Scrotal Ultrasound: Everything You Want to Know But Are Afraid to Ask! - SD

Introduction to Scrotal Ultrasound

Hello, my name is Faye Lang.

I'm a radiologist at Georgetown University Medical Center in Washington DC and it's my pleasure to talk to you today on scrotal ultrasound.

We're gonna be talking about scrotal ultrasound.

The title of this lecture is Everything you wanna Know but Are Afraid to Ask.

You can see sometimes when we are faced with initial images it can be a little confusing as to what we're looking at and we'd like to be as definitive as possible.

What are you looking at here?

Is this a young girl or is it an old woman?

It's important when we're thinking about scrotal ultrasound again to be as definitive as possible because we don't typically biopsy the testis when we are worried the clinician gets worried, the patient obviously gets worried and it often may lead to surgery and ideally you want that surgery only to be done when strongly indicated.

Testicular Anatomy

Looking at a schematic of the testes as we see here, it's obviously an avoid structure.

Looking at it on sonography, it's generally quite homogeneous and has some echogenic areas within it that we'll discuss subsequently surrounding the testes, and this comes from its grant's atlas, we can see the EPIs surrounds it, the head, the body, and the tail trails off being less conspicuous than the head because it's smaller.

In point of fact, this diagram is not exactly anatomically correct because in most patients we can see as on the sagittal ultrasound, the head of the EPIs over here, which typically measures about one centimeter in length, perhaps a little bit less, and we can see it also on this transverse scan, the region of the head of the epididymus, the body.

However, in contrast to the image or the diagram that we looked at where the body looked more posterior, in many people the body of the epididymus is more superficial than was seen on the diagram.

That's not a universal statement, but when you wanna look for the body of the epidermis, typically I look in a more superficial location and here we can see it typically measures about maybe three millimeters in diameter.

Challenge Case: Normal Epididymal Structure

Now we'll call this challenge case because I'm gonna ask you do you see any problem specifically that hypoechoic area relative to the head of the epididymus?

In point of fact, this is a normal structure which is the epidermal body as it enters into the head of the epididymus, and you can see on the clip that the body of the epididymus is typically somewhat hypoechoic relative to the portions of the head of the epidermis.

So don't fall into a trap and call that a mass.

No-Touch Testicular Lesions

Now it's very important as we've already alluded to, to be as confident as possible when we're doing scrotal ultrasound.

There are many what we'll call no touch testicular lesions, starting out with the fact that in some people the testis has relatively prominent septations.

In point of fact, the testicle is divided into lobules as we see diagrammatically here, and this is they're separated by septi, which to varying degrees can be seen on ultrasound.

Technique for Scrotal Ultrasound

So if we take this patient in whom the question was when the patient came in, was there a mass in the testis as we see a relatively hypo coic posterior area on the left side.

Now we haven't yet talked about technique.

This scan, as you can see, is done with a five megahertz linear transducer.

It's a rather old image and currently I would not advocate using a five megahertz.

I would use anything from a seven to even a 10 megahertz if possible, higher frequency, better resolution.

But in this case, I'm showing you this case because of that possible mass.

Now when I do these scans, some people prefer to put a towel to support the testes and the scrotal contents they so they raise and elevate the scrotum with a posteriorly placed towel.

I am not in favor of doing that because I would like to be able to work around the scrotum and I find that that towel somewhat obstructs my ability to do that.

Also, whenever I see something that is questionable, it's a superficial organ, you should be able to go and examine the patient and see if there's really a mass.

In this case, there was no mass palpable and what this actually represents is a pseudo mass due to the sound coming in to the testes in this direction, hitting this septation if you will, or area between the lobules and reflecting the sand away from the testes accounting for this abnormal appearance.

In point of fact, there was no miss palpable.

If you looked at the other testes from a similar approach, it was similar in appearance and if you worked around this by scanning in this direction, this no longer appeared hypo coac.

It was more genic than what we're seeing on this case.

So that is a pseudo mass due to that prominent septation.

Mediastinum Testis

Another no-touch lesion may be due to the fibro fatty tissue of the mediastinum.

The mediastinum is this area relatively central that is coursing through the normal testis in a direction that traverses the testes, in to a variable degree.

It contains nerve nerves, vessels and seminar seminiferous ducts and to in some people not in this case, it can be really quite prominent, quite echogenic and may even cause some mild acoustic shadowing.

So we can see what a mediastinum testis is.

We recognize it, we don't worry about it.

But how about in this patient who actually came in for a second opinion relative to is there a significant mass?

Again, in this case I couldn't palpate a mass notice.

Also, there are a few micro lists which we'll discuss subsequently and what is, what are their significance when we see micro LSIs?

So here is a clip done from a anterior approach and you can see why there might be a question raised as a possible mass.

What we did here when we didn't feel a mass again is we worked around this from a different approach.

Now you can see the mediastinum here is posterior, whereas here it was anterior.

So we're scanning from a more posterior approach and we are no longer seeing any abnormality.

So the dropout in this case was due to that mediastinum and this therefore was a pseudo mass due to the mediastinum.

