There is a Mass in the Scrotum: What Does it Mean? - HD

Introduction

My name's Tom Winter.

I'm a professor of radiology and chief of abdominal imaging at the University of Utah.

And we're gonna be talking about what to do when you find a mass in the scrotum.

Love this paper from one of the urology literature about five years ago entitled The Face of Testicular Pain.

This was, I was lecturing in New Zealand and I love this sign.

As you came into one town, it said, be careful driving.

We've got two cemeteries and we don't have any hospitals.

This is gonna be an ultrasound talk, but sometimes CT is the best way to evaluate the scrotum.

Here's a spectacular case given to me by Jason and moving on to the bulk of the talk, we will have a brief introduction, then we'll talk about intra testicular lesions, tumors, torsion, epididymitis, trauma, extra testicular, scrotal lesions, true masses, and then a variety of other things.

And then we'll finish up with micro lithys.

Probably the journal I read most religiously is Sports Illustrated.

So we'll be illustrating this talk with a lot of uptakes from si.

This was the very first scrotal ultrasound ever published by Fred Sample.

It's a bi stable exam showing a hemato seal.

And just look at how lucky we are with the technology that the manufacturers have given us over the ages, improved hardware and software.

We get beautiful gray scale, beautiful doppler.

This is a patient who had three testicles.

Here's an 80-year-old man whose testicle looked like a bowling pin.

He was completely asymptomatic, so we never found out what was going on there.

One thing that the clinicians justifiably ding us for is that we don't answer the question.

So when the patient comes in with pain or a mass at a spot and we dictate it's a normal ultrasound, the clinician's left wondering, did you even look at the spot that I was worried about there?

So put something in your report, along the lines of we or Joe Blow directly palpated the mass in area of point tenderness.

We looked with ultrasound with the patient's finger on it and it proved out, proved to be X, Y, or Z.

You've answered the question.

This guy came in when John Crook was pitching and he was sure that he had a testicular tumor because pro croc had been on the covers of SI right then.

And we were able to tell him, A, this is extra testicular.

And B, this is a simple cyst.

Don't worry about it.

As many of you know, croc is now a color announcer for ESPN, but he's a very funny guy.

And when he retired from the Phillies three years after his orchiectomy for testicular cancer, on the last day, he went to the pitchers mound at Veteran Stadium to get the gold watch or whatever they give you for retiring there.

And he had a custom made T-shirt, that's red, I quit.

I'm taking my ball and I'm going home.

Intra-testicular Lesions

Tumors and Focal Masses

So now moving on to tumor and focal masses.

Tumors, the most common solid neoplasms in young guys, 15 to 34-year-old.

We are taught that it's painless, but 10 to 50% present with pain, probably because it's infarcted or bleeding.

A chunk of these are bilateral colored opera really doesn't help you distinguish benign from malignant.

There's some trends, but it's not good enough.

And this was just a multifocal seminoma.

There they have a completely nonspecific appearance, but in general, solid masses in the testicle are malignant until proven otherwise.

This was an old paper by Lee Nelson though talking about a 50% false positive rate with abscess hematoma and infarct also in the differential.

This is a multifocal seminoma.

This poor guy had had his contralateral testicle removed several years before for testicular cancer, then was going whitewater rafting, couldn't get his wetsuit on, and his family doc just said, ah, that's normal, that the other testicle swells after orchiectomy, which is completely not true.

Finally came in and this was recurrent testicular tumor opposite side.

One of the biggest risks for testicular cancer is a personal or close family history of testicular cancer.

Here's another multifocal seminoma.

It can be unifocal or multifocal.

This is associated with some calcifications, but not all focal hypo coic.

Solid masses are seminoma.

If you look at this one, I'd call it a seminoma, but he had a history of melanoma.

Here it is on the PET scan.

And this was proven to be a melanoma metastasis to the testicle.

That's one of the few tumors that will metastasize there.

Besides being multifocal and unifocal, it can take over the whole testicle.

