Ultrasound in Evaluating Scrotal Pain - HD

Introduction

Hi, I'm Harris Cohen, originally from Brooklyn, New York, but I'm now chairman of radiology at University of Tennessee in Memphis. And radiologist in chief of Le Bonheur Children's Hospital in Memphis as well.

This is a lecture on ultrasound and the evaluation of scrotal pain with a particular perspective on the child and the adolescent. It's a case-based lecture, so it'll be based on several example cases in order to get us the information we should know about in evaluating the scrotum of these patients. Considerations in the pediatric patient, but also the teen and adult, are necessary for scrotal ultrasound work.

One has to be aware of the fact that variable involved ages give a variability to the images and sizes of testes and what is normal. It's therefore important to know what is normal for a particular age. Small scrotal size of the very young can hinder evaluation. Persistence can prove rewarding, placing a mass between examining fingers and placing a transducer on it may aid. And this could be your examining fingers, or it could be the patient holding the area of concern between their fingers and you placing a transducer on the actual abnormality or purported abnormality they feel in patients with undescended testes. Examination of the groin can give information as to presence or absence of testes at this site.

The testes are paired ovoid glands. They're suspended in the scrotum by spermatic cords. The tunica albuginea is a tight connective tissue covering immediately around the testis. The tunica vaginalis is residual of the processus vaginalis that closes off after birth in many children. It's closed off in fetal life in many children. And this was the extension of the peritoneum into the scrotum for descent of the testes during embryologic life. The tunica vaginalis covers or surrounds the surface of the testicle, except where the testicles attach to the epididymis and cord.

Scrotal ultrasound is highly accurate for determining the presence of a testes within the scrotum and for the evaluation of the homogeneity of a testicular echogenicity pattern. That is what you prefer. A homogeneous testicle with a linear echogenic mediastinum. Scrotal ultrasound allows you to evaluate the testicular adnexa, especially the epididymis. Testicular ultrasound is excellent for differentiating intratesticular from extratesticular abnormality. It's excellent for analyzing whether something is cystic or solid.

Typically the patient is examined in a supine position, sometimes, particularly if one is concerned about a varicocele. Examining the patient in an upright position may aid. Oftentimes one can elevate the scrotum either with a towel or other device. I like small towels surrounding the scrotum with the patient being given both ends of the small towels so they can control the scrotum. And you are not responsible for creating increased pain, particularly in an individual with a painful scrotum. High frequency transducers are used. One is fortunate in analyzing the scrotal contents compared for example, to the ovaries. In that you can see both testes side by side evaluating them for flow and echogenicity, transverse longitudinal and coronal views give us a three dimensional picture.

Pre-Lecture Questions

Some pre-lecture questions that one could look at now and not know the answer, but hopefully at the end of these cases, one will know the answer. There is an image and four choices. There's a transverse scrotal image, and the question is, is this a testicular fracture? Is it a scrotal hematoma? Is it acute testicular torsion, or one can't tell? We'll eventually find out in this 16-year-old with scrotal trauma.

Second patient, this is a fetus at 30 weeks and these are images of the scrotum. Choices for what is seen are testicular fracture, bilateral hydrocele, testicular torsion or one can't tell.

And here's a third case, an 11-year-old with an enlarged scrotum. And the question is, are you looking at epididymitis, an intrascrotal hematoma, a fixed scrotal wall, or a torsed epididymis testis on this coronal view of the scrotum.

This is an image or four images of various very young children within the first months of life and how their testes look. The fourth image has color flow in it. Analyzing the color flow within the testicle of a very young child is somewhat more difficult than for an older child or with someone with a larger testicle. The improved machinery we have today makes it a less daunting task than it was, for example, in the early 1990s. But one can see that the testes are scrotal on all these images and they are homogeneous. This is just a view of one of the testicles. Normal pediatric testes, no matter their size, are homogeneous and echogenicity and show symmetric vascular flow when one compares one testicle with the other. I'm not showing you an example of color doppler used with a testis side by side in these images, but we'll see some later.

