sonography of the acute scrotum: the four t’s of testicular imaging

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Sonography of the Acute Scrotum: The Four T’sof Testicular Imaging

Aaron F. Wittenberg, MD, Terrence Tobias, MD, Mark Rzeszotarski, PhD, and
Anthony J. Minotti, MD
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he scrotum is frequently imaged on an emergent basis.he differential diagnosis of the acute scrotum can beivided into four categories—torsion, trauma, tumor, andtesticulitis” (epididymo-orchitis). Although testicular neo-lasms are not imaged emergently, 15% are detected

ncidentally when performing an emergent scrotal ultra-ound. Therefore, the emergent sonographic examinationf the testicles should include a thorough search for malig-ancy. Images demonstrating the sonographic and coloroppler appearances of each of the “four T’s” will beeviewed. The radiographic review will focus on the imag-ng features, which are the keys to arriving at the correctiagnosis.

igh-frequency transducer sonography is the diagnos-ic modality of choice in the evaluation of the acutecrotum. When using the appropriate technique, gray-cale and Doppler images provide the informationeeded to distinguish between the four T’s of the acutecrotum: torsion, trauma, tumors, and “testiculitis”epididymo-orchitis). Normal scrotal anatomy and theharacteristic ultrasound findings of each disease wille reviewed, which will aid in distinguishing patientsho will require surgical management from those who

an be conservatively treated. Furthermore, ultrasoundan help to identify characteristic benign testicularesions, sparing the patient unnecessary biopsy orurgery.

rom the Department of Radiology, MetroHealth Medical Center, Cleve-and, OH.eprint requests: Aaron F. Wittenberg, MD, Department of Radiology,etroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH

4118. E-mail: [email protected] Probl Diagn Radiol 2006;35:12-21.2006 Mosby, Inc. All rights reserved.

363-0188/2006/$32.00 � 0
poi:10.1067/j.cpradiol.2005.10.002
2

crotal and Testicular Anatomyhe scrotum is divided into right and left by a median

aphe. This cutaneous ridge indicates the bilateralrigin of the scrotum from the labioscrotal swellings.he superficial fascia of the scrotum contains the thinartos muscle, which helps to regulate the temperaturef the scrotal contents. The superficial fascia forms anncomplete scrotal septum, which divides the scrotalontents. The layers deep to the dartos muscle are thexternal spermatic fascia, cremasteric fascia, and in-ernal spermatic fascia, which is continuous with theransversalis fascia of the abdomen.

Inside the internal spermatic fascia is the tunicaaginalis, which is a closed sac of peritoneum. Itonsists of a visceral layer that is adherent to theesticle and a parietal layer. A small amount of fluideparates the layers, which allows the testicle to movereely within the scrotum. Internal to the tunica vagi-alis is the tunica albuginea, which is the connectiveissue lining of the testicle. The tunica albuginearojects into the interior of the testicle to form theediastinum testis (Fig 1). From the mediastinum,brous septa extend into the testis, dividing it into 200

o 400 lobules, each of which contains seminiferousubules that support spermatocytes and Sertoli cells.1

he seminiferous tubules also contain Leydig cellshat secrete testosterone.

The head, body, and tail of the epididymis lie alonghe superior margin of the testicle. The head of thepididymis contains 8 to 12 ducts that converge into aarger duct in the body and tail.1 This single ductecomes the vas deferens and continues into thepermatic cord.

The spermatic cord contains the vas deferens, tes-icular artery, cremasteric artery, deferential artery,
ampiniform venous plexus, and genitofemoral
Curr Probl Diagn Radiol, January/February 2006

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erve.2 The covering of the testis is continuous withhe spermatic cord.

The right and left testicular arteries supply blood tohe scrotal contents, arising from the abdominal aortaistal to the renal arteries. They enter their respectivepermatic cord at the inguinal ring and continue alonghe posterior surface of the testicles. The deferentialrtery, a branch of the superior vesicular artery, andhe cremasteric artery, which is a branch of the inferiorpigastric artery, supply the vas deferens, epididymis,nd the peritesticular soft tissues.1

The pampiniform venous plexus is the draining veinf the testicle, which forms around the upper half ofhe epididymis and continues into the testicular veinhrough the inguinal ring.3 The right testicular veinmpties into the IVC and the left testicular vein drainsnto the left renal vein.

