Doppler in the Reproductive Systems - SD

Introduction

Hi, I'm John Rito.
I'm the chief of ultrasound CT
and MRI at Northshore University Hospital in Manhasset,
New York, and I'm gonna be talking about doppler
of the reproductive systems.

Hi. In this presentation we're going to discuss some
of the useful applications of Doppler ultrasound
for both gynecologic and male pelvic applications.
We'll review some of the DO Doppler optimization techniques,
talk about some normal doppler findings,
and finish up with some clues and pitfalls in diagnosis.

Female Pelvic Applications

I'm gonna start out by talking about some
of the applications in the female pelvis.
We'll talk about the characterization
of Adil ovarian masses in particular, we'll talk about
identification and characterization of hemorrhagic
or caral CT cysts.
Spend a few minutes talking about doppler applications
in ectopic pregnancy.
Mention retained products of conception,
and of course we'll spend a few moments on the diagnosis
of ovarian torsion.

Now for all of our studies,
we typically employ endo vaginal color Doppler imaging
for outstanding technique, usually using a five
to nine megahertz transducer.
Because the vessels are so tiny,
we utilize zero angle correction.
That is, we don't change the angle correction,
we use a zero degree angle
to obtain Doppler samples in the ovary and the uterus.
The sample volume size will be small again
because the vessels are tiny
and in general we don't use pulse doppler in normal first
trimester pregnancies
because of the potential for bio effects.

As part of the op optimization of our doppler, we're going
to adjust the color gain pulse, repetition, frequency,
and wall filter for each patient so that we're able
to visualize blood flow in the vessels of interest.

As part of our pelvic doppler studies,
we routinely look at the iliac branches, both arteries
and veins, and may focus on the uterine arteries
and veins as well as the ovarian vessels
each having its own characteristic wave form.

Uterine Arteries

Let's start out by talking about the uterine arteries.
The uterine arteries are branches
of the internal iliac artery
and we typically will look for a high resistance signal
with low diastolic flow in the non GRA state.
One of the ways we characterize this waveform is by looking
for the diastolic notch that occurs,
early on in diastole
and helps us to identify those waveforms
as arising from the uterine artery
or branches of the uterine artery.
We'd expect to see a decrease in resistance
with a rise in diastolic flow during pregnancy,
usually starting in the second trimester.

And here's an example of a endo vaginal color doppler image
of the broad ligament
and we see vessels crossing across the broad ligament
and actually inserting into the ovary here.
If we sample some of these vessels,
we'll see the characteristic waveform showing an early
diastolic notch telling us these branches originate from
the uterine artery.

So again, here's another example showing branches
of the uterine artery here providing blood
flow to the ovary.

Ovarian Blood Supply and Normal Waveforms

So now we know that the ovary typically
has a dual blood supply.
We get blood flow that arises from the ovarian artery,
which originates from the abdominal aorta,
and we'll also see branches from the uterine artery
as I mentioned, across across the broad ligament
and also insert into the ovary.

It's important to review normal doppler waveforms
that occur in the ovary
and the type of waveform
that we we see depends on the phase of the menstrual cycle.
During the follicular phase,
that is usually the first menstrual week,
the ovaries at rest.
So we expect to see relatively low velocity,
high resistance waveform.
And this example here we see velocities average about 10
centimeters per second with no visible flow in diastole
during the luteal phase of the menstrual cycle.
Typically after the second menstrual week,
we'll see an increase in both systolic
and diastolic velocities.
This is typical to see this type of blood flow
around the developing dominant follicle or luteal cyst.
You'll notice that in addition to the elevated velocities,
we have decreased resistance with a relatively low rri.

Postmenopausal ovaries are typically not active
and should demonstrate relatively low velocity,
high resistance flow.
In this example here we see velocity is about six
centimeters per second with a rel
with relatively little flow in diastole.
And this would give us a relatively high resistant index.

Now, one of the things that we would look for in trying
to characterize some of these cysts is a vascular rim
that we can identify around the corpus luteal cyst
during the luteal phase of the cycle.
In this particular example here we see a ring of vascularity
around the cyst, which some of us can describe
as a ring of fire pattern.
And we'll notice when we sample this area
of the increased vascularity,
we have velocities at average about 27
centimeters per second with a resistive index about 0.4.

