7. Radiologist's role is determination of which
internal pelvic structures are present
Associated congenital abnormalities of the
urinary tract.
Chromosomal, endocrine and clinical
assessment are required
Ultrasound and MRI are the preferred
modalities
8.
9. Majority of prepubertal males
Most commonly lies in the inguinal canal
(canalicular).
May lie higher up along the normal line of
descent (abdominal testicle)
Most abdominal testicles lie just proximal to
the inguinal ring
In a site away from the normal line of
descent (ectopic).
10.
11.
12. Ultrasound first line investigation
Located within inguinal canal
May be normal or atrophic
MRI if not found high signal on T2 and STIR
Testicular phlebography or arteriography
13.
14.
15.
16.
17. Atrophic with poor spermatogenisis
5 % are not found even at surgical exploration–
may be true agenisis
Severely atrophic cannot be located
Increased incidence of malignant neoplasia—x40
timesDevelopment of seminoma
Increased risk in contralateral normal descended
testicle
Associated seminal vesicle cysts and agenesis
18. Failure of closure of the processes vaginalis
after testicular descent
Results in a persistent communication with
the abdomen
Incomplete closure of the processes may lead
to a developmental cyst,
22. Formation of fluid between the two layers
(visceral and parietal) of the tunica vaginalis.
Mostly idiopathic
May develop as a result of infection
(epididymo-orchitis), trauma, malignant
testicular tumour or infarction (including
torsion).
Sonographically it is seen as an anechoic area
partly surrounding the testicle
23.
24.
25.
26. In infectionclinical and radiological feature
of epidydmitis
Chronic infective hydrocele (especially
tuberculous) may be associated with
considerable calcification of the tunica .
Following trauma a haematocele will exhibit
considerable echogenicity.
27.
28.
29.
30.
31. Common in elderly
The majority are seen in the epididymis.
May be single or multiple.
Classical features on ultrasound
Anechoic, showing distal acoustic
enhancement and having no appreciable wall
thickness.
32.
33.
34. Dilatation of the network of veins draining the
testicle
Usually asymptomatic.
Association with subfertility, reported in 21-39% of
males
Most frequent between 15 and 25 years of age
Almost always left-sided when symptomatic
Present with scrotal aching and/or soft scrotal
mass.
Classically these symptoms worsen during the day
while the patient is upright.
35.
36. Vast majority are primary
Due to developmental abnormalities of the
valves and/or the veins themselves.
More likely on the left, where at least 95%
are encountered.
Minority occur secondary to a lesion
compressing or occluding the testicular
vein.
37. On ultrasound varicoceles are seen as a
echo-free serpiginous structures measuring
more than 2 mm maximum diameter .
Visible flow may he seen within larger
varicoceles.
Their prominence is increased in the
upright position and with the Valsalva
manoeuvre.
38.
39.
40.
41. Inflammation of the epididymis
Mostly seen in young adult males
The clinical presentation varies in severity
and acuteness from mild pain, tenderness
and scrotal swelling
Severe pyrexal illness with marked scrotal
pain and swelling.
42. On ultrasound the epididymis shows swelling,
Diffuse or patchy reduction in echogenicity,
Doppler ultrasound demonstrates
hypervascularity.
A heterogeneous pattern of predominant
increase in echogenicity is more frequently
associated with chronic epididymitis.
Often an associated hydrocele
Edematous thickening of the overlying skin
There may be coexisting orchitis
43.
44. Inflammation of the testicle
2/3rd are unilateral.
In the acute phase ultrasound show testicular
swelling with patchy or diffuse reduction in
echogenicity.
Doppler ultrasound show increased
vascularity
Severe orchitis may be associated with
ischaemia and infarction with reduced or
absent vascularity.
45. Following resolution the testicle may return
to normal.
Severe orchitis heterogeneous areas may
develop with a potential for intra testicular
abscess formation
May result in atrophy with reduction in size
and echogenicity with little or no
spermatogenesis.
46.
47.
48. Twisting of spermatic cord with ischemia of
testes
Most frequent in the first year of life or in
adolescence, when the testicle is rapidly enlarges
The loose attachment of the testicle and
spermatic cord to the scrotum in infants and
neonates predisposes to torsion of the entire
cord above the level of the scrotum (extravaginal
torsion).