It was nothing significant.

And that's the point we're trying to make these no touch lesions, we don't want either E either you report them and you say there of no significance or you explain why there was an apparent mass.

But the bottom line is they are not significant vascular channels.

Most people when we look at the testis, the testicular artery is circumferential around the testis and then there are these perforating branches which turn at the level of the mediastinum.

That's the classic appearance, but it is not at all infrequent to see horizontal vessels easily have worked out by turning color on.

We don't worry about that, it's just a normal variant.

Cysts in the Testis

What about varying kinds of cysts that we might see?

They may be intra testicular, they may be at the very periphery of the testes and particularly these very small lesions are often palpable as you would palpate a small BB or bit of buckshot if you will, and might disturb the patient.

But particularly at the periphery here, no touch lesion, that's what we call a cyst of the tunica algen.

The tunica algen is the fibro fatty um, surface of the testes and uh, this is just beneath it.

So these go under the name Tunica Algen cysts, intra testicular cyst.

When they look simple like this and there's no mass around it, um, is almost always of no significance.

Obviously if you can palpate this, if the per the person's aware of it, you know, you might say if there's any change, if you're it's growing, come on back and let us scan you again.

But with very few exceptions these are insignificant lesions.

What about what we call cysts of the read testis?

The read d testis as we can see on the diagram is where we have a coalescence of the seminiferous tubules when the the testis at the level of the mediastinum.

Now sometimes these small tubules can dilate as we see on a transverse scan running along the course of the mediastinum and on a sagittal scan in the same plane as we showed you the mediastinum as an echogenic line earlier, but instead now going to variable degree, how much they run across and an sagittal plane never completely going completely from one end of the testis to the other very classic appearance for some dilatation of the read testis.

So why do certain people get this?

These when they dilate are more or less symmetric, not exactly to the same degree, but there is a relative bilateral symmetry in most patients.

So who gets these?

Why do we see dilatation of these tubules if you will?

Well, if there's obstruction anywhere beyond this level that is in the epididymus or in the va, you may end up with dilatation in the re testis and therefore it shouldn't surprise you if there's an obstruction say here that you not only have the dilated tubules at the level of the re testis, but you also may end up with cysts in the epidermis.

As we can see in this patient, assist in the epidermal head, these typically are non palpable at the level of the mediastinum.

We've al already said they're bilateral but not absolutely symmetric avascular.

And the bottom line is if you ask a man in whom you see this, have you had a vasectomy?

Very, very commonly the answer will be in the affirmative.

So we don't worry about those.

Calcifications and Scrotal Pearls

What about calcifications?

Another group of no touch lesions.

These can occur in a variety of locations, often involving the tunica algin, we've already said that's the outer surface of the testis and here we can see a small linear non shadowing line because of its thinness, it doesn't have shadowing.

Here we can see another one perhaps with a tiny bit of shadowing surrounded by hydro seal, localizing it clearly to the level of the tunica algen.

I don't know why people get these.

Perhaps it's scarring but there of no significance.

Sometimes we see little echogenic foci and in this case we can see it in small hydros EALs.

The hydro seals of themselves when they're small are not significant and to show that they can move.

As we can see here, these are affectionately called scrotal pearls.

Now this next clip on the right is quite funny.

It kind of looks like popcorn moving up and down and these are just small concretions.

I can't tell you exactly why people get them, but some people have suggested this could be due to inflammation of the tunica that's broken off or perhaps there's appendages that occur at the level of the EPIs.

Also at the level of the testis where little outpouching or appendages may become um, infarcted and break off accounting for these scrotal pearls.

There are absolutely no clinical significance, no touch lesions.

Echogenic Foci and Their Significance

What about seeing a small echogenic focus?

You can see some acoustic shadowing.

Here is a single echogenic focus.

Here is a grouping of them together with slight shadowing in patient two.

Well what do we make of this?

These are larger than what we would think of when we talk about micro LSIs, which we will subsequently address.

So these calcifications or areas perhaps of fibrosis, what do we make of them?

Well in this case they were of no significance.

The patient had no underlying problem.

However, in this patient that was not true.

This patient came in with some medias style adenopathy and when further imaging was done we can see there's retroperitoneal adenopathy.

This is due to a patient who actually has an underlying germ cell tumor causing the adenopathy.

Now the question is what is the relationship of that to the testis?

I can't tell you if this germ cell tumor originated from the testis, but I'd be very suspicious seeing this kind of a finding in the testis.

Is there viable tissue in the testis that accounts for the metastatic disease?

In this case, in the retroperitoneum and in the lung area, the only way we could know is by doing an orchiectomy.

And if the orchiectomy, which is definitely indicated in this situation shows that there is no living tumor, we will term this a burned out primary for inexplicable reasons.

Some people will have metastatic germ cell tumors and scarring if you will, due to an originating tumor in the testis which becomes burned out.

But the only way we can tell is by doing an orchiectomy to prove it because that's very important to know if there's living residual tumor in the testis.

