Scrotum

Chapter 23 pg 708 - DONE

• Testes 🧪 →

• Epididymis 📍 →

• Vas Deferens 🚶‍♂ →

• Ampulla of the Deferens 🏁 →

• Seminal Vesicles 🍇 →

• Ejaculatory Duct 🚰 →

• Urethra ⛲ →

• Exit the body 🚪

Flow Map: Sperm Transport 🚗💨

• Shape: Symmetrical, oval-shaped glands

• Size: ~3-5 cm long, 2-4 cm wide, ~3 cm high 📏.

• Structure: 250-400 lobules with seminiferous tubules 🧬.

  • Converge to form rete testis in the mediastinum 🔗.

• Ultrasound appearance: Smooth, medium-gray, fine echotexture 🎨

Covering:

• Surrounded by the tunica albuginea, a dense, fibrous layer.

• Mediastinum testis forms from the tunica albuginea, creating a vertical septum that supports blood vessels and ducts.

• Ultrasound Appearance: Smooth, medium-gray with a fine echotexture.

Testes 🧪

• What It Is: The fibrous outer covering of the testis.

• Main Job: Gives shape to the testis and protects it.

• Special Feature: It forms a structure inside the testis called the mediastinum testis, which supports blood vessels and ducts.

• Ultrasound: Bright, white line that divides the testis into lobules.

The Tunica Albuginea 🏰

Testes produce what?

• Main Job: ___________ .

• Structure: Inside each testis, there are many tiny structures called seminiferous tubules that help make sperm.

• Outer Layer: Covered by a tough membrane called the tunica albuginea.

Sperm and testosterone

• Length: 6-7 cm, located superior and posterolateral to the testis.

• Parts:

  • Head: Largest part (6-15 mm wide), superior to the upper pole of the testis 🧠.

  • Body: Smaller, hard to see on ultrasound 👀.

  • Tail: Slightly larger, posterior to the lower pole of the testis 🦰.

• Appendix Epididymis: Small protuberance from the head (found in 34% unilaterally, 12% bilaterally) 🧶.

• Ultrasound appearance: Isoechoic or hypoechoic, coarse texture 🔳.

Epididymis 📍

The Epididymis does what?

• What It Is: A tube-like structure attached to each testis.

• Main Job: _______________ .

• Parts:

  • Head: Located at the top of the testis.

  • Body: The middle part of the epididymis.

  • Tail: Located at the bottom of the testis, connected to the vas deferens.

• Relationship with Testes: It’s located just behind the testis.

• Appearance: It’s a little coarser on ultrasound, compared to the smooth testis.

Stores sperm and helps them mature

• What It Is: A small, extra structure that may be attached to the testis.

• Where It Is: Between the testis and epididymis, at the top of the testis. (upper pole)

• Common: Present in 92% of men unilaterally and 69% bilaterally.

• Appearance: Small, oval, and may appear hypoechoic or isoechoic on ultrasound.

Appendix Testis 🍏

• Small protuberance from the head of the epididymis.

• Found in 34% of testes unilaterally, 12% bilaterally.

• Ultrasound Appearance: Isoechoic or hypoechoic.

Appendix Epididymis 🧶

• What It Is: A two-layered sac that surrounds each testis and epididymis.

• Main Job: Provides a lubricated space for the testes to move within the scrotum.

• Parts:

  • Parietal layer: Lines the inside of the scrotum.

  • Visceral layer: Covers the testis and epididymis.

• Space Between Layers: This is where hydroceles (fluid collections) can form.

The Tunica Vaginalis 💧

• What It Is: The tube that carries sperm from the epididymis to the urethra.

• Connection: Starts from the tail of the epididymis and moves upward into the inguinal canal, eventually reaching the ampulla (enlarged portion near the seminal vesicles).

• Connection with Seminal Vesicles: It joins with the seminal vesicles to form the ejaculatory duct, which empties into the urethra.

Vas Deferens 🚶‍♂

• What It Is: The bundle of structures that suspends the testis in the scrotum.

• Contents: Includes the vas deferens, blood vessels (arteries and veins), nerves, and lymphatics.