Here's the entire testicle just filled with seminoma.

This is a really stoic farmer who was just waiting until the crops came in to come in to seek medical care.

You can see his normal right testicle here and the massively enlarged hyperemic left testicle, but this guy did great, didn't have lymph nodes and is cured.

Here's another seminoma replacing the entire testicle.

So seminomas human focal multifocal taking over the entire testicle.

We can even see this one on ct, which is kind of rare.

Another one taking over the entire testicle.

This is the mediastinum test is here.

But before we get too cocky and think, wow, if the appearance looks like the last five cases I've shown you, this is seminoma taking over the whole testicle.

Here's an example of lymphoma.

So Phil Raws wrote a phenomenal paper showing how lymphoma and leukemia tend to congregate in the testicles because chemotherapy has a hard time getting in there.

But again, that's one of the beauties of ultrasound is that we actually talk to the patients and can get a reasonable history.

So if they say, yeah, doc, I stopped taking my chemotherapy six weeks ago and now I've got this mass, you're gonna be really worried about lymphoma leukemia.

This one we did not biopsy.

We had the masses, here's the right testicle, here's the left.

But he had nodes everywhere else, so they just presumptively treated.

And you can see the left went completely invisible.

The right this turned into fibrosis, but it never panned out to be anything bad.

And again, people write about this occasionally, lymphoma's rare, but it's the most common testicular neoplasm in men, 50 years of age and older.

Here's just a beautiful 3D ultrasound by my friend Mike showing this gorgeous appearance there of the hyperemia.

And this is the very first color Doppler unit out there.

This is given to me by Bill Middleton.

This is the quantum Unit and you can see that the color Doppler looks like those old Atari video games there.

This was not oras, this was leukemia.

So just showing again, here's Unifocal seminoma, multifocal Seminoma, and then Seminoma replacing the entire testicle from one Paula was at A-A-F-I-P.

The other big category, which is actually a bit more common.

The textbooks used to say that Seminomas number one, but now mixed germ cell tumors moved into first place at around 60% or, and seminomas just under 40% right there.

We're pretty good at diagnosing these, lots of cystic change, very heterogeneous.

The urologist really doesn't care that you're smart and call this mixed germ cell tumor versus seminoma for two reasons.

One, testicular lesions that aren't purely cystic or malignant till proven otherwise.

And they're two, they're all coming out.

Here's the left testicle for comparison.

Here's a mixed germ cell tumor.

Notice how heterogeneous it is.

It has calcifications, it has solid masses in it.

Here's another one, classic appearance.

Heterogeneous, unlike the seminomas that we've seen, cystic calcifications, kind of disorganized vascularity.

This kid was playing hoops got hit came in.

You can see the hemato seal, the adherent clot in the ruptured mixed germ cell tumor.

And we'll talk more about that in a little bit.

And you can have weird mixtures of seminoma and the non seminomas tumors.

So this is seminoma and in bridal, there again, it really doesn't matter because they're all coming out.

Remember that the testicles embryologically start in the abdomen and migrate coddly.

So in America, we're so blessed we have a CT scan on every corner, but we still like to one up the CT folks.

So anytime you see a testicular tumor, always take a quick check of the ipsilateral renal hilum because that's where the nodes are going.

And you can see this mixed germ cell tumor here.

It was taken out, this area was happy and then a year later developed adenopathy.

So always check the renal hila.

Look at the, so we have hydro nephrosis in the kidney.

The kidney and the liver are mushed by this huge mass.

We have the right renal artery coming off the aorta there and this mat of nodes surrounding the aorta in the cava and again, just a mixed ger germ cell tumor.

So with these last 30 cases, 15 of seminoma and 15 of mixed germ cell tumors, you're set up for pretty much 99% of all testicular lesions.

Here's another one that came in at 11 o'clock at night for a mixed for rule out torsion.

