1. 47 yo with47 yo with
progressiveprogressive
abdominal painabdominal pain
for 1 monthfor 1 month
Radiology 2004;231:388-392

2. 25 y/o with mass
on imaging

3. Imaging of the ScrotumImaging of the Scrotum
and Testesand Testes
Jud Gash, MDJud Gash, MD

4. OutlineOutline
 AnatomyAnatomy
 ImagingImaging
 Testicular MassesTesticular Masses
 Testicular TorsionTesticular Torsion
 Scrotal TraumaScrotal Trauma
 Inflammatory DiseaseInflammatory Disease
 Extratesticular PathologyExtratesticular Pathology
 MiscellaneousMiscellaneous

5. AnatomyAnatomy

6. Scrotum - AnatomyScrotum - Anatomy
 ScrotumScrotum
 layers of fascia, muscle andlayers of fascia, muscle and
connective tissueconnective tissue
 Tunica VaginalisTunica Vaginalis
– visceral and parietal layersvisceral and parietal layers
– potential space around thepotential space around the
testestestes
 Tunica AlbugineaTunica Albuginea
– thick layer of fascia investingthick layer of fascia investing
the testesthe testes
– Along the posterior surface ofAlong the posterior surface of
the testis, the tunica albugineathe testis, the tunica albuginea
thickens to form thethickens to form the
mediastinummediastinum
– The mediastinum projectsThe mediastinum projects
inward into the testisinward into the testis

7. Testes –Testes –
Embryology andEmbryology and
AnatomyAnatomy
 TestesTestes
– 2X3X5 cm2X3X5 cm
– mediastinummediastinum
 contain rete testis - spermcontain rete testis - sperm
containing channelscontaining channels
– Appendix of testesAppendix of testes
 Mullerian duct remnantMullerian duct remnant
 EpididymisEpididymis
 Attatched to posterolateral testisAttatched to posterolateral testis
 head, body and tailhead, body and tail
 Appendix of the head and tailAppendix of the head and tail
 paradidymisparadidymis
 Spermatic cordSpermatic cord
 vas, artery, veins and lymphaticsvas, artery, veins and lymphatics
 Note: testicular lymphatics drainNote: testicular lymphatics drain
to paraaortic; while scrotum toto paraaortic; while scrotum to
inguinalinguinal

8. Testes - HistologyTestes - Histology
 Connective tissueConnective tissue frameworkframework
– tunica albugineatunica albuginea
– mediastinum testismediastinum testis
– septa which divide the organ into lobules.septa which divide the organ into lobules.
 Within theWithin the lobulelobules, the seminiferouss, the seminiferous
tubules produce sperm. Thetubules produce sperm. The
seminiferous tubulesseminiferous tubules consist of germconsist of germ
cells and Sertoli cells.cells and Sertoli cells.
– Germ cells (spermatogonia,Germ cells (spermatogonia,
spermatocytes, etc) -spermatocytes, etc) -
develop into spermatozoadevelop into spermatozoa
– sertoli cells - supporting cellssertoli cells - supporting cells
 Between the tubules, theBetween the tubules, the interstitialinterstitial
tissuetissue includes connective tissue cellsincludes connective tissue cells
and fibers, vessels, and Leydig cellsand fibers, vessels, and Leydig cells
– Leydig cells -Leydig cells - produceproduce
testosterone.testosterone.

9. Imaging ModalitiesImaging Modalities
 UltrasoundUltrasound
 Modality of choiceModality of choice
– 99% sensitive99% sensitive
– 98% accurate at98% accurate at
intratesticular vsintratesticular vs
extratesticularextratesticular
 techniquetechnique
– support scrotum onsupport scrotum on
toweltowel
– highest MHzhighest MHz
transducer (8 or 15)transducer (8 or 15)
– color and dopplercolor and doppler
– Do normal side first ifDo normal side first if
painpain
 NormalNormal
– homogeneoushomogeneous
– bright mediastinumbright mediastinum
– TransmediastinalTransmediastinal
artery or appendixartery or appendix
testistestis