Striated Appearance in the Testis

In that case, the final no-touch lesion that we'll address is when we start to see these striated appearance almost looks like a zebra effect in the testis.

What do we make out of that?

Usually there's no palp palpable abnormality and it depends upon what is going on.

Historically, most people believe that these are, this is due to fibrosis and often subsequent atrophy within the testis.

Now people who have arterial sclerotic disease are subject to getting fibrosis.

So elderly patients, perhaps diabetic patients with associated atherosclerosis can end up with this and sometimes people who have had radiation to the area of the scrotum may therefore also develop atrophy and fibrosis in their testis with disappearance.

There's no indication to do anything for it, but especially if it's as symmetric to make note of that with subsequent associated atrophy, that certainly should be mentioned and if you have any history that can account for it, you might include that in your report.

Indications for Scrotal Ultrasound

There are a whole variety of indications to do scrotal ultrasound and you can read this uh, at your leisure here.

Um, but we will address these as we continue in our discussion.

Testicular Pathology

I think it's very important to consider when you have a mass in the testis might it be a significant lesion, particularly a malignant lesion.

If you have a lesion that is solid or complex and it's palpable, it's a malignancy until proven otherwise, even if you can't feel it, particularly if it's small, I would be quite concerned if it is a simple appearing cyst and I don't feel it, we've already discussed that, I would tell the patient to keep their eye on it, make sure it doesn't get enlarged if it does come on back.

But I'm really not typically worried about those.

And if they're simple cysts, those small little peripheral cysts that I've already shown you of the tunica algen, I am not concerned about those lesions when we have pathology involving the testes.

This can involve the testes in a focal manner or a global manner.

It could be echogenic, more genic than the background tissue.

It can be iso coic or hypoechoic testicular pathology that is primary generally form, uh, belongs to one of four categories.

Neoplasm, infection, torsion or disruption.

As I've just said, this can affect the testes in a global or focal manner.

Here we have four different patients, four different abnormalities, but just based on the gray scale, I don't think we can separate what's going on.

Color becomes important as we add color to these four different cases.

Once I see color in a focal area as we see here, neoplasm will be first on my list.

History also is very important.

This is a focal testicular infarction, not surprising, no flow in the area of infarction.

Here's a patient with a very hyperemic testis and a focal area of absent flow due to an associated area of an abscess forming with infection.

And this is a traumatic disruption of the testes where there will be no flow in the area of the hematoma.

So flow and history are very important to differentiate pathology.

When I do see flow in, uh, neoplasm will be first by far on my list.

Primary Testicular Tumors

So let's talk a little bit about primary testicular tumors.

What's interesting, if you look historically in the literature, similar perhaps to breast cancer, there's an increase of germ cell tumors, which is what we'll be talking about when we think about primary testicular tumors, a disease of fairly young people and currently, and unlike what we would talk about perhaps 20 years ago, a very high incidence of being able to treat these men who develop primary testicular tumors.

Now underlying predisposing causes, a lot of things have been discussed in the literature and again, you can read this list, I'm not gonna go through it and read it to you of course.

Uh, men should be the first underlying cause to develop testicular cancer.

But it's also interesting to note that approximately 90% of primary testicular tumors occur in Caucasian men.

Two types of tumors are um, how we categorize germ cell tumors and there are approximately half and half in the way of seminomas pure seminoma and nons seminomas, the latter of which are subdivided into many different types and often you have mixed elements within the non seminomas group.

The majority of nonseminomatous tumors have mixed elements.

We can see inal, teratoma, chorio and even yolk sac tumors.

Well what did they look like on ultrasound?

The classic appearance, if you will, for a pure seminoma is a homogeneous mass as we see also on Dr. Netter's. Very nice diagram almost as though this patient posed for that drawing.

The lobules of tumor you can see surrounded by some fibrotic bands, but basically it's a fairly homogeneous tumor.

This type of tumor is reportedly increased with undescended or krypto testes and relative to the nonseminomatous group, these are less aggressive tumors that often present localized to the testes and they are very radio sensitive.

You can see the typical appearance here again in this patient a homogeneous focal mass, but there are many, many exceptions, a much more heterogeneous mass.

I'm sure you also also appreciate the associated micro LSIs in this patient.

The increased flow just tells me I'm dealing with a neoplasm.

Now contrast this to Dr. Netter's diagram and a patient with a large nonseminomatous mass.

Notice for comparison, a micro SSIS riddled, normal sized uh, testicle on the opposite side to compare to this patient with a very large mass.

And I just wanna make a a statement here and urge all men similar to the way we counsel women to do breast self-examination to please be aware of your anatomy.

Anybody who has enlarged mass especially you know, if you can't explain it by infection or trauma, it's painless.

Please, please seek out help before it achieves this very large size because neoplasm is gonna be high on that list.

The earlier it's treated, obviously you have a better chance of surviving that disease.

The nonseminomatous tumors, which again are more heterogeneous, sometimes have cystic elements and so forth in it, have a higher incidence of associated metastases are less radio sensitive because this as a group are more aggressive tubers.

Here we can see um, an example, another one, the heterogeneous appearance mixed.