• Connection: It connects the testis to the abdomen via the inguinal canal.

The Spermatic Cord 🔗

Tunica vaginalis has two layers:

• Visceral layer: touches the testis and epididymis.

• Parietal layer: lines the inside of the scrotal wall.

• The space between these two layers is where fluid can build up → forming a ___________________???

Hydrocele

Layers of the Testes

Abdominal Aorta
  ⬇
Right & Left Testicular Arteries
  ⬇ (enter spermatic cord via deep inguinal ring)
Posterior Testis → Pierces Tunica Albuginea
  ⬇
Capsular Arteries (run along surface)
  ⬇
Centripetal Arteries (toward mediastinum)
  ⬇
Recurrent Rami (Centrifugal Arteries) (curve back outward)
  ⬇
Arterioles → Capillaries

➕ Optional Branch:
Transmediastinal Artery
  ↘ Coursing through mediastinum
   ⬇
  Forms additional capsular branches (opposite side)

➕ Collateral Arterial Supply:

• Cremasteric Artery (from inferior epigastric → external iliac)

• Deferential Artery (from vesicle artery → internal iliac)
    ↘ Both can anastomose with testicular artery

Testicular Blood Flow – Arterial Supply

Pampiniform Plexus
  ⬇
Drains into 3 Sets of Veins:

• Testicular Vein
     - Right → Inferior Vena Cava
     - Left → Left Renal Vein

• Deferential Vein → Pelvic Veins

• Cremasteric Vein → Epigastric & Deep Pudendal Veins

🔼 Venous Drainage of Testes

1. ✅ Preparation:
   • No prep required.

2. 🛏 Position:
   • Supine
   • Penis placed on abdomen, covered with towel
   • Legs together or towel under scrotum for support
   • Valsalva Maneuver or Upright if varicocele is suspected

3. 🌡 Warm Gel:
   • Generously apply to scrotum
   • Use extra gel mound or stand-off pad if needed for near-field imaging

---

📍 Before Scanning – Ask the Patient

🗣 “Why are you here today?”
• Pain? Lump? Swelling? Trauma?
• Can they point to a lump?
• Any history (e.g., vasectomy)?
📝 Document: Location, duration, trauma history, symptoms

---

📷 Transducer Selection

🔍 Use 8–12 MHz linear probe
• Preferably high-resolution for best images
• Use Color Doppler & Spectral Doppler when needed

---

🔎 Step-by-Step Scanning Protocol 1⃣ Start with a Brief Survey Scan

🩻 Scan both testes from superior to inferior

🔄 Compare both sides:
• 🔸 Size
• 🔸 Shape
• 🔸 Echogenicity
• 🔸 Structure

❓ Ask yourself:
• Homogeneous or heterogeneous?
• Solid or cystic mass?
• Intra- or extratesticular?
• Is there swelling or shrinkage?
• Epididymis normal?
• Skin thickened?

---

🖼 Required Images 🔹 Gray Scale Imaging

• Long axis (sagittal): Medial, mid, and lateral
• Length & AP measurements of testes and epididymis
• Transverse (axial): Upper, mid, and lower testes
• Width measurement at mid-transverse
• Transverse head of epididymis
• 📸 Split screen view for side-by-side comparison
• 🫧 Check for: Hydrocele, hernia, spermatoceles, tunica cysts

---

🧲 Color & Spectral Doppler

• Evaluate blood flow in both testes and epididymides
• 💓 Look for:

• 🔵 Normal flow

• 🔴 Absence of flow (possible torsion)

• 🟠 Increased flow (possible inflammation)

💡 Optimize for slow flow:
• Lower PRF/scale
• Decrease wall filters
• Increase gain/power

---

🧍‍♂ Special Maneuvers for Varicocele

• Upright position
• Valsalva maneuver
→ Look for dilation of veins in spermatic cord

---

💬 Tips for Success

✨ Ask the patient questions to guide the exam
🧊 Use gel generously for best contact
🧍 Always scan both sides, even if only one is symptomatic
🧠 Think critically as you scan – compare sides
📸 Take extra views if abnormalities are seen