Josh, our resident, grabbed the vascular probe, which is too low frequency here, but a couple minutes later he smartened up, grabbed the testicular probe higher frequency and look how the dot size is much smaller there, the resolution's higher, but again, Josh was able to tell them he's having pain not from torsion, but this is a testicular malignancy.

And from when Paula was at A FIP, you see what these things look like and that explains their ultrasound appearance.

Interesting mass here, shell kinda laminated appearance.

And this is a classic epidermoid inclusion cyst.

Here's another one given to me by Mary Hollister.

These laminated concentric rings there are almost pathognomonic for an EIC.

Here's another one from Jason.

Just laminated concentric appearance.

Now realistically, every single one of these that I've seen, the surgeons have gone to the OR because nobody's gonna let a solid mass sit in the testicle.

Having said that, you can benefit the patient by telling them the surgeon that I'm pretty dang sure that this is an EIC, which is a benign lesion.

So instead of going in and just randomly doing an orchiectomy, you can bivalve the testicle and nucleate it and preserve the testicle.

Here's another one here.

Laminated concentric appearance.

Here's a pass slide on a different patient laminated concentric appearance.

Interesting guy.

He's a physician who had testicular pain or had groin pain.

We were asked to rule out hernia.

Now I wish our sonographer had not been so good here, but she was so phenomenal.

She ruled out hernia and then said, well he is got groin pain.

Let me look at the ipsilateral testicle.

Kathy looks at it and sees five lesions in the right testicle and there were pretty much similar appearance on the left testicle.

Now long differential here, but you gotta be concerned about multifocal seminoma lymphoma.

Then the guy had a chest CT and belly CT for staging and there were findings on the chest CT that prompted a mediastinal biopsy.

And it turned out when all was said and done that this is sarcoidosis.

And when I give this lecture in Japan or the Philippines, people just yawn and say, eh, another case of tuberculosis.

So grain lumous disease can present with focal testicular lesions.

Getting back to our patient here who is a physician, fortunately it turned out to be benign, but because he was in the medical field, the bronchoscopy didn't go well.

They ding the recurrent laryngeal nerve, he's hoarse, there's a lawsuit, all these incidental findings that end up wreaking more havoc than good.

And here's more recent cases, sarcoidosis there.

This one was a little bit more classic.

It's an African American in pulmonary clinic and we can see the lesions here.

Here's another one.

Same demographics but in ophthalmology clinic.

And this is a large seminoma sitting on the top right there.

And then our final case of a mass that's really unusual.

This is bilateral testicular pain.

They asked us to rule out torsion.

And we look at this and we see bilateral testicular masses.

So your heart drops, you go into the room, and you are gonna have to have a conversation with the patient saying this could be bilateral seminoma, it could be lymphoma, it could be bilateral metastatic melanoma, all of which are bad.

And what did the patient tell me that he hadn't told the sonographer, the resident or the fellow when they had all asked him if he had any medical issues?

Exactly in this case, the patient told me that he had congenital adrenal hyperplasia.

10% of the males in this room have little bits and pieces of adrenal tissue sitting in their testicles.

And for 99.999% of them it means nothing.

But if you're the one in a bazillion that has the enzymatic deficiency, congenital adrenal hyperplasia, the sensors in your brain say, we don't have enough adrenal hormones going on.

They send out chemical messengers to your whole body saying Hey, if your adrenal tissue bulk up, pump up, start producing more hormones.

And these guys have the one in 10 have a little bit of adrenal tissue in their testicles.

So it bulks up.

And there are horror stories out there of patients who receive bilateral orchiectomy and all they needed was just enzyme replacement there.

Now we do test for CAH on the heel sticks right now.

So talk to the patients and try to get that history.

And here's just another one.

From when Paula was at A FIP, bilateral adrenal rest and congenital adrenal hyperplasia, here's a patient who came in Christmas Eve, I'll always remember this case.

He had been told that he had widely metastatic renal cell carcinomas, 23 years old, he had just gotten married and the outside hospital had done a really nice biopsy of this renal mass and he's got cannon balls all over the place.

