Scrotal Pathology

Question 1

What is testicular rupture?

Answer 1

Disruption to the tunica albuginea caused by trauma.

Question 2

What are the US appearances of testicular trauma?

Answer 2

Focal change to testicle parenchymal pattern (haemorrhage or infarction)
Interruption of tunica albuginea
Irregular testicular contour
Scrotal wall thickening
Disruption of blood flow along testicle surface

Question 3

What are some complications of testicular trauma?

Answer 3

Hydrocele and haematocele
Epididymitis
Torsion

Question 4

What is testicular fracture?

Answer 4

Discontinuity of the normal testicular parenchyma (may have disruption of tunica albuginea)

Question 5

What are the US appearances of a haematocele (two stages)?

Answer 5

Acute - echogenic fluid with highly visible echoes that move
Old - low-level echoes and fluid levels/septations. More complex and develop cystic components.

Question 6

What do haematoceles develop from?

Answer 6

Bleeding/rupture of the pampiniform plexus or other extratesticular structures

Question 7

What are the two causes of torsion?

Answer 7

Absence of gubernaculum leads to twisting of the testicular within the tunica vaginalis (bell-clapper deformity) or outside of the tunica vaginalis (perinatal torsion)

Question 8

What are the S+S of testicular torsion?

Answer 8

Sudden onset of pain which can cause nausea and vomiting
Swelling on affected side

Question 9

Who are the patients most likely to get torsion?

Answer 9

Adolescents (peak age 14yo)
Undescended testicles

Question 10

What are the US appearances of very early torsion?

Answer 10

Usually normal grey-scale appearance. No colour flow.

Question 11

What are the US appearances of torsion of 4-6 hours?

Answer 11

Swollen and hypoechoic testicle. Lobes of testes become well-defined from interstitial and septal oedema. No colour flow.

Question 12

What are the US appearances of torsion of 24 hours?

Answer 12

Heterogenous testicle from haemorrhage, necrosis, infarction, vascular congestion. No colour flow.

Question 13

What are other associated findings of torsion?

Answer 13

Testicular knot - twisted spermatic cord immediately superior to testis displays whirlpool sign with CD.
Scrotal skin thickening
Reactive hydrocele
Epididymal head enlargement and decreased echogenicity

Question 14

What are some of the imaging appearances post spontaneous de-torsion, depending on the length of time since resolution?

Answer 14

Intratesticular flow may be minimal or increased. Extratesticular flow increased.

Question 15

What pathology produces similar S+S to testicular torsion?

Answer 15

Torsion of the appendix testis or appendix epididymis.

Question 16

What are the US appearances of testicular or epididymal appendix torsion?

Answer 16

Small, hypoechoic mass between epi head and superior testis.
Increased flow around the mass.

Question 17

What is epididymo-orchitis?

Answer 17

Infection of epididymis and testes

Question 18

What causes epididymo-orchitis?

Answer 18

Spread of UTI down spermatic cord.
Viruses, syphilis, tuberculosis, trauma.

Question 19

What are the signs and symptoms of epididymo-orchitis?

Answer 19

Scrotal pain increasing over 1-2 days
Fever
Urethral discharge

Question 20

What are the US appearances of epididymitis?

Answer 20

Enlarged, hypoechoic epididymis
Focal hyperechoic areas (haemorrhage)
Hyperaemia
Increased flow velocity and low-resistance waveform

Question 21

What are the US appearances of orchitis?

Answer 21

Enlarged testis
Focal - affected areas hypoechoic
Diffuse - whole testis hypoechoic

Question 22

What is the most helpful imaging tool to differentiate between torsion and infection?

Answer 22

Colour Doppler

Question 23

What are the US appearances of testicular infarction?

Answer 23

Decreased or absent flow
High resistance flow with little to no diastolic flow (reversed end diastolic indicates threatened infarction)
Focal - no flow in affected areas and heterogenous parenchyma

Question 24

What are spermatoceles?

Answer 24

Dilation of the efferent ducts of the epididymis. Contain spermatozoa.

Question 25

What are some findings that may suggest a spermatocele over a epididymal cyst?

Answer 25

Spermatocele always in epi head Contain internal echoes and septa More common in patients with vasectomy

Question 26

How do you tell a large tunica albugenia cyst from a hydrocele?

Answer 26

Hydrocele will not distort the testicle.

Question 27

Where are the three areas you can get benign extratesticular cysts?

Answer 27

Epididymis, tunica albuginea, and between layers of the tunica vaginalis.

Question 28

What are the two types of causes of varicoceles?