🧍‍♂ Patient Positioning & Prep

1⃣ Problem: Large swelling → hard to see everything with regular view

⬇

2⃣ Solution: Use tools to expand the view or enhance image quality

⬇

3⃣ Tools/Techniques:

- Panoramic view 🖼

- Curved-array probe 🔄

- Advanced imaging features ⚙

- Doppler (Color, Power, Spectral) 🌈

⬇

4⃣ Tweak Settings to Get Best View 🎛

🎯 Goal: Improve Scrotal Ultrasound Imaging, Especially When There’s Swelling (like hydroceles, hematomas)

✅ Panoramic Tool 🧷

• Moves with the probe and stitches a long image 🧵

• Good when testicle is enlarged/swollen (like a big hydrocele)

✅ Image Stitching 🧩

• Take one image ➡ move probe ➡ take second, matching edges

✅ Curved-Array Transducer 🌀

• Frequency: 5–7.5 MHz

• Use it temporarily to get whole scrotum in view, then go back to high-frequency linear probe for detai

🔍 Seeing More in One Image

⚙ Advanced Imaging Features

• Color Doppler = Direction & speed of flow 🧭

• Spectral Doppler = Velocity waveform 📈

• Power Doppler = Shows presence of flow, not direction ➡ More sensitive to slow flow 🐢

🌈 Using Doppler for Blood Flow Types

🎛 Doppler Settings to Tweak for Best View

🚨 – Scrotal Trauma

Common Causes of Scrotal Trauma

• 🚗 Car accidents

• 🏃 Sports injuries

• 🥋 Direct blows

• 🚴 Straddle injuries

🧪 Main Goal of Ultrasound :

🔎 Determine if testicular rupture has occurred — it’s a surgical emergency!

• ✅ If treated within 72 hrs → 90% testis salvage

• ❌ After 72 hrs → Only 45% salvage

Acute Scrotum

Time After Injury	Sonographic Appearance
⏱ Acute (Early)	Echogenic with moving echoes
🕓 Chronic (Later)	Low-level echoes, septations, fluid level

💉 Hematoceles (Blood in Scrotum)

• Heterogeneous on ultrasound

• May displace the testis

• Can become cystic as they evolve

• 🧊 AVASCULAR – use color Doppler to check for absence of flow

🩸 Hematomas

🎯 Use of Color Doppler in Trauma

🧍‍♂ Clinical Signs & Symptoms of

🩺 Finding	🔎 Explanation
😣 Painful, swollen scrotum	Most common and early complaint
🛑 Sudden onset of pain	Often reported after trauma
🤕 History of trauma	Key factor — from MVA, sports, straddle injury
🧊 Tenderness to touch	Suggestive of inflammation, hemorrhage, or rupture
📉 Reduced or absent blood flow (Doppler)	Suggests torsion or infarction (not visible externally)
🔥 Increased vascularity (Doppler)	Suggests infection (epididymitis/orchitis) if trauma is secondary
⚠ Signs of systemic infection (e.g., fever)	May be seen if infection accompanies trauma or occurs secondarily
🔻 Displacement of testis	Due to large hematoma pushing it aside
💧 Hydrocele or hematocele formation	May cause visible or palpable scrotal enlargement/swelling

Scrotal Trauma (Acute Scrotum)

🦠 Infection of the epididymis and sometimes the testis (orchitis)

🔍 Causes

⚠ Common	🧪 Less Common
🔽 Spread from UTI (via spermatic cord)	🧫 Mumps, syphilis, TB, viruses
💉 Trauma (rare)	🧪 Chemical causes

🧍‍♂ Clinical Signs & Symptoms

🔎 Symptom	🧠 Explanation
😣 Increasing scrotal pain	Develops over 1–2 days
🧊 Pain may be mild or severe	Variable, depending on severity
🌡 Fever	Suggests systemic infection
💧 Urethral discharge	Common with bacterial/UTI source

💻 Sonographic Findings (Gray-Scale & Doppler) 🦠 Epididymitis

• 🔍 Enlarged, hypoechoic epididymis

• ✨ Hyperemic flow on color Doppler (increased blood flow)

