity
• Wide range of appearances
High reflectivity
Heterogeneous with calcification & cystic changes
• Doppler US
Increased vascularity even in small tumor (new transducers)
Sidhu PS et al. European course book: Ultrasound of the scrotum.
European Foundation of Societies of Ultrasound in Medicine & Biology, 2011.
Distinguishing various cell types not practical
Any suspected mass prompts orchiectomy or surgical biopsy

96. Classic testicular seminoma
Hypoechoic – Homogeneous
Gray-scale US
Hypoechoic lobulated lesion
Power Doppler US
Mildly increased flow
Wittenberg AF et al. Curr Probl Diagn Radiol 2006 ; 35 : 12 – 21.

97. Testicular teratoma
Dogra VS et al. RadioGraphics 2001 ; 21 : S273 – S281.
Multiple cystic areas (2 - 15 mm)
Process involves nearly whole testis
dd: testicular tubular ectasia
Immature teratoma
Septated cystic lesion
Two solid nodules within
Mature teratoma

98. Burned-out germ cell tumor / Azzopardi scars
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Coarse calcification in lower pole
Longitudinal view of left testis
Retroperitoneal mass
Axial color view of abdomen
Grown quickly outstripping their blood supply
Appear as anything from small echogenic foci to hypoechoic masses

99. Sertoli cell tumor
Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011.
European Foundation of Societies of Ultrasound in Medicine & Biology.
Well defined tumor with linear wall calcification

100. Peutz-Jeghers syndrome
Aso C Eet al. RadioGraphics 2005 ; 25 : 1197 – 1214.
Melanin pigmentation of lips
Characteristic of Peutz-Jeghers
Several echogenic lesions
Burned-out Sertoli cell tumors
Bilateral

101. Para-aortic lymph node in testicular cancer
Enlarged para-aortic lymph node with cystic degeneration
Cokkinos DD et al. Curr Probl Diagn Radiol 2011 ; 40 : 1 – 14.

102. Testicular macro-calcification
• Benign lesion Intra-testicular cyst
Epidermoid cyst
Sertoli cell tumor
Granulomatous disease of testes
• Malignant lesion “burnt-out” tumor
Primary testicular tumor
Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011.
European Foundation of Societies of Ultrasound in Medicine & Biology.

103. Testicular microlithiasis
Bright foci of 1 – 2 mm without acoustic shadowing
Stengel JW et al. Am J Roentgenol 2008 ; 190 : S35 – S41.
Limited: < 5 microliths per US field
Classical: > 5 microliths per US field
Relative risk of concurrent neoplasm 20 fold
Annual sonographic examination

104. Testicular microlithiasis associated with seminoma
Transverse scanLongitudinal scan
Chen JL et al. J Clin Ultrasound 2010 ; 38 : 309 – 313.

105. Non-Hodgkin lymphoma
< 1% of patients with lymphoma
Hypoechoic mass replacing
most of testis
Longitudinal view of right testis
Blood flow in tumor
Color Doppler US

106. Testicular metastases
Malignant melanoma
Robertson E & Baxter G. Ultrasound 2010 ; 18 : 86 – 88.
Hypervascularity of hypoechoic areas
Blood flow of tumor deposits
Color Doppler imageGray-scale image
Multiple hypoechoic lesions
Highly suspicious of tumor deposits

107. • Presentation Mass which may be painful
• Involvement Most commonly involves epididymis
Solitary testicular involvement uncommon
• US Low reflective focal lesions
• DD Primary testicular malignancy
Clinical evidence of sarcoid elsewhere
Multiple focal lesions
Epididymal involvement
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
Genital sarcoidosis
Multi-system disorder – Non-caseating epitheloid granulomas

108. Testicular sarcoidosis
Recent diagnosis of sarcoidosis from skin lesion biopsy
Multiple hypoechoic areas within testis & epididymis
Lee JC et al. Ultrasound Quarterly 2008 ; 24 : 3 – 16.

