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IMAGING OF
SCROTUM
ROSHAN VALENTINE
ANATOMY OF SCROTUM
 Cutaneous bag containing the testis , epididymis and lower
part of spermatic cord
 Left hemiscrotum is lower than the right – Longer spermatic
cord
ANATOMY OF SCROTUM
LAYERS OF SCROTUM
ANATOMY OF SCROTUM
BLOOD SUPPLY
 Sup and deep External
pudendal A
 Scrotal br of Internal
Pudendal A
 Cremasteric br of inferior
epigastric
ANATOMY OF TESTIS
TESTIS
 Male gonad
 Size :
o At birth : 1.5cm(L) x 1.0cm(W)
o <12 years : 1-2cc
o 10-15cc (2x3x4cms-BaPL) in adults
 Puberty achieved : >4cc
ANATOMY OF TESTIS
EXTERNAL FEATURES
 Upper pole:Oriented forward and lateral
 Lower pole : Backward and medial
 Anterior border : Convex and smooth , fully covered by
tunica vaginalis
 Posterior border : Straight and partially covered by tunica
vaginalis – Epididymis along the posterolateral wall
ANATOMY OF TESTIS
COVERINGS OF TESTIS(Out to
in)
 Tunica vaginalis
 Tunica albuginea
 Tunica vasculosa
ANATOMY OF TESTIS
BLOOD SUPPLY OF TESTIS
 Testicular artery
 Collateral supply
o Cremasteric artery
o Artery to ductus deferens
ANATOMY OF TESTIS
LYMPHATIC DRAINAGE
EPIDIDYMIS
SPERMATIC CORD
IMAGING MODALITIES
USG
TECHNIQUE
 Supine position
 7-10Mhz linear array transducer
 Direct contact or stand off pad
 Examine in long and transverse axes
 Size and echogenicity of the testis and epididymis
 Scrotal skin thickness
 CDFI and PWD
 Valsalva and Upright positioning – Venous evaluation
USG ANATOMY
 Pre-pubertal testis : Low to medium echogenicity
 Post-pubertal : Homogenous and medium echogenicity
 Medistinum Testis: Echogenic band in C-C direction
 Hypoechoic thin rim of fluid around
 Epididymis
o Head : 5-12mm
o Body : 2-4mm
o Tail : 2-5mm
 CDFI and PWD(RI : 0.46-0.68)
USG ANATOMY
CDFI AND PWD
 Low resistance pattern
 Mean RI:0.62(0.48-0.75)
MRI OF SCROTUM
MRI PROTOCOL
 Supine position
 Support scrotum by towel
 T1 and T2wSE in coronal and
axial plane
 CE and Fat saturation seq
 Thin 4-5mm slices 8-20 cm
field of view
 Undescended testis : Lower
pole of kidneys
 Diaphragm : For staging
MRI OF SCROTUM
NORMAL MRI ANATOMY
PATHOLOGICAL CONDITIONS
SCROTAL WALL LESION
 Non inflammatory
 Inflammatory
 Malignant
SCROTAL WALL LESION
NON INFLAMMATORY
o Swelling : HF , idiopathic lymphedema
liver failure , venous and lymphatic obstruction
o Appearance : ONION RING
SCROTAL WALL LESION
INFLAMMATORY LESIONS
o Cellulitis
• Increased scrotal wall thickness
• Hypoechoic areas within
• Increased blood flow
o Fournier Gangrene
• Necrotizing fascitis of the wall
• KEPPSS bacteria
• Clinical > Imaging
• Gas within the scrotal wall
• Scrotal wall thickening with normal testis and epididymis
CONGENITAL ANOMALIES
CRYPTORCHIDISM
 One or both the testis fail to
migrate to the base of the
scrotum
 Course of testis
 80% in inguinal region
 Complication : Infertility ,
malignant degeneration,
torsion and inguinal hernia
CRYPTORCHIDISM
USG EXAMINATION
 Localisation
 Follow up post orchiopexy
 Areas: Inguinal canal ,
suprapubic and femoral
areas
 Intraabdominal testis – USG
less sensitive
 USG features : Iso to
hypoechoic , smaller in size ,
mediastinum testis
CRYPTORCHIDISM
MRI
 Look till lower pole of the kidneys
 Round/ovoid
 Along the path of descent
 ID
o Signal intensity pattern
• Hypointense – T1
• Hyperintense – T2
o Mediastinum Testis
o Differentiating from nodes:
Position
RETRACTILE TESTIS
 Due to hyperactive cremasteric muscle reflex
 Slides back and forth between scrotum and ext inguinal ring
 Self- limiting and no treatment
ECTOPIC TESTIS
 Location outside the descent path
 Sites : Femoral canal , suprapubic or even C/L scrotal pouch
ACUTE SCROTUM
EPIDIDYMITIS AND ORCHITIS
 MC cause in post-pubertal adults
 Cause : UTI by KEPPs>STDs
 If inflammation extends into testis : Epididymo-orchitis
 C/F : Pain , fever , dysuria +/- urethral discharge
 PREHN sign: pain relieved on elevating testis over pubic
symphysis
 Complications: Chronic pain , infertility , gangrene , abscess ,
infarction , atrophy and pyocele
EPIDIDYMITIS AND ORCHITIS
USG FINDINGS OF EPIDIDYMITIS
 Enlarged
 Hypo/heteroechoic