10. Imaging ModalitiesImaging Modalities
 MRIMRI
 problem solverproblem solver
 when US inconclusivewhen US inconclusive
 cryptorchidismcryptorchidism
 TechniqueTechnique
 support scrotum with warmsupport scrotum with warm
towelstowels
 surface coil; small fovsurface coil; small fov
 T1W and FSET2W (SSFSE),T1W and FSET2W (SSFSE),
several planesseveral planes
 3mm3mm
 Gd?Gd?
 Screen abd/pelvis for nodesScreen abd/pelvis for nodes
 NormalNormal
 homogeneous, intermediatehomogeneous, intermediate
on T1W and bright on T2Won T1W and bright on T2W
 tunica albiginea andtunica albiginea and
mediastinum darkmediastinum dark

11. Imaging ModalitiesImaging Modalities
 CTCT
 used for staging of testicular cancer and forused for staging of testicular cancer and for
inguinal hernias and infection (Fourniersinguinal hernias and infection (Fourniers
gangrene)gangrene)
 Nuclear MedicineNuclear Medicine
 ?PET/CT?PET/CT

12. MassesMasses
 Key: intra vs extratesticular; solid vs cystKey: intra vs extratesticular; solid vs cyst
 IntratesticularIntratesticular
 solid - most malignant and germ cell originsolid - most malignant and germ cell origin
 mimics/tumor like lesions - infarcts,mimics/tumor like lesions - infarcts,
orchitis/abscess and hematomaorchitis/abscess and hematoma
– Orchiectomy for benign disease will occurOrchiectomy for benign disease will occur
 cystcyst
 ExtratesticularExtratesticular
 solid - most are benignsolid - most are benign
 CysticCystic
 CalcificationsCalcifications

13. Testicular CancerTesticular Cancer
 #1 cancer killer of young men#1 cancer killer of young men
 peak age 20 -45; 90% whitepeak age 20 -45; 90% white
– Incidence of GCT increased inIncidence of GCT increased in
cryptorchidismcryptorchidism
 PresentationPresentation
– painless mass, mild pain or heavinesspainless mass, mild pain or heaviness
– 10% present with acute scrotum10% present with acute scrotum
 US study of choiceUS study of choice
 95% survival rate95% survival rate

14. Testicular CancerTesticular Cancer
 ClassificationClassification
– Germ Cell (90%) - MalignantGerm Cell (90%) - Malignant
 SeminomaSeminoma
 Non-seminoma (embryonal cell,Non-seminoma (embryonal cell,
choriocarcinoma, teratoma, yolk sac)choriocarcinoma, teratoma, yolk sac)
 MixedMixed
– Non-Germ cell –rare; usually benignNon-Germ cell –rare; usually benign
 leydigleydig
 sertolisertoli
– SecondarySecondary
 leukemia, lymphomaleukemia, lymphoma
 met (prostate)met (prostate)

15. Testicular Cancer - GCTTesticular Cancer - GCT
 SpreadSpread
– LymphaticLymphatic
 follows veinsfollows veins
 1st echelon nodes1st echelon nodes
– retroperitoneal at kidneysretroperitoneal at kidneys
 Further tumorFurther tumor
– iliac nodesiliac nodes
– supraclavicularsupraclavicular
 epididymal & skin involvementepididymal & skin involvement
lead to inguinal nodeslead to inguinal nodes
– hematogeneous and directhematogeneous and direct
invasion later (x chorio)invasion later (x chorio)
 lung>liver and brainlung>liver and brain

16. Testicular Cancer - GCTTesticular Cancer - GCT
 StagingStaging
– TNMTNM
– PracticalPractical
 low stagelow stage
– testis, epi ortestis, epi or
cordcord
– mild nodesmild nodes
 Advanced stageAdvanced stage
– skinskin
– heavy nodesheavy nodes
– hemotogeneoushemotogeneous

17. Testicular Cancer - GCTTesticular Cancer - GCT
 Tumor markersTumor markers
 alpha-fetoprotein, human chorionicalpha-fetoprotein, human chorionic
gonadotropingonadotropin
 well-established role in the diagnosis,well-established role in the diagnosis, staging,staging,
prognosis, and follow-up of germ cell tumorsprognosis, and follow-up of germ cell tumors