Rotation of the cord within the tunica vaginalis
(intravaninal torsion) is the commonest situation
in the older age group.
49.
50.
51.
52.
53. Torsion may be complete or incomplete and
spontaneous torsion and detorsion may occur
The degree of torsion determines the severity of
the ischemia
In the acute stage ultrasound may be normal or
demonstrate a swollen testicle with patchy or
diffuse hypoechogenicity .
The epididymis may also become swollen and
echo-poor.
There may be a reactive hydrocele and the
overlying scrotal skin may be thickened and
oedematous.
54. Doppler ultrasound with sensitivity of 85% in the
diagnosis of torsion reduced vascularity
(absence or poor colour flow, reduced peak
systolic velocities) compared with the unaffected
side.
Given the importance of operating within a few
hours of the onset of symptoms
Neither the performance nor interpretation of an
ultrasound examination should delay surgical
treatment.
If there is doubt the urologist should operate on
clinical grounds
56. The testicular appendix (hydatid of Morgagni) are
vestigial scrotal appendices may undergo torsion
Presents with acute scrotal pain and localized
swelling and tenderness.
On ultrasound there is a focal soft-tissue mass
adjacent to the upper pole of the epididymis which
is often heterogeneous with a central echo-poor
area and an associated hydrocele.
57.
58. Blunt scrotal trauma commonly results in
hemorrhage around the testicle (haematocele)
and intratesticular hematoma,
May be associated with a tear of the tunica
albuginea.
More significant trauma may be associated
with demonstrable fragmentation of the
testicle.
59. Ultrasound is the imaging modality.
The commonest finding is a complex
haemorrhagic hydrocele (haematocele)
The underlying testicle may show areas of
contusion or haematoma, visible as echo-
poor areas, often with a relatively linear
configuration.
60. The testicle may be deformed by subcapsular
haemorrhage.
There may be rupture of the capsule (tunica
albuginca ) with disruption of the underlying
testicle and associated haematoma .
The testicular tear may be linear or complex,
May be fragmentation of the testicle.
Hinweis der Redaktion
Anatomy Scrotum
Normal Sagittal Image Testis.
Normal Sagittal image head of epididymis
Wide variety of phenotypes.
This is a complex situation with a wide variety of phenotypes.
Neonate with bifid scrotum, micropenis, and hypospadius.
the testes may normally be retractile into the groin
Cryptorchidism because of the cremasteric muscle reflex retractile. If, however, the testicle can never be located within the scrotum, it can be considered undescended.
they may i.e. further cranially within the pelvis or retroperitoneum.
Ectopic testicles are uncommon
Ultrasound can be regarded as the first-line investigation to locate an undescended testicle, being quick and able to locate the testicle at its commonest sites (within the inguinal canal or just proximal to it ). The testicle may look relatively normal, although the longer it has been undescended the more likely it is to be small. If the testicle cannot be identified on ultrasound, a more extensive search may be performed with MRI. This is a better modality than CT as it avoids radiation and the testicle shows a conspicuous high signal on T2 weighted and STIR sequences.
Testicular phlebography or arteriography bas been employed in the search for undescended testes. If both ultrasound and MRI are negative it is unlikely that these angio graphic procedures will detect the missing organ, as it is probably absent or extremely atrophic.
The testicle is typically low signal on T1 and high signal on T2.
The normal testicle exhibits intense diffusion restriction, and these sequences can aid confident identification.
T1 and T2 weighted axial and coronal sequences, especially with a small field of view (FOV) are advisable as well as diffusion weighted imaging. The testicle is typically low signal on T1 and high signal on T2. The normal testicle exhibits intense diffusion restriction
The hyperintensity is consistent with restricted diffusion
The normal left testicle is identified lying within the left side of the scrotal sac.
The undescended smaller right testicle is intra-peritoneal in location, lying medial to the right external iliac vessels.
Transverse STiR images from MRI examinations of patients with undescended testicles (arrow) in the proximal end of the inguinal canal (A)
suprapubic pouch (B)
and pelvis (C).