This was a mixed um, nonseminomatous tumor.

Now just looking at this patient, it's fairly homogeneous.

You might say, well could that be a seminoma?

Sure it could be. But this turned out on pathology to be an abri tumor.

Here we have very bright echoes, perhaps some calcification with shadowing and that was a teratomas tumor.

Two other examples of tumors, a pure seminoma homogeneous and again a relatively homogeneous similar appearing tumor which was a nonseminomatous tumor.

Now in this case it wouldn't surprise you when we talk about nonseminomatous and the subcategories.

Remember we said you could have RY tumors, you could have CHO carcinomas and mixtures.

Well those types of tumors when you have RY elements for example, just like an embryo has elevated HCG, I'm sorry, an embryo has elevated alpha fetal protein associated with it.

That is true with some of the nonseminomatous tumors, especially if it had RY elements or if it has CHO just like choriocarcinoma has elevated HCG.

So does choriocarcinoma in the testes.

What is the role of these hormones or proteins that might be elevated?

These are tumor markers.

We don't use them so much to make the diagnosis, although if I knew the tumor marker was elevated I would certainly categorize what I saw most likely as a nonseminomatous tumor.

The role of tumor markers as the word markers suggests is following therapy to make sure that these markers go down to zero, are no longer recordable, are no longer present because they shouldn't be.

If you are tumor free, you will follow that patient.

Therefore subsequently with these blood tests to see if they start to become um, measurable and start to increase then you know the patient has residual tumor present and will need therapy for that.

Metastatic Tumors to the Testes

What about non-primary or metastatic tumors to the testes?

Lymphoma and leukemia are some of the most common to occur.

They tend to affect the t, the testes bilaterally and they are often um, somewhat moy the testes become enlarged, they become heterogeneous.

Increased flow again is not specific metastatic disease of other types of tumors.

We see lung, prostate, gi, renal, melanoma, not as common as lymphoma and leukemia and are seen as end stage manifestations of metastatic disease.

These people often will have widespread metastatic disease.

Here is somebody with chronic lymphocytic leukemia bilaterally in large testes with a lot of increased blood flow symmetrically.

These testes are not as hard as infirm as people who have primary tumors and it would be unusual to have somebody present with bilateral primary testicular tumors.

And of course the history is important as we can see in somebody known to have um, a lymphoma or a leukemia.

Just one other point I wanna make is that sometimes when these people are treated for their lymphomas or leukemias there is a pipe type of barrier that may prevent that chemotherapy from um, treating the testicular component of that disease.

So it would be important to to watch if you see some abnormality in somebody's testes after they've had chemotherapy to recognize that they may have not achieved the goal of good therapy when with respect to the scrotum.

Microlithiasis

Now what about this controversial issue of micro?

The literature would suggest that there are many entities that are associated with micro LSIs.

The literature also suggests there's a predisposition to germ cell tumors in people who have this.

Although that incidence is controversial, A very nice article I'll reference here was published to bring our attention to the association of microglia to intratubular germ cell neoplasia.

Now it's very unfortunate that we don't have a marker for who has associated intra germ cell intratubular germ cell neoplasia.

When somebody has micro LSIs, the best we have are some references in the literature to suggest when you have micro LSIs you may have a relevant increase maybe up to 22 times.

Notice that when we're looking and we see micro list, there's an elevated.

When we're thinking about micro LSIs, we would like to suggest you use a high frequency transducer and have more than a singular or perhaps even more than five micro lists per image.

This is a widely quoted article, um, that came from Mallinckrodt in St. Louis suggesting that we should consider micro SSIS as limited when there are few micro liths, the association of neoplasm perhaps 2% more than five micro lists per image increasing the likelihood of having associated tumors.

But I will stress that it's important to have good technique.

If you're gonna see micro ssis megahertz matters, low megahertz poorer resolution, you won't see as much, much micro LSIs.

The equipment matters again, lower frequency, maybe a seven megahertz to a 15 megahertz older equipment, newer equipment you will see more micro LSIs.

So megahertz and equipment matters here.

Here we have obviously classic micro ssis, huge number, a few micro liths in a patient as we see in this scan.

But what shall we conclude?

Well here we have classic micro ssis with an associated germ cell neoplasm here, however, we have only a few micro lists and this patient also has a seminoma.

How do I counsel a patient?

Well if I see a large number of micro lists, I'm gonna alert that patient particularly to do self-examination.

What if I only see a few micro lists?

The literature is still fuzzy on that with regard to this, there is clearly not the, the bottom line is we don't really know If I could know if this patient had intratubular germ cell neoplasia, obviously I would be concerned.

Um, but I can't, there's no marker for that.

So in general we tend to ignore limited micro ssis and I think we definitely should follow people who have this extensive degree of micro ssis because these are clearly people at a higher risk.

Epididymitis

Let's now move away from the testis and talk about other entities in the neighborhood in the scrotum, beginning with epididimitis, which is a retrograde spread of infection from the urethra, prostate or bladder.

It's somewhat analogous to pelvic inflammatory disease, which is also a retrograde infection through the cervix uterus into the tubes and ultimately may affect the ovaries in a female.