Fortunately the medical student, your typical medical student did the 200 page history and physical and that prompted a scrotal ultrasound exam.

And I do the scrotal ultrasound exam right here and the chairman of urology standing over my shoulder as I'm scanning, I tell Paul what was going on and he looks at the patient and says, congratulations Mr. Smith.

You have widely metastatic testicular cancer.

But when you think about it, his five year survival just went from one or 2% up to 95 plus percent.

So young males with lung mets or adenopathy all over the place always offer to do a scrotal ultrasound.

And I always think of pathology as the gold standard, but if you learn more, it turned out they had core biopsy, this nice trans hepatic biopsy.

The pathologist said he was told it was a renal mass biopsy and it looked like renal cell, but this is just adenopathy in the renal hilum pushing out upon review of the slides, what about cystic testicular lesions?

We spent a lot of time talking about solid ones.

These can be an abscess or an infarct, a hematoma, a tru cyst.

Couple other things again, I said I get my medical literature from Sports Illustrated and this was a shot on the Tour de France right here, kind of appropriate for a GU talk.

So this gentleman came in with cystic solid in calcification.

I called it a mixed germ cell tumor, I'll call it that the next a hundred times.

I see it turned out to be a diabetic with an infarct.

So again, we're not perfect.

This is classic here, essentially pathognomonic, these feel very hard, but this is a cyst of the Tunica algen.

It's completely benign.

The only thing you need to do with this is to tell the patient that it's benign and not to get surgery.

We don't need to do follow up on them.

There are usually singular, they can be multiple as we see in this case, right in the Tunica Algen once in a few moons they can actually be hyper coic.

Here's a true intra testicular cyst.

I see this about once every five years.

This one was completely cystic and this turned out to be a true intra testicular cyst and we followed him up every year for five or six years and then he got bored and quit coming back.

This one right here was scanned by a buddy of mine.

They did a great job scan the cyst every which way from Sunday it was completely cystic the patient and they told him it was benign.

The patient was kind of a hypochondriac and good for him.

He comes back six months later and there's a solid nodule in there and this is a germ cell tumor of the testicle there.

So just like dermoids have protean manifestations, once in a billion years you can get a cystic teratoma in the testicle that will degenerate into a solid mass there.

This is almost the exception that proves the rule.

But in general, because of this case, whenever I see a purely cystic intra testicular lesion, I have the patient come back at some schedule just to follow it up.

Remember we're distinguishing intra testicular from the cysts of the tunica algen, which are always benign up here.

This is Nat mini, this is tubular ectasia.

This is Don't touch.

This is just the plumbing system of the testicle.

And some people tend to have a little bit more prominent than the other.

It's typically bilateral and these are just, you hear tubular ectasia dilatation of the mediastinum testis or the READi testis.

And here's the READi testis on 3D ultrasound gorgeous images here.

And when this dilates a little bit, you'll get this appearance.

Not to get this confused, this is a testicular prosthesis put in following orchiectomy for testicular cancer.

Some other things that can present.

Torsion

So here's a patient that has testicular torsion.

So normal gray scale, normal color, abnormal color on the affected side.

So that's the typical presentation.

But we're lucky in America because we have good medical care.

This was a great article by Dr.

Brando done 15 years ago from South America where people weren't so fortunate and they would have torsion and gutted out and then get to a clinic a week later and then by then the pain's gone and they present with a testicular mass and you think, ah, that's a testicular tumor.

No, it's just that testicle that's twisted round and round been dragged up into the top of the scrotum there.

So remember that mist torsion can present as a testicular mass.

And here's an one of our torsions from the operating room right there just showing what it looks like, how it gets dragged up.

And just as an aside, again from Jason Wagner, if you're really into testicles, you can go to Oline Missouri.

You can go downtown Oline Missouri and participate in the Testicle Festival.

So they're probably up to the 21st annual right now.

So again, here are two patients with missed torsions, big hypo coic masses on the affected sides right there.

