us scrotum gilani 1 (2)

8/3/2019 Us Scrotum Gilani 1 (2)

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Gross Anatomy Methods of Imaging Scrotum / Testis

US techniques

Pathologies:

US appearances of various pathologies

Summary


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Testes are oval shaped organs inside scrotum.

Surrounded by T.vaginalis.

Epididymis tail forms vas deferens.

Av. size 4 x 3 x 2.5 cms.

Wt: 10-19 gms.


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Vascular SupplyVascular Supply

Arterial flow from aorta bytesticular art.

Deferential & cremasteric

arteries supply extra testicular

components Venous flow via testicular vn.


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With Doppler, flow in spermatic artery & testicular art. & its

branches is of low resistance

(mean 0.6; range 0.5-0.7) with a relative broad systolic part.


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ULTRASOUND SCROTUMULTRASOUND SCROTUM


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1. Plain x-rays except skeletal mets.

2. US (Gray Scale/Color/Power Doppler).

3. Nuclear Medicine.4. CT Scan (primarily for staging of Ca)

5. MRI: localization, Staging & Characterization

of testicular lesions6. Angiography (Embolization)

7. PET/CT primarily for staging of Ca/chemo-

response


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UltrasonographyUltrasonography 1st imaging procedure to evaluate scrotum.

High frequency transducers (>10 MHz) with

color Doppler facilities.


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1. Evaluate a mass or pain in testis.

2. Identify & monitor infection/inflammation of

testis or epididymis.3. Identify testicular torsion.

4. Monitor recurrence of testicular Ca.

5. Locate undescended testis.6. Identify hydrocele, spermatocele etc.

7. Guided testicular biopsy

8. Evaluate an injury to testis.


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Reassurance / Privacy. Analgesia.

Warm Gel. (body temp.)

Towel under scrotum. Unaffected testes 1st.


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High frequency probe. Color & Spectral Doppler.

Spectral allows differentiation b/w arterial &

venous Flow Venous flow is compromised 1st.


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ImagingApproaches:ImagingApproaches:

performed most often with transducer in direct

contact with skin with gel.

?? stand-off pad can be used for evaluation ofsuperficial structures & lesions


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ImagingApproaches:ImagingApproaches:

performed with pt. in supine position &

scrotum supported by towel placed b/w thighs.

Additional maneuver's(coughing/Valsalva) required


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Imaging Protocols

2 planes: Longitudinal axes.

Transverse axes.

Size & echogenicity of both testes compared /evaluated.

Epididymis compared with opp. side.


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Normal USNormal US MeasurementsMeasurements

Scrotal wall thickness is approx. 2-8 mm

depending on state of contraction of cremastericmuscle.


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Normal US MeasurementsNormal US Measurements size depends on age & stage of sexual

development.

symmetric, ovoid structures

at birth, mx approx. 1.5 x 1.0 cm.


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US SCROTUM


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PrePre--pubertal testes:pubertal testes:

low to medium echogenicity

Pubertal & postPubertal & post--pubertal testes:pubertal testes: medium homogeneous echogenicity.

Mediastinum testisMediastinum testis::

echogenic band of variable thickness & length Rete testis:Rete testis:

a hypoechoic area adjacent to mediastinum testis


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Appendix testis:Appendix testis: ovoid structure 5 mm in length

in groove b/w testis &

epididymis.

AppendixAppendix epididymis:epididymis: more often pedunculated


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Testicular perfusion can beevaluated with

1. Color Doppler.

2.Power Doppler.3. Spectral Doppler.


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ColorColor DopplerDoppler US:US:

reliably demonstrates intra-testicular arterial &

venous flow. Power Doppler:Power Doppler:

valuable because of increased sensitivity to low-flow states & independence of Doppler angle

correction. PulsedPulsed DopplerDoppler US:US:

useful for identifying flow in testes with use of time-velocity spectrum to quantify blood flow.


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US SCROTUMUS SCROTUM


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Classification:Classification:

1. Scrotal wall abnormalities.

2. Abnormalities of spermatic cord.

3. Epididymis.

4. Testicular abnormalities.


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SCROTALWALLABNORMALITIESSCROTALWALLABNORMALITIES NonNon--intlammatoryintlammatory causes:causes:

Heart failure.

Lymphedema. Hypoalbuminemia.

Inflammatory causes:Inflammatory causes: Cellulitis.