If it's retrograde, it wouldn't surprise you to suggest that the tail of the EPIs is initially involved as we see on Dr. Netter's diagram and then it can progress to involve the head.

The testis can be involved either by flow of the, or the infection spreading from the head into the mediastinum and then into the testis or by contiguous spread of infection as we see here on Dr. Netter's diagram with a perhaps 20% um, association of testicular involvement with people who have epididimitis.

So it shouldn't surprise you when somebody has acute epididimitis that the tail of the EPIs, which is typically inconspicuous as I mentioned at the beginning of this talk, becomes much more conspicuous and may even be larger in comparison to the head of the epididymus hydros EALs are often seen simple or complex.

Here's a case where there's bright echogenic foci, some of which have shadowing.

The clip will show you these perhaps to a better degree.

These were actually little air bubbles in this unfortunate man who had very, very severe epidermal oras.

I'm gonna come back to this case in a few minutes.

Abscesses hard to know.

Sometimes again, I bring your attention to the enlarged tail more than the body and more than the head.

But by turning color on and seeing a void, a flow, you might bring up the possibility that this patient is developing aleman as he was and subsequently developed an abscess similar to all inflammations.

And here we can have contiguous spread in this case involving the testicle with an abscess.

Doppler would show increased flow with any kind of inflammation.

Typically the epididymus is not all that vascular.

You do see a little bit, but certainly not to this degree.

And the testis also in this case on the right side has increased flow compared to the opposite side suggesting accompanying oris.

Now what's going on in this case is this acute epididimitis with an enlarged tail.

Actually not this is a mimicker or superficially you might make an error but it's a lookalike.

What is this? Well there's hyperemia in this structure, but is this coursing to the head of the epidermis?

As I've shown you previously, we don't see the head of the epididymus in the expected location, but now I see it, but that is not associated with the area that I'm showing you back here, which is the same structure as we're looking at here.

So what's going on here?

Well, let's turn to our diagram and realize that what we're looking at here is actually a prominent ductus deference or vast deference.

Remember it's a retrograde infection and in some people, for some reason this inflammation is much more prominent than the inflammation in the epi demist.

I've also seen people call this a hernia.

Always look up by the inguinal canal and you will realize that there is no hernia at that level accounting for this structure.

So don't get fooled, this is inflammation, but don't call it a hernia.

Recognize it for what it is. Look carefully.

How about um, the differential for acute epididimitis?

It can be different, different, difficult sometimes to associate from torsion and you say, how could that be?

Well, acute epididimitis can come on relatively rapidly, which is why sometimes torsion enters into the differential and people who have tumor can also have concurrent inflammation associated with it.

So anytime you have what looks like a focal abnormality in the testis, which might be oris, think in the back of your mind, could it possibly be, uh, a neoplasm?

And if a patient is being treated for epididimitis and there's associated oris, make sure you follow that patient to make sure what's in the test is improves or goes away with therapy.

Testicular Torsion

Let's discuss torsion.

Now an important entity tends to occur in fairly young men who have a predisposing congenital abnormality of the way their testis is invested in their scrotal sac.

Normally as the testis descends and it comes from the high retroperitoneum into the scrotum, it pushes the the associated peritoneum in front of it.

And for some reason, instead of calling the peritoneum, we've already mentioned the tunica algen as being the surrounding structure.

At the periphery of the testis, we now call the the um, peritoneal surface as it enters into the scrotal sac.

The tunica vaginalis that is just the associated peritoneum that's come down through the inguinal canal in utero and is in front of the testis because the test is normally is invested and is sealed down at the level of the EPIs with the tunica va or peritoneum in front of it, but not all around it.

An abnormal investment is when the tunica one, uh, when the testis says it comes down into the um, scrotal sac is completely surrounded by the tunica vaginalis.

It's almost analogous to putting your hand into a sock.

That would be the testis surrounded by the tunic of vais or the peritoneum completely surrounding it and not having a solid um, attachment if you will, of the epidermal le level into the scrotal sac.

So here we have a large hydros eal, but notice this patient's lying on their back and the testis is here but there's no fluid behind it.

Well why is that? You would think with gravity there should be fluid behind here, but there's not because at this level which is the level of the EPIs, there is a solid attachment of the scrotum and epididymus to the scrotum itself.

So there's no fluid behind it here, however, we have a sagittal and transverse scan.

This is a neonate if, and I'm gonna come back to this patient but I'm showing you this because no matter where I went, there was only a small degree of attachment of the testes, otherwise it was free to rotate and that's known as the bell clapper deformity.

This would be analogous to the testes here minimally attached, free to rotate on its axis, the classic bell clapper deformity.

So when you have somebody with a large hydros seal, look around and make sure that you can see that firm attachment.

Failure to see that puts that patient at high risk for a torsion.

Well what are the features of torsion?

Obviously it's acute pain and most people will come to see seek help rather quickly within about six hours following the onset of their symptoms.