Characterization of Ovarian Cysts

Here's a patient that presented
with acute right lower quadrant pain,
and you'll notice we see a complex looking cyst
in the right ovary with areas of tissue
and nodularity associated with the cyst.
Now this might cause some concern
because it's not a simple looking cyst,
and we might worry that this is something
a little bit more worrisome,
but again, turning color doppler on, we can see
that there's only vascularity in the wall of the cyst.
There's no evidence of increased blood flow in the solid
component or the nodularity, which is related
to blood within the cavity of the cyst.
And so we can identify this as a hemorrhagic cyst
and simply follow the patient
for a follow-up scan if we choose.

Here's another example of a patient that presents
with an abnormal cyst, some pelvic pain.
We notice that there are internal low level echoes within
the central portion of the cyst.
When we turn color doppler on, we see
that there's only vascularity
around the periphery of the cyst.
There's no evidence of internal vascularity
to cause us concern
that this might represent a solid neoplasm
and we can demonstrate this peripheral vascularity
with color doppler and we can also see it as well
with power doppler imaging, again showing a ring
of vascularity around the hemorrhagic cyst.
And again, if there's any need for follow-up,
we can have the patient come back during the first week
of a subsequent menstrual cycle again
during the early follicular phase when this
cyst should have resolved.

Ectopic Pregnancy

Now one of the more important applications of
doppler imaging in the female pelvis is a characterization
in analysis of patients with suspected ectopic pregnancy.

Now, the typical sonographic findings in a patient
with ectopic pregnancy include an absence
of an intrauterine pregnancy.
We may see an abnormal sac
or evidence of fluid within the endometrial canal
and colo dopa can also help us show
that there is no evidence of placental flow in the uterus.
Of course, we're gonna spend some time in the adexo looking
for evidence of an embryo or an ectopic sac
or mass to show us the location of the ectopic pregnancy.

Many times, in addition to finding the ectopic pregnancy,
we'll see evidence of free pelvic fluid studies
that we've done in the past show that in up to 85%
of patients we can demonstrate placental flow
with colo doppler imaging either in the uterus
or in the ad nexa to document the location
of the ectopic pregnancy.

Studies done at Yale years ago have shown
that we can identify placental flow in an
intrauterine pregnancy.
The area of increased vascularity
that we have here on this image is related to invasion
of the trophoblast into the uterine myometrium,
and we can identify this as early as five weeks
after the last menstrual period.
So it's 36 days after the LMP.
We can start to see evidence of placental flow in an IUP
and we use a velocity cutoff of 21 centimeters per second
to identify placental flow in the uterus.
Again, this is obtained with zero angle correction
because the vessels are too small, we're not really able
to angle correct, so zero degree angle correction
with a velocity of at least 21 centimeters per second
to demonstrate intrauterine placental flow.

So the value of color doppler in the evaluation
of intrauterine pregnancy lies in the ability
to detect placental flow to confirm the presence of a normal
or abnormal intrauterine pregnancy.
In addition, we routinely use colo doppler
to show us evidence of increased flow in patients
with an incomplete abortion.
In other words, a patient may present
to the emergency department positive pregnancy test may have
vaginal bleeding, and we'll see evidence of
increased vascularity,
although there's no evidence of a normal IUP allowing us
to make a diagnosis of incomplete abortion.

Following delivery patients may persist
with vaginal bleeding or an elevated pregnancy test.
And again, color DOPA is helpful to identify areas
of increased vascularity
to show retained products of conception.

Here's an example of a patient that presented
with vaginal bleeding positive pregnancy test
and the question is viability.
Now our image here is a transvaginal view of the uterus
and we can identify the endometrial canal,
but we don't see any evidence of the sac,
no fluid within the canal to suggest a presence
of an intrauterine pregnancy.
And many of these cases we would be concerned
for an ectopic pregnancy in a patient presenting
with a positive pregnancy test and vaginal bleeding.
But before we turn to the next,
I think it would be important to turn on CLI doppler.
In this particular case, we can see evidence
of increased vascularity associated
with the endometrial canal.
This vascularity has a peak systolic velocity
of over a hundred centimeters per second
with a low resistance flow pattern, which is consistent
with intrauterine placental flow.
So now we have evidence
of placental tissue within the uterus in a patient
with vaginal bleeding, allowing us to make a diagnosis
of incomplete abortion in this case
and not worrying about the possibility of ectopic pregnancy.

