DMS 176: Testicular Pathology

Sonographic Findings of Intratesticular Varicocele

Ultrasound with color Doppler is the exam of choice Three common patterns • Tubular (most common) • Cystic • Mixed

Sonographic Findings of Orchitis

-Enlarged, focal or diffuse hypoechoic testicle -Acute Phase • Hypoechoic testis • Hyperemic flow - produces "balls of fire" appearance -Chronic Phase • Scrotal wall thickening • Atrophied testis

Two types of Testicular Torsion

-Extra-vaginal/supra-vaginal • Torsion occurs at the level of the external inguinal ring • Rare and occurs in neonates -Intra-vaginal • More common type and is usually due to "bell clapper" deformity • Epididymis and testis are not properly anchored posteriorly letting the testicle move freely • Typically occurs in adolescents and young adults • Torsion occurs in the tunica vaginalis with a long spermatic cord

Tunica Albuginea Cysts

-Most common extratesticular benign mass -Typically manifest as small (2-5 mm) palpable masses -Can be single or multiple -Arise from tunica albuginea with an uncertain origin -Characteristically located at the upper anterior or lateral aspect of the testicle -Larger lesions may compress the testicular parenchyma and simulate an intra testicular mass -More commonly seen in males 50-60 years of age -Present as painless scrotal lump -Anechoic, well-defined with through transmission

Scrotal (Inguinal) Hernia

-Protrusion of bowel into the tunica vaginalis of the scrotum • --External (indirect) vs. internal (direct) • External results when the intestines pass through the external ring and into the scrotum • This canal usually closes between the 8th month of fetal life and after the first month post birth • Most common • Internal occurs due to weakness in the floor of the inguinal canal

Time Sensitive of Testicular Torsion

-Timing is critical - may cause infertility • <6 hours from onset of symptoms - approx. 80-100% salvage rate • 6-12 hours from onset of symptoms - approx. 70% salvage rate • >12 hours from onset of symptoms - salvage rate is near 0% -Degree of twisting may vary between 180-540 degrees of torsion -Manual detorsion is often performed in the ER • Testicles commonly rotate toward midline • Testicle is rotated outward like "opening a book"

Intratesticular Cysts

-Usually nonpalpable and incidentally detected -Benign -Usually located near the mediastinum testis -Probably originate from the rete testis -Appear well-marginated, imperceptible wall, anechoic with posterior acoustic enhancement and no flow on color Doppler

Sonographic Findings of Testicular Torsion

-Whirlpool sign of spermatic cord • A spiral-like pattern when the spermatic cord is assessed during US Three Phases -Acute • Enlarged testi and epididymis • Hypoechoic, inhomogeneous • Reactive hydrocele -Chronic • 24-28 hours post torsion -pain may disappear • Testi atrophies • Epididymis remains enlarged and hyperechoic

Incarcerated Hernia

Blood supply is obstructed in the bowel

Clinical Presentation of Varicocele

Can be asymptomatic If symptomatic presentations include • Scrotal mass/swelling • Scrotal pain • Testicular atrophy • Infertility or subfertility

Testicular Infarct

Commonly results from torsion or trauma

Sonographic Findings of Pyocele

Echogenic fluid collections with thick septations and calcifications

Spermatocele

• A common type of extra-testicular cyst of the epididymis containing sperm • Retention cyst located along the vas deferens or the head of the epididymis • Painless, incidental finding but can present as a mass lesion if large • More common than epididymal cysts, but can appear very similar • Unlike epididymal cysts, spermatoceles often contain low-level echogenic proteinaceous fluid and spermatozoa • May be idiopathic or secondary to an infectious or inflammatory process • May be associated with a prior vasectomy

Epididymal Cyst

• Most common epididymal mass • Usually of lymphatic origin and more commonly seen in the head - can occur anywhere in the epididymis • Contain clear serous fluid, lymphocytes, spermatozoa and debris • Sonographically may be indistinguishable from spermatocele