Not to be confused with the tumor.

This is another kid who was playing hoops got hit that probably towards his testicle there.

Here's the normal contralateral testicle.

This was only 18 hours time and I actually went to the operating room on this one and the testicle was completely black.

And here's another more recent one, but same thing, the testicle was completely black in the or heterogeneous.

So just remember that torsion can present as a mass.

It may mimic a testicular cancer here, but usually the clinical history is enough to differentiate it and you, you're not gonna have blood flow in the mass and most tumor masses will have blood flow within them.

Epididymitis

There are other vascular etiologies for testicular masses.

I used to work with this delightful general surgeon, had the best bedside manner on the patient, but I got about 10 cases of hernia repairs from him where he would fix their hernia and they never recurred.

That was the good news.

But the bad news is he would tighten down the inguinal canal so much that it prevented a recurrence of the hernia.

But it also took out the testicular artery as it was coming down the inguinal canal.

Here's another one of his testicular infarcts.

After the hernia repair, epididimitis may occasionally present as a scrotal mass.

You know, we all know the C-sharp epididymus head, body tail globus, major corpus globus, minor 3D ultrasound there.

But these can get infected.

It's a slightly older age group than torsion but only by a decade.

And the mechanism is the bugs.

Generally it's an STD, the bugs coming down the urethra, down the S deens into the epididymus inflaming it right there.

But again, you're really not that much in a quandary over differential diagnosis.

These patients hurt, it's inflamed, they have a fever, they have a discharge.

Normal EPIs here, contralateral enlarged hypo coic irregular.

So that's the etiology, the Massey Palpates.

Here's another one, big mass up in the globus major.

Here's another patient.

You could play devil's advocate and say, how do you know that that's not a testicular tumor?

Well I think the center's outside of the testicle, but I don't know that for sure.

But this guy had such a great clinical history that we just followed him and on antibiotics and he got better look at the marked hyperemia in the EPIs in this patient there.

So in general you have only minimal blood flow in the EPIs, but when you have epididymitis you have a lot of blood flow.

Same thing over here, enlarged epididymus and then the ips, lateral testicle has lots and lots of blood flow within it there.

So in general, most patients with epididimitis have a concomitant oras.

So they have an epididimitis and we'll see that at ultrasound.

We thought we were the first people in the world to make this observation, but Phil Rawls pointed out years ago that this was published in a paper that was read by 1.5 billion people on the planet of this earth.

And so this is Jerry Lee Lewis and his album cover Great Balls of Fire.

And when I give this lecture in Japan, nobody laughs because they don't have the synonym of balls for testicles.

But right before he passed away, Phil sent me this video, this audio clip that I wanna play for you.

So Jerry Lee Lewis publishing years ago on that topic.

Now we think of Epididimitis as a totally benign thing, takes some antibiotics and get better.

But 40% of people have complications and these can be nasty scrotal abscesses, testicular infarctions, infertility.

So here's another epidemo orus always remember this case.

One of my more boneheaded mistakes.

This was a super, super sweet kid with down syndrome.

Came in with vague scrotal pain, couldn't communicate that well with us.

We did a great job examining his testicles and his epididymus.

We were phenomenal there, perfect pictures.

But what we didn't do was complete the exam and look at the whole scrotum.

And when he came back two days later with pain, I dropped the probe and where he hurt and this was just a big abscess on his perineum where the scrotum was attaching stuck an 18 gauge needle into this and got out Frank pus there.

Here's a diabetic C captain with fournier's gangrene, kind of a crackling mass in the scrotum.

This is from my buddy Myron.

You can't even see the scrotum here.

There's so much gas in there.

This was another trauma case there.

Scary, scary complication of epi.

The next two or three cases I'm gonna show you are all young kids who thought they knew better and weren't gonna treat their antibiotic, take their antibiotics.

So here's the normal left testicle, right testicle is enlarged hypoechoic, no blood flow, skin thickening that testicle died.

Here's another one.