he Normal Testicular Ultrasoundxaminationhe testicles should be symmetric and ovoid struc-

ures, measuring about 4 cm3 in an adult, approxi-ately 5 � 3 � 2 cm.4 Before the age of 12, the

esticles are approximately 1 to 2 cm3 in volume. Thetage of development of the germ cell elements andubular maturation determines the echogenicity of theesticles. Prepubertal testicles are of low to mediumchogenicity and postpubertal testicles demonstrateedium echogenicity, as seen in Fig 1.5

The mediastinum testis appears as an echogenic linextending in a cranio-caudal fashion. The rete testes iseen in 20% of patients and appears as a hypoechoicrea with a striated configuration peripherally or adja-ent to the mediastinum testis (Fig 2). The tunicalbuginea is an echogenic line around the testicles.he space between the two lines of the tunica albug-

nea contains a small amount of fluid and is seen as annechoic rim around the testicle.

The epididymal head is 5 to 12 mm in length and isest seen in the sagittal plane.6 It lies atop the testiclend is isoechoic to the testicle. The body of thepididymis is smaller, measuring 2 to 4 mm.6 The tailf the epididymis is the curved portion that is along thenferior portion of the testicle and becomes the prox-mal portion of the ductus deferens.

Assessing testicular perfusion is an important com-onent of every testicular examination. Even if infec-ion and torsion are not clinically suspected, a sono-

IG 1. (A) Ultrasound exam of the testicles shows the normal homo-eneous echotexture. (B) An echogenic band is seen in the middle of

he testicle, representing the mediastinum testis, a normal anatomictructure. (C) Color Doppler imaging demonstrates symmetric flow to

raphic evaluation of testicular blood flow must be

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outinely included. Color Doppler reliably shows in-ratesticular flow. Power Doppler ultrasound yields aigher gain and is therefore more sensitive for detect-ng low flow. Pulsed Doppler is used to quantify bloodow. In the testicle, the arterial flow is normally lowesistance, having a mean resistive index of 0.62.7

echnical Tipshe sonographic examination of the testis should beerformed with the patient in the supine position andhe scrotum supported by a towel placed between thehighs. A 7- to 10-megahertz high-frequency linearrray transducer yields optimal image quality. Theestes should be examined in the transverse and

IG 2. (A) Hypoechoic appearance of the rete testis, a normalnatomic structure that is seen in 20% of patients. (B) The normal rete

estes do not demonstrate increased blood flow. (Color version ofgure is available online.)

ongitudinal planes. The size and echogenicity of each a

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pididymis and testicle are compared with those on theontralateral side. The asymptomatic testicle should bemaged first while adjusting the color Doppler andulsed Doppler gain settings to demonstrate goodisualization of low-velocity blood flow. This allowsor optimal evaluation of blood flow in the affectedesticle. Finally, transverse images, including portionsf each testis on the same image, should be acquired inoth grayscale and color Doppler modes. If there areny palpable abnormalities or nodules, scans shouldnclude this area with a finger placed beneath the areand the transducer placed directly over the nodule.

orsionesticular torsion, or torsion of the spermatic cord, issurgical emergency where rapid diagnosis and treat-ent are essential for preserving the viability of the

ffected gonad. In the clinical setting, the symptoms ofhis disease can mimic other nonsurgical etiologiesuch as epididymo-orchitis and testicular tumors. Ifhe patient presents within an early time window, theltrasound examination will play the critical role inetermining whether the patient needs to go to theperating room for surgical repair.

In the United States, testicular torsion afflicts 1 invery 125 males, almost all of whom are under the agef 20.8 If torsion is repaired within 6 hours of the onsetf symptoms, salvage rate ranges from 80 to 100%.fter this time, there is a rapid drop-off with a salvage

ate approaching 20% after 12 hours.9 Retrospectivetudies have demonstrated a relationship between theegree of twisting of the spermatic cord with testicularschemia and salvageability. Decreased flow is seenhen the cord twists 120°, and occlusion of the

esticular artery occurs at 720°.10

Testicular torsion has been categorized into twoypes, based on their pathophysiology: extravaginalnd intravaginal. As discussed earlier, the normalesticle is covered on its posterolateral surface by theunica vaginalis. This does not allow for any signifi-ant rotational mobility. In intravaginal testicular tor-ion, there is an abnormal insertion of the tunicaaginalis on the affected testicle. The attachment tohe testicle is abnormally high in position and encircleshe epididymis and distal spermatic cord. This isnown as the “Bell-Clapper deformity,” which has a2% prevalence and is bilateral 40 to 80% of theime.11 The superior insertion of the tunica gives the
ffected testicle rotational mobility within the hemi-

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crotum, like the ringing clapper within a bell. In theeonate whose testicle has not yet descended into thecrotum, the testicle is outside of (and therefore andot fixed to) the tunica vaginalis. The testis is notttached to the scrotal wall, allowing for rotationalobility.Clinically, these patients almost always present

ith acute onset of unilateral scrotal pain. About halff these patients will have unilateral scrotal swellingith complaints of nausea or vomiting. Often, theyave had a history of intermittent pain that was similarut self-limited (presumably due to torsion and detor-ion).9 Neonates will present with a unilateral swollennd discolored scrotum.