 Indirect signs of inflammation :
Hydrocele , scrotal wall thickening ,
pyocele
USG FINDINGS IN ORCHITIS
 Heterogeneous echogenicity
 Multiple hypoechoic lesions if focal
 Usually unilateral( diff from
Lymphoma & Leukemia)
EPIDIDYMITIS AND ORCHITIS
CDFI and PD
 100% sensitivity
 Hyperemia
 High flow , low resistance
pattern
 RI< 0.5
 Reversal of diastolic flow
in acute epididymoorchitis
– s/o Venous infarction
EPIDIDYMITIS AND ORCHITIS
MRI on Epididymitis
 Enlarged epididymis with
high signal intensity on
contrast enhanced T1W
 Area of hemorrhage and
hyper vascularity
MRI on Orchitis
 Homogeneous/heterogen
eous hypointense on T2W
TORSION
Torsion
Extravaginal
Neonates
Entire sac rotates
Intravaginal
In Vaginal sac
Pubertal
TORSION
TORSION
BELL CLAPPER DEFORMITY
TORSION
 Rotation of testis on long axis of spermatic cord
Torsion
Venous
Edema and
hemorrhage
Arterial
Ischemia
and necrosis
TORSION
SALVAGE RATE
o <6 hours – 100%
o 6-12 hrs – 70%
o 12-24 hrs - 20%
TORSION
CLINICAL FEATURES
 Sudden onset of pain
 Nausea
 Vomiting
 Low grade fever
 O/E : Swollen , tender and inflamed hemiscrotum
TORSION
USG features
 Vary with duration and degree of rotation
 Grey Scale – Nonspecific (Normal if hyperacute)
 < 6 hours : Testicular swelling and hypoechogenicity
 >24hrs: Heterogeneous due to congestion , hemorrhage and
infarction
 Enlarged hypoechoic epididymal head : if deferential artery is
involved
 Scrotal wall thickening
 Reactive hydrocele
TORSION
CDFI
 CDFI or PD signal present with clinical manifestation :
Doesnot exclude torsion
 Absence of identifiable intratesticular flow
o Sensitivity 86%
o Specific 100%
o Accuracy 97%
SPECTRUM OF APPEARANCES
Torsion of appendix testis
 Blue dot sign : Torsion of appendix
 USG
o Hyperechoic mass with central
hypoechoic area adjacent to
superior poleof
testis/epididymis
o Reactive hydrocele
o Scrotal skin thickening
o Increased peripheral flow on
CDFI
o To rule out testicular torsion
and acute epididymo-orchitis
TORSION
MRI
 Early diagnosis of incomplete torsion
 ‘WHIRLPOOL’ pattern : twisted cord as multiple low
intensity curvilinear pattern
 Torsion knot as signal void
 Intermittent torsion : Enlarged testis and Hyperintense
on T1 and T2
 MR Spectroscopy - Decreased levels of beta – ATP in
acute torsion
TORSION
TORSION
 Tc-99m Pertechnate scan
SCROTAL TRAUMA
 Mostly direct injury
 Open and penetrating injury – Immediate surgery usually
 Blunt injury
o Exclude testicular rupture(emergency)
o Hematoma from hematocele
o Follow up
SCROTAL TRAUMA
USG
 Hematoma – Well defined
hypoechoic SOL
 Rupture – Irregular contour,
hypo/hyperechoic areas
 Scrotal hematoma – Non
specific wall thickening
 Hematocele – Int echoes in
the fluid in vaginal sac
 Chronic hematocele – Thick
septae and wall thickening
SCROTAL TRAUMA
MRI
 When USG is non yielding
 Testicular rupture : Loss of integrity of tunica albuginea
TESTICULAR TUMORS
Testicular Cancer
CLASSIFICATION
o Germ Cell (90%) - Malignant
• Seminoma
• Non-seminoma (embryonal cell, choriocarcinoma, teratoma, yolk sac)
• Mixed
o Non-Germ cell –rare; usually benign
• leydig
• sertoli
o Secondary
• leukemia, lymphoma
• met (prostate)
TESTICULAR TUMOR
 MC malignancy affecting young men of 20-34 yrs of age
 Risk factors: Cryptoorchidism , testicular atrophy(mumps),
testicular microlithiasis, klinefelters ,downsyndrome
 C/F: Painless mass, vague discomfort
 USG : differentiate Intratesticular(malignant) and
Extratesticular(benign) lesions
TESTICULAR TUMOR
GERM CELL TUMOR
 90-95% of testicular cancers
GCT
Seminomatous
Non
Seminomatous
GERM CELL TUMORS
 TUMOR MARKERS
o LDH
o AFP(Never elevated in Seminoma)
o hCG(choriocarcinoma , majority of NSGCT)
SEMINOMA
 MC testicular tumor
 4th to 5th decade
 Best prognosis
 Chemosensitive and radiosensitive
SEMINOMA
Seminoma
Typical(85%) Anaplastic(10%)
Spermatocytic
(Best Px)
SEMINOMA
USG
 Homogenous hypoechoic lobulated lesion
 Entire testis replaced by tumor(>50%cases)
 Cystic components are rare
 Confined to Tunica albuginea
 Mets to Lung , brain
SEMINOMA
SEMINOMA
MRI
 T1W : Homogenous and relatively isointense
 T2W : Hypointense
NSGCT