Case One: 6-Year-Old with Scrotal Pain

So here's the first case. Case one, a 6-year-old with scrotal pain. This is a transverse image. One sees the contents of the scrotum. T marks off the right testicle because the scrotum was small in size, evaluation was somewhat limited. The testes marked off by TS homogeneous and normal and doppler analysis showed it to have symmetrical vascular flow. So the question is, is the study normal? And the answer is that there is a round extra testicular mass that should not normally be seen. It's pointed to by the black arrow. The diagnosis is torsion of the appendix testes, and we'll discuss this torsion of the testicular or epididymal appendages.

There are up to five appendages, which are vestigial remnants within the scrotum. The most common one is the appendix testes. It's seen off the upper pole of the testicle. And as mullerian duct remnant, it's the most common appendage to tors. There's an appendix epididymis, which is at the head of the epididymis, which is of mesonephric origin. And there is an appendix called the vas aberrans, which is at the junction of the epididymal body and tail. And these are the three that one should be most concerned about that they may or may not tors.

Again, I am marking off in blue the three major appendages and I marked them off in blue because the torsion of them when analyzed by light on physical exam have often through transillumination been noted as showing a small circular oval dark area called the blue dot sign. And the arrow points to part of a netter drawing that shows a torsed appendix testes, testicular and epididymal. Appendix torsion occurs usually at six to 12 years of age. It's at a younger time than typical testicular torsion, which is usually seen when the testicle grows larger or status post puberty pain swelling. Local erythema may simulate testicular torsion. In one pediatric series, it was the cause of 35% of acute scrotal pain. 45% of those cases were testicular torsion, 15% were epididymitis. But as many as 35% of these children with acute scrotal pain had it due to appendage torsion.

Early on, when the problem first occurs to the child, the child may note localized upper scrotal pain and one might feel immobile pea size nodule attached to the testes or epididymis, which on color flow would not show flow. Transillumination again would show a blue or black body the blue dot sign. The problem is that with time, if one doesn't evaluate the child at the point of early pain, eventually there'll be enough scrotal swelling. That one won't know this as a small focal area of concern. And the patient will be seen by you with a scrotum that looks the same as the scrotum. You would have to be concerned for actual testicular torsion and not torsion of an appendage.

So this is an example of a normal appendage seen as a small three millimeter oval or comma shaped structure. T marks the testes. This image allows you to see it better because there's a large hydrocele, which is incidental in this patient. This is an 11-year-old with a torsed appendix testes on the right, the left side looked normal. This image is a little bit higher than most of the testicle and was created for you to see the torsed more prominent than normal appendix testes.

Case Two: 15-Year-Old with Four Days of Scrotal Pain

Another case 15-year-old with four days of scrotal pain. This is a transverse image using extended field of view technique. And we can see two testes, one on the right and one on the left. The one on the left looks homogeneous. That is what we consider normal. The one on the right is heterogeneous. What do you see? So you probably see what I just said. Heterogeneous predominantly echoic, right testicle. And when one sees this, one must consider the possibility that this is what some people have used the term missed torsion or subacute torsion 'cause it was never seen, it wasn't missed. And some people believe that the echogenic area is hemorrhagic. Necrotic areas are usually echoic and hemorrhagic areas account typically for the increased echogenicity imaging.

Subtle or obvious differences in echogenicity can be helpful in diagnosing torsion. However, such differences can occur with infection or orchitis as well. The key tool for the diagnosis of testicular torsion is color doppler. We see on this linear array image in which from my point of view, we don't see the periphery of either the right testicle or the left testicle. We're just seeing the medial two thirds of each testicle, but we see them side by side. So I'm showing this as an example of side by side testes in which you look at the homogeneity and maybe it looks similar. Maybe there are subtle echoic areas on the left, But it may be difficult to figure out what's abnormal here With color doppler, however, we obviously know, and here's the color Doppler image, and one sees color within the testicle on the right side, but on the left side, one sees color just at the periphery around the testicle, but none within the testicle itself. So this was an individual with a left testicular torsion.

A spectral pattern of the color area can prove whether the vessel being analyzed arterial as in this spectral pattern or venous. It is said that with torsion venous signal is lost before arterial signal, but in reality that seems not to be a problem. In diagnosis, one will see either decreased vascular flow to the testicle in an intermittent or a partial torsion. One may see no flow whatsoever in a complete torsion that some people believe looking at dog experimentation that there should be a 540 degree twist or greater to completely lose vascular flow.