And if we can operate in that golden period, which is considered about six hours, often the testes can be salvaged, the EPIs is typically enlarged and the testicle may have a normal or an abnormal appearance.

And typically when it's abnormal in appearance, that means you're beyond that golden period where you can salvage the testes.

The other findings including skin thickening, hydros, eal, epidermal enlargement, none of these findings are specific.

So how do we make the diagnosis?

Well first, what does it look like?

Three different patients.

Asymmetry is what we see here in the first patient.

The right side was the symptomatic side.

Notice the skin thickening, not a specific finding and not surprising once the testis does not have an appearance that is similar to the normal side, that is often seen in a non-viable situation that patient required orchiectomy.

Here we see again asymmetry, but in this case it was the left testes that was symptomatic.

And I'm showing you this case to show the dramatic difference in echogenicity between patient one, which was hypo coic.

Patient two was echogenic and in this case it was a non-viable left testis, which was very hyper, uh, hyper coic.

And in this case they both looked the same.

So which is the abnormal ca side, I don't know based on imaging.

But clinically it was this side and this patient had a viable testis.

Well how am I supposed to tell you that was viable?

How would I know? I can't tell on gray scale because it's similar to the opposite side.

Obviously the answer is with torsion.

You wanna look at the blood flow.

If the testicle especially has normal echogenicity, there's a good chance there may be a viable testis.

Here there's a heterogeneous testis on the symptomatic side, there's no blood flow, not surprisingly that's non-viable.

If you're entertaining the diagnosis.

Similar to what we do in women looking for the so-called whirlpool sign or twisted uh, area where the um, ligament leads into the ovary looking for the twist, you can do the same thing in a man.

You come up into the, at the inguinal level and you can see this case was done by my colleague when I worked at the Brigham Hospital in Boston.

This was done by Rusty Brown.

You can see a whirlpool sign here or a twisting of the testicular artery.

And there we have a case of a viable but tors um, inguinal um, testicular artery at the level of the inguinal canal.

Now remember I showed you a bell clapper.

I said it was a neonate.

This is actually a newborn baby I was brought in from.

I was brought in, I was on call, I was asked to look at this newborn that had a purple scrotum bilaterally.

And when I looked at this newborn, I noticed the bell clapper, which I've already alluded to.

And this testes had no blood flow and was heterogeneous, clearly abnormal.

And I suggested that was an infarcted testis on this side.

So what did I do at this point?

Well this testis is not gonna work for this neonate and unfortunate, but that's what sometimes happens.

I put color on and I was surprised to see how much blood flow there was in the testes with the bell clapper type of deformity.

But I am not a pediatric radiologist and I was unsure if this was normal.

I suspected this was hyperemic and increased flow.

Well how was I to prove that?

Well what I actually did was I said I think it's too much flow.

I actually went to the next neighboring little boy baby in the neonatal um area and I looked at his testes and there was only a small amount of flow.

So I clearly knew this was hyperemic.

And what I suggested then was that this was a detours testes that was now hyperemic because of what we call a mis torsion.

What do you do when there is a mis torsion or a detorsion?

You get on the phone immediately and you call the physician who's taking care of this baby because this baby needs to go to the OR right now because we've already known that the other testicle was infarcted.

If he to this testis and uh, lost this testis on day one of life, he would have no testicular function And that was what was proven at surgery.

Bell clapper deformities always have to go to surgery.

Let's look at another challenge case.

This looks like a torsion patient was acutely symptomatic on the right side.

Looks like an torsion with an infarction but four minutes later there's now a hyperemic testis on the right side and the patient was feeling better and I followed this patient 10 minutes later there was normal bilateral symmetric blood flow.

So what was going on in this case is also a patient who had a detorsion that occurred during the ultrasound scan.

So it was not an infarction, it was another torsion that had detours.

And if I only saw this patient at this point in time, I would've had to read out a normal ultrasound study.

But 10 minutes earlier we saw no flow.

What should happen to this patient?

You've gotta get on the phone. Call the clinician.

This patient needs to go to the operating room.

Shortly thereafter, the study to evaluate as was noted in this case at surgery there was a bell clapper and this had to be fixed clinically at surgery.

And as a word of caution, whenever there's a bell clapper on one side, the other side has to be surgically looked at because very commonly there will be bilateral bell clapper deformities as was the case here.

So this was a very fortunate man he was able to keep both his testes and we happened to see the torsion that detours.

Testicular Infarction

So testicular infarction.

The first indication or the primary reason why people have testicular infarction is torsion with a bell clapper.

Other times when you can get testicular infarction, although not nearly as common, so smaller letters would be post and sometimes post-surgery.

Let's look at a couple of cases.

Here is a patient in whom clinically there was symptom symptomatic epidermal or on the right side and on this particular date there's increased flow going along with the known epidermal or oris.

So the right side is the symptomatic side.

Now about a week later we looked at the same right testis and there was no longer blood flow comparing it to the left.

Always when you're doing a comparison, start on the asymptomatic side to set your color parameters and then look at the symptomatic side.

So clearly asymmetry, no flow.

Heterogeneous, this was an infarcted testis.