 3rd – 4th decade
 Can have multiple histologic patterns
USG Inhomogneous echotexture(71%)
o Ill defined margins(45%)
o Echogenic foci(35%)
o Cystic components(61%)
MRI
o T1W : Isointense to Hyperintense
o T2w : Hypointense
o Gd-T1 :Heterogenous (necrosis, mixed cell types)
NSGCT
EMBRYONAL CARCINOMA
 3rd decade
 USG
o Predominantly
hypoechoic
o Poorly defined
margins
o Inhomogeneous
echotexture
o Invades Tunica and
distorts the
contour of testis
YOLK SAC TUMOR
 Endodermal sinus tumor/infantile embryonal carcinoma
 80% of pediatric testicular tumors
 AFP 
 USG
o Inhomogeneous
o Echogenic foci
CHORIOCARCINOMA
 Highly malignant
 Microvascular invasion – hence hematogenous mets
 USG : Heterogenous mass
TERATOMA
 Composed of all three
germ cell layers
 Any age group
 USG
o Large and
inhomogenous
mass
o Cystic components
more common
BURNT-OUT GERM CELL TUMOR
 When growth > supply
 Histology : No tumor
cells , but replaced by
scar and fibrous tissue
 USG
o Small echogenic
foci / hypoechoic
mass or merely an
area of calcification
MIXED GERM CELL TUMOR
 More common than any
other testicular tumor
except seminoma
 Any combination of cell
types
 variety of cell types
expressed in variable
appearance
NGCT
 Tumors of gonadal stroma(Leydig , sertoli and
gonadoblastoma
 May be endocrinally active – precocious puberty ,
gynecomastia
 5% of testicular cancer
• higher in peds
 90% benign
 Indistinguishable from GCT
 USG
o Small in size
o Smooth contour
o Homogenous hypoechoic
LEYDIG CELL TUMOR
 1-3% of all testicular
neoplasm
 Usually benign
 Hormonally active
USG
 Hypoechoic nodule
MRI
 T1W : Isointense
 T2W: Hypointense
 CE :Hyperenhance
SERTOLI CELL TUMOR
 1% of all testicular CA
 First 4 decades of life
 Mostly benign
 MRI imaging NOT
SPECIFIC
NGCT
LYMPHOMAS
 MC testicular neoplasm after
60 years
 Can involve C/L seminoma ,
epididymis and spermatic
cord
 Appearance
o Deposits as focal or
diffuse hypoechoic
hypervascular areas
o Enlarged usually
o T1 and T2 hypointense
lesions
NGCT
METASTASIS
 Rare and seen in older patients
 Primaries – Lung , Kidney and prostate
 USG : Non specific
STAGING OF TESTICULAR CANCER
 pTX: Primary tumor cannot be assessed (if no radical orchiectomy has
been performed, TX is used.)
 pT0: No evidence of primary tumor (e.g., histologic scar in testis)
 pTis: Intratubular germ cell neoplasia (carcinoma in situ)
 pT1: Tumor limited to testis and epididymis without lymphatic/vascular
invasion
 pT2: Tumor limited to testis and epididymis with vascular/lymphatic
invasion, or tumor extending through the tunica albuginea with
involvement of the tunica vaginalis
 pT3: Tumor invades the spermatic cord with or without
vascular/lymphatic invasion
 pT4: Tumor invades the scrotum with or without vascular/lymphatic
invasion
STAGING OF TESTICULAR CANCER
REGIONAL LYMPH NODES (N)
 NX: Regional lymph nodes cannot be assessed
 N0: No regional lymph node metastasis
 N1: Metastasis in a single lymph node, 2cm in greatest
dimension
 N2: Metastasis in a single lymph node, 2-5 cm in greatest
dimension; or multiple lymph nodes, 5 cm in greatest
dimension
 N3: Metastasis in a lymph node >5cm in greatest dimension
STAGING OF TESTICULAR CANCER
DISTANT METASTASIS (M)
 MX: Presence of distant metastasis cannot be assessed
 M0: No distant metastasis
 M1: Distant metastasis
 M1a: Non-regional nodal or pulmonary metastasis
 M1b: Distant metastasis other than to non-regional nodes
and lungs
STAGING OF TESTICULAR CANCER
STAGING OF TESTICULAR CANCER
RISK STRATIFICATION
CT
 MC for tumor spread , Staging and follow up
 Detection of lymphadenopathy
 Extranodal mets in Lung and liver
 Nodes <1cm suspicious if at the site of drainage
o Renal hila on left
o Aortocaval in right
 Cut off for nodes : 7mm
 NSGCT : Enlarged necrotic LN or heterogenous contrast
enhancement
PET(FDG-PET)
 Differentiation of active disease from fibrosis/mature
teratoma in patients with residual mass following
chemotherapy
 Initial staging and disease assessment after orchidectomy
 Identification of suspected recurrences in the context of
elevated circulating serum markers
 Predicting response to treatment.