• ⚪ Focal hyperechoic spots if hemorrhage is present

• 📊 Low resistance Doppler waveform (↑ systole & diastole)

🦠 Orchitis (when it spreads to testis)

• 📏 Enlarged testis (focal or diffuse)

• 🎨 Hypoechoic or heterogeneous appearance

• 🔥 Hyperemic flow if infected

• 🧊 Scrotal wall thickening

• 💧 May be associated with hydrocele (fluid around testis)

🧪 Severe Complications

🧠 Condition	🩺 Sonographic Clues
🧪 Testicular infarction	⚠ Absent or decreased flow, high resistance waveform, reversed diastolic flow
💥 Pyocele (pus collection)	Complex hydrocele with septations, debris, and loculations

🔥 Epididymo-Orchitis

Torsion = twisting of the spermatic cord → cuts off blood supply 🚫🩸
A surgical emergency that needs immediate diagnosis!

⚠ Clinical Signs & Symptoms

❗ Symptom/Sign	📘 Notes
⚡ Sudden onset of scrotal pain	Classic hallmark
😖 Severe pain	Usually intense, unilateral
🧊 Swelling	Affected side, scrotal wall thickening
🤢 Nausea & vomiting	Common with severe pain
🔁 Prior episodes of pain	May suggest intermittent torsion
📈 Peak incidence at age 14	Most common in adolescents, but can happen at any age
🎯 Undescended testis = 10× risk	Very high-risk group

⏳ Timing Matters

🕐 Time Since Torsion	🔧 Testis Salvage Rate
Within 5–6 hours	80%–100% 🌟
6–12 hours	~70% ⚠
>12 hours	~20% or less 🔥

🧬 Cause

• 📍 Bell Clapper Deformity: abnormal tunica vaginalis ➡ allows free rotation

• Often bilateral anatomic anomaly

• Starts with venous obstruction, then arterial occlusion → ischemia/infarction

💻 Sonographic Findings 📊 Gray-Scale Imaging

⏱ Time Frame	🧪 Sonographic Features
<4 hours	Testis may appear normal
4–6 hours	Enlarged, hypoechoic testis; lobes visible due to edema
>24 hours	Heterogeneous texture (due to necrosis, hemorrhage, infarction)
⬆ Epididymis	Enlarged, ↓ echogenicity or heterogeneous
⚫ Twisted Cord	Seen as round/oval extratesticular mass
💧 Reactive hydrocele & scrotal wall thickening	May be present

🎨 Color Doppler

🔍 Feature	📘 What It Shows
❌ Absent flow	Diagnostic of torsion
✅ Normal flow in opposite testis	Used as comparison
⚠ Adjust PRF & wall filter	Important for detecting slow flow
↔ Spontaneous detorsion	May show hyperemia or minimal flow → mimics infection
📍 Appendix torsion	Small hypoechoic mass near epididymis/testis; increased flow around it

🔄 Testicular Torsion

(A) Severe _________ in patient with scrotal pain, swelling, and edema.

The testis is swollen against a rigid tunica albuginea. Scrotal skin thickening is evident.

(B) Power Doppler shows hyperemic perfusion surrounding the testis but little intratesticular flow, despite the use of sensitive Doppler settings.

(C) Spectral Doppler waveform of an intratesticular artery demonstrates a high- resistance waveform. Reversed flow is seen in diastole (arrow). This is a serious finding, indicating threatened infarction.

Epididymo-orchitis

Testicular __________ in an adolescent patient with sudden onset of right testicular pain, accompanied by nausea and vomiting.

(A) Color Doppler shows normal flow within the parenchyma of the left testis.

(B) The right testis and epididymis are avascular with color Doppler imaging, with the same settings used to show flow on the asymptomatic side.

(C) Transverse ultrasound image showing both testes in right testicular torsion. The right testis is swollen and hyperechoic compared with the normal left testis.