This was the person I showed you who had the air in the hydros eal and he had infarcted his testis and had a very bad outcome requiring surgical removal of this testis.

Now what about this case?

Left side was symptomatic, no blood flow and often when there is an infarction, the testis is somewhat more heterogeneous.

The epi, uh, the um, tunica algen becomes a little more prominent as does the mediastinum because of the conspicuity of the heterogeneously hypo coic testis.

Well what was going on in this patient?

I asked him, I was surprised to see this.

He said he had had surgery a month earlier and had a hematoma that had developed in his groin.

So I went up and I looked at his groin and he had this resolving hematoma and I said, didn't you have a lot of pain at that time?

He said Yes, but I just had hernia surgery and since I was post-op I thought that my pain was all post-op.

Well his problem was this hematoma compressed his testicular artery resulted in a subsequent infarction.

So this testis no longer was any use to him in terms of function.

So that's why I put postoperative as another reason why you can get a testicular infarction.

Traumatic Disruption of the Testis

What about these three different individuals?

What's going on here?

Notice the irregular outline to the testes.

Somewhat heterogeneous. Notice the loss of the tunica and an associated hypoechoic heterogeneous area.

Notice the same thing in this case, loss of the tunica algin and a hypo coic mass.

Well, with the appropriate history, the loss of contour definition, it wouldn't surprise you with the history to suggest a traumatic disruption in each of these cases.

Now each of these patients should go to the operating room in an urgent fashion.

Number one to try if you can, to repair the abnormality.

This is actually this case, this could be debrided and it was primarily sutured and the patient did okay, so in addition to try to salvage the affected testes.

Another reason to bring these people to the OR is because failure to do so.

Some people believe the ex ex extrusion of testicular contents may lead to the development of antibodies that can uh, affect spermatogenesis and a man can render himself sterile by the antibody response to the ex to the sperm that is no longer contained within the testes.

That is uh, believed by some, but I don't believe all urologists.

But this is one of the findings with testicular disruption.

Parenchymal abnormality we've already mentioned it can be diffuse as we see in this case or somewhat more focal as we see here.

The history will help solve what this is due to.

But any of these patients who have focal abnormality or diffuse abnormality should probably go to the OR to ensure whether or not there is a disruption at the edge of the tunica algen.

Here's a lacerated testis.

Extratesticular Pathology

What about extra testicular pathology?

We've been mentioning epi ditis, but let's talk briefly about these uh, different entities.

We've mentioned hydros seals.

We said it's fluid between the layers of the tunic of vaginalis where the peritoneum has come down in utero and should be superior.

Anterior inferior but not posterior to the testis.

A little fluid is okay, I don't report it but obviously a large amount is something to report.

Who gets these? A lot of people get this.

There are many different indications.

I've already showed you this very large hydros eal, no posterior involvement, no posterior fluid.

Here's a simple hydros eal. Here's a complex hydros.

Eal history becomes important.

This could be pus, it could be blood hydros.

EALs are unusual with tumors.

They occur with everything else.

Often idiopathic but not commonly with tumors.

Just bear that in mind.

Now sometimes I've seen people have um, some diagnostic dilemma.

Is it a hydros eal? What is it? 'cause fluid to them.

You think of hydros eal where in reality it was it's a focal abnormality or cyst at the level of the epididymus.

Most often these are at the head of the epididymus as we see here in Dr. Nettas diagram. And often because it's a focal area of an abnormality, it can push and displace the testis as we see here.

It can be simple small as we see here.

You may or may not wanna report that I don't think these small ones need to be reported here.

We can see it's pushing down.

It would be a palpable mass in this case, but it is focal, it is not assist in the testis, it's pushing against it.

Here's a larger one when we start to see echoes within them, some people would then characterize that more likely to be a spermatocele.

But I don't know how you really separate epidermal cyst from one that contains sperm and sometimes they may even look solid.

There'd be no flow here.

Um, and sometimes they are solid.

And then you might wanna think of a sperm granuloma which often will occur in a patient who has had a vasectomy.

Can I tell this from a tumor?

Well if there's no blood flow it would be very unlikely to be a tumor.

Tumors are unusual at the level of the epidermis.

They tend to occur more in the tail, the epididymus.

But um, this turned out to be a sperm granuloma.

Multiple small epidermal cys in this case.

Varicocele

Varials obviously are dilated veins like varicose veins and they occur often quoted in men who have infertility.

Although if you look at the literature they can be seen in many, many men.

And there is a crossover here in just varying studies.

What I think is important is to define varicose seals as to whether they are primary or secondary and secondary or acquired varicose seals.

By primary I mean people who have problems with um, incompetent veins such that the drainage through spermatic vein is deficient and you end up with stasis of blood.

Now this occurs typically on the left side because of the negotiation of left spermatic vein into the left renal vein, making that sharp left-handed turn.

That seems to be difficult in many cases.

And you have with associated incompetent valves, you develop dilated veins in the scrotum on the left side, the right side is not as difficult to negotiate the returning blood through this traumatic vein because of the oblique course directly into the inferior vena cava in most men.