18. Testicular Cancer -Testicular Cancer -
ImagingImaging
 UltrasoundUltrasound
 hypoechoic masshypoechoic mass
 heterogeneous, echogenic, calcification,heterogeneous, echogenic, calcification,
cystic, multiple or completely replace thecystic, multiple or completely replace the
testistestis
 may show increased vascularitymay show increased vascularity
 Small tumors usually hypovascularSmall tumors usually hypovascular
 MRIMRI
 Isointense on T1W and hypointense on T2WIsointense on T1W and hypointense on T2W

19. SeminomaSeminoma
 Most common GCTMost common GCT
 slightly older ageslightly older age
– does not occurdoes not occur
before pubertybefore puberty
 uniform,uniform,
hypoechoichypoechoic
(hypointense), esp(hypointense), esp
when smallwhen small
 excellent prognosisexcellent prognosis

20. SeminomaSeminoma
 30 yo with painless30 yo with painless
massmass

21. Large seminomaLarge seminoma

22. Multifocal SeminomaMultifocal Seminoma

23. Embryonal carcinomaEmbryonal carcinoma
 In 90% of mixedIn 90% of mixed
GCT, rarely inGCT, rarely in
pure formpure form
 MoreMore
aggressiveaggressive
 Less wellLess well
defined and lessdefined and less
homogeneoushomogeneous

24. Yolk Sac TumorYolk Sac Tumor
(endodermal sinus(endodermal sinus
tumor)tumor)
 80% of pediatric80% of pediatric
testicular tumorstesticular tumors
(Most common in(Most common in
children <2yo)children <2yo)
 occurs in mixedoccurs in mixed
GCT in adultsGCT in adults
 Elevated Alpha-Elevated Alpha-
fetoproteinfetoprotein

25. TeratomaTeratoma
 #2 tumor in kids#2 tumor in kids
 common in mixed GCTcommon in mixed GCT
in adultsin adults
 tend to be benign in kidstend to be benign in kids
more unpredictable inmore unpredictable in
adultsadults
 complex, cysticcomplex, cystic
appearanceappearance
 controversial recontroversial re
epidermoid cystepidermoid cyst

26. ChoriocarcinomaChoriocarcinoma
 Rare but mostRare but most
aggressive GCTaggressive GCT
 EarlyEarly
hematogeneoushematogeneous
mets commonmets common
 elevated HcGelevated HcG
 Poor prognosisPoor prognosis
 HeterogeneousHeterogeneous
massmass

27. Mixed Germ Cell TumorMixed Germ Cell Tumor
 More common thanMore common than
any other testicularany other testicular
tumor excepttumor except
seminomaseminoma
 Any combination ofAny combination of
cell typescell types
 variety of cell typesvariety of cell types
expressed inexpressed in
variablevariable
appearanceappearance

28. ““burned out” Germ Cellburned out” Germ Cell
TumorTumor
 Phenomenon of patientPhenomenon of patient
presents with widespreadpresents with widespread
metastatic disease withmetastatic disease with
involuted primary tumorinvoluted primary tumor
 ?etiology. ?outgrown blood?etiology. ?outgrown blood
supplysupply
 Primary tumors have a variablePrimary tumors have a variable
appearance. Small and can beappearance. Small and can be
hypoechoic, hyperechoic, orhypoechoic, hyperechoic, or
merelymerelyan area of focalan area of focal
calcification.calcification.
 Histologic analysis may revealHistologic analysis may reveal
minute amounts of residualminute amounts of residual
tumor or only dense depositstumor or only dense deposits
of collagenof collagen with scatteredwith scattered
inflammatory cellsinflammatory cells
22 yo presented with back pain and
lower extremity weakness. Initial
work-up showed an extradural mass,
retroperitoneal adenopathy, and lung
metastases. Physical examination of
the testes was negative. After biopsy
of a cervical node revealed
metastatic germ cell tumor, scrotal
sonography was performed
22 yo presented with back pain and
lower extremity weakness. Initial
work-up showed an extradural mass,
retroperitoneal adenopathy, and lung
metastases. Physical examination of
the testes was negative. After biopsy
of a cervical node revealed
metastatic germ cell tumor, scrotal
sonography was performed