109. Testicular adrenal rests
Essential to recognize (avoid unnecessary orchidectomy)
• Cause Congenital adrenal hyperplasia
More commonly 21-hydroxylase deficiency
• US Multiple hypoechoic areas near mediastinum
Usually bilateral
Frequent epididymal involvement
• Doppler Hypervascular: vessels course without θ changes
• DD Bilateral malignant tumors: rare (2 – 3%)

110. Adrenal rest / Adrenal remnants
Aso CE et al. RadioGraphics 2005 ; 25 : 1197 – 1214.
Nodule in epididymal head
Several hypoechoic lesions in upper pole of testis

111. • Presentation Painless lump – Most common on left
• US Homogeneous hypoechoic mass
Difficult to separate from testis
• Doppler Central vascular pattern toward periphery
Disorganized pattern in primary tumor
• DD Testicular tumor
99mTc-sulphur colloid scan diagnostic
Spleno-gonadal fusion
Accessory spleen in pelvis or scrotum fused to gonadal organs
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.

112. Spleno-gonadal fusion
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
Color Doppler US
Ordered vessels at central aspect
Splenic tissue at histology
Iso-echoic lesion at upper pole
Simulating primary testicular tumor
Gray-scale US of left testis

113. Intra-testicular cystic lesions
Rare – Avoid unnecessary surgical intervention
• Benigns Tunica albuginea cyst
Frequent Intra-testicular simple cyst
Epidermoid cyst
Tubular ectasia of rete testis
Intra-testicular varicocele
Abscess
Hemorrhage (infarction)
• Malignants Teratoma Most frequent
Rare Large seminoma
Dogra VS et al. RadioGraphics 2001 ; 21 : S273 – S281.

114. Cyst of tunica albuginea
Ma OJ et al. Emergency ultrasound, 2nd edition.
Bhatt S et al. Diagn Interv Radiol 2011 ; 17 : 52 – 63.
Alvarez DM et al. J Clin Imaging Sci 2011 ; 1 : 5 -
Partially calcified cyst
of tunica albuginea
Well defined cyst
Posterior enhancement
Tunica albuginea cyst
with milk of calcium

115. Cyst of tunica vaginalis
Tunica vaginalis cyst visible in presence of hydrocele
Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011.
European Foundation of Societies of Ultrasound in Medicine & Biology.

116. Intra-testicular simple cyst
≥ 40 years – Solitary – Near mediatinum
• Causes Congenital, post-trauma, post-inflammatory
• Size 2 – 20 mm in diameter
• Association Extra-testicular spermatocele
• Examination Usually not palpable – Not firm even if large
• US Anechoic, thin wall, posterior enhancement
• Treatment No treatment
Palapable cyst should be removed 2
1 Dogra VS et al. RadioGraphics 2001 ; 21 : S273 – S281.
2 Hamm B et al. Radiology 1988; 168 : 19 – 23.

117. Intra-testicular cyst
Anechoic lesion – Imperceptible wall – Posterior enhancement
Surrounding thin rim of testicular parenchyma → intratesticular cyst
Search for wall irregularity which may suggest cystic tumor
Kim W et al. RadioGraphics 2007 ; 27 : 1239 – 1253.

118. Epidermoid cyst
Mistaken for malignancy if absence of classic US findings
• Manifestation Painless mass in 20 – 40 year old patient
• US features Varies with degree of maturation
Type 1 „„Onion-ring‟‟ – Suggestive – Teratoma
Type 2 Densely calcified mass
Type 3 Cyst with rim & peripheral/central calcification
Type 4 Mixed pattern: heterogeneous & poorly defined
Suggestive No color Doppler flow - Negative tumor markers
• Treatment Enucleation – Orchidectomy (often performed)
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.