We also utilize color doppler in the evaluation of patients
with suspected ectopic pregnancy in the uterus.
We use C Doppler to look for evidence of placental flow.
Now if we see a sac
or abnormal sac like structure with fluid
in the endometrial canal will look
for the presence of placental flow.
Not seeing flow in this area raises the possibility
of a pseudo gestational sac.
And then we'll turn our attention to the adex A looking
for evidence of increased vascularity in an
occult ectopic pregnancy.
As many times we won't see a tubal ring
or a donut shaped structure, which will allow us
to identify the location of an ectopic pregnancy.

Another application of colo doppler in the setting
is following patients
after methotrexate where we look
to see decreased vascularity over time
to assess the efficacy of treatment.

Here's an example of a patient
that presents four weeks status post in vitro fertilization.
The HCG level is 800,
and here we have an Inova image
of the uterus showing a small sac like structure within
the endometrial canal.
Low level echoes are identified within the structure
suggesting an abnormal intrauterine pregnancy
or the possibility of
a pseudo gestational sac with an ectopic pregnancy.
The first thing I'm going to do here is turn color on
to look at the sac within the endometrial canal.
C Doppler demonstrates e evidence of vascularity
around the sac, but the peak systolic velocity is only up
to about 13 centimeters per second.
So it's not up to the level of 21 centimeters per second
where I know it's placental flow associated with the sac.
So these findings suggest the possibility
of a pseudo gestational sac.
And now we're gonna turn our attention to the ad nexa.
And here we have a an image of the left adnexa.
Somewhat complicated here.
It looks like we see an ovary with some follicles,
perhaps some vessels, maybe some soft tissue in this area.
Again, we're gonna turn color on to sort
of sort out the anatomy here.
And color allows us
to fill in the surrounding vascular structures.
And now we clearly see a well-defined tubal ring
or gestational sac in the ad nexa allowing us
to determine the location of the ectopic pregnancy.

Here's another example.
Here's a patient that presents with pelvic pain
and this question of an adnexal mass.
And again, what we see here on the gray scale image is sort
of an ill-defined area of soft tissue.
Now this might represent hematoma, perhaps it's a bowel loop
and that's where color Doppler is so helpful is we can try
to characterize this tissue with a little bit more detail.
Here on this clip, we can see that there's evidence
of arterial flow associated with this soft tissue.
So we know it's not hematoma
and it's a pattern not typical of bowel.
So again, now we're more comfortable being able
to determine the location
of the ectopic pregnancy based on the appearance
of abnormal color flow
in this soft tissue scene in the adexo.

So here's the example of an ectopic pregnancy visualized
with the aid of color flow dopp.

Ovarian Torsion

Let's move on and talk about ovarian torsion.
And here's certainly an application
where Cholo Doppler serves a very important purpose,
allows us to demonstrate abnormal blood flow associated
with the ovary Occurs.

Ovarian torsion is associated with about 3%
of gynecologic emergencies occurring more often in
premenopausal patients.
There's usually a mass associated with the ovary,
which serves as the focal point for the twist.
And we know that torsion of the normal ad nexa is uncommon,
but it's not impossible as the ovary may be displaced
by an adnexal mass producing decreased blood flow.

The sonographic findings associated
with ovarian torsion include an enlarged ovary
or mass, which may be cystic complex
or solid and appearance.
It's typically associated with edema and free fluid.
And one of the things that we tend to look for is an unusual
location of the ovary, which might be in the cul-de-sac
or twisted toward the fundus of the uterus.
Another important finding is coiling
or twisting of the vascular pedicle feeding the
Ovary.

The hallmark for the diagnosis
of ovarian torsion is the failure to detect arterial
and venous flow within the ovary.
Sometimes will detect peripheral flow around the ovary,
which may be related to chronic torsion
from reactive inflammation
and sometimes we'll see decreased flow which could be
associated with a partial torsion.