Fournier gangrene. ScrotalScrotal wall malignantwall malignant lesions:lesions:

Metastases from melanoma, lung & anal Ca Inguinal & scrotal swelling:Inguinal & scrotal swelling:

Inguinal hernia.

Hydrocele.

Pyocele.


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ABNORMALITIES OF SPERMATICABNORMALITIES OF SPERMATIC

CORD:CORD:

Varicocele.

encysted hydrocele of cord.

Tumors: Rhabdomyomas.

Sarcoma.


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EPIDIDYMISEPIDIDYMIS EpididymoEpididymo--orchitisorchitis::

Acute/chronic

Epididymal masses:Epididymal masses:1. Epididymal Cyst

2. Spermatocele

3. Sperm Granuloma,

4. Tumors

5. Adenomatoid Tumors

6. Papillary Cystadenoma

7. Rare Tumors


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TESTICULARABNORMALITIESTESTICULARABNORMALITIES Testicular Torsion:Testicular Torsion:

Extra/Intravaginal Torsion Of Spermatic Cord Leading To

Vascular Occlusion. Orchitis:Orchitis: Primary & Secondary

Benign Testicular Mass:Benign Testicular Mass:1. Intra Testicular Cysts

2. Epidermoid Cyst

3. Intratesticular Varicocele MalignantMalignant TesticularTesticular TumorsTumors::

Germ Cell Tumors: Seminomatous

NonSeminomatous


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SCROTUM

(ACUTE)


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1. TesticularTorsion2. Epididymitis/Orchiti

s.

3. Hydrocele.

4. Varicocele.5. ScrotalTrauma.

1. Undescended Testis.

2. Testicular Carcinoma.

3. Testicular Microlithiasis.4. Testicular & Epididymal

Cysts

5. Epidermoid Cyst.

6. Gonadal Stromal Tumor.

7. Epididymal Masses.

8. Testicular Atrophy.


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DefinitionDefinition Spontaneous or traumatic twisting of

testis & spermatic cord within

scrotum,

resulting in vascular occlusion /infarction.


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BestBest diagnostic clue:diagnostic clue:

or absent testicular blood flow on colorDoppler US.

95% unilateral.


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HistoryHistory & Prognosis& Prognosis

Testicular viability depends on:

duration of symptoms

degree of torsion (> 540 worse)

Absent blood flow occurs with any degree oftorsion lasting >4 hrs.


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US FINDINGSUS FINDINGS vary with duration & degree of rotation.

during ac. phase US may be normal.

Enlarged testis & epididymis.

Heterogeneous echo-texture, most often

echogenicity.

Edema of scrotal wall. 2 hydrocele.

Intra-testicular necrosis, or hge if delayed

diagnosis.


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US FINDINGSUS FINDINGS

ColorColor DopplerDoppler

useful

In ac. torsion sensitivity, 80-90%

Absent or flow. Comparison with opp. testes is mandatory.


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Caveat:Caveat:Normal US (Gray-scale & Doppler)

does not exclude early or partial torsion.

Repeat examination at 1-4 hrs. intervals ifconservatively managed.


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CD shows no flow to testicle &

enlargement of epididymis &

spermatic cord, which are

avascular as well

CD image of both testes shows enlargement,

slightly decreased echogenicity, & absent

flow on left side.


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COLORDOPPLERFINDINGSCOLORDOPPLERFINDINGS


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DEFINITION:DEFINITION:Infection / inflammation of epididymis &/or testis

BESTDIAGNOSTIC CLUE:BESTDIAGNOSTIC CLUE:

Enlarged, hyperemic epididymis &/or testison color Doppler US


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IMAGINGIMAGING FINDINGSFINDINGS

Acute epididymitis:

Enlarged epididymis,

echogenicity

coarse heterogeneous echo pattern due to edema &

hemorrhage. Chronic epididymitis:

Enlarged hyperechoic epididymis.


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US Findings:US Findings:

edema of testes with heterogeneous parenchymal

echogenicity

may be focal or diffuse.

Spermatic cord

appear hypoechoic with assoc. hyperechoic fatwithin.

Reactive hydrocele with low level internal echoes.


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Color Doppler USColor Doppler US Findings:Findings:

Highly sensitive & specificity.

Echogenicity - variable.

Doppler flow is invariably . On CDnumber & concentration of vessels

in affected region. Diffuse or focal hyperemia in body & tail

epididymis vascularity of testis.