On grayscale ultrasound examination, the testis canppear normal within the first 6 hours of onset (FigB). After this, the affected testicle demonstratesiffuse hypoechogenicity and enlargement when com-

IG 3. (A) Doppler examination of the testicles demonstrates absencef flow in the left testicle, consistent with torsion. (B) The normalomogeneous echogenicity of the left testicle is a strong predictor ofiability.

ared with the contralateral side. This appearance is i

urr Probl Diagn Radiol, January/February 2006

aused by vascular engorgement and edema fromeduced blood flow and venous drainage. In addition,he epididymis will usually demonstrate enlargementnd become hypoechoic or heterogeneous due toemorrhage (Fig 4). The twisted and enlarged sper-atic cord can be seen, along with scrotal thickening

nd an ipsilateral hydrocele. After 24 hours, theesticle develops a heterogeneous appearance due tonfarction and hemorrhage.

Color or power Doppler is the primary method foriagnosing testicular torsion, with an 86% sensitivitynd 100% specificity.9 Both color and power Dopplerechniques have demonstrated similar sensitivities foretecting torsion. Flow to the involved testicle isbsent (Fig 3A), but may be normal or increased if theesticle has spontaneously detorsed. Care should beaken to optimize the scanner settings for detection oflow flowing blood, which is often seen in normalesticles, especially in the pediatric population. Thisncludes increasing the gain, decreasing the pulseepetition frequency, and using a small color sampleindow.10 The role of spectral Doppler remains un-etermined, but it may be of benefit in examining theiastolic flow and resistive indices to correlate with aorsed spermatic cord.

Subacute or chronic torsion may demonstrate in-reased flow to the epididymis. Incomplete or partialorsion can demonstrate normal flow and is therefore aiagnostic dilemma. Also, orchitis can cause ischemiaf the testicular parenchyma, which can mimic torsion.linical history can help significantly when theseroblematic imaging appearances are encountered.

raumaevere testicular trauma results in testicular fracture,upture, or hematoma. Common causes include motor-ehicle accident, athletic injury, and straddle injuries.requently, testicular trauma is associated with pelvicractures. Blunt trauma accounts for 85% of testicularnjuries, while penetrating injury accounts for 15%.12

ny foreign bodies should be localized on ultrasoundxamination (Fig 5). It is important to comment onhether the foreign bodies are intratesticular or extrat-

sticular. Eighty percent of testicular ruptures can beepaired if salvage surgery is conducted within 72ours after the onset of trauma.13 Therefore, a promptnd accurate ultrasound diagnosis of testicular rupture
s critical.
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The ultrasound findings in the setting of testicularrauma include a break in the tunica albuginea, testicularontour irregularity, hematoma, poorly defined borders

IG 4. (A) Doppler examination demonstrates absence of blood flowo the left testicle. The echogenicity is normal. (B) Normal blood flow isemonstrated in the contralateral testicle. (C) The left epididymis isnlarged and heterogeneous, consistent with vascular engorgementnd/or hemorrhage as both the testicle and the epididymis arerained by the pampiniform plexus.

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n the setting of a shattered testicle (Fig 6), it is importanto assess the degree of blood flow to the larger fragments,s a partial testicular salvage may be possible. Coloroppler is necessary for evaluation of possible disruptionf capsular or testicular blood flow.

A hematocele is a collection of blood between theeaves of the tunica vaginalis, caused by intratesticular orxtratesticular bleeding. An acute hematocele can appearchogenic, while a subacute hematocele can have theppearance of a hypoechoic fluid collection containingeptations. If a large hematocele is present, a testicularupture should be suspected. If a small hematocele isresent, there is little risk of rupture and surgical explo-ation should not be considered.