Here's a classic case of ovarian torsion
where we see an enlarged ovary with multiple cysts
and colo Doppler fails to demonstrate any arterial
or venous flow within the ovary.
And of course we're gonna check that with pulse doppler.
So the failure to de detect arterial
and venous flow with color and pulse doppler is clearly
diagnostic, in the right clinical setting
for ovarian torsion.
Again, assuming that you've optimized your parameters,

here's a patient that presented
with right sided pelvic pain.
You'll notice toward the top of this endo vaginal image
that we have a retroverted uterus.
We can see the endometrial canal
and notice that we have an enlarged right ovary sitting in
the cul-de-sac turn color
doppler on and we can see flow in the iliac vessels.
We can also appreciate color flow in the uterine vessels,
but there's no evidence of any vascularity within the
enlarged right ovary.
And of course we're gonna confirm that with pulse doppler.
And as we move these sample volume through the ovary,
we detect no arterial or venous flow.
So again, classy case of ovarian torsion.

This patient presented with acute right lower quadrant pain
and in this case we see a rather heterogeneous mass on the
right side and it has this echogenic component which is
suspicious for a dermoid.
Now hair color dopa is helpful
because not only does it show his absence
of flow within the ovary itself,
but it gives us the appearance of a coil spring
or what I call a slinky sign,
which shows us the twisted vascular pedicle.
So this is considered a very helpful sign in the diagnosis
of ovarian torsion.

In this paper that was published a few years ago in the
Journal of Ultrasound in Medicine, we see a series
of 21 patients with documented ovarian torsion, all
of them having this classic twisted
or whirlpool sign on gray scale and kalo dopa.
The author also noted that all
of these patients had evidence of ovarian mass
and felt that the Whirlpool sign was the most definitive
sign for ovarian torsion.

So doppler plays an important role in the diagnosis
of ovarian torsion.
The absence of flow is diagnostic.
If we see arterial
but not venous flow, that's suspicious
for at least a partial torsion.
But it's important to note that you can have arterial
and venous flow with partial torsion.
We've seen this time and again where
because there's incomplete twisting of the vascular pedicle,
you can see flow within the ovary.

Here's a patient that presented with pelvic pain.
We see an enlarged ovary, somewhat heterogeneous appearance.
So just based on the clinical pattern
of unilateral pelvic pain
and enlarged ovary with a heterogeneous appearance,
we're suspicious about the possibility of ovarian torsion.
We turn color on
and we can demonstrate some blood flow within the ovary.
And as we sample these vessels, we see
that we're getting arterial flow,
but we're not able to demonstrate any venous flow throughout
this enlarged ovary,
which I think is very suspicious for a partial torsion.
And this patient was sent full laparoscopy
and was proven to be a partial torsion.

So I think it's important to keep in mind the constellation
of findings associated with torsion.
Typically unilateral pain,
an enlarged ovary which may have a heterogeneous
or ADEMs appearance,
an unusual location which can be in the cul-de-sac
or near the fundus of the uterus.
We look for evidence of the whirlpool sign
and of course an abnormal
vascular pattern on pulse staler all point
toward ovarian torsion.

Male Pelvic Applications

Let's move on and we'll talk about some
applications in the male pelvis.

Scrotal Anatomy

Here we have a diagram of the scrotal sac
and you can see here that as we open up the sac,
we can see the testis around the periphery
of the posterior aspect of the testis.
We can identify the epididymus
and the vessels will then arise
and ascend into the spermatic court.

Here's a look at the vascular anatomy of the testis.
The testicular artery will come down to the level
of the testicle
and give off the capsular artery, which travels
around the periphery of the testis
and will give off these capsular arteries,
which will then move into the substance of the testes.
And here we have a color Doppler image showing the capsular
artery around the periphery
and the centripetal arteries
as they penetrate toward the center of the testicle.

Here's another diagram showing the both the
arterial and venous anatomy.
Again, we can appreciate
that the testicular artery is a branch
of the abdominal aorta
and we can see it ascends into the pelvis
and we can see both the deferential
and the cremasteric arteries being branches
of the iliac arteries.
And all the vessels will travel together within
the spermatic cord.
Venous outflow typically returns
Through The PFO and flexis
and on the left side the testicular vein will empty
into the left renal vein, whereas on the right side,
the testicular vein empties directly into
the inferior venia cava.
And this is one of the reasons that we
will see varicose seals occurring more often on the left
side due to reflux because of the anatomy
and the relationship between the testicular vein
and the renal vein on the left.

So in the spermatic cord we'll have the avast deference,
we'll have the cremasteric deferential
and testicular arteries as well as the pone flexes.
In addition, both the cremasteric and sympathetic nerves
and lymphatic vessels will travel in the spermatic court.