Intratesticular Varicocele

• A rare entity, occurring in 2% of symptomatic population • Dilated intratesticular veins seen in relation to the mediastinum testis and extending peripherally • Usually seen in the presence of ipsilateral extratesticular varicocele • Most occur on the left side • Testicular pain is attributed to the stretching of the tunica albuginea due to dilatation of veins • Increased incidence in men who have undergone prepubertal orchidopexy for acquired undescended testis

Testicular Fracture (Rupture)

• A rip or tear in the tunica albuginea resulting in extrusion of testicular contents • Trauma may be blunt, penetrating or degloving • Relatively uncommon • Many present with hematoceles (blood in the tunica vaginalis) • Most patients present to the ER with a history of injury soon after event

Epidermoid Cysts

• AKA Keratocysts • Rare, benign lesions of germ-cell origin • Painless, non-tender testicular mass • Well-circumscribed and lie beneath the tunica albuginea • Filled with cheesy-white keratin

Scrotal Calcifications

• AKA Scrotal Pearls or Scrotoliths • Benign extra testicular macro-calcifications within the scrotum • Frequently occupy the potential space of the tunica vaginalis or sinus of the epididymis • No clinical significance, usually an incidental finding and asymptomatic • Unknown etiology

Sonographic appearance of Hydrocele

• Anechoic with through transmission, may be present with septations • May be unilateral or bilateral

Sonographic Assessment of Testicular Fracture

• Assess for disruption of the tunica albuginea, which is normally a smooth echogenic line • Signs of disruption include loss of continuity, crinkling, or retraction • Extrusion of the seminiferous tubules can occur (and may mimic a complex hematocele) • Assess with Doppler as seminiferous tubules should retain arterial blood supply to differentiate between this and a complex hematocele

Testicular Trauma

• Blunt trauma is the most commonly occurring form and usually results from athletic injury may also result from MVA or assault • Penetrating trauma is usually due to gunshot wounds and less commonly due to stab wounds, animal attacks, and self-mutilation • Testicular rupture and testicular ischemia/infarct are two severe complications • In degloving or avulsion injury, the scrotal skin shears off, and skin grafting may be required • Delay or inaccurate diagnosis may result in decreased fertility, delayed orchiectomy, infection, ischemia or infarction, and atrophy • US is ideal for the assessment of scrotal trauma • Surgical management is required for testicular rupture and large hematoceles • Penetrating scrotal trauma will also typically require surgery • Small testicular hematomas may be managed conservatively

Hematocele

• Collection of blood within the scrotal sac usually the result of trauma • Clinically presents as painful scrotal mass - mimics infection or torsion

Sonographic Appearance of Testicular Infarct

• Depends on age of infarction • Initially -Focal or diffuse heterogeneous testicle • Over time -Testicle decreases in size -Develops areas of increased echogenicity representing fibrosis or calcifications

Varicocele

• Dilatation of the pampiniform venous plexus of the testicular veins which drain the testicle • 90% seen on left side - due to longer route to drain into left renal vein, higher pressure than IVC • Most frequently encountered mass of the spermatic cord • Most common correctable cause of male infertility • May be caused by compression of spermatic veins due to muscle strain and incompetent spermatic venous valves

Ectasia of Rete Testi

• Dilated testicular mediastinal tubules • More common in men over the age of 55 years • A benign condition thought to result from the partial or complete obliteration of the efferent ducts • Spermatozoa-containing cysts which communicate with the tubular system into the epididymis • Often bilateral • Associated with spermatoceles and may occur as result of a vasectomy

Sonographic Findings of Epididymitis

• Enlarged epididymis, usually involving the head • Depending on the time of evolution, echogenicity may be decreased, increased or heterogeneous • If testicle is involved - hypoechoic testicle • Increased blood flow (hyperemia) within epididymis, testis or both • May be associated with a reactive hydrocele • Scrotal wall thickening