29. CryptorchidismCryptorchidism
 6% of full term neonates; 1% at one6% of full term neonates; 1% at one
year; 10% bilateralyear; 10% bilateral
 Increased risk of:Increased risk of:
– Testicular carcinoma (most seminomas)Testicular carcinoma (most seminomas)
– InfertilityInfertility
 Disordered embryogenesisDisordered embryogenesis
 Associated with other GU anomalies:Associated with other GU anomalies:
agenesis/ectopy of kidney andagenesis/ectopy of kidney and
absence/cyst of SVabsence/cyst of SV
 Risk of cancer increased in contra-lateralRisk of cancer increased in contra-lateral
testis, even if descendedtestis, even if descended
 Risk of cancer not reduced appreciablyRisk of cancer not reduced appreciably
with orchiopexywith orchiopexy
– Note: single post-pubertal bxNote: single post-pubertal bx
recommended to identify intratubularrecommended to identify intratubular
germ cell neoplasm (cis) as marked riskgerm cell neoplasm (cis) as marked risk
factorfactor

30. CryptorchidismCryptorchidism
 Clinical Problem: nonpalpableClinical Problem: nonpalpable
testistestis
– DDX: cryptorchidism vs agenesisDDX: cryptorchidism vs agenesis
– Important distinctionImportant distinction
 Agenesis: no txAgenesis: no tx
 Cryptorchidism: orchiopexy atCryptorchidism: orchiopexy at
2yrs; close exam and bx post-2yrs; close exam and bx post-
pubescentpubescent
– Role of imaging:Role of imaging:
 MRI study of choice (US and CTMRI study of choice (US and CT
lack specificity)lack specificity)
– Laporoscopy: Many feel study ofLaporoscopy: Many feel study of
choice (dx and tx)choice (dx and tx)

31. Retractile TestisRetractile Testis
 (Hyper)active cremasteric reflex, prompted(Hyper)active cremasteric reflex, prompted
by anxiety, trauma, etc., may pull the testisby anxiety, trauma, etc., may pull the testis
out of the scrotum (prescrotal orout of the scrotum (prescrotal or
intracanalicular)intracanalicular)
 Not uncommon in trauma setting, especiallyNot uncommon in trauma setting, especially
in boys (2-3%).in boys (2-3%).
 Recommend PE to differentiate retractileRecommend PE to differentiate retractile
testis from true cryptorchidismtestis from true cryptorchidism

32. MicrolithiasisMicrolithiasis
 Uncommon (.5%)Uncommon (.5%)
 increased associationsincreased associations
 cryptorchidism,cryptorchidism,
infertility, Klinefelterinfertility, Klinefelter
syndrome, Downsyndrome, Down
syndrome, alveolarsyndrome, alveolar
microlithiasis, and,microlithiasis, and, mostmost
important,important, testiculartesticular
carcinomacarcinoma
 Calculi withinCalculi within
Seminiferous tubulesSeminiferous tubules

33. MicrolithiasisMicrolithiasis
 US diagnosisUS diagnosis
 5 or more5 or more
calcificationcalcification
 may be bl andmay be bl and
diffuse or focaldiffuse or focal
 Risk or coexistentRisk or coexistent
or subsequentor subsequent
carcinomacarcinoma
controversialcontroversial
 as is need andas is need and
duration of us followduration of us follow
upup

34. Non-Germ cell tumorsNon-Germ cell tumors
 5% of testicular cancer5% of testicular cancer
 higher in pedshigher in peds
 Sertoli (sex cord) and LeydigSertoli (sex cord) and Leydig
(interstitial) cell(interstitial) cell
 Also other rare cell linesAlso other rare cell lines
 90% benign90% benign
 Indistinguishable from GCTIndistinguishable from GCT
 Calcifying Sertoli Cell TumorCalcifying Sertoli Cell Tumor
 pediatric age grouppediatric age group
 multiple calcified massesmultiple calcified masses
 PJ and Carney syndromePJ and Carney syndrome