Normal Arterial Flow in Testes and Epididymis

Now let's take a look at normal arterial flow associated
with the testes and EPIs.
This work also came out of Yale from Dr.
Taylor's lab and this paper was published
by Janice Brown in radiology
and in this study we found that the peak systolic velocity,
the normal peak systolic velocity in the testis averages
about eight centimeters per second
and diastolic velocity is 3.8 centimeters per second
with an average RI of 0.5.
We See similar velocities in the EPIs
and the the peak systolic velocity average is about nine
centimeters per second and diastolic velocity is 3.5
centimeters per second with a resistive index about 0.6.

Acute Scrotal Pain Differentials

Now when patients present with acute scrotal pain,
we have a fairly straightforward differential diagnosis.
Of course, our major concern is testicular torsion
as this warrants urgent surgical intervention,
but more often we'll see evidence of oras or mitis.
Another possibility is torsion of the appendix testis.
And this is something that we think about
especially in younger patients or children less commonly.
Patients who present with acute scrotal pain
will have a complication of a testicular tumor
or they may have evidence of a hernia.

Testicular Torsion

Let's start out with a discussion
of acute testicular torsion.
This results from interruption of the blood supply due
to a twist of the spermatic cordon.
This is very similar to the
to the situation we just discussed with regard
to ovarian torsion.
Both of these require, emergent surgical intervention
with testicular torsion.
We wanna be sure to find, the make the diagnosis early
because there's only a 50% salvage rate after eight hours
and there's only about a 20% salvage rate after 12 hours.
So the sooner the diagnosis is made, the better.
Again, we see this well commonly in children
and very commonly it's related to the bell
and clapper deformity, which is related to a failure
of posterior attachment of the tunic
of vais to the scrotal wall.
Normally the tunic of vaginalis will hold a testis in place.
When there's an absence
or failure of the normal anchoring, you'll have swinging
and twisting of the spermatic cord
and twisting of the vascular pedicle.

Now the ultrasound findings
that is the gray scale findings are fairly nonspecific.
You may see testicular enlargement.
The testis may be hypo coic heterogeneous.
There may be a presence of a hydro scale
and associated scrotal wall thickening
doppler can be very helpful
because we'll see an absence
of intra testicular blood flow in patients
with a complete testicular torsion.
If we, if we see no central flow
but increased per testicular flow, we think about a mist
or a chronic torsion.
Sometimes we'll see decreased flow within the testes
or biphasic or non pulsatile flow, which can be associated
with a partial torsion.
And studies have shown that dola can have a sensitivity
of 79 to 89% in specificity of 77
to a hundred percent for the diagnosis of test torsion.

Here's some cases of patients with documented test torsion.
Here's an obvious case of a patient with pain on the right
and you can see on this transverse view which compares both
testis that we have an absence of flow on the right side
and we see vessels in the
nor normal asymptomatic left testis.
And this is probably the best view to get
because it's comparing both sides asymptomatic
and the asymptomatic side.
Of course we always do pulse stop
and here you can see we have a relatively large sample
volume as we fish for flow throughout the testis
and we have no evidence of flow in this particular case.

Here's a patient that presented with left scrotal pain
and again, the transverse view is extremely helpful here
because we do see evidence
of vascularity on the asymptomatic right side
and there's an absence
of blood flow on the symptomatic side.
If we sample the normal side,
we have arterial and venous flow.
In this case, arterial flow is
above the baseline venous flow
underneath normal flow pattern.
On the symptomatic side, we have heterogeneous appearance
on the gray scale image.
Color doppler shows us no evidence of vascularity
and an absence of normal flow with pulse do.

Here's a patient that presented with left pain and swelling
and again, very similar picture.
We have arterial and venous flow on the right.
We see no evidence of flow on the left,
you can see the left testis has a heterogeneous picture
and we see some evidence of per testicular flow,
which we have to be careful about because with a chronic
or mis torsion, the flow can be per testicular
and this can be related to hyperemia
or reactive inflammation.
In this particular case,
there is no flow within the testis just flow in the
periphery, the so-called halo signs.
We have to be careful where we see color flow coming from.