BENIGN INTRATESTICULAR LESIONS
BENIGN INTRATESTICULAR LESIONS
CYSTS
 Incidentally
detected usually
 Symptomatic ,
palpable and solid
component :
? suspicious
BENIGN INTRATESTICULAR LESIONS
TUNICA ALBUGINEA CYST
 Small palpable masses
 Upper anterior/lateral
aspect
USG
 Cystic and peripheral
 Internal echoes are
rare
MRI
 Similar to fluid in all
sequences
BENIGN INTRATESTICULAR LESIONS
TUBULAR ECTASIA
 Multiple tiny cystic areas with no flow
on CDFI
 Associated with epididymal
obstruction
EPIDERMOID AND DERMOID CYSTS
 Rare
 Palpable simple cysts
 Echogenic margins
 No malignant potential
BENIGN INTRATESTICULAR LESIONS
ADRENAL RESTS
 Associated with CAH
 Common embryonic origin of
adrenals and gonads
 USG
o Multifocal
o Bilateral hypoechoic lesions
BENIGN INTRATESTICULAR LESIONS
CALCIFICATION
Calcification
Intratesticular
Macro(Calcifying
tumors)
Microlithiasis
Extratesticular Scrotoliths
BENIGN INTRATESTICULAR LESIONS
CALCIFICATION
 Testicular microlithiasis
o Multiple small hyperechoic foci +/- shadowing
o 5 /transducer field is abnormal
o 18-75% association with neoplasia
o Follow up required if seen
CALCIFICATIONS
 Occurs as a complication
of epidiymo-orchitis
 Can rupture into tunica
vaginalis – pyocele
 USG:
Fluid filled
hypoechoic/ echogenic
areas with peripheral
vascularity.
Should be correlated
with clinical symptoms.
TESTICULAR ABSCESS
 Can occur secondary to
torsion, vasculitis,
leukemia,
hypercoagulable state.
 Seen as peripherally
placed, wedge shaped,
hypoechoic mass, with
decreased or no
vascularity.
 Usually shows decrease
in size on follow up.
TESTICULAR INFARCTION
TESTICULAR INFARCTION
MRI
 T1W : Isointense
o Hemorrhagic infarct : Hyperintense
 T2W : Variable but usually hypointense
 CE : Rim enhancement
INTRATESTICULAR VARICOCELE
 ?etiology.
?significance
 May cause pain
 (+/-)extratesticular
varicoceles
 Findings
• tubular, serpiginous
structures with venous
doppler/color flow
which increases with
valsalva
EXTRATESTICULAR PATHOLOGIES
EXTRATESTICULAR PATHOLOGIES
HYDROCELE
 Serous fluid in tunica vaginalis
 Two types
o Congenital: Persistent processus
vaginalis
o Acquired : Idiopathic , post
inflammatory , torsion , trauma or
tumor
 USG
o Anechoic collection around the testis
o Internal echoes/Few septations : chronic
EXTRATESTICULAR PATHOLOGIES
HEMATOCELE AND PYOCELE
 Post hemorrhage and abscess formation
 USG
o Multiple septations
o Echogenic debris
o Thickening of scrotal skin
o Calcification
EXTRATESTICULAR PATHOLOGIES
INGUINOSCROTAL HERNIA
 Dx usually clinically
 May contain bowel or omentum
 Essential to distinguish obstructed from
non obstructed
 Strangulation
o Akinetic dilated bowel loop in the
sac
o Hyperemia of scrotal soft tissue and
bowel
EXTRATESTICULAR PATHOLOGIES
EPIDIDYMAL CYST and SPERMATOCELE
 MC scrotal lesion
 Spermatocele
o 20 to obstruction of spermatic
pathway
o Usually located in head of
epididymis
 Epididymal Cyst
o Less common
o Anywhere in epididymis
 USG : Anechoic well circumscribed
cysts
EXTRATESTICULAR PATHOLOGIES
SPERM GRANULOMA
 Post vasectomy or epididymal obstruction
 USG
o Hypoechoic lesion
o Focal calcification +/-
EXTRATESTICULAR PATHOLOGIES
POSTORCHIDECTOMY SCROTUM
 Empty hemiscrotum
 Fluid collection /hematoma – Early post-op period
 Thickened scrotal wall
 Poorly defined hypoechoic lesion – Recurrence
 Testicular prosthesis : Made of silicone
o Sharply defined anechoic structure with excessive
reverberations
EXTRATESTICULAR TUMORS
BENIGN
Adenomatoid
Hemangioma
Lipoma
Neurofibroma
Leiomyoma
MALIGNANT
Liposarcoma
Fibrosarcoma
Lymphoma(Adults)
Rhabdomyosarcoma in
(children)
EXTRATESTICULAR TUMORS
 Usually benign
 MC :
Adenomatoid
tumor of
epididymis/sper
matic cord
 USG
o Solitary , well
defined ,
round to oval
o Variable
echogenicity
LIPOMA
 MC benign
tumor of
spermatic cord
USG
 Well defined
homogenous
and hyperechoic
MRI
 Uniform and fat
signal intensity
in all sequences
SUMMARY
 Use of Gray-scale, pulsed, and color Doppler US can help to
establish the correct diagnosis of a variety of pathologic
conditions involving the scrotum.