Testicular torsion diagnosis, look for sarcopenic parenchyma compared to the opposite normal side. If there is a normal side early on, parenchyma on both the torsed side and the non torsed side may look normal, prove there's vascular flow, especially prove that there's arterial flow. Look for symmetry of flow either by spectral pattern and or gross color. Evaluation beware cases in which you see lesser flow on the side of concern, which suggests more subtle intermittent torsion or partial torsion.

This is an image of a 15-year-old with four days of scrotal pain. One can see that the right testicle is more echoic than the left testicle, And one doesn't see them again perfectly well because of the linear array transducer used. I sometimes use a curved linear array, which allows me to see complete testicle on right side and left side. So again, the torsed side, the side without any flow within it. The right side is somewhat echoic. In an ultrasound quarterly article of 2002 Brundo discussed testicular torsion. One of the things he stated was that some individuals are more prone to torsion than others, and this is because some people have a tunica vaginalis that does not completely surround the testicle, but allows the epididymis and a portion of testicle to be naturally tacked to the scrotal wall. While some individuals are set ups for potential torsion because they have a tunica vaginalis that surrounds the testicle and it prevents posterior epididymis from being attached to the posterior scrotum. So this testicle sits within the scrotum surrounded by tunica vaginalis, which has no part of the testicle tacked and looks like a clapper in a bell, potentially twisting and decreasing vascular flow from the testicular vessels seen superiorly testis.

Testicular torsion is the most common cause of acute painful scrotum in boys symptoms depend on the duration of torsion, the number of twists and how tightly the vessels are compressed. All this helps determine completeness of torsion and the possibilities of long-term salvage. It is said that 450 to 540 degree twists will yield torsed testes, at least in dog experiments. Time to diagnose testicular torsion is of the essence. Why is it of the essence? Because metagenic injury occurs in six hours and this may be a conservative concept and light cell damage occurs in 10 hours. Salvage rates are said to occur at 80 to a hundred percent if the patient is treated five hours from the pain onset. But if the patient is in the or six to 12 hours from the onset of pain, 70% of the testes will be salvaged. And if it's greater than 12 hours from the onset of pain, only 20% of the torsed testes will be salvaged.

So here is the upper one half of these images are from the right testicle. The lower one half is from the left testicle. One notes no flow within the testicle and an echoic testicle on the right and one sees flow on the left within the testicle, both in the longitudinal image to your left and the transverse image to your right. This was a 13-year-old who had pain after riding a horse and had a torsed right testicle.

The whirlpool sign described in 2006 by a single radiologist out of India in sonographic differential diagnosis of the acute scrotum realtime whirlpool sign, a key sign of torsion, which was in Journal of Ultrasound and Medicine. As noted on the slide, the doctor noted that a twist or turn in the normally straight spermatic cord is a morphologic indicator of torsion that can be confirmed. A color Doppler of 221 acute scrotal studies performed by this individual 61 who had a whirlpool sign and no flow distal to the kink because instead of a straight spermatic cord, there's a kink in it and they use the term he uses the term whirlpool. 61 of those individuals with a whirlpool and no flow distally had testicular torsion. And four such patients had intermittent torsion. And this is an example. These are some images from the original article in which one can see testicle, but one sees the extra testicular structures is not straight. There's like a curve to them. And this is the whirlpool sign.

This is an example of a 16-year-old, 16 hours of gradually increasing pain. And one sees not a straight line, but one sees this curved magenta line that I've marked off as the whirlpool sign of the structures seen superior to the testicle. So the spermatic cord is not straight but kinked. And that's worrisome for the whirlpool sign. Here's a color doppler of the testicle distal to the kink, and one sees no flow whatsoever within the testicle, although it appears homogeneously normal. And this is another example of a whirlpool sign in which one sees testicle. But if one looks at the structures above it, the vessels feeding into it, they're at a curve And you can see the little waist of that curve at the yellow arrow.

So in Brundo's article, they show the clapper and bell phenomena in a drawing that can lead to spermatic cord twisting. And here's an example of how he would see a 180 degree twist on your left and how a 720 degree twist would be seen on your right. And the typical torsion develops either from a 360 or a 450 to a 540 degree twist, which is essentially saying a complete revolution to a one and a half twists. Lesser twists. For example, this 180 degree twist, which was noted in surgery, may be seen by not a lack of flow, but an asymmetric flow pattern. And in such a case, one would have to know which is the testicle that hurts because let's say you have increased flow on one side compared to the other. If the painful side is the one with the greater amount of flow, it might be an infection and not an intermittent torsion. In this case in particular, when sees a rounding of the testicle on the right, which is normal, but the left testicle looks like is in a different axis, which sometimes is an indicator of torsion. It can be simulated by technique and how one places the testicle. But oftentimes in torsion, the normal testicle will be in vertical position and the torsed testicle might be in horizontal position.