Failure of descent by the age of 2-3 years is associated with abnormal development of the testicle and this is particularly severe if it continues beyond puberty.
it is distinctly possible that a number are so severely atrophic that they cannot be located. Testes that remain undescended (especially abdominal testes) in boys above the age of 5 years also suffer from an increased incidence of malignant neoplasia, up to 40 times normal, usually with the development of seminoma.
Cyst-usually in the upper scrotum or inguinal region.
the normal embryologic development of the processus vaginalis, which arises as an out pouching of the parietal peritoneum at the beginning of the 3rd month of gestation. After the testis descends into the scrotum (between the 7th and 9th months of gestation), the processus vaginalis is obliterated.
transmit disease processes (ascites) or become the site of a hernia.
(in comparison to cysts, which do not surround the testicle).
Ultrasound demonstration of a hydrocele seen as an echofree area partly surrounding a normal testicle
When infection is a cause there are usually obvious clinical and radiological features of epididymitis.
especially on the rare occasions when infection is sufficiently severe for frank pus (pyocele) to develop.
but a variety of other agents may be responsible, although now tuberculosis is rare.
The hydrocele may demonstrate internal echoes ,
commonest infective organisms are usually bowel-related Gram-negative bacilli
Ultrasound showing an infected, partly septated echogenic hydrocele
Ultrasound (A) showing dense peripheral calcification around the exterior of a chronic inflammatory hydrocele. This is also visible on the plain film (B).
Encysted hydrocele. (a) Diagram shows a fluid collection that does not communicate with the peritoneum or the scrotum. (b) Longitudinal US image in a 12-year-old boy shows a complex ovoid encysted lesion proximal to the testis (T), a finding indicative of an encysted hydrocele with protein and cholesterol contents.
Large hydrocele with peritesticular fluid in the tunica vaginalis (A small appendix testis can be seen)
Simple cysts are extremely common
particularly in the upper pole of epidydmis and in the scrotum. They may be seen at any age from adolescence onwards but are most common in the elderly.
Haemorrhage or infection may alter the appearance of a pre- existing cyst to show some degree of echogenicity, occasionally with a visible fluid level
infection or trauma (including vasectomy) may provoke the creation of a cystic lesion with internal echoes, partly due to the presence of spermatazoa spermatocele. These again are more common in the upper pole of the epididymis.
Ultrasound showing (A) a classical echo-free well-defined thin-walled solitary epididymal cyst and (B) a cluster of simple cysts.
Ultrasound of infected epididymal cyst showing debris and fluid level.
Spermatocele
Occasionally they present relatively acutely as a manifestation of a renal carcinoma. Treatment may be offered for discomfort or as part of the management of subfertility.
confusion with cysts is unlikely, even when the varicocele is small, but confirmation of their nature can he obtained with slow-flow Doppler Ultrasound.
The classical cause is a left-sided renal cell carcinoma extending along the renal vein as far as the termination of the testicular vein, but benign (for example, hydronephrosis) and other malignant conditions (including abdominal lymphadenopathy) can provoke a varicocele on either side.
There is a higher risk of an underlying cause, particularly a tumour if the varicocele is of recent onset with an acute presentation, the patient is older than 40 years.
Ultrasound of varicocele seen as echo-free serpiginous structures.
Intratesticular varicocele with a tortuous dilatated intra testicular vein with reflux during valsalva
Testicular phlebography and percutaneous embolisation of varicocele. The testicular vein in this patient has a wide termination unprotected by a valve and at least one small accessory connection to the renal vein (A). The catheter is manipulated into the distal testicular vein (B) to commence deploying the coils (C).
usually due to ascending infection with Gram-negative bacilli is common.
with a second peak in late middle age and the elderly, when it may be associated with cystitis and/or prostatitis in association with benign prostatic disease and bladder outflow obstruction.
Although usually asymmetrical, epididymitis is not uncommonly bilateral.
often nodular and particularly affecting the lower or upper pole.
although sometimes the epididymis shows considerable heterogeneity and even rarely a diffuse increase in echogenicity.
Rarely the condition progresses so that there is demonstrable abscess formation within the epididymis. There is of variable size, which may be septated and contain echogenic fluid. Severe cases may be associated with and (in up to 20% of cases).