Answer 28

Primary - venous valve incompetence Secondary - masses, hydronephrosis, cirrhosis, nutcracker syndrome, retroperitoneal mass.

Question 29

What are the US appearances of a varicocele?

Answer 29

Numerous tortuous tubes within spermatic cord Measure >2mm diameter Increase in size with valsalva Retrograde fill with CD and valsalva

Question 30

How can we differentiate between a tumour vs. a scrotal abscess?

Answer 30

Clinical symptoms Interval change

Question 31

What are the US appearances of an intratesticular haematoma (two stages)?

Answer 31

Acute - isoechoic or heterogenous compared to parenchyma Chronic - hypoechoic or anechoic

Question 32

What is a physical sign unique to torsion of the epididymal or testicular appendix?

Answer 32

Blue discolouration of the skin

Question 33

What other pathologies are hydroceles associated with?

Answer 33

Epididymo-orchitis, torsion

Question 34

What causes a pyocele?

Answer 34

Untreated infection, abscess rupture into the space

Question 35

What are some events/pathologies that cause of a haematocele?

Answer 35

Trauma, surgery, neoplasms, torsion

Question 36

What are the US appearances of a hydrocele?

Answer 36

anechoic (or low-level echoes) excess fluid on the anterolateral side of testicle.

Question 37

What are the US appearances of a pyocele/haematocele?

Answer 37

internal echoes, thickened septations, loculations. Air within space indicates abscess (abscess can occur without air)

Question 38

What is a sperm granuloma and where are they located?

Answer 38

Chronic inflammatory reaction to extravasation of spermatozoa. Located anywhere in epididymis or vas deferens.

Question 39

What are the US appearances of sperm granuloma?

Answer 39

Well-defined, heterogenous, solid mass that's hypo or isoechoic to epi. Calcs not generally present. Increased flow when inflammation present.

Question 40

What is tubular ectasia and where is it located?

Answer 40

Dilation of the rete testes. Located in the rete testes (mediastinum of the testicle).

Question 41

What causes tubular ectasia?

Answer 41

Anything that may obstruct the movement of sperm from the testes to the epididymis.

Question 42

What are the US appearances of tubular ectasia?

Answer 42

Prominent hypoechoic channels near the mediastinum. Avascular.

Question 43

What other pathology may tubular ectasia mimic? How can you differentiate between the two?

Answer 43

Intratesticular varicocele. Use CD with valsalva - tubular ectasia will not fill with colour.

Question 44

What is microlithiasis and what US criteria must be seen to make this diagnosis?

Answer 44

Tiny calcs throughout the testicles. Calcs must be <3mm each and there must be more than ≥5 calcs per image.

Question 45

What congenital abnormalities/pathologies is microlithiasis associated with?

Answer 45

Cryptorchidism, infertility, varicoceles, testicular atrophy.

Question 46

What are the US appearances of intratesticular varicocele?

Answer 46

Hypoechoic tubes passing from mediastinum to parenchyma.

Question 47

What anatomical abnormality increases the likelihood of testicular cancer?

Answer 47

Cryptorchidism.

Question 48

What are the S+S of testicular cancer?

Answer 48

Painless lump Testicular enlargement Vague scrotal discomfort

Question 49

What are the US appearances of a seminoma?

Answer 49

Hypoechoic Smooth, well-defined walls Usually no calcs

Question 50

What are the US appearances of a teratoma?

Answer 50

Complex (solid + cystic) Well-defined borders Dense foci that produce shadowing

Question 50

What are the US appearances of a embryonal cell carcinoma?

Answer 50

Hypoechoic Calcs Irregular borders May contain cystic areas

Question 51

What are the US appearances of a choriocarcinoma?

Answer 51

Irregular borders Complex lesion Focal necrosis and calcs

Question 51

What are the US appearances of mets to the testes?

Answer 51

Solid hypoechoic lesion (uncommon but can appear hyperechoic or heterogenous)

Question 51

What are the US appearances of testicular lymphoma and leukaemia?

Answer 51

Enlarged testes Diffuse or focal areas of decreased echogenicity Hypervascularity

Question 52

What are the US appearances of chronic lymphocytic leukaemia?

Answer 52

Well-circumscribed Anechoic Posterior enhancement

Question 53

What are three different anatomical anomalies that may arise in relation to the testes?

Answer 53

Cryptorchidism Anorchia Polyorchidism

Question 54

What are the complications of cryptorchidism?

Answer 54

Infertility (higher temperatures inhibiting spermatogenesis) Higher risk of cancer and torsion