So there are simulators for testicular torsion. There are overlapping signs and symptoms that occur with epididymitis and epididymitis with the appendix testes or the appendix epididymis torsion. We discussed earlier, strangulated hernias may produce pain. A traumatic hemorrhagic hydrocele may be associated with such pain, a traumatic testicular fracture as well. Rarely in the pediatric group, a testicular tumor might be the cause. It is said that in newborns testicular or scrotal pain may be caused by meconium induced peritonitis. I have not seen such a case myself.

Case Three: 2-Year-Old with an Enlarged Scrotum

Case three, a 2-year-old with an enlarged scrotum. A normal testes was seen. But this is contents of the scrotum and the diagnosis is well in trying to make the diagnosis. One notes that there's a tubular structure within the scrotum. I've told you that the testes is normal. This is a little bit of the normal testes, but this structure contains echogenicity with ring down with dirty shadowing. Maybe some fluid, maybe some bright echoes in what might be meconium. And this is a very young child with herniated bowel. My moving image did not move.

This is an example of a fetus whose scrotum is seen. This is the penis and cross-section. This happens to be the cord. And the fetus has no hydrocele. This fetus has small amount of hydrocele and this neonate has a larger amount of hydroceles. 15% of newborns have hydroceles. Most are non communicating. They do not increase in size and they resorb by six to nine months. A communicating hydrocele, on the other hand, suggests a patent processus vaginalis, allowing peritoneal contents to enter the scrotum. And if so, one has to check for hernia.

Here are images of A Fetal scrotum in which a large hydrocele is seen, although one can see very nicely the two testes that are normal. And the linear echogenicity within the testicle is mediastinum testis. And this individual as a neonate shows a large hydrocele on the right and a smaller hydrocele on the left and testes. These appear completely normal. This is an image out of cfi that shows what an unclosed processus vaginalis might look like. That will allow fluid from the abdomen to enter the contents of the scrotum and how a bowel loop in the case of an unclosed processus vaginalis may come into the scrotum and be seen to the side of a testicle.

Case Four: 4-Year-Old with an Enlarged Scrotum and Bulging Groin Bilaterally

Another case, case four 4-year-old, an enlarged scrotum in bulging groin bilaterally. This is a longitudinal view through the left scrotum and groin. When the scrotum looked big, if one compressed it, there would be an increase in size of the bulge at the groin. This suggested, and I'm placing a line at the inguinal crease, it suggested an unusual hydrocele known as an abdominoscrotal hydrocele. This is a patient the same, the patient with abdominoscrotal hydrocele, this is an mr from that exam showing how there is fluid in the scrotum and extending all the way up in the peritoneum on the left side and also the right side, not as well seen on the right side. In that case, the collection of fluid in the tunica extends along the spermatic cord and through the inguinal canal into the abdominal cavity. This is treated by total excision.

This is an abdominoscrotal hydrocele, and that's just to show you that it gets bigger if you compress it. This is an example of a funicular hydrocele, a spermatic cord hydrocele, which has hydrocele going through the crease but not surrounding the testicle. There is no communication with the tunica vaginalis. In this case, T stands for testicle. And these are other examples of funicular hydroceles seen as large anechoic areas. In this case, within the upper portion of the scrotum, the normal testicle was seen inferior to it hydrocele.

In a child, normally with testicular descent, there is some fluid that comes down into the patent processus vaginalis, and some of it may remain when the processus vaginalis closes off. If it doesn't close off as seen in some neonates particularly prematures, then one has to worry if the contents of the scrotum increase in amount, that one has a hernia. One can also see fluid in the scrotum with a patent processus vaginalis, if there's a VP shunt, a ventricular peritoneal shunt, the hydrocele may extend superior to the inguinal region. As in this example I showed you a abdominoscrotal hydrocele, and sometimes hydroceles contain echoes as any fluid-filled structure. This may be because of chronic hydroceles and it's said to be due to cholesterol crystals. But hemorrhagic peritonitis or infectious material can also have echoes within a fluid containing area.