 MRI is useful adjunct in many cases – to differentiate intra
and extratesticular masses .
Imaging of the scrotum

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Imaging of the scrotum

  • 2. ANATOMY OF SCROTUM  Cutaneous bag containing the testis , epididymis and lower part of spermatic cord  Left hemiscrotum is lower than the right – Longer spermatic cord
  • 4. ANATOMY OF SCROTUM BLOOD SUPPLY  Sup and deep External pudendal A  Scrotal br of Internal Pudendal A  Cremasteric br of inferior epigastric
  • 5. ANATOMY OF TESTIS TESTIS  Male gonad  Size : o At birth : 1.5cm(L) x 1.0cm(W) o <12 years : 1-2cc o 10-15cc (2x3x4cms-BaPL) in adults  Puberty achieved : >4cc
  • 6. ANATOMY OF TESTIS EXTERNAL FEATURES  Upper pole:Oriented forward and lateral  Lower pole : Backward and medial  Anterior border : Convex and smooth , fully covered by tunica vaginalis  Posterior border : Straight and partially covered by tunica vaginalis – Epididymis along the posterolateral wall
  • 7. ANATOMY OF TESTIS COVERINGS OF TESTIS(Out to in)  Tunica vaginalis  Tunica albuginea  Tunica vasculosa
  • 8. ANATOMY OF TESTIS BLOOD SUPPLY OF TESTIS  Testicular artery  Collateral supply o Cremasteric artery o Artery to ductus deferens
  • 13. USG TECHNIQUE  Supine position  7-10Mhz linear array transducer  Direct contact or stand off pad  Examine in long and transverse axes  Size and echogenicity of the testis and epididymis  Scrotal skin thickness  CDFI and PWD  Valsalva and Upright positioning – Venous evaluation
  • 14. USG ANATOMY  Pre-pubertal testis : Low to medium echogenicity  Post-pubertal : Homogenous and medium echogenicity  Medistinum Testis: Echogenic band in C-C direction  Hypoechoic thin rim of fluid around  Epididymis o Head : 5-12mm o Body : 2-4mm o Tail : 2-5mm  CDFI and PWD(RI : 0.46-0.68)
  • 15.
  • 16. USG ANATOMY CDFI AND PWD  Low resistance pattern  Mean RI:0.62(0.48-0.75)
  • 17. MRI OF SCROTUM MRI PROTOCOL  Supine position  Support scrotum by towel  T1 and T2wSE in coronal and axial plane  CE and Fat saturation seq  Thin 4-5mm slices 8-20 cm field of view  Undescended testis : Lower pole of kidneys  Diaphragm : For staging
  • 18. MRI OF SCROTUM NORMAL MRI ANATOMY
  • 20. SCROTAL WALL LESION  Non inflammatory  Inflammatory  Malignant
  • 21. SCROTAL WALL LESION NON INFLAMMATORY o Swelling : HF , idiopathic lymphedema liver failure , venous and lymphatic obstruction o Appearance : ONION RING
  • 22. SCROTAL WALL LESION INFLAMMATORY LESIONS o Cellulitis • Increased scrotal wall thickness • Hypoechoic areas within • Increased blood flow o Fournier Gangrene • Necrotizing fascitis of the wall • KEPPSS bacteria • Clinical > Imaging • Gas within the scrotal wall • Scrotal wall thickening with normal testis and epididymis
  • 24. CRYPTORCHIDISM  One or both the testis fail to migrate to the base of the scrotum  Course of testis  80% in inguinal region  Complication : Infertility , malignant degeneration, torsion and inguinal hernia
  • 25. CRYPTORCHIDISM USG EXAMINATION  Localisation  Follow up post orchiopexy  Areas: Inguinal canal , suprapubic and femoral areas  Intraabdominal testis – USG less sensitive  USG features : Iso to hypoechoic , smaller in size , mediastinum testis
  • 26. CRYPTORCHIDISM MRI  Look till lower pole of the kidneys  Round/ovoid  Along the path of descent  ID o Signal intensity pattern • Hypointense – T1 • Hyperintense – T2 o Mediastinum Testis o Differentiating from nodes: Position
  • 27. RETRACTILE TESTIS  Due to hyperactive cremasteric muscle reflex  Slides back and forth between scrotum and ext inguinal ring  Self- limiting and no treatment ECTOPIC TESTIS  Location outside the descent path  Sites : Femoral canal , suprapubic or even C/L scrotal pouch
  • 29. EPIDIDYMITIS AND ORCHITIS  MC cause in post-pubertal adults  Cause : UTI by KEPPs>STDs  If inflammation extends into testis : Epididymo-orchitis  C/F : Pain , fever , dysuria +/- urethral discharge  PREHN sign: pain relieved on elevating testis over pubic symphysis  Complications: Chronic pain , infertility , gangrene , abscess , infarction , atrophy and pyocele