We had a normal ultrasound 12 days before.

Now he comes back with a focal abscess in the testicle, kind of multifocal, lost the testicles.

Here's another one.

This was sent to us as testicular tumor and good for the outside docs because one of the take home points on this talk is that intra testicular masses are malignant until proven otherwise.

Seen several lawsuits where the radiologist tried to get really cute and show off how much knowledge he or she had.

And listed differential with 10 things including sarcoid and TB and infarct and who knows what and tumor was on the list but it was at number four and the poor family doc didn't know what to make of it.

So sent 'em out and they came back with widely metastatic cancer.

So solid masses in the testicle are malignant until proven otherwise.

Having said that, we scanned this guy and he kind of gave us a history that sounded good for epidem otitis.

So we told the urologist and when John took him to the operating room instead of just automatically doing a orchiectomy, he bivalve it, scooped it out, saved the testicle and this was a central infarct following epididimitis.

Kind of an unusual case here.

So the epidermis is abnormal, the testicle is grossly abnormal here.

You know, look at the mass heterogeneity.

Could this be tumor?

I mean I guess it could be, but we've got all the extra testicular manifestations and this is a really unusual case of TB of the testicle following BCG therapy.

We give BCG therapy for bladder cancer all the time.

And once in a while you'll get a tuberculous, epidemo oras and it can mimic tumor, it can occur years later.

It's the only case of this I've ever seen scrotal trauma.

Trauma

This again is from Sports Illustrated.

We all know how understated the British are.

And this was on the occasion of the first all women's rugby match between Oxford and Cambridge and the British newspaper that si got the article from all it said was an identified protestor ran onto the field, he was ejected by the referee.

So scrotal trauma takes about 50 kilos of pressure to rupture the tunica algen.

Most urologists are gonna explore if there's any question of rupture because that preserves testicular function may obviate infertility there.

But remember our kid playing basketball in the mixed germ cell tumor section and associated neoplasm may predispose to rupture after minor injury and 15% of patients with testicular tumors present following trauma.

So in the rare cases where they don't go to the operating room, be wary of anything you're calling in intra testicular hematoma, they should change rapidly over a couple days.

And I got that quote from the literature I've seen hematomas that took weeks to months to go away.

So you need to follow these things here.

Here is just following trauma, a big mass heterogeneous there.

And the initial read from the ER ultrasound was, this is a testicular hematoma.

No this is a hematoma but there's an underlying mixed germ cell tumor that pre predisposed.

Here's another one, hematoma here.

Disruption in the tunic algen.

This could be a seminoma, but he was explored and that turned out to be a hematoma.

Here's another one.

Hemato seal mass could be testicular hematoma.

He was explored that turned out to be a hematoma.

Another one, same thing, hematoma mass could be a tumor.

He was explored that turned out to be a hematoma.

But once in a while you'll get something that people call a hematoma and it turns out to be a seminoma.

This is a great case given to me.

My friend Cynthia, this gentleman was a personal protective assistant for a business that wasn't quite up and up and this is from San Diego.

They went south of the border, acquired some merchandise, there was some dispute over the merchandise and people got a bit upset, came back to the us.

Three months later he comes into the UCSD emergency room saying, doc, I've just had this nagging testicular pain for three months.

Cynthia's a really smart gal, looks at this, is like, wow, this is totally weird.

So she goes ahead and gets a plane film.

Look at this.

The guy had been shot in the testicle three months before and didn't know it.

Now this is a 22 caliber low velocity handgun round.

The gentleman was wearing a leather jacket so that kind of slowed it down.

But I just wanted to put this in for your differential.

Anytime you have a interest testicular mass, you need to ask yourself, could this patient have been shot three months before and not know it now extra testicular in general, most extra testicular lesions are benign.

Extra-testicular Lesions

Now there's one report from Harvard that says they can be malignant and there's a lot of hullabaloo in the literature, but it more or less boiled down to you're Harvard, you're gonna get every weird thing on the planet.