Case Five: 3-Year-Old with an Enlarged Scrotum

Another case a 3-year-old with an enlarged scrotum. And we were told to evaluate the patient for pain possible torsion. We were told to come in emergently. It wasn't we, it was me. And we came in for this emergency. These are the images. This is transverse coronal image of the scrotum. An arrow marks off a very thick scrotal wall. It should be thin. And the two testes marked off as ts are homogeneous and normal. The testes are normal. There was no torsion, but there was a very thick scrotal wall. So what could be the cause of this? This is just another view of the scrotum in an area above the testicle. I was just showing you how thick the scrotal wall was and any thoughts about the cause.

So the family forgot to relate some history and that was that the patient had nephrotic syndrome and the scrotal wall was very edematous. So a kid with low protein, a kid who has a nephrotic syndrome may show up with an enlarged scrotum that may simply be scrotal wall thickening. And this is a closeup of the left hemiscrotum of this child with a thickened scrotum, but no significant abnormality within the within the scrotum itself, and particularly not the testicle. So not all scrotal enlargement is due to scrotal mass or fluid. Causes of acute scrotal swelling include torsion of the testes or testicular appendage. Hydrocele varicocele trauma tumor idiopathic scrotal edema. And he shown line perian scrotal enlargement unrelated to mass or enlargement of the testicle may be seen with hydrocele, hematocele, hernia or scrotal wall edema.

Case Six: Two-Day-Old with an Enlarged Scrotum

A sixth case, a two day old with an enlarged scrotum. We see two testes. One appears relatively homogeneous. It was a difficult technically difficult case to do. And one of the testes had an echogenic surrounding outer area with an anechoic central area. So the diagnosis, looking at the anechoic central area without any flow within it, suggests that there's been a torsion since this was a newborn. The torsion probably occurred in fetal life. Unhappily, the vascular flow on the left side was the same as on the right side. And this individual was one of a number of individuals I've seen in my life. Born with bilateral testicular torsion, Attempting to see flow within the testicle might actually save an occasional testicle. If this torsion has occurred very near birth, much further out in time, it won't be able to be saved. I think in four of our bilateral torsions, therefore involving eight testes. We had data flow in one and we were able to save one testicle, or at least our urologists were.

This is an example of an individual who's born with a large echoic area and a lesser echoic area within the two testes. These heterogeneous testes were evidence of perinatal testicular torsion. It said that on physical exams such patients will not react to testicular pressure, will not feel any pain. The images you just saw were actually seen as when this patient was a fetus. So we already knew that the patient probably had bilateral testicular torsion as a fetus. However, these were done on the outside and the fetal scrotum was read as having bilateral hydrocele in truth, this is a hydrocele on the right side, but the left testicle is actually heterogeneous with a large echoic upper half and a more echogenic lower one half. The testicle on the right side appears somewhat more heterogeneous than it should be in somewhat smaller than it should have been. So both these testes were already heterogeneous and fetal life and they had already been torsed for a while. Probably.

Testicular torsion exists in two types. There is the intravaginal type that are predominantly the ones that teenagers have, in which only the spermatic cord twists and the typical newborn type, which is the extravaginal type predominantly in which spermatic cord and tunica vaginalis twist. This individual also happened to have a torsed appendix testes.

Case Seven: 11-Year-Old with Enlarged Scrotum After Being Kicked

Case number seven, an 11-year-old with enlarged scrotum after being kicked by a friend at camp. I've done a number of ultrasounds of scrotum in children who have been kicked by friends in camp. And it's not often a good result. This is a large anechoic area. We contained echogenicity and an individual with a normal testicle. And so therefore this would be a hematocele. Now one could say that it's again, hemorrhagic proteinaceous or infectious material, but in this case it's a hematocele. And again, chronic hydroceles have been stated to contain echogenicity due to cholesterol crystals.

This is another teenager kicked by a friend. And here is the images of a longitudinal testes. So any thoughts? Should I worry? And the answer is yes. I should worry. This is a fractured testicle. Now how do I know it's a fractured testicle? Because it has irregular margins. It also has this heterogeneous area within it. But it is the nonsmoothness of the scrotal wall that intimates the breakage of the tunica albuginea, which is very thick covering. And when it fractures, one will see the testicle is no longer maintaining its routine shape.

