Vascular abnormalities of scrotum

Varicocele

Collection of abnormal dilated serpiginous vein posterior to the testes that extend to the spermatic cord (pampiniform plexus)

Idiopathic - incompetent values in internal spermatic vein

Secondary - increased pressure caused by abdominal mass or hydronephrosis

Can also be related to inguinal hernia or herniorrhapy

Most common cause of male infertility

Varicocele

Normal vein diameter

0.5-1.5mm

______________ more common due to the left gonadal vein emptying into the left renal vein, not IVC

Left varicocele

Nutcracker syndrome

Superior mesenteric artery compresses the left renal vein causing increased pressure and stasis in the venous systems of the left kidney and left testicle

USA varicocele

Extratesticular - Multiple tortuous anechoic structures proximal to upper pole of testis

Intratesticular - multiple cystic structures within the rete testes that fill with color on Doppler eval

Veins dilate with Valsalva

>2mm diameter abnormal with pt supine

If pt stands for exams, hydrostatic pressure causes vessels to dilate

>2.5mm diameter abnormal for standing exam

Upper abdomen should be eval for mass when varicocele is found on right

Varicocele

Infarction

Loss of blood flow to a portion or all of the testicle

Can be focal or diffuse

Related to torsion, trauma, bacterial endocarditis, leukemia and vasculitis

USA Infarction

Varying echogenicity with age of infarct

Acute - hypoechoic area

Chronic - hyperechoic calcs, reduced size of testicle

Use color to help with diagnosis

Testicular infarct

<4 hours torsion

Absent flow in testicle, normal teste

>4 hours testicular torsion

Increased teste size, heterogeneous, hydrocele, absent flow

>24 hours testicular torsion

Scrotal wall thickening, areas of infarct and necrosis within teste

Testicular torsion

Most common before age 30yrs

Larger testicles are those with tumor formation present a greater risk of torsion

Acute testicular pain, swollen scrotum, N/V

CRITICAL

Teste salvage rate

• <6hrs = excellent

• 6-12hrs = declining

• >12hrs = poor

Epi and appendix testis can undergo torsion without testicle

USA Torsion

Blue dot sign: blue dot under skin surface of scrotun

Variable echogenicity

Acute torsion - enlarged testicle, hypoechoic and mottled appearance

Areas of infarct may be seen if progressive

Color AND PW Doppler necessary for diagnosis

Complete torsion

Absence of intratesticular flow

Document color Doppler views of the normal side first, then image the affected side with the same color Doppler setting

Partial torsion

May still demonstrate some high resistance flow with absent or reversed diastolic flow in the affected teste

Comparison of the PW Doppler waveforms from both sides can assist in diagnosis

Asymmetry of the resistive indices can indicate partial torsion

RI value greater than 0.7 = partial torsion

Complete torsion RI value

1.0

Normal RI values in testicle

0.5-0.7

Epididymal torsion

Hypoechoic enlarged epididymis mass with variable echotexture and no vascularity

Normal testicular appearance and vascularity

Torsion of the Appendix testis

Hypoechoic enlarged mass with variable echotexture and no vascularity

Located between a normal teste and a normal epi

Normal testicular and epi appearance and vascularity

Testicular torsion

Testicular rupture

Ruptured testicle

Critical finding, requires immediate intervention

Areas of hemorrhage and infarction can be seen

Hematocele formation

Orchiectomy with possible prosthetic placement

Scrotal hernia

Small intestine, colon and/or omentum falls into scrotal sac through abnormal opening in the inguinal canal

Scrotal hernia USA

Echogenic material within scrotal sac

May see dirty shadowing from air within bowel

Valsalva used to demonstrate peristalsis of herniated abdominal contents

Color Doppler used to evaluate suspected herniated bowel loops for vascularity

Inguinal hernia

Sperm granulomas

Extravasation of the spermatozoa into tissues around epi

Sperm granulomas USA

Solid hypoechoic or heterogeneous mass

May contain calc

Fibrous pseudotumor

Rare, non-neoplastic mass

Made of fibrous tissue

Fibrous pseudotumor USA

Solid hypoechoic or heterogeneous mass

Scrotal wall thickening

Fluid accumulates in these tissues of the scrotum

Inflammatory causes include cellulitis and Fournier gangrene

Normal vascularity present when there is non-inflammatory cause

Scrotal wall thickening risk factors for inflammatory disease

Obesity, diabetes, or pt is immunocompromised

Inflammatory scrotal wall thickening USA

Wall thickness >8mm

Presence of hypoechoic areas with increased vascularity

Non-inflammatory causes of scrotal wall thickening

CHF, lymphedema, liver failure, and lymphatic and venous obstruction

Non-inflammatory scrotal wall USA

Scrotal wall thickness >8mm

Layers of altering hypoechoic and hyperechogenicity

Scrotal wall thickening

Post-vasectomy changes

Epididymal enlargement and inhomogeneity

Development of sperm granulomas and cysts

Dilated rete testes

Clinical Hx and color Doppler are used to differentiate post-surgical changes from acute epididymitis

NO hypervascularity with post-surgical changes; hypervascularity with acute epi

Most common residual effect of a vasectomy

Spermatic granulomas

When evaluating a pt for a suspected varicocele, the pt should be scanned:

While performing Valsalva strain

While standing

While supine

All of the above

All of the above

How is testicular torsion diagnosed

Comparing the PW Doppler of the centripetal arteries on both sides

If flow is identified in both testicles, but the RI values differ greatly, ________ should be strongly suspected

Partial torsion on the right side with the higher RI value

Which of the following is a risk factor for torsion?

Men over 60yrs

Bell clapper deformity

Small testicles

All of the above

Bell clapper deformity

What describes the appearance of a testicular prosthetic on US

Round structure with reflective borders and an anechoic lumen

What abnormalities can be evaluated by asking the pt to do a Valsalva

Hernia, varicocele, nutcracker syndrome

Which of the following is a non-inflammatory cause for scrotal wall thickening?

Orchitis

Epididymitis

CHF

Systemic HTN

CHF