So since you have a direct flow into the central vasculature of the renal vein or the IVC, when you have these primary varicose seals if you will, you should see change as a patient Val salva or assumes an erect position.

In those situations you will see change within the varicose seal with an acquired or secondary varicose seal.

There's a Fran obstruction either at the level of the renal vein or at the level where the right renal uh, right spermatic vein uh, joins the inferior vena cava.

And then because there's a Fran obstruction, you do not see those changes with various maneuvers including val Salva or change in the patient's position.

And here are just some examples of the location where varicose seals can occur.

They can be at the level of the cord, they can be anywhere within the scrotum.

So you have to look carefully here we have one that's entering the testis small.

You can see it often with color flow.

Here you can see the enlargement as the patient assumes an erect position.

Here you can see slow flow.

You must, if you're going to use color, adjust your settings to a slow flow, uh, parameters.

But you really need to have color here you can see just with a clip, I'm sorry, just with a clip.

You can see if I come back to that clip you can see flow.

All you have to do is turn your gain or volume control up on your gray scale and make the image large.

And these, the slow flow assumes that the red cells are gonna clump together in what's known as ru low and you can see it and sometimes you can't see it with color at all because the flow is so slow.

So these clips are are nice to show you varicose seals.

By that we mean three millimeters or so or greater or clumping of veins that tend to be fally dilated.

We would call a varicose seal.

Unusual Cases

Now just to end with a few, if you don't mind the pun oddball cases here we have a patient who has a lot of serpiginous structures coursing within the testis itself you turn color on.

Wouldn't surprise you to note that this is an intra testicular varicose seal has the same clinical implication in some people with associated infertility as the extra testicular varicose seal that we just discussed.

This is an interesting case on the right side.

This patient noted some thick rubbery consistency around his right testis clinically which brought him to our ultrasound lab.

When you put color on again no um, when you just put a clip on and turned up your gain, no color needed.

Here you can see very, very slow flow on the right side.

So what does this turn out to be?

That was an acquired right-sided osee and these are whenever you see a new, particularly on the right side varicose seal, you know this shouldn't happen.

You shouldn't have vari seals on the right very commonly because it's easy to negotiate the flow into the right uh, from the right into the inferior vena cava with that new acquired varicose seal.

We looked up here and not surprising to us he had a tumor obstructing the flow causing that new dilated veins on the right side.

What about this case? Somebody shows you this image.

You might think there's a mass involving the right testis but then we went in and we looked at the patient and I don't see any mass looked fine.

What was causing this a finger was palpating the testis.

You don't wanna take a picture like that because all you can do is cause confusion.

That is something that you might wanna, anytime my patient says I feel a mass, I wanna feel it myself but I don't wanna take a picture which could cause confusion on the other hand.

Can contrast that to this case where there clearly is a mass in the test is gradual acoustic shadowing.

If I showed you an ovary with a finding like this, you might suggest that was a dermoid or a teratoma, which is what it was surgically.

This is an ant mini if you look at this case focus on it.

No flow clip looks like an onion skin doesn't it?

That's called onion skinning.

And that is an ant mini associated with an epidermoid cyst.

A benign condition since it has a classic appearance as we see here, this is benign.

We took the patient to surgery, helped the surgeon localize it, he shelled it out and I just show it to you 'cause it does look like an onion skin.

What about these two couple of last cases in this case it looks like apparent enlargement on the right side.

Notice micro liths on the left, no visible echoes in this.

What's going on here?

Well this is bigger than this side is bigger better.

Well if you looked at this case, there wasn't really this degree of asymmetry.

What this is, I'm sure some of you will know, is a prosthesis.

This prosthesis has fluid in it that conducts sound more slowly and more as it goes through the prosthesis more slowly.

This is interpreted as um, a longer distance for the sound to go through and it causes it to look apparently larger.

It was not larger. What about this case?

This patient on a sagittal scan has what looks like two testicles.

And as a matter of fact he had four testicles.

So he had poly orid.

This patient in truth was a four star general.

He was very happy when I told him he had four testes, one for each star on his lapel.

He was a very happy person to hear that it was of no clinical significance.

The last case is very interesting and intriguing.

As you look at people, you may see people who have noticed the dilated, slightly dilated EPIs in this case.

And if you cone down on it, you can see movement within those, the dilated epididymus.

And in this case, this was a patient who actually had lived in India and this was Arias.

But I'll show you a case that was done at the Brigham Hospital where until recently I was working and this patient had no never traveled.

And this is not arias. I'm gonna say what is it?

We don't know for sure, but most of these people almost exclusively had had vasectomies.

I know Mary Frady who works at the Brigham, has recently looked at this and she calls these dancing sperm.

I don't know if you wanna call it that because sperm are really too small to see.

But these are concretions that are moving within dilated tubules and are probably of no significance, especially if somebody has had a vasectomy.

Conclusion

So I will thank Dr. Netter and others who I've taken their artwork from and thank you for your attention.

Uh, and I hope this has put your mind more ease into when to worry when you're doing testicular ultrasound.