Intratesticular hematomas appear as hyperechoic col-ections within the testicle that become complex and/orystic over time. Hematomas are characteristically avas-ular on Doppler ultrasound. If there is flow within auspected hematoma, the possibility of an actively hem-

IG 5. (A) A round echogenic focus with posterior acoustic shadowingonsistent with a metallic BB is seen adjacent to the lower pole of theight testicle. (B) A small crescent of heterogeneous echogenicityurrounding the BB likely reflects a small extratesticular hematoma.

rrhaging hematoma or a neoplasm should be suspected.


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If there is diffuse hyper- or hypoechogenicity of theesticle with an accompanying testicular hematoma, aesticular rupture should be suspected and the patienthould undergo surgical salvage. Epididymal hematomasnd small testicular contusions pose little risk of long-erm sequelae.

Ten to 15% of testicular tumors manifest themselvesfter trauma.14 Therefore, testicular abnormalities de-ected after the onset of trauma should be sonographi-ally followed to resolution.

umorsesticular tumors can present with pain due to asso-

IG 6. A patient in his mid-twenties sustained blunt perineal traumand multiple pelvic fractures as a result of a motorcycle accident. Onhysical exam, the scrotum was massively swollen. (A) Sonographicxamination displays the absence of a normal right testicle. The rightemiscrotum is filled with mixed echogenic debris, representing frag-ents of fractured testicle. (B) Doppler imaging shows blood flowithin a large segment, likely representing a vascularized fragment of

esticle.

iated hemorrhage or infection. They can be detected C


ncidentally while sonographically surveying the acutecrotum. Seminomas and testicular lymphomas fre-uently result in orchitis secondary to obstruction ofhe seminiferous tubules.

Testicular carcinoma is most commonly seen in 20-o 34-year-old men. Ten percent of patients withesticular cancer present with acute symptoms such asever and pain, while 10% are detected followingrauma and 10% are detected after presenting withomplaints related to metastatic disease.11

Grayscale ultrasound is nearly 100% accurate foretecting testicular tumors.15 Mimics of malignancynclude hematomas, orchitis, and abscesses. It is there-ore important to correlate the ultrasound findings withhe patient’s history and symptoms. A follow-upltrasound examination may be useful to prevent annnecessary biopsy or orchiectomy.

Testicular tumors are divided into germ-cell tumorsnd non-germ-cell tumors. The germ-cell tumors makep nearly 95% of all testicular malignancies.16 Theyre further classified into seminomatous and nonsemi-omatous germ-cell tumors.

The seminomatous germ-cell tumors (seminomas)re the most common type of testicular tumor, typi-ally affecting 30 to 40 year olds. Cryptorchidism is aisk factor. The seminomas are highly sensitive toadiation and chemotherapy. On grayscale ultrasoundxamination, seminomas appear homogeneously hy-erechoic. Most seminomas demonstrate increasedow on color Doppler examination. Fig 7 demon-trates the typical sonographic characteristics of sem-nomas. The entire testicle may be replaced by tumor.he primary tumor is usually confined to the tunicalbuginea on discovery. At the time of presentation,5% of the patients have evidence of metastaticisease, either by lymphatic spread to the retroperito-eal lymph nodes or by hematogenous spread to theungs or brain.15

The nonseminomatous germ-cell neoplasms areade up of embryonal cell tumors, yolk sac tumors,

horiocarcinomas, and teratomas. These tumors dem-nstrate a heterogeneous echotexture with irregular orll-defined margins. Echogenic foci within the sub-tance of the tumors represent areas of hemorrhage,alcification, or fibrosis.17 They frequently have cysticomponents, consistent with regions of necrosis. Em-ryonal cell carcinomas tend to distort the testicle andrequently invade the tunica albuginea. Yolk sac tu-ors are characteristically seen in pediatric patients.
horiocarcinomas tend to be highly malignant, char-
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cteristically presenting with hemorrhagic lung andrain metastatic lesions. Serum beta-HCG is elevatedn patients with choriocarcinoma. Teratomas are seenn pediatric and adult patients. They are composed ofndoderm, ectoderm, and mesoderm. The echogenicoci usually seen in teratomas reflects elements ofalcium, immature bone, fat, and fibrosis.