  • 30. EPIDIDYMITIS AND ORCHITIS USG FINDINGS OF EPIDIDYMITIS  Enlarged  Hypo/heteroechoic  Indirect signs of inflammation : Hydrocele , scrotal wall thickening , pyocele USG FINDINGS IN ORCHITIS  Heterogeneous echogenicity  Multiple hypoechoic lesions if focal  Usually unilateral( diff from Lymphoma & Leukemia)
  • 31. EPIDIDYMITIS AND ORCHITIS CDFI and PD  100% sensitivity  Hyperemia  High flow , low resistance pattern  RI< 0.5  Reversal of diastolic flow in acute epididymoorchitis – s/o Venous infarction
  • 32. EPIDIDYMITIS AND ORCHITIS MRI on Epididymitis  Enlarged epididymis with high signal intensity on contrast enhanced T1W  Area of hemorrhage and hyper vascularity MRI on Orchitis  Homogeneous/heterogen eous hypointense on T2W
  • 36. TORSION  Rotation of testis on long axis of spermatic cord Torsion Venous Edema and hemorrhage Arterial Ischemia and necrosis
  • 37. TORSION SALVAGE RATE o <6 hours – 100% o 6-12 hrs – 70% o 12-24 hrs - 20%
  • 38. TORSION CLINICAL FEATURES  Sudden onset of pain  Nausea  Vomiting  Low grade fever  O/E : Swollen , tender and inflamed hemiscrotum
  • 39. TORSION USG features  Vary with duration and degree of rotation  Grey Scale – Nonspecific (Normal if hyperacute)  < 6 hours : Testicular swelling and hypoechogenicity  >24hrs: Heterogeneous due to congestion , hemorrhage and infarction  Enlarged hypoechoic epididymal head : if deferential artery is involved  Scrotal wall thickening  Reactive hydrocele
  • 40. TORSION CDFI  CDFI or PD signal present with clinical manifestation : Doesnot exclude torsion  Absence of identifiable intratesticular flow o Sensitivity 86% o Specific 100% o Accuracy 97%
  • 42. Torsion of appendix testis  Blue dot sign : Torsion of appendix  USG o Hyperechoic mass with central hypoechoic area adjacent to superior poleof testis/epididymis o Reactive hydrocele o Scrotal skin thickening o Increased peripheral flow on CDFI o To rule out testicular torsion and acute epididymo-orchitis
  • 43. TORSION MRI  Early diagnosis of incomplete torsion  ‘WHIRLPOOL’ pattern : twisted cord as multiple low intensity curvilinear pattern  Torsion knot as signal void  Intermittent torsion : Enlarged testis and Hyperintense on T1 and T2  MR Spectroscopy - Decreased levels of beta – ATP in acute torsion
  • 46. SCROTAL TRAUMA  Mostly direct injury  Open and penetrating injury – Immediate surgery usually  Blunt injury o Exclude testicular rupture(emergency) o Hematoma from hematocele o Follow up
  • 47. SCROTAL TRAUMA USG  Hematoma – Well defined hypoechoic SOL  Rupture – Irregular contour, hypo/hyperechoic areas  Scrotal hematoma – Non specific wall thickening  Hematocele – Int echoes in the fluid in vaginal sac  Chronic hematocele – Thick septae and wall thickening
  • 48. SCROTAL TRAUMA MRI  When USG is non yielding  Testicular rupture : Loss of integrity of tunica albuginea
  • 49.
  • 51. Testicular Cancer CLASSIFICATION o Germ Cell (90%) - Malignant • Seminoma • Non-seminoma (embryonal cell, choriocarcinoma, teratoma, yolk sac) • Mixed o Non-Germ cell –rare; usually benign • leydig • sertoli o Secondary • leukemia, lymphoma • met (prostate)
  • 52. TESTICULAR TUMOR  MC malignancy affecting young men of 20-34 yrs of age  Risk factors: Cryptoorchidism , testicular atrophy(mumps), testicular microlithiasis, klinefelters ,downsyndrome  C/F: Painless mass, vague discomfort  USG : differentiate Intratesticular(malignant) and Extratesticular(benign) lesions
  • 53. TESTICULAR TUMOR GERM CELL TUMOR  90-95% of testicular cancers GCT Seminomatous Non Seminomatous
  • 54. GERM CELL TUMORS  TUMOR MARKERS o LDH o AFP(Never elevated in Seminoma) o hCG(choriocarcinoma , majority of NSGCT)
  • 55. SEMINOMA  MC testicular tumor  4th to 5th decade  Best prognosis  Chemosensitive and radiosensitive
  • 57. SEMINOMA USG  Homogenous hypoechoic lobulated lesion  Entire testis replaced by tumor(>50%cases)  Cystic components are rare  Confined to Tunica albuginea  Mets to Lung , brain
  • 59. SEMINOMA MRI  T1W : Homogenous and relatively isointense  T2W : Hypointense