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ColorColor DopplerDoppler FindingsFindings::

In severe EO, avascular areas withinhyperemic testis or epididymis suggests focal

infarction.

Inflammation of epididymis & testis is asstd

with vascular resistance.

RI


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CDUS


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DIAGNOSTIC CHECKLISTDIAGNOSTIC CHECKLISTConsider:Consider:

Torsion if low or absent flow within testis.

Image InterpretationImage Interpretation Pearls:Pearls:

Hyperemic & enlarged epididymis &/or testis.


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Definition:Congenital or acquired serous fluid

contained within layers of tunica vaginalis.

Best diagnostic clue:Best diagnostic clue:Scrotal fluid surrounding testis


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GrayscaleGrayscale US Findings:US Findings:Acute HydroceleAcute Hydrocele

Crescentic anechoic fluid collection surrounding

anterolateral aspect of testis

Testis is displaced postero-medially


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GrayscaleGrayscale US Findings:US Findings:


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ChCh HydrocelesHydroceles (CH):(CH):

Low-level, mobile echoes.

Cholesterol crystals cause low-level mobile

echoes indistinguished from inflammatory

debris. Diffuse scrotal wall thickening

Parietal calcifications & scrotoliths.


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DefinitionDefinition

Dilatation of veins of pampiniformplexus >2-3 mm in diameter.

Best diagnostic clueBest diagnostic clue Dilated serpiginous veins behind

superior pole of testis on CD-US Distention, due to retrograde flow,

with Valsalva.


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GENERALFEATURESGENERALFEATURESSIZE:SIZE:

Normally veins in pampiniform plexus are 2 mm

In Varicocele multiple veins are >2-3 mm &

further increase in size with Valsalva


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Grading of varicoceles on USGrading of varicoceles on USRELAXED

STATEDURINGVALSALVA

Normal 2 mm 2.7mm

Small varicocele 2.5-4mm increase by 1mm

Moderate varicocele 4-5mm increase by > 1.2 mm

Large varicocele > 5mm increase by > 1.5mm


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GRAYSCALEUS FINDINGS:

Technique:Technique:

US should be performed in supine & standing

positions & with Valsalva maneuver.


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GRAYSCALEUS FINDINGS: Multiple, hypoechoic, serpiginous, tubular structures.

Varying size >2 mm in diameter.

Occ. low level internal echoes can be detected in dilatedveins 2 to slow flow.


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Color Doppler Findings:Color Doppler Findings: 100% with CD-US

Bidirectional CD US (erect with quiet breathing)

2 varicoceles result frompressure on spermatic

vein, resulting in non-decompressible veins.


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Color Doppler Findings:Color Doppler Findings:


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Definition:Definition:

Malignant germ cell tumor of testis

Best diagnostic clue:Best diagnostic clue:

Discrete hypoechoic or mixed echogenic

testicular mass, vascularity


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Morphology:Morphology: Common neoplasm in males b/w ages 15-34 yrs

Mostly unilateral, 8% bilateral.

Seminoma - most common

Bilateral in 1-3%.


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DIAGNOSTIC CHECKLIST:DIAGNOSTIC CHECKLIST:ImageImage InterpretationInterpretation Pearls:Pearls:

Presence of discrete mass on gray-scale US with

abnormal intrinsic vessels on CD should raise

suspicion of testicular Ca.


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Color Doppler FindingsColor Doppler Findings Tumor < 1.5 cm - commonly hypo-vascular,

Tumors > 1.6 cm are more often hyper-vascular

Disorganized flow is typical.

Cystic areas are avascular.


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DEFINITIONSDEFINITIONS

Incomplete descent of testis into base of scrotum.


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IMAGING FINDINGSGeneral Features

BestBest diagnostic clue:diagnostic clue:

Unilateral absence of testis in scrotum

Location:Location: Anywhere from kidney to inguinal

canal

Bilateral in 10%

Inguinal canal most common (80%)

Size:Size: Cryptorchid testis smaller than normal

testis

Adults:

Undescended testis exhibit different

degrees of atrophy


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GRAYSCALEUS FINDINGS:GRAYSCALEUS FINDINGS:

20-88% sensitivity to detect inguinal position of

testis.

Ovoid homogeneous, less echogenic, well-circumscribed structure smaller than normal

descended testis.

Echogenic line of mediastinum testis. Testes


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us scrotum gilani 1 (2)

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