Torsion

Definition & Location:

• Cystic dilation of the efferent ductules of the epididymis

• Always located in the epididymal head

Contents:

• Filled with proteinaceous fluid and spermatozoa

Causes / Associations:

• May occur more frequently after vasectomy

Symptoms:

• Usually asymptomatic

• May be palpable and cause patient concern

Sonographic Appearance:

• Seen as simple cysts or multiloculated cystic collections

• May contain internal echoes

• Shows posterior acoustic enhancement

🧪 Spermatocele

Definition & Location:

• Small, clear cysts that contain serous fluid

• Found anywhere within the epididymis

Symptoms:

• Generally asymptomatic

• May be palpable

Sonographic Appearance:

• Simple, fluid-filled structures

• Thin walls

• Posterior acoustic enhancement

Note:

• Ultrasound cannot reliably differentiate between spermatocele and epididymal cyst

🧫 Epididymal Cyst

Definition & Location:

• Found in the tunica albuginea (lining around the testis)

• Extratesticular, typically near the testicular surface

Symptoms:

• Generally asymptomatic

• Can become large enough to displace or distort the testis

Sonographic Appearance:

• Usually small, anechoic, thin-walled

• May cause distortion of the testis, unlike hydroceles

• Shows posterior acoustic enhancement

🩸 Tunica Albuginea Cyst

🔍 Definition & Location

• Abnormal dilation of the veins in the pampiniform plexus, located within the spermatic cord.

📌 Types

Primary Varicocele

• Caused by incompetent venous valves in the spermatic vein

• More common on the left side

• Anatomical reason:

  • The left spermatic vein drains at a steep angle into the left renal vein

  • Compression of the left renal vein between the aorta and superior mesenteric artery can occur

Secondary Varicocele

• Due to increased pressure on the spermatic vein

• Can result from:

  • Renal hydronephrosis

  • Abdominal mass

  • Liver cirrhosis

  • Retroperitoneal malignancy (e.g. invading the left renal vein → noncompressible varicocele)

• ⚠ In men >40 years old, a noncompressible varicocele warrants evaluation for a retroperitoneal mass

🧬 Clinical Significance

• Associated with male infertility

  • More common in infertile men

  • Treatment may improve sperm count in ~53% of cases (though it's still debated)

• Intratesticular varicocele may occur (near the mediastinum)

  • Clinical significance unknown, but potentially impacts fertility like extratesticular types

💡 Sonographic Findings Extratesticular Varicocele

• Numerous tortuous tubes of varying sizes near epididymal head

• May show moving echoes → indicates slow venous flow

• >2 mm diameter

• Enlarges with Valsalva or upright position

• Color Doppler:

  • Confirms venous flow

  • Shows retrograde filling with Valsalva

  • Requires sensitive settings for slow flow (low PRF & wall filter)

  • ⚠ Flash artifact may occur — instruct patient to hold still

Intratesticular Varicocele

• Appears as straight or serpiginous channels from mediastinum into testis

• Can mimic tubular ectasia of the rete testis on gray-scale

• Key difference:

  • Color Doppler shows venous flow in varicocele

  • Tubular ectasia shows no flow

💢 Varicocele

🔍 Definition

• Occurs when bowel, omentum, or other abdominal structures herniate into the scrotum.

🧪 Clinical Evaluation

• Often clinically diagnosed, but ultrasound is used when the diagnosis is unclear or equivocal.

📊 Most Common Contents

1. Bowel — most common

2. Omentum

💡 Sonographic Findings

✅ Confirmatory Sign

• Peristalsis of bowel loops on real-time imaging → confirms diagnosis

  • Can be documented with cine clips or video recording

📺 Appearance Based on Contents

• Fluid-filled bowel

  • Easy to recognize on ultrasound

• Air-filled bowel

  • Shows bright echoes with:

    • Dirty acoustic shadow

    • Ring artifact

• Solid stool-filled loops

  • Harder to detect

• Omental hernia

  • Appears brightly echogenic due to omental fat

Clinical Findings

• Scrotal mass or swelling
  → This is often palpable and may extend from the inguinal canal into the scrotum.

• Soft, reducible mass
  → The hernia may be pushed back into the abdomen manually, especially when the patient is lying down.