35. LymphomaLymphoma
 5% of testicular tumor5% of testicular tumor
 #1 in over 50 y/o#1 in over 50 y/o
 only 1% of lymphomaonly 1% of lymphoma
patientspatients
 May beMay be
 only site of diseaseonly site of disease
 along with other diseasealong with other disease
 site of recurrencesite of recurrence
 AppearanceAppearance
 Indistinguishable fromIndistinguishable from
GCTGCT
 Multiple, bl hypoechoicMultiple, bl hypoechoic
nodulesnodules

36. Leukemia and MetsLeukemia and Mets
 Common site of recurrenceCommon site of recurrence
 primary disease uncommon hereprimary disease uncommon here
 Appearance variableAppearance variable
 uni or bluni or bl
 focal or diffusefocal or diffuse
 hypo or hyperechoichypo or hyperechoic
 Solid organ metsSolid organ mets
 rare; usually disease widespreadrare; usually disease widespread
 prostate and lungprostate and lung

37. Tumor-like lesionsTumor-like lesions
 ““intratesticular mass is cancer untilintratesticular mass is cancer until
proven otherwise”proven otherwise”
 Traditional teaching: 95% malignantTraditional teaching: 95% malignant
 BUT, more benign lesions being identifiedBUT, more benign lesions being identified
 Not all testicular lesions are tumorsNot all testicular lesions are tumors
 As many as 30% of orchiectomies for testicular lesionsAs many as 30% of orchiectomies for testicular lesions
end up being benignend up being benign ((Haas GP, Shumaker BP, Cerny JC. The high incidence ofHaas GP, Shumaker BP, Cerny JC. The high incidence of
benign testicular tumors. J Urolbenign testicular tumors. J Urol 19861986;136:1219 -1220);136:1219 -1220)
 recognition of these entities may prevent needlessrecognition of these entities may prevent needless
orchiectomyorchiectomy
 Still, rather needless orchiectomy thanStill, rather needless orchiectomy than
missed cancer. Thus will havemissed cancer. Thus will have
orchiectomy for benign disease.orchiectomy for benign disease.

38. Tumor-like lesionsTumor-like lesions
 DDX:DDX:
 orchitisorchitis
 Hematoma/contusionHematoma/contusion
 infarctinfarct
 cyst (see next)cyst (see next)
– mimics teratomamimics teratoma
 adrenal restsadrenal rests
– 2% of adults have2% of adults have
– Enlarged in CAH orEnlarged in CAH or
rarely Cushingsrarely Cushings
– BL hypo massesBL hypo masses
 sarcoidosissarcoidosis
 sperm extractionsperm extraction

39. Sperm Extraction*Sperm Extraction*
 Sperm extraction forSperm extraction for
infertility are becominginfertility are becoming
more commonmore common
 In a % (varies from20-In a % (varies from20-
80%) Focal testicular80%) Focal testicular
lesions can resultlesions can result
 ?hematoma, infarct?hematoma, infarct
 FindingsFindings
 anterior andanterior and
subcapsularsubcapsular
 hypoechoichypoechoic
 hyperechoic, calcifichyperechoic, calcific
 History may allow closeHistory may allow close
F/UF/U *S Strauss, AJR 2001 176: 113

40. Intra-testicular CystsIntra-testicular Cysts
 OverviewOverview
 Tunica Albuginea cystsTunica Albuginea cysts
 Simple cystSimple cyst
 Cystic transformation of the rete testesCystic transformation of the rete testes
 epidermoidepidermoid
 intratesticular spermatoceleintratesticular spermatocele
 Intratesticular varicoceleIntratesticular varicocele
 AbscessAbscess
 InfarctInfarct

41. Tunica Albuginea CystTunica Albuginea Cyst
 ?etiology?etiology
 Middle ageMiddle age
 Key to diagnosisKey to diagnosis
 peripheral locationperipheral location
 simple cystsimple cyst
 usually 2-5 mmusually 2-5 mm

42. Simple CystSimple Cyst
 Usually >40 yoUsually >40 yo
 2mm to 2cm2mm to 2cm
 single or multiplesingle or multiple
 Usually nearUsually near
mediastinummediastinum