  • 60. NSGCT  3rd – 4th decade  Can have multiple histologic patterns USG Inhomogneous echotexture(71%) o Ill defined margins(45%) o Echogenic foci(35%) o Cystic components(61%) MRI o T1W : Isointense to Hyperintense o T2w : Hypointense o Gd-T1 :Heterogenous (necrosis, mixed cell types)
  • 61. NSGCT
  • 62. EMBRYONAL CARCINOMA  3rd decade  USG o Predominantly hypoechoic o Poorly defined margins o Inhomogeneous echotexture o Invades Tunica and distorts the contour of testis
  • 63. YOLK SAC TUMOR  Endodermal sinus tumor/infantile embryonal carcinoma  80% of pediatric testicular tumors  AFP   USG o Inhomogeneous o Echogenic foci
  • 64. CHORIOCARCINOMA  Highly malignant  Microvascular invasion – hence hematogenous mets  USG : Heterogenous mass
  • 65. TERATOMA  Composed of all three germ cell layers  Any age group  USG o Large and inhomogenous mass o Cystic components more common
  • 66. BURNT-OUT GERM CELL TUMOR  When growth > supply  Histology : No tumor cells , but replaced by scar and fibrous tissue  USG o Small echogenic foci / hypoechoic mass or merely an area of calcification
  • 67. MIXED GERM CELL TUMOR  More common than any other testicular tumor except seminoma  Any combination of cell types  variety of cell types expressed in variable appearance
  • 68. NGCT  Tumors of gonadal stroma(Leydig , sertoli and gonadoblastoma  May be endocrinally active – precocious puberty , gynecomastia  5% of testicular cancer • higher in peds  90% benign  Indistinguishable from GCT  USG o Small in size o Smooth contour o Homogenous hypoechoic
  • 69. LEYDIG CELL TUMOR  1-3% of all testicular neoplasm  Usually benign  Hormonally active USG  Hypoechoic nodule MRI  T1W : Isointense  T2W: Hypointense  CE :Hyperenhance
  • 70. SERTOLI CELL TUMOR  1% of all testicular CA  First 4 decades of life  Mostly benign  MRI imaging NOT SPECIFIC
  • 71. NGCT LYMPHOMAS  MC testicular neoplasm after 60 years  Can involve C/L seminoma , epididymis and spermatic cord  Appearance o Deposits as focal or diffuse hypoechoic hypervascular areas o Enlarged usually o T1 and T2 hypointense lesions
  • 72. NGCT METASTASIS  Rare and seen in older patients  Primaries – Lung , Kidney and prostate  USG : Non specific
  • 73. STAGING OF TESTICULAR CANCER  pTX: Primary tumor cannot be assessed (if no radical orchiectomy has been performed, TX is used.)  pT0: No evidence of primary tumor (e.g., histologic scar in testis)  pTis: Intratubular germ cell neoplasia (carcinoma in situ)  pT1: Tumor limited to testis and epididymis without lymphatic/vascular invasion  pT2: Tumor limited to testis and epididymis with vascular/lymphatic invasion, or tumor extending through the tunica albuginea with involvement of the tunica vaginalis  pT3: Tumor invades the spermatic cord with or without vascular/lymphatic invasion  pT4: Tumor invades the scrotum with or without vascular/lymphatic invasion
  • 74. STAGING OF TESTICULAR CANCER REGIONAL LYMPH NODES (N)  NX: Regional lymph nodes cannot be assessed  N0: No regional lymph node metastasis  N1: Metastasis in a single lymph node, 2cm in greatest dimension  N2: Metastasis in a single lymph node, 2-5 cm in greatest dimension; or multiple lymph nodes, 5 cm in greatest dimension  N3: Metastasis in a lymph node >5cm in greatest dimension
  • 75. STAGING OF TESTICULAR CANCER DISTANT METASTASIS (M)  MX: Presence of distant metastasis cannot be assessed  M0: No distant metastasis  M1: Distant metastasis  M1a: Non-regional nodal or pulmonary metastasis  M1b: Distant metastasis other than to non-regional nodes and lungs
  • 79. CT  MC for tumor spread , Staging and follow up  Detection of lymphadenopathy  Extranodal mets in Lung and liver  Nodes <1cm suspicious if at the site of drainage o Renal hila on left o Aortocaval in right  Cut off for nodes : 7mm  NSGCT : Enlarged necrotic LN or heterogenous contrast enhancement
  • 80. PET(FDG-PET)  Differentiation of active disease from fibrosis/mature teratoma in patients with residual mass following chemotherapy  Initial staging and disease assessment after orchidectomy  Identification of suspected recurrences in the context of elevated circulating serum markers  Predicting response to treatment.