• Changes with position or straining
  → The swelling increases with standing or Valsalva (straining, coughing, etc.)

• May be painful or painless

  • Painless in many cases.

  • Pain or discomfort may occur with prolonged standing, heavy lifting, or if the hernia becomes incarcerated (trapped).

• Bowel sounds in the scrotum (very suggestive!)
  → Clinicians may even auscultate (listen) and hear gurgling—which strongly suggests bowel content.

• Incarceration or strangulation signs (emergency):

  • Severe pain

  • Redness or firmness

  • Signs of bowel obstruction (nausea, vomiting, no bowel movements)

Scrotal Hernia

These fluid collections form in the potential space between the visceral and parietal layers of the tunica vaginalis.

💧 Hydrocele, Hematocele, Pyocele

🌊📖 Definition

• Serous fluid collection

• Most common cause of painless scrotal swelling

⚠ Causes

• Idiopathic (unknown origin)

• Associated with:

  • Epididymo-orchitis

  • Testicular torsion

  • Trauma

  • Neoplasm (tend to have smaller hydroceles)

🧪 Sonographic Findings

• Fluid-filled area outside the anterolateral aspect of the testis

• Typically anechoic, but may show low-level echoes (cellular debris)

• More internal echoes seen in infectious cases

• Better visualization of debris with:

  • High-frequency transducers

  • Harmonic imaging

• May appear more anechoic with:

  • Frequencies < 7 MHz

  • Low dynamic range

Clinical Findings

• Painless scrotal swelling
  → This is the key clinical feature of a hydrocele.

• May be palpable by the patient or physician.

• Typically not tender, unless associated with infection, trauma, or torsion.

Hydrocele

🧫 📖 Definition

• Pus collection in the tunica vaginalis

• Caused by:

  • Untreated infection

  • Ruptured abscess

🧪 Sonographic Findings

• Indistinguishable from hematoceles on ultrasound

• Internal echoes

• Thick septations

• Loculations

• Presence of air = confirms abscess (but not always present)

Clinical Findings

• Occurs due to untreated infection or abscess rupture

• Painful and tender scrotum

• May present with:

  • Redness

  • Fever

  • Systemic signs of infection (chills, malaise)
    → These aren't directly listed but can be inferred based on the pus and infectious nature.

Pyocele

📖 Definition

• Blood collection in the tunica vaginalis

• Caused by:

  • Trauma

  • Surgery

  • Neoplasm

  • Torsion

🧪 Sonographic Findings

• Same appearance as pyocele:

  • Internal echoes

  • Thick septations

  • Loculations

• Cannot be definitively differentiated from pyocele by ultrasound alone

Clinical Findings

• Usually occurs after trauma, surgery, torsion, or neoplasm

• Painful scrotal swelling (especially if acute)

• Tenderness is likely due to blood accumulation

• May present with bruising or discoloration of the scrotum (not always noted in the text but commonly known)

🩸 Hematocele

✅ Definition / Cause:

• A chronic inflammatory reaction to extravasation of spermatozoa (sperm leakage into surrounding tissue).

• Most commonly seen in patients with a history of vasectomy.

👨‍⚕ Clinical Findings:

• Frequently painful (helps distinguish from epididymal tumors, which are usually painless).

• Usually found in post-vasectomy patients.

• May be palpable.

• Can be located anywhere within the epididymis or vas deferens.

📸 Sonographic Findings:

• Appears as a well-defined solid mass.

• Echotexture: Hypoechoic or isoechoic relative to the epididymis.

• Often heterogeneous in appearance.

• Calcifications are not commonly present.

• Color Doppler: May show increased flow if inflammation is present.

🔍 Key Diagnostic Notes:

• Ultrasound’s main role: Determine if the mass is intratesticular or extratesticular:

  • Extratesticular masses (like sperm granulomas) are much less likely malignant than intratesticular ones.

• Cannot be reliably distinguished from epididymal tumors on ultrasound alone.

• Patient history (e.g., vasectomy) is essential in narrowing the differential.

• Strongly associated with vasectomy history.