Sex cord and stromal tumors have a nonspecificltrasound appearance. They are more rare than semi-omatous and nonseminomatous tumors. Sertoli cellumors and Leydig cell tumors (Fig 8), the mostommon of the sex cord-stromal tumors, can affectny age group.16 Although histologically benign, theyo exhibit endocrine manifestations, typically as a

IG 7. A 35-year-old presents with left testicular pain. (A) Grayscaleltrasound reveals a hypoechoic lobulated lesion in the right testiclehich has mildly increased flow (B) on Doppler exam. (Color versionf figure is available online.)

esult of increased estrogen secretion. o

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Lymphoma represents 5% of testicular tumors, usu-lly presenting as an enlarged testicle.11 Diffuse non-odgkin lymphoma is the most common type of lym-homa to involve the testicles. They tend to infiltrate theubstance of the testis more than seminoma and involvehe entire testis, extending to the epididymis and sper-atic cord. On grayscale ultrasound, lymphoma appears

s a homogeneously hypoechoic testicle or as multifocalypoechoic lesions of varying sizes (Fig 9). Color Dopp-er shows increased vascularity regardless of the size ofhe lesion.

Leukemic infiltration of the testis is found at autopsyn approximately 50% of patients with acute leukemiand 25% of patients with chronic leukemia. Five to 10%

IG 8. A 50-year-old presents with left testicular pain and gynecom-stia. (A) Ultrasound of the left testicle reveals a solid and cystic masshich has internal flow on Doppler (B). This was a pathologicallyroven Leydig cell tumor that secreted estrogen, explaining thisatient’s gynecomastia. (Color version of figure is available online.)

f patients in clinical remission will have persistent


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eukemic infiltrates within the testicle. The blood–testisarrier prevents chemotherapeutic agents from reachinghe testicle and therefore the testis can act as a sanctuaryor leukemia cells. The ultrasound appearance of leuke-

IG 9. A 4-year-old male presents with painless swelling of the rightcrotum. (A) Sonographic examination demonstrates an enlarged rightesticle that has abnormal heterogeneous echotexture (B). Color Dopp-er (C) reveals increased flow to the abnormal testicle. The abnormalityas shown to be lymphoma at biopsy.

ia is nearly identical to that of lymphoma. o


Patients with orchitis or neoplasm can present with thecute onset of scrotal pain. The grayscale and Dopplerltrasound appearance of the two entities are similar,hich can act as a confounding factor for the interpreting

adiologist. Other avascular lesions that can mimic aumor on grayscale ultrasound include hematoma andocal infarction. It is therefore important to combine thelinical history and ultrasound findings when presentinghe clinicians with differential possibilities. Even if annfectious process is strongly considered, a follow-upltrasound examination should be obtained to exclude aumor and document complete resolution of the abnormalndings.

Testiculitis” (orchitis)cute epididymo-orchitis is the most common cause

IG 10. In this patient presenting with left lower quadrant pain andysuria, (A) the left testicle appears enlarged and relatively hypo-choic when compared to the contralateral side. (B) There is diffuseypervascularity on color Doppler imaging. The findings are consistentith epididymo-orchitis. (Color version of figure is available online.)

f the acute scrotum. The infectious process usually

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egins in the epididymal head and invades the testicley direct extension. Approximately 33% of cases ofpididymitis progress to involve the testicle, eitheriffusely or focally. The grayscale findings are non-pecific and include an enlarged hypoechoic testicleFig 10A). Indirect signs of inflammation can be seenuch as a reactive hydrocele or a pyocele with associ-ted scrotal wall thickening. On color Doppler imag-ng increased blood flow to the testicle and epididymisFig 10B) is a more specific and sensitive finding. Inmmunocompromised patients orchitis can rapidlyrogress to an intratesticular abscess, as seen in Fig 11.n adolescents, orchitis is commonly caused by sexu-lly transmitted organisms such as Chlamydia tracho-atis and Neisseria gonorrhoeae. In prepubertal boys

nd males over 35 years of age, Escherichia coli androteus mirabilis are the most common causative

IG 11. Testicular abscess in a diabetic patient in his early seventiesith acute and chronic epididymo-orchitis. (A) There is a heteroge-eously hypoechoic complex collection within an enlarged left testicle.B) Color Doppler reveals hypervascularity of the testicle with absencef flow within the sonolucent area of necrosis. (Color version of figures available online.)

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IG 12. In this patient with a history of untreated orchitis, (A) the leftesticle is small and demonstrates hypoechoic areas of decreasedchogenicity containing foci of calcification. (B and C) Dopplermaging reveals a small amount of flow to the normal-appearingeriphery of the left testicle. The abnormal hypoechoic central portionshow absence of blood flow, suggesting that segments of the leftesticle have become infarcted as a result of long-standing infection.
Color version of figure is available online.)