43. EpidermoidEpidermoid
 Keratonizing squamousKeratonizing squamous
epithelium filled withepithelium filled with
cheesy laminated stuffcheesy laminated stuff
 appearanceappearance
 echogenic rimechogenic rim
 ““onion skinned” due toonion skinned” due to
layerslayers
 ““solid” appearingsolid” appearing
 avascularavascular

44. EpidermoidEpidermoid
 Unable to totallyUnable to totally
exclude solid lesionexclude solid lesion
usually andusually and
orchiectomy oftenorchiectomy often
neededneeded
 MRIMRI
 high signal on T1high signal on T1
and T2and T2

45. Cystic Transformation ofCystic Transformation of
the Rete Testisthe Rete Testis
 Due to obstruction of efferentDue to obstruction of efferent
ductules with resultant ectasiaductules with resultant ectasia
 older menolder men
 FindingsFindings
 uni or bluni or bl
 tubular cystic areastubular cystic areas
 in/near mediastinumin/near mediastinum
 epididymal cystsepididymal cysts
 DDX: cystic GCT (esp teratoma)DDX: cystic GCT (esp teratoma)
 usually has soft tissueusually has soft tissue
 not tubularnot tubular
 MRI can may be helpfulMRI can may be helpful

46. Intra-testicularIntra-testicular
SpermatoceleSpermatocele
 Near mediastinumNear mediastinum
 cystic, can becystic, can be
septatedseptated
 containscontains
spermatozoaspermatozoa

47. Intras-testicularIntras-testicular
VaricoceleVaricocele
 ?etiology. ??etiology. ?
significancesignificance
 May cause painMay cause pain
 (+-)extratesticular(+-)extratesticular
varicocelesvaricoceles
 FindingsFindings
 tubular, serpigineoustubular, serpigineous
structures withstructures with
venous doppler/colorvenous doppler/color
flow which increasesflow which increases
with valsalvawith valsalva

48. Testicular TorsionTesticular Torsion
 Most common in adolescentsMost common in adolescents
 Acute scrotumAcute scrotum
 DDXDDX
– torsiontorsion
– orchitisorchitis
– traumatrauma
– tumortumor
 Due to “bell and clapper”Due to “bell and clapper”
deformitydeformity
 lackof normal fixation in thelackof normal fixation in the
scrotumscrotum
 Urologic EmergencyUrologic Emergency
 salvage rate related to timesalvage rate related to time
– 90%-100% detorsion within 690%-100% detorsion within 6
hours of painhours of pain
– 20%-50% after 12 hours20%-50% after 12 hours
– 0%-10% if detorsion greater0%-10% if detorsion greater
than 24 hoursthan 24 hours
 consider doing own USconsider doing own US

49. Testicular TorsionTesticular Torsion
 FindingsFindings
 Early, testis is normal; laterEarly, testis is normal; later
becomes enlarged andbecomes enlarged and
hypoechoichypoechoic
 Lack ofLack of SignificantSignificant
detectable flowdetectable flow
 reactive hydrocelereactive hydrocele

50. Torsion of AppendigesTorsion of Appendiges
Torsed appendix testis

51. Scrotal TraumaScrotal Trauma
 2 Categories2 Categories
 penetrating (surgery)penetrating (surgery)
 blunt (imaging)blunt (imaging)
 TesticularTesticular
Fracture/ruptureFracture/rupture
 disruption of t. albugineadisruption of t. albuginea
with bleeding andwith bleeding and
extrusion of S.T.extrusion of S.T.
 surgical emergencysurgical emergency
 Trauma inducedTrauma induced
torsion/Infarct a knowtorsion/Infarct a know
complicationcomplication
Types of injury:
Contusion
Hematoma
Fracture/rupture
hematocele
Types of injury:
Contusion
Hematoma
Fracture/rupture
hematocele