Sonographic Appearance of Testicular Abscess

• Enlarged testicle • Predominantly complex • Most present with epididymitis • Reactive hydrocele • Scrotal skin thickening • Increased peripheral vascularity

Sonographic Appearance of Testicular Fracture

• Fracture line can be seen as a hypoechoic and avascular area within the testis • A tunica albuginea rupture may also be present

Sonographic Appearance of Scrotal (Inguinal) Hernia

• Hernia sac identified in inguinal canal extending into scrotum • Hernia sac may contain echogenic bowel, shadowing from air in bowel and fluid within bowel • Presence of peristalsis confirms diagnosis • May be visualized using the Valsalva maneuver

Sonographic Appearance of Hematocele

• Immediately following trauma, will appear anechoic • Increased echogenicity and often contains thick septations in chronic setting

Epididymitis

• Inflammation of the epididymis which may extend to the testis causing epididymo-orchitis • Most common cause of acute scrotum in post pubertal males • Usually caused by STD in men under 35 • Most commonly from Chlamydia • May also be caused by prostatitis • Usually caused by UTI in men older than 55 • Rare in prepubescent boys • Managed with simple analgesia and oral antibiotics • May cause infertility • Infection usually originates in the bladder or prostate gland, spreads through the ductus deferens and the lymphatics of the spermatic cord to the epididymis, and may extend to testis • Due to this progression, infection starts in the tail of the epididymis • As the infection spreads, it can ascend the body and later the head of the epididymis

Orchitis

• Inflammation of the testi caused by an infection, which is rarely isolated, and when in conjunction with the epididymis is called epididymo-orchitis • Almost all cases are associated with epididymitis • Isolated orchitis can be seen in mumps and syphilis • Most common cause in men under 35 is Chlamydia

Clinical Findings of Scrotal (Inguinal) Hernia

• Most commonly present with swelling and/or pain in the relevant groin, iliac fossa, loin and testicular pain • Swollen scrotum • Persistent or intermittent palpable mass

Testicular Abscess

• Most commonly the result from untreated or severe epididymo-orchitis • Typically affects young sexually active adult males • Presents with testicular/scrotal pain, swelling and fever

Sonographic Findings of Ectasia of Rete Testi

• Multiple small cystic or tubular anechoic structures that replace and enlarge the testicular mediastinum • The geographic shape, lack of mass effect, and lack of internal vascularity are helpful to distinguish this benign condition from a partially cystic tumor

Testicular Torsion

• Occurs when the spermatic cord becomes rotated or twisted • Leads to venous occlusion and arterial ischemia causing infarction of the testicle - documented flow does not exclude torsion • Majority of cases are spontaneous or in the setting of minor/incidental trauma • Occurs most often during adolescence - more commonly between ages of 12-18 • More common on left side

Clinical Presentation of Epididymal Cyst

• Palpable mass • Can be asymptomatic

Risk factors of Scrotal (Inguinal) Hernia

• Prematurity and low birth weight • Patent processus vaginalis • Urologic conditions, including cryptorchidism • Abdominal wall defects • Family history • Weakened abdominal musculature, often brought on by advanced age, strain, and previous abdominal surgery

Doppler Evaluation of Testicular Torsion

• Presence of color flow depends on the degree of torsion • Color will be low or absent - comparison of flow must be made with contralateral testis • Presence of flow does not exclude torsion

Pyocele

• Pus in scrotal sac • Result of trauma or ruptured abscess

Clinical Findings of Epididymitis

• Ranges from mild tenderness to a severe febrile process with acute unilateral scrotal pain • Pain increases over a 1-2 day time period • Acute scrotal swelling • May have pyuria • Leukocytosis , fever • Hard palpable area posterior to testis