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Increased blood flow to the epididymis and testicles a well-established criteria for the diagnosis ofpididymo-orchitis. Burks and coworkers determinedhat the sensitivity of color Doppler in diagnosingpididymo-orchitis is 100%.19 The hyperemia seen inrchitis demonstrates a high-flow, low-resistance pat-ern (resistive index �0.5) due to the increased num-er and concentration of identifiable vessels withyperemia.20

Chronic orchitis presents as an enlarged orhrunken testicle demonstrating increased echogenic-ty with or without calcifications (Fig 12). Multisep-ated fluid collections can be seen surrounding theesticle.

onclusionigh-frequency ultrasound examination with coloroppler is the study of choice for evaluation of the

cute scrotum. Knowledge of the normal and patho-ogic appearance of the testicles is necessary to reachhe proper diagnosis in patients presenting with testic-lar torsion, trauma, tumors, and epididymo-orchitis.s testicular pathology can have overlapping gray-

cale ultrasound appearance, clinical history and coloroppler imaging are essential to achieve the correctiagnosis. Evaluation of the unaffected testicle ismportant, as subtle differences in echotexture andlood flow can be revealed when compared with theormal testicle.

In the setting of presumed infection, an abnormalityf testicular architecture should be followed withltrasound until there is complete resolution, so as toxclude an underlying malignancy.

REFERENCES

1. Moore KL. Clinically Oriented Anatomy, 3rd edition. Balti-
more, MD: Williams and Wilkins, 1992. p. 149-51, 307.

2. Langer JE. Ultrasound of the scrotum. Semin Roentgenol1993;28:5-18.

3. Giorgo G. Cardiovascular (inferior vena cava). In: WilliamsPL, ed. Gray’s Anatomy: The Anatomical Basis of Medicineand Surgery, 38th edition. New York, NY: Churchill Living-stone, 1995. p. 1600-1

4. Doherty FJ. Ultrasound of the nonacute scrotum. Semin USCT MRI 1991;12:131-56.

5. Krone KD, Carroll BA. Scrotal ultrasound. Radiol Clin NorthAm 1985;23:121-39.

6. Dambro TJ, Stewart RR, Barbara CA. The scrotum. In:Rumack CM, Wilson SR, eds. Diagnostic Ultrasound, 2ndedition. St. Louis, MO: Mosby, 1998. p. 791-821.

7. Scoutt LM, Zawin ML, Taylor KJ. Doppler US. Part II.Clinical applications. Radiology 1990;174:309-19.

8. Rumack C. Diagnostic Ultrasound, 3rd edition. St. Louis, MO:Mosby-Year Book, 2005. p. 874-7.

9. Stehr M, Boehm R. Critical validation of color Dopplerultrasound in diagnostics of acute scrotum in children. EurJ Pediatr Surg 2003;13:386-92.

0. Kalfa N, Veyrac C, Baud C, et al. Spermatic cord in childrenwith testicular torsion: impact on the surgical strategy. J Urol2004;172:1692-5.

1. Dogra VS, Gottlieb RH, Oka M, et al. Sonography of thescrotum. Radiology 2003;227:18-36.

2. Cass AS. Testicular trauma. J Urol 1983;129:299-300.3. Bhandary P, Abbitt PL, Watson L. Ultrasound diagnosis of

traumatic testicular rupture. J Clin Ultrasound 1992;20:346-8.4. Herbener TE. Ultrasound in the assessment of the acute

scrotum. J Clin Ultrasound 1996;24:405-21.5. Guthrie JA, Fowler RC. Ultrasound diagnosis of testicular

tumors presenting as epididymal disease. Clin Radiol 1992;46:397-400.

6. Woodward PJ, Sohaey RP, O’Donoghue MJ, et al. Tumorsand tumorlike lesions of the testis: radiologic-pathologiccorrelation. Radiographics 2002;22:189-216.

7. Schwerk WB, Schwerk WN, Rodeck G. Testicular tumors:prospective analysis of real-time ultrasound patterns andabdominal staging. Radiology 1987;164:369-74.

8. Luker GD, Siegel MJ. Color Doppler sonography of the acutescrotum in children. AJR 1994;163:649-55.

9. Burks DD, Markey BJ, Burkhard TK, et al. Suspected testic-ular torsion and ischemia: evaluation with color Dopplersonography. Radiology 1990;175:815-21.

0. Horstman WG. Scrotal imaging. Urol Clin North Am 1997;
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sonography of the acute scrotum: the four t’s of testicular imaging

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