52. Scrotal TraumaScrotal Trauma
 UltrasoundUltrasound
 Normal - excludes seriousNormal - excludes serious
injuryinjury
 hematoma - echogenic orhematoma - echogenic or
hypoechoic; roundedhypoechoic; rounded
 Hematocele - extratesticularHematocele - extratesticular
fluid; echoes or echogenicfluid; echoes or echogenic
 Infarct - absent flowInfarct - absent flow
 FractureFracture
– Heterogeneous testicle;Heterogeneous testicle;
diffuse or focaldiffuse or focal
– irregular or ill-defined contourirregular or ill-defined contour
or bulgeor bulge
– often just a “often just a “messmess””

53. Scrotal TraumaScrotal Trauma
 MRIMRI
– May play future roleMay play future role
in detection ofin detection of
disruption of thedisruption of the
tunica albuginea (ietunica albuginea (ie
rupture)rupture)

54. Scrotal Trauma:Scrotal Trauma: extremeextreme
mountain bikersmountain bikers..
Krauscher F Radiology 2001May;219(2):427-31USKrauscher F Radiology 2001May;219(2):427-31US

55. Inflammatory DiseaseInflammatory Disease
 Epididymitis/orchitisEpididymitis/orchitis
 usually retrotrade infection from bladder and prostateusually retrotrade infection from bladder and prostate
 rarely traumatic, surgical, etcrarely traumatic, surgical, etc
 orchitis from epididymitis (except mumps)orchitis from epididymitis (except mumps)
 ““acute scrotum” in adolescents (kids,acute scrotum” in adolescents (kids,
elderly)elderly)
 testicular torsiontesticular torsion
 traumatrauma
 infectioninfection
 torsion of epididymal or testicular appendagestorsion of epididymal or testicular appendages
 Imaging is to confirm diagnosis andImaging is to confirm diagnosis and
excluded complication (surgery)excluded complication (surgery)
 abscessabscess
 infarctioninfarction

56. Inflammatory DiseaseInflammatory Disease
 Ultrasound FindingsUltrasound Findings
– involves epididymisinvolves epididymis
plus/minus testisplus/minus testis
 focal or diffusefocal or diffuse
enlargementenlargement
 hypoechogenicityhypoechogenicity
 INCREASED FLOWINCREASED FLOW
 reactive hydrocelereactive hydrocele
 Nuclear medicineNuclear medicine
 increased flow andincreased flow and
activityactivity

57. Inflammatory DiseaseInflammatory Disease
 MRIMRI
 edema andedema and
inflammation oninflammation on
T2WT2W
 increasedincreased
enhancementenhancement

58. Orchitis with InfarctionOrchitis with Infarction
 58 yo with scrotal58 yo with scrotal
pain and swellingpain and swelling
for 4 daysfor 4 days

59. ExtratesticularExtratesticular
PathologyPathology
 Normal Extratesticular VariantsNormal Extratesticular Variants
 Spermatocele and epididymal cystSpermatocele and epididymal cyst
 Sperm granulomaSperm granuloma
 VaricoceleVaricocele
 HydroceleHydrocele
 HerniaHernia
 Extratesticular TumorExtratesticular Tumor

60. Extratesticular VariantsExtratesticular Variants
 Appendix of theAppendix of the
epididymisepididymis
 Isoechoic to epididymisIsoechoic to epididymis
 May calcifyMay calcify
 Appendix of the testesAppendix of the testes
 Isoechoic to testesIsoechoic to testes
 Cyst of MorgagniCyst of Morgagni
 Dilation of theDilation of the
paradidymisparadidymis
 Cystic; can appearCystic; can appear
solidsolid

61. Spermatocele andSpermatocele and
epididymal cystepididymal cyst
 very commonvery common
 usually within/near head ofusually within/near head of
epididymisepididymis
 usually asymptomatic andusually asymptomatic and
present incidently or aspresent incidently or as
palpable masspalpable mass
 Epididymal CystEpididymal Cyst
 Cystic on USCystic on US
 SpermatoceleSpermatocele
 UltrasoundUltrasound
– Cystic (may not be ableCystic (may not be able
to differentiate fromto differentiate from
epididymal cyst)epididymal cyst)
– Low level echoesLow level echoes
– Rarely hyperechoicRarely hyperechoic