But most of the time stuff that's in the scrotum but outside the testicle is benign.

The classic tumors, the adenoid tumor, we've already seen a bunch of cases of epididimitis and you can have sperm granulomas and post vasectomy changes.

But here are two adenoid tumors.

A third are hypoechoic, a third are ISO coic and a third are hyper coic to the testicle.

Here's three of them or two of them.

These are benign but usually urologists are uncomfortable with a solid mass.

So they take them out and here's what they look like in the lab.

Weird things.

These are inflammatory pseudo tumors like we can get anywhere else in the body.

We had no idea what this was.

We're worried that it was melanoma or some weird rhabdomyosarcoma.

So these came out, but that's all that turned out to be appendiceal torsion.

There are five embryologic remnants that can stick around in the testicle and the environments there.

Now most of these are from the appendix, which is a perinephric or Malian origin.

The next biggest group is the meph or wolfen.

And I have no idea what the inferior and superior organs of howler or the organ of giraldi are, but it's in the same spectrum.

So here's appendix testicle.

I like this one because it looks like Bugs Bunny.

Here's appendix Epididymus.

Here's appendix testicle.

And the only significance to these is that they have blood flow and they can twist and tors and they hurt.

This is the etiology for the acute scrotum in a big chunk of pediatric patients.

It's the slow call, so-called blue dot sign right there.

All you do is treat this with Motrin.

It goes away and it is a very common cause, probably the most common cause of the scrotal pearl or scrotal boulder that you see falling around here.

This is just a tourist appendix epididymus.

And here's another one.

And often the patient palpates a lump right there.

So you just want to confirm as we said that you put your finger, that's what they're feeling and then you can be very reassuring.

And this is from Phil.

This is the mother of all scrotal pearls.

You know, this was during Gulf War one and you know, probably the biggest one I've ever seen, you know, practicing at LA County, Phil saw some really cool stuff.

Verica seals, we all know what they are, they have two complications.

They can cause infertility.

Although the strength of that association is being progressively weakened with the recent literature, most of the literature says that unless you can see it from across the room, it's probably not important.

But having said that, male infertility is about 50% of all cases of infertility.

So it's an easy thing to treat.

And then we'll talk about the other thing that's important.

So here's number one.

You know, just a big varicose seal right there.

We've all seen these two more.

They augment with Val Salva as we see here.

They augment.

If you stand the patient up, here's a 3D image reversal of flow.

But the other thing besides infertility and Duchy pain is abdominal mass.

So remember the testicles start in the abdomen and they migrate coddly.

So all of the embryology follows that.

And the adenopathy associated with testicular tumors hits up here.

Now 85% of verica seals are on the left side and that's because you have two right angles.

The left renal vein, or I'm sorry, the left testicular vein, the left renal vein in the IBC.

Whereas the right side's a straight shot.

But imagine if you had a mass of any type renal retroperitoneal sarcoma up here that's gonna pick off the testicular vein and give you a varicose seal.

So here's an example of a varie il.

Here's, we were still doing IVPs back then.

I have no idea why, but we saw a mass in the testicle, found the mass on the IVP.

This is one of our surgeons.

We missed it the first time because we didn't check the renal hilum.

He came in with pain, said when I operate a long time I have a lot of pain.

So there's the varicose seal, we looked ipsilateral and there's just a massive mat of adenopathy surrounding the aorta right there.

And here's a ct.

So the lymphoma caused his varicose seal.

That's how we diagnosed his lymphoma was when we did the ultrasound for the second time and looked up at the renal hilum right there, they biopsied him and that's what that turned out to be.

This is pretty rare.

This is an intra testicular varicose seal.

It was billed as a testicular mass by the outside docs.

But good for them.

Masses in the testicle are malignant until proven otherwise.

So sent to a specialty center, but you can actually see the blood flow going in there.

So it's just a varicose seal that's backed up hernias.

The best way to learn this is to listen to Cindy Wrapper.