Epididyimitis with a thickened hypervascularized epididymis. The testis is normal.
may be seen in systemic viral illness (classically mumps) or in association with bacterial epididymitis. Up to 25% of postpubertal males with mumps will suffer some degree of orchitis, usually 7-10 days after the parotitis.
Other viruses implicated include echoviruses, group B arboviruses and the lymphocytic choriomeningitis virus.
Again there is a substantial risk of subsequent atrophy leading to a small echo-poor testicle The underlying organisms are usually the same as for epididymids, although rarely chronic epididymitis, especially with abscess formation, may be due to tuberculosis. Calcific scars may be seen following any form of orchids.
Ultrasound of aggressive epididymitis showing a heterogeneous mass with areas of reduced and increased echogenicity adjacent to the lower pole of the testicle.
Ultrasound of severe orchitis. The bulk of the testicle shows diffuse reduction in echogenicity. The heterogeneous area in the lower pole represents a developing abscess.
extra-vaginal (supra-vaginal)
torsion occurs at the level of the external inguinal ring
seen in neonates
intra-vaginal
more common variety due to bell clapper deformity
typically occurs in adolescents and young adults
Different patterns of torsion have been described.
This is most often due to poor testicular attachment to the posterior scrotal wall by an abnormally narrow mesentery, which predisposes to rotation of the cord.
Transverse scan of both testicles showing normal left testicle and right testicular torsion. Note the hypoechogenicity of the right testicle
Transverse plane through both testes. The power Doppler image of the scrotum demonstrates right testicular perfusion. The swollen left testicle is not perfused
If torsion is incomplete, the testicle remains viable longer: 80% up to 12 h and 40% up to 24 h. Even in this situation, however, viability falls to 10% after 24 h
and the rapidity with which irreversible changes occur within the testicle. Surgical treatment of complete torsion within 5hour is associated with a testicular salvage rate of 80%, which falls to 20 17- or less after 12 h.
False positives (for example ischaemia associated with severe epididymo-orchids) and false negatives (due to difficulty in obtaining an adequate colour flow, intermittent nature of torsion, etc.) are encountered and there is still considerable controversy as to the role of this investigation in the management of these patients.
Incomplete torsion of testis with high resistance to-and-fro flow
Spectral Doppler shows high resistance flow in left testis with diastolic reversal, while the right testis shows normal low resistance flow.
Ultrasound of an infarcting testicle. There are extensive areas of reduced echogenicity within the substance of the testicle. The adjacent epididymis is also markedly diseased and swollen.
(such as the epididymal appendix)
This may slough off and become calcified, giving rise to mobile highly echogenic shadowing foci between the layers of the tunica vaginalis (scrotoliths or scrotal pearls).
Torsion of the appendix epididymis in an adult with a swollen appendix and increased vascularity of the epididymis
The role of imaging depends on the surgical approach. Where there is substantial trauma, surgical exploration, drainage of hematoma and repair of testicular tears may enhance the subsequent viability of the testicle
Scrotal hematoma may he complicated by abscess formation.
severe testicular damage may be followed by subsequent atrophy.
Traumatic changes in the testis with a contusion and hematoma without vascularity
This sonogram of a different patient following trauma reveals in homogeneous testicular echotexture and a fracture line (arrow).
Ultrasonography of a three-days old testicular rupture: the tunica cannot longer be seen, the pro lapsing testicular tissue appears inhomogeneous.
Scrotal sonography - reveals three testes
Magnetic resonance imaging (MRI) examination was done, which showed normal T 1 and T 2 images of right testis and lower testis of left hemiscrotum.The upper testis of left hemiscrotum showed increase signal intensity on T1 and decreased signal intensity on T2 images, suggestive of torsion and hemorrhagic necrosis .Minimal hydrocele was noted in both hemiscrota.
Longitudinal US image of the spermatic cord in a 1-year-old boy shows an inguinoscrotal hernia that contains bowel (arrowheads). A patent internal inguinal ring also is seen (arrows).
Pyocele with an irregular septated cystic mass
Epididymo-orchitis with a hypervascularized swollen testis and epididymis
Cystic dilatation of the rete tesis with intratesticular cysts left testis