Rupture or fracture of the testicle may occur with abuse, with motor vehicle accidents, with sports straddle injuries thought to be a 50 kilogram pressure or greater rupture requires immediate intervention. There's a 90% salvage of ruptured testes if operated on within 72 hours according to at least one source fractures with a small amount of hematoma. But no rupture does not require surgery if the tunica albuginea is intact. And flow is normal according to some sources as well.

These two individuals needed surgery. The individual on your left shows flow only to a portion of the testicle. That person had irregular testicular shape border, which is part of what I just showed you. And then the individual on your right, this testicle on the right, you can see that the testicle is a normal shape except at the bottom of it. Where it blows out here, there's a step off and that's an indicator of a fracture of the tunica albuginea.

So in another case, a hospital tale. I've arrived at AM the handoff team tells me the teenager on our stretcher is going to the or to treat a testicular fracture. I decide to look for myself. Easy enough. If you have a transducer, something I suggest everyone do. Radiologists who don't put their hands on transducers are doing a disservice to themselves and their patients. This is the transverse scrotal image. It's heterogeneous, it's irregularly shaped. Is this a fracture testicle? That's the question. But one should always look at things in two planes. So by looking at the orthogonal longitudinal plane, one sees that actually the area of concern, the heterogeneous area, is an area inferior to a normal testicle Patient had developed, a large hematoma became echoic or heterogeneous over time. And the testicle because of this large hematoma, had been pushed north in the days of nuclear medicine scintigraphy. For testicular torsion, this would've been a false positive because if one believed that the testicle was down low in the scrotum, it would not have any flow to it because the hematoma wouldn't have any flow to it. So it's very fortunate that we live in a time that we can do real time examinations of the testes, which is something that's only been around since probably the early 1990s when good vascular flow analysis via color doppler allowed us to move from scintigraphy of the testes to ultrasound and color doppler of the testes.

So again, this was a hematoma that pushed the normal testicles. Superiorly always look at the scrotum from top to bottom. Another example, H stands for hematoma and T stands for testicle. This Is a patient who was not as lucky. This was a teenager who had a in quotes friend who attacked them with a hammer has an irregular shape to the testicle. It's irregular contour, it's heterogeneous echogenicity indicates fracture.

Case Eight: 17-Year-Old with Scrotal Pain

Case number eight, a 17-year-old with scrotal pain. We see, Well Look at this. Tell me what you see. I ask for diagnosis rather than diagnosis because there are two of them. One can see multiple small densities throughout the testicle without shadowing. This is classic testicular microlithiasis in which five or more non-shadowing bright echogenicities are noted on a single image. But there's also something else. And the something else is a mass that's seen within this testicle. Testicular microlithiasis, particularly the classic type, has been associated with increased incidents of testicular tumors. In particular seminomas. And this is an example of one of those.

There's a lot of controversy with regard to testicular microlithiasis. Again, it's one to three millimeter concretions in degenerating seminiferous tubules. Usually there's bilateral involvement. It's said that there is a 0.6% prevalence of the classic variety in normal population with a 2.7% prevalence total of five calcifications throughout the testes. In the general population, it's been associated with cryptorchidism, kleinfelter syndrome, male factor infertility and pulmonary and CNS and pulmonary and central nervous system microglia. But there's debate about the degree of association with testicular germ cell tumor development. Some people suggesting 40% of individuals may have it, which is much too high, or others suggesting that there's a relative risk of two to 20 times normal in the development of malignancy or the potential development of malignancy. Debate continues. There is a desire by a number of people that these patients be followed at least a couple of times on a Q six month to one year basis. But beyond that, it's very difficult to get patients to come back.

Testicular tumors in males, 95% are highly malignant germ cell type. 35 to 50% of these are seminomas. With a mean age of 37 years of age, the most common tumors would be found in cryptorchid testes. Five to 10% of cryptorchid individuals actually have the abnormality in the contralateral descended testes. Seminomas are very radio slash chemosensitive luer. And Siegel at one point said that pediatric tumors are more isoechoic and colored doppler may aid perspicuity, particularly in the pediatric group. In analyzing testicular microlithiasis, one has to know that there are other intratesticular calcifications and one shouldn't confuse the punctate foci of a microlith with a large coarse calcifications seen in burnt out germ cell neoplasms. So this is an example of a burnt out germ cell neoplasm.