Tom Stavros or Mike Williams give their phenomenal talk on hernias there, but they present as scrotal masses sometimes, you know, this is an obvious one.

Here's another farmer who was really stoic, had a bunch of pain, waited out until crop season was over, comes in with a scrotum the size of a basketball and borrowing from Dr.

Netter.

You know, this is what we're seeing.

But even though we think of scrotal hernias as bowel, the majority of them, well let me show you one more bowel one here.

So you can see the scrotal wall and you can see the peristalsis has the bowel is coming through, but the majority of scrotal hernias are actually fat, not bowel.

So they look really weird the first time you see 'em in your career.

Here's longitudinal on the left inguinal canal transverse on the left inguinal canal.

The resident thought this was a tumor but the testicle was actually squished below this.

Here's the normal contralateral testicle and this is a big fat containing hernia.

Here's another one, fat containing hernia coming through.

And you can see when you val salva, you get a lot of stuff moving.

Microlithiasis

Testicular micro SSIS will finish up with this.

This is the most floored example of this I've ever seen.

We actually did a mammogram after that and here's the slide when they took it out.

I'm gonna skip through this because I think we've reached some consensus in the literature there.

Bill Middleton did a lot of the great work on this.

So you define it as more than five on one image.

There's classic, there's limited, it occurs about 5% of the healthy population right there.

This is the number one plaintiff's attorney in town.

So even though we didn't see a mass, we went ahead and did an MR just because everybody was so paranoid right there.

Here's another example.

It's typically bilaterally symmetric.

This is a kid with down syndrome who had a ingrown hair sebaceous cyst and we incidentally picked up the micro ssis.

This is still five on one image so it's still classic.

You can have rarely in our paper we found a couple that were focal like this.

Who knows if that's old trauma or infarct, but why is it important?

And for a long time there's a lot of literature talking about the association with testicular cancer and we and others contributed to that.

But remember the classic dictum correlation does not imply causation.

So the big point in your day-to-day practice is if you see a mass in micro ssis, you ignore the micro SSIS because a solid mass is cancer till proven otherwise and you don't care about the micro ssis.

If you get one thing from this section, just remember that you gotta mass AMAs trumps everything else.

And here are a couple cases just of classic testicular tumors associated with fairly fluoride, testicular, micro ssis.

This one had micro SSIS elsewhere.

Macro SSIS here.

A solid mass.

I called it a tumor, I'll call it a tumor in the next thousand years.

Turned out to be another diabetic with an infarct.

So tons of literature and it's kind of interesting but I won't bore you with it.

Take a look at a paper we wrote in the yellow Journal of June this year.

And bottom line, summing up all the literature.

There is no use of routine ultrasound surveillance for patients with testicular micro ssis who are at low risk for testicular cancer.

So if they're a low risk patient and you see micro ssis, you don't do anything else, you may tell them to palpate their testicles once a month or something like that.

And here's a template that we suggested.

You don't have to use this, but we're just saying Myis is present without intra testicular mass or other worrisome findings.

In the absence of any other risk factors for testicular cancer in the big ones, our contralateral orchiectomy father or brother with testicular cancer history of crypt organism or mal descent or testicular atrophy, no further imaging or biochemical follow-up is necessary.

All that is recommended is routine monthly testicular self exam.

Having said that, if you see micro thiis but his twin brother had testicular cancer, then you're gonna refer him to a urologist.

Conclusion

So we had a brief introduction.

We talked about tumors and focal masses in the testicle.

They are malignant until proven otherwise with very few exceptions.

Torsion can present as a mass epi mitis can present as a mass.

15% of testicular tumors present following trauma.

Then we moved on to the extra testicular system.

There's the true masses like the adenoid tumor and there are things like varicose, EAL hernia infection.

And then we finished up with micro ssis, which in a low risk patient doesn't need anything other than monthly physical exam right there.

Now this is generally what the residents say to me when I've been talking too long.

So I think we'll go ahead and quit at this point.

Thank you very much.