• Can occur at the site of vas deferens ligation.

Sperm Granuloma

🧵✅ Definition:

• Uncommon, benign condition.

• Involves dilation of the rete testis tubules (located at the mediastinum testis, the hilum area).

Clinical Findings:

• Typically affects men ≥45 years old.

• Associated with epididymal obstruction on the same side.

• Often seen with:

  • Spermatoceles

  • Epididymal/testicular cysts

📸 Sonographic Findings:

• Hypoechoic tubular structures near the echogenic mediastinum.

• Avascular on Doppler.

• Must be differentiated from intratesticular varicocele:

  • Tubular ectasia = no flow

  • Intratesticular varicocele = slow venous flow
    (requires low PRF & Valsalva)

Tubular Ectasia of the Rete Testis

💧 ✅ Definition:

• Simple fluid-filled cysts located within the testis, near the mediastinum.

Clinical Notes:

• More common in men >40 years.

• Often incidental and do not require treatment.

• Associated with extratesticular spermatoceles.

📸 Sonographic Findings:

• Anechoic lesion

• Smooth borders

• Posterior acoustic enhancement

Intratesticular Cysts

🟡 ✅ Definition:

• Tiny intratesticular calcifications
  (<3 mm, usually multiple).

• May be associated with malignancy, but the relationship is unclear.

Clinical Notes:

• Usually bilateral

• May also be associated with:

  • Cryptorchidism

  • Klinefelter syndrome

  • Infertility

  • Varicocele

  • Testicular atrophy

  • Male pseudohermaphroditism

• Annual ultrasound follow-up may be recommended

📸 Sonographic Findings:

• Multiple bright, non-shadowing echogenic foci scattered in testis

• Not considered abnormal unless >5 seen on one image

Testicular Microlithiasis

✅ Overview:

• Most common malignancy in men aged 15–35

• Peak: Ages 20–34

• 95% of testicular tumors are germ cell type

• Highly malignant

• Most often painless, presenting as:

  • A lump

  • Testicular enlargement

  • Vague scrotal discomfort

⚠ Risk Factors:

• Undescended testicles (cryptorchidism): 2.5–8x more likely

• More common in white men

🧪 Labs:

• ↑ hCG

• ↑ Alpha-fetoprotein (AFP)

CLINCAL FINDING:

Most patients:

• Painless lump

• Testicular enlargement

• Vague discomfort in the scrotum

Germ Cell Tumors

✅ Overview:

• Rare

• Usually occurs later in life

• Often bilateral, with multiple lesions

⚠ Primary Tumors May Originate From:

• Prostate

• Kidney

• Lung, pancreas, bladder, colon, thyroid, melanoma (less common)

📸 Sonographic Appearance:

• Solid hypoechoic mass

• May also appear hyperechoic or mixed

❌ No specific clinical findings mentioned

Metastasis to the Testicle

✅ Overview:

• Lymphoma:

  • 1–7% of all testicular tumors

  • Most common secondary testicular malignancy in men >60

• Leukemia:

  • Most common in children

  • Seen in ~8% of kids with leukemia

Clinical Findings:

• Weight loss

• Anorexia

• Weakness

• Unilateral or bilateral testicular enlargement

📸 Sonographic Appearance:

• Homogeneous hypoechoic testis

• Or multiple focal hypoechoic areas

• Increased vascularity with Doppler

• Chronic lymphocytic leukemia may show anechoic mass with through-transmission

Lymphoma & Leukemia

✅ Overview:

• Testes fail to descend into the scrotum

• Most common location: Inguinal canal

• More common in preterm babies

• Bilateral in 10–25%

⚠ Complications if untreated:

• Infertility

• ↑ Risk of testicular cancer

• ↑ Risk of torsion

📸 Sonographic Appearance:

• Smaller, less echogenic testis

• Oval, homogeneous

• Mediastinum rarely seen

Clinical findings:

• ❌ Not described with classic clinical symptoms — but text says:

  • May be palpable in the inguinal canal

  • Can lead to infertility, cancer, and torsion if untreated

  • Scrotum may appear empty

Cryptorchidism (Undescended Testis)