Another cause of an intratesticular calcifications include Leydig cell tumors or Sertoli cell tumors, which can be associated with precocious puberty. And this is an example of a 12-year-old with very echogenic structures that were calcified within the testicle. This individual again had a Leydig cell tumor.

Case Nine: 15-Year-Old with Scrotal Pain and Mass

The ninth case is a 15-year-old with scrotal pain and mass. The right testicle seen in sagittal plane has above it a very large epididymis, particularly when compared to the left side in which the epididymis looks normal. And this was an individual with enlarged right epididymis or epididymitis. Remember that despite the fact that tumors are typically painless, remember that despite the fact that tumors are typically painless, 15% can present with pain and mass, which may simulate epi. A teenager with sexual history with testicular pain is often considered a patient with epididymitis until disproven ultrasound can easily tell you that there's no testicular mass in this patient and can easily tell you that color flow is normal.

This is an example again of a prominent epididymis on a longitudinal image, upper one half of a right testicle and the epididymis itself. But notice there's an anechoic area within the epididymis. Also note that there's some increased vascular flow seen on this black and white image of a color flow image, increased flow to the epididymis and normal or greater flow to the testicles supports the diagnosis of epididymitis. One has to remember as a caution though, that a testicular torsion that has been detorsed may have significant flow to it for a while. Status post detorsion in 2006, new bound blast and rushed and said that 5% of torsion cases have hypervascular flow to the epididymis. One should remember that this is a 12-year-old with increased flow to the epididymis due to epididymitis.

This is an individual who has anechoic area in the epididymis that extends into the testicle. And this is an example of direct extension of epididymitis to the testicle as an epididymo-orchitis.

Case Ten: 14-Year-Old with Enlarged Scrotum and History of Illness

Our 10th case is a 14-year-old who was previously sick with an enlarged scrotum. This is the letter M is on a hypoechoic scrotal mass within the testicle. The key point here is this patient has been sick in the past and the patient had leukemia. Leukemia does not typically show up as testicular mass, but treated leukemia can have recurrence seen as testicular mass because the leukemia cells used to accumulate in the spinal column and the testicle. And so recurrences occurred in the spinal column, but because of significant improvement in treatment, leukemic cells now have their sanctuary site particularly in testicle. And so if leukemic involvement of the testis or lymphoma, the testicular occurs, it's usually seen in cases of recurrence in which there's a blood gonad barrier, which protects the leukemic cells from the chemotherapeutic agents. The involvement is usually multifocal within the testicle as opposed to the case I just showed you that looked unifocal. And usually the areas seen have areas of increased flow.

So all three of these testes are in individuals with leukemia. You can see the increased flow here, you can see the hypoechoic area here. Here was just a heterogeneous testicle that was a leukemic. This is a 17-year-old presented with abdominal pain who had leukemia as a 6-year-old. And one sees this mantle of nodes and the transverse abdomen. And we then looked in the testicle and we see this heterogeneous testicle with two large hypoechoic areas within it. And this was leukemic recurrence in testicle, although the most common solid tumor in 20 to 35 year olds. Testicular tumors can occur in children, but they're extremely unusual. One to 1.5% of all malignant tumors of childhood are testicular. And 3% of all testicular tumors will occur in children echoic areas within the testis may include infarction, torsion infection or tumor leukemic infiltration or hematoma.

Review of Pre-Lecture Questions

So now we're back to the original three questions and hopefully, You got something out of this lecture so you can answer these correctly. So this is question one. A 16-year-old with scrotal trauma, one sees this heterogeneous area within the scrotum, but one knows that one should look with an orthogonal plane to make sure that this is not what this is a hematoma.

The second question, the 30 week fetus. We know that both testes are abnormal. There's some hydrocele on the right side, but there is evidence of bilateral testicular torsion. And one can see the 30 week old fetus is color doppler showing no flow on the right side. This is this color doppler is actually in the neonate. So this is a post-delivery image showing missed or subacute or older testicular torsion.

And then this is the 11-year-old with an image that might have been hard to interpret, but you know now that this is a thick scrotal wall. In the case of an individual who had liponephrosis in this case, the end.