  • 82. BENIGN INTRATESTICULAR LESIONS CYSTS  Incidentally detected usually  Symptomatic , palpable and solid component : ? suspicious
  • 83. BENIGN INTRATESTICULAR LESIONS TUNICA ALBUGINEA CYST  Small palpable masses  Upper anterior/lateral aspect USG  Cystic and peripheral  Internal echoes are rare MRI  Similar to fluid in all sequences
  • 84. BENIGN INTRATESTICULAR LESIONS TUBULAR ECTASIA  Multiple tiny cystic areas with no flow on CDFI  Associated with epididymal obstruction EPIDERMOID AND DERMOID CYSTS  Rare  Palpable simple cysts  Echogenic margins  No malignant potential
  • 85. BENIGN INTRATESTICULAR LESIONS ADRENAL RESTS  Associated with CAH  Common embryonic origin of adrenals and gonads  USG o Multifocal o Bilateral hypoechoic lesions
  • 87. BENIGN INTRATESTICULAR LESIONS CALCIFICATION  Testicular microlithiasis o Multiple small hyperechoic foci +/- shadowing o 5 /transducer field is abnormal o 18-75% association with neoplasia o Follow up required if seen
  • 89.  Occurs as a complication of epidiymo-orchitis  Can rupture into tunica vaginalis – pyocele  USG: Fluid filled hypoechoic/ echogenic areas with peripheral vascularity. Should be correlated with clinical symptoms. TESTICULAR ABSCESS
  • 90.  Can occur secondary to torsion, vasculitis, leukemia, hypercoagulable state.  Seen as peripherally placed, wedge shaped, hypoechoic mass, with decreased or no vascularity.  Usually shows decrease in size on follow up. TESTICULAR INFARCTION
  • 91. TESTICULAR INFARCTION MRI  T1W : Isointense o Hemorrhagic infarct : Hyperintense  T2W : Variable but usually hypointense  CE : Rim enhancement
  • 92. INTRATESTICULAR VARICOCELE  ?etiology. ?significance  May cause pain  (+/-)extratesticular varicoceles  Findings • tubular, serpiginous structures with venous doppler/color flow which increases with valsalva
  • 94. EXTRATESTICULAR PATHOLOGIES HYDROCELE  Serous fluid in tunica vaginalis  Two types o Congenital: Persistent processus vaginalis o Acquired : Idiopathic , post inflammatory , torsion , trauma or tumor  USG o Anechoic collection around the testis o Internal echoes/Few septations : chronic
  • 95. EXTRATESTICULAR PATHOLOGIES HEMATOCELE AND PYOCELE  Post hemorrhage and abscess formation  USG o Multiple septations o Echogenic debris o Thickening of scrotal skin o Calcification
  • 96. EXTRATESTICULAR PATHOLOGIES INGUINOSCROTAL HERNIA  Dx usually clinically  May contain bowel or omentum  Essential to distinguish obstructed from non obstructed  Strangulation o Akinetic dilated bowel loop in the sac o Hyperemia of scrotal soft tissue and bowel
  • 97. EXTRATESTICULAR PATHOLOGIES EPIDIDYMAL CYST and SPERMATOCELE  MC scrotal lesion  Spermatocele o 20 to obstruction of spermatic pathway o Usually located in head of epididymis  Epididymal Cyst o Less common o Anywhere in epididymis  USG : Anechoic well circumscribed cysts
  • 98. EXTRATESTICULAR PATHOLOGIES SPERM GRANULOMA  Post vasectomy or epididymal obstruction  USG o Hypoechoic lesion o Focal calcification +/-
  • 99. EXTRATESTICULAR PATHOLOGIES POSTORCHIDECTOMY SCROTUM  Empty hemiscrotum  Fluid collection /hematoma – Early post-op period  Thickened scrotal wall  Poorly defined hypoechoic lesion – Recurrence  Testicular prosthesis : Made of silicone o Sharply defined anechoic structure with excessive reverberations
  • 101. EXTRATESTICULAR TUMORS  Usually benign  MC : Adenomatoid tumor of epididymis/sper matic cord  USG o Solitary , well defined , round to oval o Variable echogenicity
  • 102. LIPOMA  MC benign tumor of spermatic cord USG  Well defined homogenous and hyperechoic MRI  Uniform and fat signal intensity in all sequences
  • 103. SUMMARY  Use of Gray-scale, pulsed, and color Doppler US can help to establish the correct diagnosis of a variety of pathologic conditions involving the scrotum.  MRI is useful adjunct in many cases – to differentiate intra and extratesticular masses .

Editor's Notes

  1. Vasculosa lines the lobules Mediastinum testis : thickened Post border of tunica albuginea
  2. Cremasteric- inf epi art – br ext ilia Artery to ductus – inf vesical art- br int iliac
  3. Use of contrast material can aid in differentiating between a benign cystic lesion and a cystic neoplasm. Gadolinium-enhanced imaging can also be used to assess for areas of absent or reduced testicular perfusion, such as in segmental testicular infarct
  4. Scrotal wall thickening
  5. Diff from LN
  6. Nodes : Adjacent to vessels or below inguinal ligament
  7. GdE T1 fat sat T1
  8. Hemorrhage and infarction
  9. Sudden onset of pain and swelling
  10. Alrge tumor with cystic spaces occupying most of the lesion
  11. T1 T2 CE , scrotal pearl
  12. Differentiate from seminoma
  13. Melanoma metastasis. Longitudinal scan shows a hypoechoic mass in the upper pole of the testis and epididymis.
  14. S1-AND S2/3 - OR
  15. Epidermoid cyst (benign). G, Typical whorled appearance; H, typical peripheral calcification. I, Transverse scan shows hypoechoic mass with central calcifications similar to other tumors on gray scale, but avascular on Doppler examination
  16. Adrenal rest. Intraoperative color Doppler image shows an intratesticular mass (arrows) with blood flow present near the mediastinum testis.
  17. Real time peristalsis
  18. Coronal T2 , hypo compared to testim MRI variable findings