119. Intra-testicular epidermoid cyst
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.
Stengel JW et al. AJR 2008 ; 190 : S35 – S41.
“Onion-ring‟‟appearance
Layers of compacted keratin
Well-circumscribed mass
Thick hyperechogenic wall
Heterogeneous with sonolucent center

120. Tubular ectasia of rete testis
Benign – Very common – > 50 years – Bilateral in 1/3
• Causes Epididymal obstruction (infection – trauma)
Post-vasectomy patients
• US Multiple hypoechoic oval structures
Located in mediastinum testes
Absence of color Doppler flow
• DD Intra-testicular varicocele
Cystic dysplasia of testes: congenital
Cystic malignant tumor: Teratoma
Stewart VR & Sidhu PS. Clin Radiology 2007 ; 62 : 289 – 302.

121. Tubular ectasia of rete testis
Frequent association with spermatocele or epididymal cyst
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
Fluid-filled dilated tubular structures
Nearby intra-testicular cyst
Sagittal gray-scale US

122. Cystic dysplasia of testes
Rare – Congenital – Renal malformation
Enlarged testis
Multiple irregular anechoic areas
measuring few millimeters each
Pathology specimen
showing multiple cysts
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.

123. Epididymal cyst
Common (20 – 40% of asymptomatic men)
Lee JC et al. Ultrasound Quarterly 2008 ; 24 : 3 – 16.
Epididymal tailEpididymal bodyEpididymal head
Indistinguishable
from spermatocele

124. Spermatocele
Cystic dilatations of efferent ductules
Well defined cyst in epididymal head – Fluid debris level
Typical of spermatocele
Lee JC et al. Ultrasound Quarterly 2008 ; 24 : 3 – 16.
Differentiate spermatocele from epididymal cyst by US not possible

125. Acute scrotum
 Inflammatory conditions
 Vascular conditions
 Scrotal trauma
 Testicular tumors
 Inguinal hernia
 Acute idiopathic scrotal edema
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.

126. Inguinal hernia
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.
Bowel loop herniation into scrotum
Increased tunical fluid surrounding the testis
Diagnosis supported by visualization of peristaltic activity
Fluid
Hernia Testis

127. Complications of inguinal herniorrhaphy
• Hernia recurrence
• Epididymo-orchitis
• Hematoma Inguinal canal & scrotum
• Testicular ischemia Rare - more in recurrent hernia repair
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.

128. Scrotal wall edema
Marked thickening of scrotal wall
Following inguinal hernia repair
Sidhu PS et al. European Course Book – Ultrasound of the scrotum – 2011.
European Foundation of Societies of Ultrasound in Medicine & Biology.

129. Testicular ischemia
after inguinal hernia repair
Dellabianca C et al. J Ultrasound 2011 ; 14 : 205 – 207.
No intra-testicular vascular signal
Cremasteric vessel hypertrophy
Inhomogeneous hypoechoic testis
Bowel loop in scrotum
(recurrence of hernia)

130. Acute scrotum
 Inflammatory conditions
 Vascular conditions
 Scrotal trauma
 Testicular tumors
 Inguinal hernia
 Acute idiopathic scrotal edema
Turgut AT et al. Ultrasound Clin 2008 ; 3 : 93 – 107.

131. Acute idiopathic scrotal edema
• Etiology Possible allergic origin
• Presentation From 4 months to 18 years
Sudden onset of non-hemorrhagic edema
Redness of scrotal wall
• US Scrotal walls thickening & hypervascularity
Characteristic findings
• Evolution Resolves spontaneously in 3 – 4 days
One or more relapses in next years
• Treatment Conservative
Aso CE et al. RadioGraphics 2005 ; 25 : 1197 – 1214.
Halb C et al. Ann Dermatol Vénéréol 2010 ; 137 : 775 – 781.

132. Acute idiopathic scrotal edema
Aso C Eet al. RadioGraphics 2005 ; 25 : 1197 – 1214.
Marked thickening of scrotal walls
Normal testes & tunicae
Increased vascularity seen at color Doppler imaging
1-year-old boy

133. References

134. Thank You