Here's another example here of a my torsion, no evidence of
of significant vascularity within the testicle,
but we do see a halo of of blood flow
around the testis on para doppler.
And here of course on the transverse view we see evidence
of blood flow on the asymptomatic right side only increased
vascularity around the testis on the left,

Similar to the discussion of ovarian torsion, we can look
for evidence of a whirlpool sign to help make the diagnosis
of testicular torsion.
Again, we can see with both complete and partial torsion,
but we're not gonna see it with epidemo arthritis.
Here we can identify the sign is an acute rotation
of the spermatic cord, either with an axial sweep
of the cord up and down
or perhaps on a sagittal view through the testes.
And according to this paper published in the Journal
of Ultrasound Medicine, the presence
of the whir Pooh sign is the most specific sign
for the diagnosis of testicular torsion.

Here in this example, you can appreciate the twisting
of the vascular pedicle adjacent to the abnormal testis.

Here's another example of a patient that presents
with test torsion.
Again, no evidence of of flow within the testis.
And as we look at the spermatic cord,
you can see a tight knot within the cord.

Here's a patient that presented
with the right scrotal pain, eight years old.
Here we're comparing the left side and the right side.
The left side was the asymptomatic side
and we were able to demonstrate both
arterial and venous flow.
On the symptomatic side, it only looked like we were able
to demonstrate low velocity venous flow, and this is unusual
because we should lose venous flow First.
In a patient that has evidence of torsion,
there was no arterial signals shown within this case.
And because of the asymmetry
and the absence of documented arterial flow,
this patient was sent for exploration
and the diagnosis was partial testicular.

So one must be cautious to look for sym symmetrical arterial
and venous flow on both sides.
Venous flow may not be seen
and again, like ovarian torsion, if we don't see
venous flow, then we have to be concerned
that there's at least a partial torsion.
So always compare both sides
and damped Arterial signals may simulate venous
flow such as in this case.

Epididymitis and Orchitis

Let's talk about epididimitis oris, which accounts
for the majority of patients that present
with scrotal pain usually involves the epididymus alone
about 20% of the time is associated with oras.
If untreated, it can go on to form evidence of a PSE
or an abscess Similar to
testicular torsion,
patient may have epidermal testicular enlargement
with a hypo coic or heterogeneous pattern.
They may have an adjacent hydrocele
and scrotal wall thickening.
So it's very difficult to make the diagnosis based on the
gray scale findings alone.

Fortunately, we have a much different picture
with doppler imaging.
Unlike testicular tors which has decreased
or absent flow in the testis,
we see increased intra testicular blood flow associated
with epididimitis and oris.
And a study that was also done at Yale by Janis Brown
and published some years on radiology.
We found increased blood flow with a peak systolic velocity,
typically greater than 15 centimeters per second associated
with epi ditis or oas.
We also defined peak systolic velocity ratios greater than
1.7 for epi ditis
and approximately two to one
for oras.

Here's an example of a patient with unilateral scrotal pain.
Here we see an enlarged epididymus marked increased
vascularity within the epididymus
with surrounding hydros eal.

Here we're comparing blood flow in a patient with oras
comparing the left side and the right side.
On the asymptomatic side,
the peak systolic velocity is about
eight centimeters per second.
Here on the symptomatic side
where we see increased vascularity on colo dopa,
the peak STO velocity is greater than 25
centimeters per second.
So again, elevated velocities
and a peak systolic velocity ratio greater than two to one.

This patient presented with left scrotal pain
and as we look on the right side first we can see a
relatively homogeneous pattern.
On the right testis we see blood flow within the testis
with a normal arterial flow pattern.
We move over to the left side, we see an enlarged epididymus
with evidence of small cysts surrounding hydro seal.
And of course when we turn color doppler on markedly
increased vascularity On the symptomatic side here,
when we take a look at the testis,
we see a little bit more heterogeneity,
some edema of the testis.
We see increased vascularity not only in the testis itself
but in the surrounding soft tissues as well
as elevated velocities associated with the testis,
all consistent with LEP epididimitis.

Our next case is out of a 16-year-old who presented
with left testicular pain.
In this particular case, we see focal areas
of decreased echogenicity associated with the testis, which
not given the history would be concerning for malignancy.
And we compare the right side,
which has a relatively homogeneous pattern.
And on the left side here we see these
focal hypo coic areas.
We turn on color and para doppler
and we can see that there's evidence
of increased vascularity associated
with these hypo coic areas in the testes raising the
possibility of oras.