62. Sperm GranulomaSperm Granuloma
 Sperm extravasationSperm extravasation
can result in granulomacan result in granuloma
formationformation
 Often occurs afterOften occurs after
vasectomyvasectomy
 Painful (unlike tumor)Painful (unlike tumor)
 UltrasoundUltrasound
 Isoechoic toIsoechoic to
hyperechoic mass inhyperechoic mass in
the epididymisthe epididymis
 Rarely may calcifyRarely may calcify

63. VaricoceleVaricocele
 Dilated intrascrotal veinsDilated intrascrotal veins
 incompetent valvesincompetent valves
in testicular veinsin testicular veins
 rarely due to mass,rarely due to mass,
etcetc
 Worry about unilateralWorry about unilateral
right sided varicoceleright sided varicocele
 Infertility, heavinessInfertility, heaviness
 Common (15-20%)Common (15-20%)
 FindingsFindings
 L>R, bl commonL>R, bl common
 veins > 2-3mmveins > 2-3mm
 dilation excacerbateddilation excacerbated
by valsalva andby valsalva and
standingstanding

64. Hydrocele (hematoceleHydrocele (hematocele
& pyocele& pyocele
 Fluid w/I tunica vaginalisFluid w/I tunica vaginalis
 HydroceleHydrocele
– Small amount of fluid normalSmall amount of fluid normal
– EtiologiesEtiologies
 congenital - persistent peritonealcongenital - persistent peritoneal
communicationcommunication
 AcquiredAcquired
– Reactive(trauma, infection, torsion)Reactive(trauma, infection, torsion)
– In adults, not uncommon withIn adults, not uncommon with
unknown etiology (diminishedunknown etiology (diminished
reabsorbtion)reabsorbtion)
 HematoceleHematocele
– Echogenic fluid; trauma, tumor orEchogenic fluid; trauma, tumor or
surgerysurgery
 PyocelePyocele
– Echogenic collection; septations andEchogenic collection; septations and
debrisdebris

65. HerniaHernia
 Via patentVia patent
processus vaginalisprocessus vaginalis
 complex masscomplex mass
 look for peristalsislook for peristalsis

66. Extratesticular tumorExtratesticular tumor
 Rare, mostly benignRare, mostly benign
 Adenomatoid tumorAdenomatoid tumor
 Only tumor with anyOnly tumor with any
frequencyfrequency
 HamartomatousHamartomatous
lesionlesion
 Adolescents andAdolescents and
young adultsyoung adults
 Tail of epididymisTail of epididymis
most common sitemost common site
 Isoechoic toIsoechoic to
hyperechoichyperechoic

67. ReviewReview
 Solid massSolid mass
– GCTGCT
 SeminomaSeminoma
 Non-seminomaNon-seminoma
– Embryonal, yolk sac, teratoma, choriocarcinoma, mixedEmbryonal, yolk sac, teratoma, choriocarcinoma, mixed
– Sertoli; LeydigSertoli; Leydig
– Secondary (Lymphoma, mets)Secondary (Lymphoma, mets)
– MimicsMimics
 Orchitis, trauma, infarct, adrenal, sarcoid, sperm extractionOrchitis, trauma, infarct, adrenal, sarcoid, sperm extraction
– Cystic lesionsCystic lesions
 EpidermoidEpidermoid
 Cystic lesionsCystic lesions
 Tunica Albuginea cystsTunica Albuginea cysts
 Simple cystSimple cyst
 Cystic transformation of the rete testesCystic transformation of the rete testes
 epidermoidepidermoid
 intratesticular spermatoceleintratesticular spermatocele
 Intratesticular varicoceleIntratesticular varicocele
 AbscessAbscess
 InfarctInfarct
 TorsionTorsion
 TraumaTrauma
 EpidimoorchitisEpidimoorchitis
 Extratesticular DiseaseExtratesticular Disease
– Normal Extratesticular VariantsNormal Extratesticular Variants
– Spermatocele and epididymal cystSpermatocele and epididymal cyst
– Sperm granulomaSperm granuloma
– VaricoceleVaricocele
– HydroceleHydrocele
– HerniaHernia
– Extratesticular TumorExtratesticular Tumor
 Adenomatoid tumorAdenomatoid tumor