✅ Overview:

• Very rare

• Testicle located outside normal descent path

• Most common location: Superficial inguinal pouch

❌ No clinical findings explicitly listed

Testicular Ectopia

✅ Overview:

• Unilateral in ~4% of nonpalpable testes (more common on left)

• Bilateral anorchia is rare (0.6–1%)

• Patients have XY genotype

• Associated with:

  • Hypoplastic scrotum

  • Micropenis

  • Delayed puberty

Clinical Findings:

• Empty, hypoplastic scrotum

• Micropenis

• Delayed puberty due to hormonal imbalance

Anorchia (Absent Testis)

✅ Overview:

• Extremely rare (~80 cases reported)

• Left side more common (75%)

• Bilateral in 5%

• Testes may be in scrotum, inguinal canal, or retroperitoneum

⚠ Associated Risks:

• ↑ Malignancy

• ↑ Cryptorchidism

• ↑ Inguinal hernia

• ↑ Torsion

📸 Imaging Clue:

• Duplicated testis is often small, and no efferent duct system

🔹 Clinical Findings:

• ❌ No direct clinical symptoms listed

  • But associated risks include malignancy, cryptorchidism, hernia, and torsion

Polyorchidism (Testicular Duplication)

1. Normal Anatomy & Physiology

• Testes:

  • Symmetric, oval-shaped glands in the scrotum.

  • Sonographic appearance: smooth, medium-gray with fine echotexture.

• Epididymis:

  • 6–7 cm tubular structure.

  • Begins superiorly, courses posterolaterally to the testis.

• Blood Supply:

  • Arteries: Right and left testicular arteries arise from the abdominal aorta (just below renal arteries).

  • Veins: Venous drainage via pampiniform plexus.

• Tunica Vaginalis:

  • Contains a potential space between visceral and parietal layers.

  • Site where hydrocele, pyocele, or hematocele may develop.

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2. Sonographic Pathologies A. Trauma

• Scrotal rupture:

  • Focal alteration of parenchymal pattern

  • Interruption of tunica albuginea

  • Irregular contour, wall thickening, hematocele

B. Infection/Inflammation

• Epididymo-orchitis:

  • Infection of epididymis and testis

  • Often from lower urinary tract infection

• Pyocele:

  • Pus collection

  • Results from untreated infection or ruptured abscess

• Sperm granuloma:

  • Chronic inflammatory reaction to sperm leakage

  • Common post-vasectomy

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3. Vascular & Structural Abnormalities

• Torsion of the spermatic cord:

  • Due to abnormal testicular mobility

  • Often caused by bell clapper deformity

• Varicocele:

  • Dilated veins of pampiniform plexus

  • Caused by incompetent venous valves

• Hernia:

  • Bowel, omentum, or other structures herniate into scrotum

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4. Cysts and Benign Conditions

• Scrotal Cysts:

  • Usually extratesticular

  • Benign fluid collections

• Hydrocele:

  • Serous fluid in tunica vaginalis

  • Most common cause of painless scrotal swelling

  • May be idiopathic or associated with epididymo-orchitis/torsion

• Tubular ectasia of rete testis:

  • Benign, uncommon

  • Associated with spermatocele or epididymal obstruction

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5. Testicular Tumors

• General Notes:

  • Extratesticular masses = usually benign

  • Intratesticular masses = more likely malignant

  • Tumors classified as germ cell or non–germ cell

• Germ Cell Tumors:

  • Elevated hCG and AFP

  • Seminoma: Homogeneous, hypoechoic, smooth border

  • Embryonal carcinoma: Heterogeneous, less defined, calcifications, hemorrhage, cysts

  • Teratoma: Heterogeneous, well-defined, may have acoustic shadowing

• Lymphoma:

  • 1–7% of testicular tumors

  • Most common bilateral secondary neoplasm in men >60

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6. Congenital Anomalies

• Undescended testis (cryptorchidism):

  • Testis not in scrotum, can't be manipulated into place

• Orchiopexy:

  • Surgical correction by placing testis in scrotum

KEY PEARLS