And here again, we have a transverse view
comparing both sides.
And on the symptomatic side,
we clearly have increased vascularity compared
to the asymptomatic side.
Again, multiple images showing asymmetry
of blood flow with increased flow.
On the symptomatic side,
if we compare the velocities from the
asymptomatic side to the symptomatic side,
we we see the velocities on the right at 6.5 compared
to 22 on the symptomatic side.
So again, elevated velocities,
high ratio on the side with oras.

Now when we see areas of decreased echogenicity, we do need
to exclude underlying malignancy.
So I think in this population it'd be prudent
to have the patient come back for a follow-up study
after treatment to make sure that these areas
of abnormal echogenicity have resolved.
The patient does not have an underlying tumor.

Here's a case of oras that has progressed
to an abscess with gas.
We see a focal hypo coic area with these very bright
echoes within this area.
We have a little bit of ring down artifacts here
and this, the flex of gas in a patient
that has developed an abscess.
And here we can see the fluid component within the abscess.
Notice we have increased vascularity around the abscess.

Varicocele

Let's talk about varicose seal.
This represents a dilatation of the veins
of the pampiniform plexus.
We call it idiopathic variceal when it's related
to incompetent valves of the testicular veins.
It's secondary varicose seal when it's related
to increased pressure from a mass
or compression from another problem such
as a hydronephrosis.
Varicose Seals are more commonly seen on the left side
about 98% of the time,
but they can be bilateral in up to 70% of patients
and they can involve up to 15 to 20% of the male population.
Feral rep represents the most common correctable cause
of male infertility
and can represent 20 to 40% of infertile MI males
and the cause for the infertility of thought be due
to oligospermia.

In patients that present with varicose cell,
we typically look for tubular
and coic structures in the scrotal sac
adjacent to the testis.
We look for a diameter of the vein
of at least three millimeters And we can discri.
We can discriminate a varicose cell from a spermatocele
with colo doppler
by demonstrating flow within these tubular structures.
The flow is typically slow with a venous pattern
and we can show reversal flow with the Valsalva maneuver
and we can demonstrate this both with color
and with pulse doppler.

Here we have a patient with a varicose seal
and having the patient perform a Valsalva maneuver,
we can show increased blood flow on the color Doppler image
and if we place the pulse sample volume within within the
varicose seal, we can demonstrate ink freeze flow due
to reflux down the veins during valve cell.

Here's another example.
At rest we're able
to demonstrate the tubular structure here measures about
three and a half millimeters,
and with Val Salva we see increased blood flow
through the variel and you can see an increase in
size of the vessel.

Torsion of the Appendix Testis

I'm gonna finish up here with a discussion of torsion
of the appendix testis, otherwise called the hym Gagne.
This represents a remnant of the Malian duct,
which is typically attached to the upper pole of the testis,
and we can identify it typically when there's presence
of a hydrocele by the small structure between the testis
and the epididymus.

When patients have torsion of the appendix testis,
it can have a very similar clinical pattern to torsion
or epididimitis,
and it's important to make the correct diagnosis
because surgery in this case is unnecessary.
Over time, the appendix testis may break off
and become calcified resulting in the
so-called scrotal pearl.

Now, we would try to make the diagnosis with ultrasound
by looking for a hyper coic heterogeneous nodule.
In the classic location, again medial to the epidermal head,
the epididymus and the spermatic cord can be swollen
and hyperemic again simulating infection
and thus mimicking epididimitis.
But the testis is usually normal.

In these cases, patients with torsion
of the appendix testis will present
with unilateral cleal pain, again, simulating someone
who might have underlying epididimitis or aas.
But we consider the diagnosis commonly in children
and we look for the nodule
between the epididymus and the testis.

He is a classic example
where we see the heterogeneous nodule in the typical
location between the epididymus and the testis.
With color doppler,
we can see increased vascularity in the periphery around the
tors appendix testis,
and surrounding inflammation that can involve the adjacent
EPIs testis and surrounding soft tissues.
Being able to identify the enlarged nodule
surrounding inflamm inflammation allows us
to make the diagnosis of horgen of the appendix testis.

Conclusion

In conclusion, duplex
and colo doppler add important diagnostic information.
In patients that present with pelvic pain,
it can aid in the diagnosis of multiple FA male
and female applications.
It's very useful for characterizing different
causes of pelvic pain.
As usual, it's important to incorporate the clinical history
information from the physical exam
and laboratory data to improve our diagnostic accuracy.

Thank you.