Testicular Microlithiasis

• Relatively common condition that represents the deposition of multiple tiny calcifications throughout the testes • Most common criterion for diagnosis is that of five microcalcifications in one testicle • Incidental and asymptomatic • Frequently seen as tiny punctate echogenic foci with no shadowing - commonly bilateral • Thought to be associated with risk for testicular CA • Present in 50% of men with a germ cell tumors

Sonographic Findings of Spermatocele

• Round or oval, well-defined, hypoechoic lesion • Usually measuring 1-2 cm • Demonstrate posterior acoustic enhancement • Usually irregular, with fine low-level internal echoes and sometimes septations • Commonly unilocular but can be multilocular • Unilateral, bilateral, single or multiple

Sonographic Appearance of Varicocele

• Seen as dilated anechoic tubular structures >2 mm lateral to testi • Distend when patient is standing, with Valsalva or with abdominal compression • May become thrombosed due to slow blood flow • Diagnosed by increased flow with color Doppler when Valsalva maneuver is performed or in standing position • Reversal of flow with color occurs when intra-abdominal pressure increases due to incompetent valves

Hydrocele

• Serous fluid that accumulates within the visceral and parietal layers of the tunica vaginalis • May be congenital or acquired, idiopathic, or caused by trauma, torsion, neoplasms, epididymitis (most common) or orchitis • Most common fluid collection of the scrotum • May be seen in utero and is of no significant value

Sonographic Findings of Incarcerated Hernia

• Similar to typical scrotal hernia • No peristalsis • Absence of blood flow within the mass

Sonographic Findings of Epididymal Cyst

• Solitary or multiple • Well defined, anechoic with no internal echoes • Posterior acoustic enhancement • Larger cysts may contain septations and displace the testi

Clinical Findings of Testicular Torsion

• Sudden onset of severe unilateral testicular pain • Swelling/redness of scrotum • Scrotal tenderness • N&V • Affected testicle sits higher and more horizontal in the scrotum

Clinical Findings of Pyocele

• Swelling and pain • Possible fever and/or leukocytosis

Sonographic Appearance of Scrotal Calcifications

• Usually shows a mobile hyperechoic extratesticular focus in the potential tunica space • If large enough, exhibits posterior acoustic shadowing • May be free floating if there is an accompanying hydrocoele

Clinical Findings of Incarcerated Hernia

• Very painful mass • Scrotal swelling • Pressure and inflammation

Sonographic Appearance of Epidermoid Cysts

• Well-defined, solid, non-vascular hypoechoic masses • Echogenic capsule or onion ring pattern - formed by multiple layers of keratin

Cryptorchidism

•"hidden testicle" - undescended testicle •Absence of a testis (or testes) in the scrotal sac •Testes develop in the abdomen and at 21 weeks of gestation begin to migrate toward the inguinal canal through the deep inguinal ring Migration is complete at 30 weeks Descent into the scrotum takes place at birth or shortly after •Undescended testicle Spontaneous decent may occur in the first year Usually descend within first 3 months •Increases risk of malignancy and infertility •Most common location is in inguinal canal or pre scrotal area •Less than 10% are located in the abdomen •Anorchia or congenital absence is rare •CT and MRI are used to image abdominal testi •Full bladder may aid in abdominal evaluation by US

Sonographic Findings of Cryptorchidism

•Absence of a testis in the scrotal sac •The undescended testis is a homogeneously hypoechoic ovoid structure, similar to the contralateral testis •May be detected high up in the scrotum or within the inguinal canal •US may be limited in intra-abdominal or pelvic testes •Smaller than normal •Testicle may be mobile or slide between the scrotal sac and inguinal canal

Orchiopexy

•Treatment of choice -surgically move testi into scrotum and permanently fix it there •Usually performed on patients aged 2-10

Causes of Cryptorchidism

•premature birth (birth occurs before full descent of testes) •intrauterine growth restriction (IUGR) •associations with smoking, alcohol intake during pregnancy •androgen insensitivity syndrome •congenital syndromes •gestational diabetes